A prospective randomized controlled study on the repair of skin and soft tissue defect in functional areas of children with full-thickness skin grafts from different sites of abdomen
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摘要:
目的 对比分析采用腹部不同位置全厚皮片修复小儿功能部位小面积皮肤软组织缺损创面的效果。 方法 采用前瞻性随机对照研究方法。2019年1月—2020年6月，空军军医大学第一附属医院收治60例符合入选标准的因功能部位小面积皮肤软组织缺损需行全厚皮片移植修复的女性住院患儿。按随机数字表法将患儿分为2组，剔除随访脱落患儿后，侧腹部组纳入28例、下腹部组纳入29例，年龄分别为5（3，8）、5（3，7）岁。对下腹部组患儿20（12，26）cm2创面采用于腹下区横行皮纹处切取的（24±10）cm2全厚皮片修复，侧腹部组患儿23（16，32）cm2创面采用于脐平面以下至腹股沟以上的侧腹部区切取的（24±9）cm2全厚皮片修复，供区切口均行连续皮内缝合。术后供受区均行-10.64~-6.65 kPa持续负压治疗，术后7 d开始应用医用皮肤减张闭合器治疗供区。记录供区使用医用皮肤减张闭合器情况、供区术后并发症发生情况及拆线时间并计算并发症发生率；术后7 d，采用自行设计的疗效满意度调查表调查患儿家长对患儿疗效的满意度；术后1、6个月，采用温哥华瘢痕量表（VSS）评估供区瘢痕情况并计算2个时间点VSS评分差值，用直尺测量供区瘢痕宽度并计算2个时间点瘢痕宽度差值。对数据行独立样本t检验或Cochran&Cox近似t检验、Mann-Whitney U检验、Fisher确切概率法检验。 结果 侧腹部组术后供区应用医用皮肤减张闭合器时间≥4周患儿比例明显高于下腹部组（P<0.05）。术后7 d，侧腹部组中出现供区切口部分裂开、供区周围皮肤红肿、供区脂肪液化的患儿各1例，下腹部组1例患儿供区出现切口部分裂开；下腹部组患儿供区术后并发症发生率明显低于侧腹部组（P<0.05）。与侧腹部组相比，下腹部组患儿供区术后拆线时间显著缩短（t'=17.23，P<0.01）。术后7 d，下腹部组患儿家长对患儿疗效的满意度评分明显高于侧腹部组（t'=20.14，P<0.01）。术后1、6个月，下腹部组患儿供区瘢痕的VSS评分分别为（2.7±0.9）、（2.8±1.0）分，均明显低于侧腹部组的（7.1±2.2）、（9.1±2.7）分（t值分别为10.00、11.15，P<0.01）。术后6个月，侧腹部组患儿供区瘢痕的VSS评分较术后1个月明显升高（t=3.10，P<0.01），而下腹部组患儿供区瘢痕的VSS评分较术后1个月升高不明显（P>0.05）；侧腹部组患儿供区瘢痕的VSS评分差值明显大于下腹部组（Z=-8.12，P<0.01）。术后1、6个月，下腹部组患儿供区瘢痕宽度分别为2.0（1.0，2.0）、2.0（2.0，3.0）mm，均明显窄于侧腹部组的6.0（4.0，10.0）、8.5（5.0，12.0）mm（Z值分别为-13.41、-14.70，P<0.01）；术后6个月，侧腹部组患儿供区瘢痕宽度较术后1个月明显增宽（Z=-2.79，P<0.01），而下腹部组患儿供区瘢痕宽度较术后1个月增宽不明显（P>0.05）；侧腹部组患儿供区瘢痕宽度差值明显大于下腹部组（Z=-14.93，P<0.01）。 结论 采用下腹部全厚皮片修复小儿，尤其是女性患儿功能部位小面积皮肤软组织缺损创面的方法，行之有效、简便易行、符合美学修复原则；与侧腹部全厚皮片移植相比，下腹部全厚皮片移植术后供区并发症发生率低、瘢痕增生不明显，值得临床推广使用。 Abstract:Objective To compare and analyze the effect of repairing small skin and soft tissue defect wounds in functional areas of children with full-thickness skin grafts from different sites of abdomen. Methods A prospective randomized controlled study was conducted. From January 2019 to June 2020, 60 female children with small skin and soft tissue defects in functional areas requiring full-thickness skin grafting, who met the inclusion criteria, were admitted to the First Affiliated Hospital of Air Force Medical University. According to the random number table, the children were divided into two groups, with 28 cases left in lateral abdomen group aged 5 (3, 8) years and 29 cases in lower abdomen group aged 5 (3, 7) years after the exclusion of several dropped-out children in follow-up. In lower abdomen group, 20 (12, 26) cm2 wounds of children were repaired with (24±10) cm2 full-thickness skin graft from transverse skin lines in the inferior abdomen area, while in lateral abdomen group, 23 (16, 32) cm2 wounds of children were repaired with (24±9) cm2 full-thickness skin graft from below the umbilical plane to above the groin in the lateral abdomen area. All the children were treated with continuous