扩张皮瓣整复大面积烧伤后面颈部瘢痕挛缩畸形的临床效果

张伟; 张卫东; 陈斓; 栾夏刚; 杨飞; 李泽; 刘峰; 王德运

doi:10.3760/cma.j.cn501225-20230706-00248

扩张皮瓣整复大面积烧伤后面颈部瘢痕挛缩畸形的临床效果

doi: 10.3760/cma.j.cn501225-20230706-00248

武汉大学同仁医院暨武汉市第三医院烧伤科，武汉　　430060

基金项目:

湖北省卫生健康科研基金 WJ2019H433

武汉市临床医学科研项目 WX17A03, WX11A04

武汉市医学科研项目 WG19B02

详细信息

通讯作者:
王德运，Email：13971239318@163.com

计量
- 文章访问数: 3395
- HTML全文浏览量: 84
- PDF下载量: 48
- 被引次数: 0
出版历程
- 收稿日期: 2023-07-06

Clinical effects of expanded flaps in reconstructing scar contracture deformities in the face and neck after extensive burns

Department of Burns, Tongren Hospital of Wuhan University ＆ Wuhan Third Hospital, Wuhan 430060, China

Funds:

Scientific Research Fund of Health Commission of Hubei Province of China WJ2019H433

Clinical Medical Research Project of Wuhan WX17A03, WX11A04

Medical Science and Research Project of Wuhan WG19B02

More Information

Corresponding author: Wang Deyun, Email: 13971239318@163.com

摘要

摘要: 目的探讨扩张皮瓣整复大面积烧伤后面颈部瘢痕挛缩畸形的临床效果。方法采用回顾性观察性研究方法。2016年5月—2022年9月，武汉大学同仁医院暨武汉市第三医院收治17例大面积烧伤后面颈部瘢痕挛缩畸形患者，其中男13例、女4例，年龄23~55岁，颈部挛缩程度Ⅱ度者3例、Ⅲ度者14例，12例患者合并面部瘢痕挛缩畸形。Ⅰ期于面、胸、肩、腹部等处置入34个额定容量为100~600 mL的长方形皮肤软组织扩张器（以下简称扩张器）注射生理盐水扩张。Ⅱ期切除瘢痕组织、松解挛缩，纠正畸形，局部转移2个扩张面部皮瓣、带蒂转移17个扩张皮瓣、游离移植15个扩张皮瓣修复松解后继发创面（对7个皮瓣行动脉增压），并使用吲哚菁绿荧光显影技术评估移植时皮瓣动脉血流灌注和静脉回流状况。除2个面部皮瓣外的32个皮瓣切取面积为10 cm×8 cm~36 cm×16 cm，将31个皮瓣供区创面直接缝合封闭，1个皮瓣供区创面采用自体刃厚头皮移植修复。观察并记录扩张器的埋置部位皮肤状态、扩张时间、注射生理盐水总量，皮肤软组织扩张术并发症发生情况，Ⅱ期术后皮瓣成活情况。随访患者面颈部远期整复效果和皮瓣供区恢复情况。末次随访时，采用利克特5级量表评价患者的疗效满意度。结果 17例患者的34个扩张器埋置部位中，22个部位为深Ⅱ度烧伤后浅表瘢痕皮肤，8个部位为多次供皮后浅表瘢痕皮肤，4个部位为正常皮肤。经4~15个月的扩张，扩张器注射生理盐水总量为238~2 000 mL，扩张区域无并发症发生。Ⅱ期术后，2个带蒂移植皮瓣蒂部远端部分坏死，坏死创面分别经皮瓣修整和对侧扩张胸三角皮瓣游离移植后愈合，其余皮瓣均完全成活。随访6~18个月，2个扩张脐旁皮瓣和1个扩张腹股沟皮瓣较臃肿，行修薄术后臃肿改善，其余皮瓣外观、质地良好；所有皮瓣供区均恢复良好。末次随访时，所有患者面颈部瘢痕挛缩畸形均明显改善，患者疗效满意度：8例非常满意、9例比较满意。结论采用胸部、腹部等部位的扩张皮瓣，综合应用局部转移、带蒂转移、游离移植方式，可使大面积烧伤后面颈部瘢痕挛缩畸形得到有效整复，在恢复术区功能的同时改善外观，且患者满意度高，值得临床推广。
- 烧伤 /
- 瘢痕 /
- 颈 /
- 挛缩 /
- 扩张术 /
- 穿支皮瓣 /
- 显微外科手术
Abstract: Objective To investigate the clinical effects of expanded flaps in reconstructing scar contracture deformities in the face and neck after extensive burns. Methods A retrospective observational study was conducted. From May 2016 to September 2022, 17 patients with scar contracture deformities in the face and neck after extensive burns were admitted to Tongren Hospital of Wuhan University ＆ Wuhan Third Hospital, including 13 males and 4 females, aged 23 to 55 years, with 3 patients having degree Ⅱ cervical contracture, 14 patients having degree Ⅲ cervical contracture, and 12 patients having facial scar contracture deformity. In the first stage, 34 rectangular skin and soft tissue expanders (hereinafter referred to as expanders) with rated capacity of 100-600 mL were inserted into the face, chest, shoulder, and abdomen, and then the normal saline was injected for expansion. In the second stage, the scar tissue was removed and the contracture was released to correct