基于“MLT”原则采用扩张皮瓣整复面颈部瘢痕的方法及其临床效果

陶明秋; 黄覛韬; 梁鹏飞; 张明华; 张丕红; 何志友; 曾纪章; 周捷; 崔旭; 郭乐; 周思拓; 杨燕; 谢庭鸿; 黄晓元

doi:10.3760/cma.j.cn501225-20231215-00244

基于“MLT”原则采用扩张皮瓣整复面颈部瘢痕的方法及其临床效果

doi: 10.3760/cma.j.cn501225-20231215-00244

中南大学湘雅医院烧伤整形科,长沙　　410008

基金项目:

湖南省自然科学基金面上项目 2023JJ30909

湖南省自然科学基金青年基金项目 2022JJ40791

详细信息

通讯作者:
黄覛韬,Email：hmt1987123@126.com

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出版历程
- 收稿日期: 2023-12-15

Methods and clinical effects of reconstructing facial and cervical scars with expanded flaps based on the "MLT" principle

Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha 410008, China

Funds:

General Program of Hunan Natural Science Foundation of China 2023JJ30909

Youth Science Fund Program of Hunan Natural Science Foundation of China 2022JJ40791

More Information

Corresponding author: Huang Mitao, Email: hmt1987123@126.com

摘要

摘要: 目的探讨基于“MLT”原则采用扩张皮瓣整复面颈部瘢痕的方法及其临床效果。方法该研究为回顾性观察性研究。2019年1月—2022年5月,中南大学湘雅医院收治74例符合入选标准的烧创伤后面颈部瘢痕患者,其中男38例、女36例,年龄5~58岁,单纯面部受累者24例、单纯颈部受累者24例、面部和颈部均受累者26例,瘢痕面积12~145 cm²。遵循色泽、质地与面部相似；皮瓣面积足够大以修复整个缺损；皮肤组织足够薄,能传递表情,以利于面部形态和五官的塑形的“MLT”原则,Ⅰ期行皮肤软组织扩张器（以下简称扩张器）置入术,Ⅱ期行扩张器取出+瘢痕切除+皮瓣移植术修复继发创面,将皮瓣供区创面直接缝合。术后采用硅凝胶制剂、激光治疗等抗瘢痕增生。观察并记录扩张器扩张倍数、扩张周期,皮肤软组织扩张术并发症发生情况,以及采用的皮瓣类型、Ⅱ期术后皮瓣成活情况。术后随访,评估患者面颈部远期整复效果和皮瓣供、受区恢复情况。结果 135个扩张器扩张倍数为1.36~3.00倍,扩张周期为6~14个月。行皮肤软组织扩张术期间,8例患者出现扩张器置入后切口愈合不良、7例患者出现扩张器破裂、5例患者出现扩张器置入后切口感染、3例患者出现扩张器外露、2例患者出现注射壶注水困难、1例患者出现注射壶漏水。8例患者采用颈横动脉与旋肩胛动脉双血供肩背部扩张皮瓣,11例患者采用颈横动脉前穿支扩张皮瓣,12例患者采用胸廓内动脉穿支扩张皮瓣,16例患者采用上胸部及颈部串联扩张皮瓣,5例患者采用胸背动脉穿支扩张皮瓣,22例患者采用邻近旋转推进扩张皮瓣。Ⅱ期术后,71例患者皮瓣完全成活；1例患者皮瓣出现血运障碍,经高压氧治疗后成活；2例患者皮瓣末端出现坏死,经换药后愈合。术后对42例患者随访3~24个月,皮瓣颜色、质地、厚度均佳,与受区周围正常皮肤组织相近,面颈部外形及功能明显改善,皮瓣供、受区创面位置隐蔽且瘢痕形成较轻。结论整复面颈部瘢痕时,遵循“MLT”原则,在术前精心设计扩张皮瓣,Ⅱ期手术时重建亚单位内局部美学特征,术后积极采取规范的抗瘢痕治疗措施,整复后可使皮瓣颜色、质地、厚度与面颈部正常皮肤接近,面颈部外形及功能改善明显,遗留线性瘢痕较轻,有利于提升治疗效果。
- 瘢痕 /
- 外科皮瓣 /
- 烧伤 /
- 面部 /
- 颈 /
- 扩张术 /
- 创面修复
Abstract: Objective To explore the methods and clinical effects of reconstructing facial and cervical scars with expanded flaps based on the "MLT" principle. Methods The study was a retrospective observational study. From January 2019 to May 2022, 74 patients with facial and cervical scars after burn or trauma injuries who met the inclusion criteria were admitted to Xiangya Hospital of Central South University, including 38 males and 36 females, aged from 5 to 58 years, including 24 patients with simple facial involvement, 24 patients with simple cervical involvement, and 26 patients with both facial and cervical involvement, with scar area ranging from 12 to 145 cm². By following the "MLT" principle (color and texture similar to the face; flap area large enough to reconstruct the entire defect; skin tissue thin enough to transmit the expression, so as to facilitate the shape of the face and five features); in the stage Ⅰ surgery, the skin and soft tissue expanders (hereinafter referred to as the expanders) were implanted, and in the stage Ⅱ surgery, the expander removal+scar resection+flap transplantation to repair the secondary wound was performed, and the wound in the donor area of flap was directly sutured. After operation, silicone gel preparation and laser therapy were used to prevent scar hyperplasia. The expansion ratio and time period of expanders, the occurrence of complications of skin and soft tissue expansion surgery, the type of flap used, and the survival of flap after the stage Ⅱ surgery were observed and recorded. The long-term effect of facial and cervical reconstruction and the recovery of donor area and recipient area of flap were evaluated during the postoperative follow-up after surgery. Results The expansion ratio of 135 expanders ranged from 1.36 to 3.00 times, and the expansion time period ranged from 6 to 14 months. During skin and soft tissue expansion surgery, 8 patients had poor healing of incisions after expander placement, 7 patients had expander rupture, 5 patients had infection in incisions after expander placement, 3 patients had expander exposure, 2 patients had difficult filling the injection pot, and 1 patient had water leakage from the injection pot. Dorsal shoulder expanded flaps with double blood supply of transverse cervical artery and circumflex scapular artery were used in 8 patients, the expanded flaps of anterior transverse carotid artery perforator were used in 11 patients, the expanded flaps of internal thoracic artery perforator were used in 12 patients, tandem expanded flaps of upper chest and neck were used in 16 patients, dorsal thoracic artery perforator expanded flaps were used in 5 patients, and adjacent rotary propulsive expanded flaps were used in 22 patients. After the stage Ⅱ surgery, the flaps of 71 patients were completely survived. One patient had blood circulation disorder in the flap, and the flap survived after hyperbaric oxygen treatment. Necrosis occurred at the end of the flaps in 2 patients, which healed after dressing change. After the surgery, 42 patients were followed up for 3 to 24 months. The color, texture, and thickness of flaps were good and similar to the surrounding normal skin tissue in the recipient area, the appearance and function of the face and neck were significantly improved, and the wound location in the donor and recipient areas of flaps was concealed with slight scar formation. Conclusions In the reconstruction of facial and neck scars, by following the "MLT" principle, the expanded flap was carefully designed before surgery, the local aesthetic features within the subunit are reconstructed during the stage Ⅱ surgery, and standard anti-scar treatment measures are actively adopted after surgery. After reconstruction, the color, texture, and thickness of flaps were close to the normal skin in face and neck, and the appearance and function of face and neck are significantly improved, with less linear scars left. It is beneficial to improve the therapeutic effect.
- Cicatrix /
- Surgical flaps /
- Burns /
- Face /
- Neck /
- Dilation /
- Wound repair
陶明秋：设计研究,实施研究,采集、分析、解释数据,撰写文章；黄覛韬、梁鹏飞：酝酿和设计试验,实施研究,修改文章,研究经费支持,对文章的知识性内容作批评性审阅；张明华、张丕红、曾纪章、周捷、黄晓元：实施研究,研究指导,对文章的知识性内容作批评性审阅；何志友、崔旭、郭乐：实施研究,采集和分析数据,研究指导；周思拓、杨燕、谢庭鸿：实施研究,采集数据