intradermal suture at the donor site incision and received continuous negative pressure treatment of -10.64 to -6.65 kPa in the donor and recipient areas after operation. The donor site was treated with a medical skin tension-reducing closure device since post-surgery day (PSD) 7. The use of medical skin tension-reducing closure device at the donor site, postoperative complications and suture removal time of the donor area were recorded, and the incidence of complications was calculated. On PSD 7, a self-designed efficacy satisfaction questionnaire was used to investigate the parents' satisfaction with the curative effect of their children. In post-surgery month (PSM) 1 and 6, Vancouver scar scale (VSS) was used to evaluate the scar at the donor site, and the VSS score difference between the two time points was calculated; the scar width at the donor site was measured with a ruler, and the scar width difference between the two time points was calculated. Data were statistically analyzed with independent sample t test or Cochran & Cox approximate t test, Mann-Whitney U test, and Fisher's exact probability test. Results The proportion of children in lateral abdomen group who used the medical skin tension-reducing closure device in the donor area for equal to or more than 4 weeks after surgery was significantly higher than that in lower abdomen group (P<0.05). On PSD 7, there was one case of partial incision dehiscence in the donor area, one case of peripheral skin redness and swelling in the donor area, and one case of fat liquefaction in the donor area in lateral abdomen group, and one case of partial incision dehiscence in the donor area in lower abdomen group. The incidence of postoperative complications at the donor site of children in lower abdomen group was significantly lower than that in lateral abdomen group (P<0.05). Compared with that in lateral abdomen group, the suture removal time at the donor site of children after surgery in lower abdomen group was significantly shorter (t'=17.23, P<0.01). On PSD 7, the satisfaction score of parents with the curative effect of their children in lower abdomen group was significantly higher than that in lateral abdomen group (t'=20.14, P<0.01). In PSM 1 and 6, the VSS scores of scar at the donor site of children in lower abdomen group were 2.7±0.9 and 2.8±1.0, respectively, which were significantly lower than 7.1±2.2 and 9.1±2.7 in lateral abdomen group (with t values of 10.00 and 11.15, respectively, P<0.01). In PSM 6, the VSS score of scar at the donor site of children in lateral abdomen group was significantly higher than that in PSM 1 (t=3.10, P<0.01), while the VSS score of scar at the donor site of children in lower abdomen group was not significantly higher than that in PSM 1 (P>0.05). The VSS score difference of scar at the donor site of children in lateral