the deformity. Two expanded facial flaps were transplanted in local fashion, 17 expanded flaps were transplanted in pedicled fashion, and 15 expanded flaps were freely transplanted to repair the secondary wounds after release, with artery pressurization was performed in 7 flaps. Indocyanine green fluorescence imaging was used to evaluate the arterial blood perfusion and venous return of the flaps during transplantation. The incision area of 32 flaps except 2 facial flaps was 10 cm×8 cm-36 cm×16 cm. The wounds of 31 flap donor sites were closed by direct suture, and the wound of 1 flap donor site was repaired by autologous split-thickness scalp transplantation. The skin condition of inserted place, expansion time, and total amount of normal saline injection of expanders, complications of skin and soft tissue expansion surgery, and survival of flap after the second stage surgery were observed and recorded. The long-term face and neck reconstruction effect and recovery of flap donor area were followed up. At the last follow-up, the 5-level Likert scale was used to evaluate the efficacy satisfaction of patients. Results Of the 34 expander inserted places in 17 patients, 22 places were superficial scar skin after deep partial-thickness burns, 8 places were superficial scar skin after multiple skin donations, and 4 places were normal skin. After 4 to 15 months of expansion, the total normal saline injection volume was 238 to 2 000 mL, with no complications occurred. After the second stage surgery, the distal part of 2 pedicled flaps was partially necrotic, and the necrotic wounds were healed after flap dressing and free transplantation of contralateral expanded triangular flaps, respectively; the other flaps survived completely. During 6 to 18 months of follow-up, except for 2 expanded paraumbilical flaps and 1 expanded groin flap, which were bloated and improved by flap thinning, the appearance and texture of the other flaps were good, and all the flap donor sites recovered well. At the last follow-up, the face and neck scar contracture deformities were significantly improved in all patients, and the satisfaction of curative effect of patient was very satisfactory in 8 patients and relatively satisfactory in 9 patients. Conclusions The expanded flaps of chest, abdomen, and other parts, combined with local advance, pedicled, and free transplantation, can effectively reconstruct scar contracture deformities in the face and neck after extensive burns, restore the function of operative area and improve the appearance simultaneously, with high degree of patient satisfaction, which is worthy of promotion in clinic.
- Burns /
- Cicatrix /
- Neck /
- Contracture /
- Dilatation /
- Perforator flap /
- Microsurgery
张伟：手术操作、数据整理、论文撰写、论文修改、经费支持；张卫东、陈斓、栾夏刚、杨飞、李泽、刘峰：手术操作、数据整理、论文修改；王德运：手术操作、论文修改、研究指导、经费支持

所有作者均声明不存在利益冲突

HTML全文

参考文献(30)