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图 1 采用头部旋转推进扩张皮瓣和双侧颈部旋转推进扩张皮瓣美学整复例1患儿烧伤后面部瘢痕的效果。1A、1B、1C.分别为双侧颈部扩张1年2个月后的正面观、左侧后仰观、右侧后仰观；1D、1E、1F.分别为Ⅱ期额部扩张器取出+额部瘢痕切除+头部旋转推进扩张皮瓣移植术后患者正面观、左侧平视观、右侧平视观,显示皮瓣色泽、厚度与面部正常皮肤接近,颌颈角、口周、下颌轮廓线等局部美学特征重建效果佳；1G、1H、1I.分别为Ⅲ期术后10个月,患者正面观、左侧平视观、右侧平视观,显示皮瓣供、受区瘢痕增生较轻

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图 2 采用头部旋转推进扩张皮瓣和左侧颈部串联扩张皮瓣美学整复例2患儿烧伤后头面部瘢痕的效果。2A、2B.分别显示头部Ⅰ期术前鼻翼两侧瘢痕挛缩牵连,左侧头部额顶颞区烧伤后瘢痕性秃发；2C.头部Ⅰ期术后扩张10个月正面观；2D.头部Ⅱ期术后2个月左侧面观,显示皮瓣厚度与正常头皮接近,皮瓣供、受区创面瘢痕增生轻；2E.颈部Ⅰ期术后扩张7个月正面观,扩张的皮肤色泽与面部接近；2F.颈部Ⅱ期左侧颈部串联扩张皮瓣移植术后即刻,皮瓣1次扩张后修复一侧面部创面；2G、2H、2I.分别为颈部Ⅱ期术后10个月正面观、正面后仰观、左侧平视观,显示皮瓣色泽、厚度与面颈部正常皮肤接近,口角歪斜得以矫正,颌颈角形态佳

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