abdomen group was significantly greater than that in lower abdomen group (Z=-8.12, P<0.01). In PSM 1 and 6, the scar widths at the donor site of children in lower abdomen group were 2.0 (1.0, 2.0) and 2.0 (2.0, 3.0) mm, respectively, which were significantly narrower than 6.0 (4.0, 10.0) and 8.5 (5.0, 12.0) mm in lateral abdomen group (with Z values of -13.41 and -14.70, respectively, P<0.01). In PSM 6, the scar width at the donor site of children in lateral abdomen group was significantly wider than that in PSM 1 (Z=-2.79, P<0.01), while the scar width at the donor site of children in lower abdomen group was not significantly wider than that in PSM 1 (P>0.05). The difference of scar width at the donor site of children in lateral abdomen group was significantly greater than that in lower abdomen group (Z=-14.93, P<0.01). Conclusions The use of full-thickness skin grafts from the lower abdomen to repair small skin and soft tissue defect wounds in functional areas of children, especially girls, is effective, simple and easy to operate, and conforms to the principle of aesthetic repair. Compared with transplantation with full-thickness skin graft from the lateral abdomen, lower abdominal full-thickness skin grafting has a low incidence of donor site complications and no obvious scar hyperplasia, which is worthy of clinical promotion. -
Key words:
- Child /
- Burns /
- Wound healing /
- Skin transplantation /
- Lower abdomen /
- Full-thickness skin graft /
- Functional area
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参考文献
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2 采用下腹部全厚皮片修复例1患儿左手背跑步机热压伤后创面。2A.术前，左手示指、中指及环指背侧创面情况；2B.左手创面清创后即刻；2C.供区切取皮片后继发创面；2D.供区皮内缝合后即刻；2E.术后7 d换药时，供区切口愈合良好，拆线并使用医用皮肤减张闭合器；2F.术后10 d换药，左手移植皮片成活；2G.术后6个月，左手移植皮片色泽基本接近周围正常皮肤颜色、无瘢痕挛缩，左手外观佳；2H.术后6个月，供区瘢痕呈线形，较图2D无明显增宽
3 采用侧腹部全厚皮片整复例2患儿沸水烫伤致右手掌创面愈合后瘢痕挛缩伴活动受限。3A.术前，右手示指、中指、环指及小指瘢痕挛缩情况；3B.右手瘢痕松解后创面情况；3C.植皮后即刻情况；3D.供区皮内缝合即刻；3E.术后7 d换药时，供区切口愈合可，轻度红肿，拆线；3F.术后10 d换药，右手移植皮片成活；3G.术后1个月，供区切口瘢痕呈线形；3H.术后6个月，供区切口瘢痕呈隆起线形，较图3G明显增宽
表1 2组功能部位小面积皮肤软组织缺损/瘢痕患儿一般资料比较
组别 例数 年龄［岁， M（Q 1，Q 3）］ 身体质量指数 （kg/m2， 病损部位（例） 创面面积［cm2，M（Q 1，Q 3）］ 手 眼睑 颈 足 侧腹部组 28 5（3，8） 16.5±2.5 19 4 3 2 23（16，32） 下腹部组 29 5（3，7） 16.7±1.9 18 6 2 3 20（12，26） 统计量值 Z=-0.39 t=0.34 — Z=-0.14 P值 0.701 0.735 0.884 0.890 注：“—”表示无此统计量值；创面面积指烧伤后原发创面面积或瘢痕切除后继发创面面积 
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表2 2组功能部位小面积皮肤软组织缺损/瘢痕患儿各时间点供区瘢痕的VSS评分比较（分，
组别 例数 术后1个月 术后6个月 t值 P值 侧腹部组 28 7.1±2.2 9.1±2.7 3.10 0.003 下腹部组 29 2.7±0.9 2.8±1.0 0.48 0.633 t值 10.00 11.15 P值 <0.001 <0.001 注：VSS为温哥华瘢痕量表
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表3 2组功能部位小面积皮肤软组织缺损/瘢痕患儿各时间点供区瘢痕宽度比较[mm，M(Q 1,Q 3)]
组别 例数 术后1个月 术后6个月 Z值 P值 侧腹部组 28 6.0（4.0，10.0） 8.5（5.0，12.0） -2.79 0.005 下腹部组 29 2.0（1.0，2.0） 2.0（2.0，3.0） -1.71 0.088 Z值 -13.41 -14.70 P值 <0.001 <0.001
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