[1]	De DeckerI, HoeksemaH, VerbelenJ, et al. A single-stage bilayered skin reconstruction using Glyaderm® as an acellular dermal regeneration template results in improved scar quality: an intra-individual randomized controlled trial[J/OL]. Burns Trauma, 2023,11:tkad015[2023-07-06]. https://pubmed.ncbi.nlm.nih.gov/37143955/. DOI: 10.1093/burnst/tkad015.
[2]	王炜 .整形外科学[M].杭州:浙江科学技术出版社,1999:826.
[3]	PukancsikD, KelemenP, GulyásG, et al. Clinical experiences with the use of ULTRAPRO® mesh in single-stage direct-to-implant immediate postmastectomy breast reconstruction in 102 patients: a retrospective cohort study[J]. Eur J Surg Oncol, 2017,43(7):1244-1251. DOI: 10.1016/j.ejso.2017.01.236.
[4]	KongW, XiaoY, WangB, et al. Comorbidities of scars in China: a national study based on hospitalized cases[J/OL] Burns Trauma, 2021,9:tkab012[2023-07-06]. https://pubmed.ncbi.nlm.nih.gov/34212062/. DOI: 10.1093/burnst/tkab012.
[5]	吕国忠,许瓅文.重视大面积烧伤早期康复预防后期严重并发症[J].中华烧伤杂志,2017,33(5):257-259.DOI: 10.3760/cma.j.issn.1009-2587.2017.05.001.
[6]	GreenhalghDG. Management of facial burns[J/OL]. Burns Trauma,2020,8:tkaa023[2023-07-06]. https://pubmed.ncbi.nlm.nih.gov/32665953/. DOI: 10.1093/burnst/tkaa023.
[7]	韩军涛,谢松涛,陶克,等.自体瘢痕复合皮修复大面积深度烧伤后期畸形12例[J].中华烧伤杂志,2014,30(5):457-458.DOI: 10.3760/cma.j.issn.1009-2587.2014.05.025.
[8]	沈余明.深度烧伤后瘢痕增生挛缩畸形的手术治疗[J].中华烧伤杂志,2019,35(6):401-404.DOI: 10.3760/cma.j.issn.1009-2587.2019.06.001.
[9]	MinP, LiJ, BrunettiB, et al. Pre-expanded bipedicled visor flap: an ideal option for the reconstruction of upper and lower lip defects postburn in Asian males[J/OL]. Burns Trauma, 2020,8:tkaa005[2023-07-06]. https://pubmed.ncbi.nlm.nih.gov/32341918/. DOI: 10.1093/burnst/tkaa005.
[10]	AcartürkTO, BengürFB. Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps[J]. Injury, 2020,51 Suppl 4:S63-67. DOI: 10.1016/j.injury.2020.02.112.
[11]	OgawaR. Surgery for scar revision and reduction: from primary closure to flap surgery[J/OL]. Burns Trauma, 2019,7:7[2023-07-06]. https://pubmed.ncbi.nlm.nih.gov/30891462/. DOI: 10.1186/s41038-019-0144-5.
[12]	陈璧,贾赤宇,徐明达,等. 自体皮源奇缺条件下瘢痕挛缩畸形的晚期临床修复[J]. 中华烧伤杂志,2003,19(6):361-364. DOI: 10.3760/cma.j.issn.1009-2587.2003.06.014.
[13]	RoseEH. Aesthetic reconstruction of the severely disfigured burned face: a creative strategy for a "natural" appearance using pre-patterned autogenous free flaps[J/OL]. Burns Trauma,2015,3:16[2023-07-06]. https://pubmed.ncbi.nlm.nih.gov/27574662/. DOI: 10.1186/s41038-015-0014-8.
[14]	何永静,朱礼昆,杨蔚琪,等.预扩张肩胛皮瓣游离移植修复大面积面颈部瘢痕[J].中华整形外科杂志,2017,33增刊:50-53.DOI: 10.3760/cma.j.issn.1009-4598.2017.s1.011.
[15]	马显杰,李杨,王璐,等.颈横动脉颈段皮支皮瓣修复颈部瘢痕挛缩[J].中华烧伤杂志,2012,28(4):256-259.DOI: 10.3760/cma.j.issn.1009-2587.2012.04.005.
[16]	楚菲菲,唐银科,刘超华,等.扩张后胸三角皮瓣修复儿童面颈部病损[J].中华小儿外科杂志,2022,43(4):294-298.DOI: 10.3760/cma.j.cn421158-20210513-00238.
[17]	KhoongYM, HuangX, GuSC, et al. Imaging for thinned perforator flap harvest: current status and future perspectives[J/OL]. Burns Trauma, 2021,9:tkab042[2023-07-06]. https://pubmed.ncbi.nlm.nih.gov/34926708/. DOI: 10.1093/burnst/tkab042.
[18]	刘云菡,黄昕,李海洲,等. 扩张的胸廓内动脉穿支皮瓣联合血管增压在面颈部瘢痕整复中的临床应用[J]. 中华烧伤与创面修复杂志,2022,38(4):313-320. DOI: 10.3760/cma.j.cn501120-20210928-00334.
[19]	QingLM, WuPF, ZhouZB, et al. A design for the dual skin paddle circumflex scapular artery perforator flap for the reconstruction of complex soft-tissue defects in children: anatomical study and clinical applications[J]. Ann Plast Surg, 2019,83(4):439-446. DOI: 10.1097/SAP.0000000000001814.
[20]	张淼淼,潘晓峰,刘坤,等. 旋肩胛动脉穿支皮瓣治疗腋窝严重瘢痕挛缩[J]. 实用医学杂志,2022,38(10):1298-1301. DOI: 10.3969/j.issn.1006-5725.2022.10.024.
[21]	傅秀军,王琛,梁奕敏,等. 双侧扩张肩胛皮瓣在儿童、青少年大面积颌颈部瘢痕修复中的应用:7例报道[J]. 上海口腔医学,2021,30(3):332-336. DOI: 10.19439/j.sjos.2021.03.022.
[22]	GohTLH, ParkSW, ChoJY, et al. The search for the ideal thin skin flap: superficial circumflex iliac artery perforator flap--a review of 210 cases[J]. Plast Reconstr Surg, 2015,135(2):592-601. DOI: 10.1097/PRS.0000000000000951.
[23]	陈斓,张伟,谢卫国,等.扩张髂腹股沟皮瓣游离移植整复大面积烧伤后严重瘢痕挛缩畸形的临床效果[J].中华烧伤与创面修复杂志,2022,38(4):321-327.DOI: 10.3760/cma.j.cn501225-20220210-00021.
[24]	AkitaS, HayashidaK, TakakiS, et al. The neck burn scar contracture: a concept of effective treatment[J/OL]. Burns Trauma, 2017,5:22[2023-07-06]. https://pubmed.ncbi.nlm.nih.gov/28717655/. DOI: 10.1186/s41038-017-0086-8.
[25]	MahboubT,KhalilH.Post-transfer flap expansion for management of severe post-burn contraction neck[J].J Craniomaxillofac Surg,2010,38(5):365-367.DOI: 10.1016/j.jcms.2009.10.007.
[26]	张伟,谢卫国,张卫东,等.吻合血管的扩张皮瓣治疗大面积烧伤患者瘢痕挛缩畸形[J].中华烧伤杂志,2019,35(6):410-416.DOI: 10.3760/cma.j.issn.1009-2587.2019.06.003.
[27]	顾舒晨,李海洲,高雅姗,等. 吲哚菁绿荧光造影在背部扩张穿支皮瓣设计中的应用[J]. 中华整形外科杂志,2020,36(3):251-256. DOI: 10.3760/cma.j.cn114453-20200218-00056.
[28]	ZhangYX, XiaoWT, NgS, et al. Infrared thermography-guided designing and harvesting of pre-expanded pedicled flap for head and neck reconstruction[J]. J Plast Reconstr Aesthet Surg, 2021,74(9):2068-2075. DOI: 10.1016/j.bjps.2020.12.102.
[29]	DongC, ZhuMH, HuangLG, et al. Risk factors for tissue expander infection in scar reconstruction: a retrospective cohort study of 2374 consecutive cases[J/OL]. Burns Trauma, 2021, 9: tkaa037[2023-07-06]. https://pubmed.ncbi.nlm.nih.gov/33426134/. DOI: 10.1093/burnst/tkaa037.
[30]	董琛,余州,刘维,等. 皮肤软组织扩张器置入部位感染风险的临床预测模型的构建与验证[J]. 中华烧伤杂志,2021,37(9):846-852. DOI: 10.3760/cma.j.cn501120-20200619-00314.

下载: 全尺寸图片幻灯片

1 扩张腹股沟皮瓣联合扩张面部皮瓣移植整复例1患者火焰烧伤后面颈部瘢痕挛缩畸形。1A.烧伤后2个月，可见前胸有片状肉芽组织，下腹部供区创面已愈合；1B.双侧面部皮肤软组织扩张器（以下简称扩张器）置入后9个月，Ⅱ期行右侧面部皮瓣移植术前；1C、1D.分别为扩张面部皮瓣局部转移术后15个月，面颈部正位、左侧位观；1E、1F.分别为双侧下腹部扩张器置入术后12个月，腹部扩张器左侧位、正位观；1G.左侧扩张腹股沟皮瓣切取完成后即刻；1H.左侧扩张腹股沟皮瓣移植于右侧下颌部+颈部后，吲哚菁绿荧光显影显示皮瓣蒂部远端血流灌注良好；1I.左侧扩张腹股沟皮瓣移植修复右侧下颌部+颈部瘢痕切除松解后创面术后3个月，口角歪斜和下唇外翻均得到明显矫正；1J.右侧扩张腹股沟皮瓣移植于左侧下颌部+颈部瘢痕切除松解后创面即刻，吲哚菁绿荧光显影显示皮瓣蒂部远端血流灌注良好；1K、1L.分别为末次皮瓣移植术后7个月面颈部右、左侧面观，瘢痕挛缩畸形明显改善

下载: 全尺寸图片幻灯片

2 右侧扩张脐旁皮瓣游离移植整复例2患者火焰烧伤后颈部瘢痕挛缩畸形。2A.右侧脐旁皮肤软组织扩张器注水扩张完成，扩张瘢痕皮肤未见破溃；2B、2C.分别为Ⅱ期术前颈前瘢痕切除范围设计和颈部瘢痕挛缩松解术后即刻；2D.Ⅱ期术中，切取扩张脐旁皮瓣，皮瓣携带3条腹壁下动脉穿支；2E.Ⅱ期术后2周，皮瓣完全成活；2F.Ⅱ期术后随访10个月，颈部畸形明显改善，颏颈角存在

下载: 全尺寸图片幻灯片

3 左侧扩张胸三角皮瓣带蒂移植联合左侧扩张腹股沟皮瓣游离移植整复例3患者火焰烧伤后面颈部瘢痕挛缩畸形。3A.胸部皮肤软组织扩张器置入10个月，颈部后仰受限；3B.Ⅱ期术前，设计切取以颈横动脉锁骨上穿支为蒂的扩张胸三角皮瓣，面积为23 cm×10 cm；3C.扩张胸三角皮瓣切取完毕，吲哚菁绿荧光显影显示，蒂部远端（红色箭头）动脉灌注良好；3D.Ⅱ期术前，下腹部扩张11个月，设计左侧扩张腹股沟皮瓣，面积为21 cm×11 cm；3E.左侧扩张腹股沟皮瓣断蒂后即刻；3F.左侧扩张腹股沟皮瓣游离移植于下唇和颈颏部瘢痕切除松解后创面即刻；3G.扩张腹股沟皮瓣移植于面颈部，吻合血管完毕，吲哚菁绿荧光显影显示，蒂部远端（红色箭头）血运丰富；3H.末次扩张皮瓣移植术后随访6个月，唇外翻得到矫正，面颈部外观良好

下载: 全尺寸图片幻灯片