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摘要:
目的 探讨颈项部复杂创面的修复策略及其临床效果。 方法 该研究为回顾性观察性研究。2014年3月—2023年12月,武汉大学同仁医院暨武汉市第三医院烧伤科收治31例符合入选标准的颈项部复杂创面患者,其中男20例、女11例,年龄25~80岁,包括17例放射性溃疡患者、8例电烧伤患者、6例坏死性软组织感染患者。入院时创面面积为8.0 cm×5.0 cm~51.0 cm×21.0 cm。所有患者入院后先行多学科团队协作诊疗及全身支持治疗,再行Ⅰ期清创联合负压伤口疗法；坏死组织彻底清除后,Ⅱ期根据创面特征选择修复方式：行游离组织瓣移植者22例、带蒂组织瓣移植者5例、局部组织瓣联合自体头部刃厚皮片移植者4例。游离组织瓣面积为15.0 cm×8.0 cm~45.0 cm×10.0 cm,带蒂组织瓣面积为11.0 cm×6.5 cm~17.0 cm×8.0 cm,局部组织瓣面积为5.0 cm×3.5 cm~7.0 cm×5.0 cm。将所有组织瓣供区创面直接缝合。术后行颈项部功能康复训练及组织瓣供受区综合瘢痕治疗。术后观察组织瓣成活情况、外形,组织瓣供受区创面愈合情况、感染或溃疡复发情况,以及供皮区创面愈合情况。末次随访时,采用温哥华瘢痕量表（VSS）评估组织瓣供受区瘢痕情况,通过自制颈部康复功能评定量表评估颈项部疼痛、活动度、肌力、日常生活能力,按照文献的方法评估患者对治疗效果的满意度。 结果 术后所有组织瓣均完全成活且外形良好；组织瓣供受区创面均愈合良好,未见感染或溃疡复发；供皮区创面愈合好。Ⅱ期术后随访时间为6~48个月。末次随访时,27例患者中组织瓣供区瘢痕VSS评分为2分者16例、3分者7例、5分者2例、7分者2例,组织瓣受区瘢痕VSS评分为3分者17例、4分者8例、5分者2例；另外4例患者颈项部瘢痕VSS评分为5分者2例、7分者2例。在颈项部康复功能评定中,所有患者疼痛情况、肌力均评定为优,活动度和日常生活能力评定为优者22例、良者9例。患者中对治疗效果非常满意者23例、比较满意者7例、一般满意者1例。 结论 基于多学科团队协作的精准诊断和治疗体系与个体化修复策略,结合术后系统性功能康复训练及瘢痕综合管理方案,可有效促进颈项部复杂创面愈合,改善颈项部功能及减轻瘢痕,并提高患者满意度,具有重要临床应用价值。 Abstract:Objective To investigate the repair strategies and clinical outcomes for complex cervico-occipital wounds. Methods This study was a retrospective observational study. From March 2014 to December 2023, 31 patients with complex cervico-occipital wounds who met the inclusion criteria were admitted to the Department of Burns of Tongren Hospital of Wuhan University & Wuhan Third Hospital. There were 20 males and 11 females, aged 25-80 years, including 17 cases of radiation-induced ulcers, 8 cases of electrical burns, and 6 cases of necrotizing soft tissue infection. The wound sizes ranged from 8.0 cm×5.0 cm to 51.0 cm×21.0 cm on admission. All patients underwent multidisciplinary team collaborative diagnosis and treatment, systemic support therapy, followed by debridement and negative-pressure wound therapy on stage Ⅰ. After complete removal of necrotic tissue, the wound repair was performed on stage Ⅱ according to the wound feature. The free tissue flaps transplantation was performed in 22 cases, the pedicled tissue flaps transplantation was performed in 5 cases, and transplantation of local tissue flaps combined with split-thickness skin grafts from head was performed in 4 cases. The sizes of free tissue flaps ranged from 15.0 cm×8.0 cm to 45.0 cm×10.0 cm, the sizes of pedicled tissue flaps ranged from 11.0 cm×6.5 cm to 17.0 cm×8.0 cm, and te sizes of local tissue flaps ranged from 5.0 cm×3.5 cm to 7.0 cm×5.0 cm. All wounds in the donor sites of tissue flaps were closed directly. After the operation, functional rehabilitation training of cervico-occipital region and comprehensive scar treatment of the donor and recipient sites of tissue flaps were performed. The postoperative survival and appearance of tissue flaps, wound healing and recurrence of infection or ulcer in the donor and recipient sites of tissue flaps, and wound healing in the donor and recipient sites of skin grafts were observed. At the last follow-up, the scars in the donor and recipient sites of tissue flaps were evaluated by Vancouver scar scale (VSS), the pain, range of motion, muscle strength, and daily living ability of cervico-occipital region were evaluated by a self-made neck rehabilitation function assessment scale, and the satisfaction of patients with the therapeutic effect was surveyed by a literature-based method. Results After surgery, all tissue flaps survived completely and had a good appearance, the wounds in the tissue flap donor and recipient sites healed well with no infection or ulcer recurrence, and the wounds in the donor sites of skin grafts healed well. The follow-up period was 6-48 months after stage Ⅱ surgery. At the last follow-up, among the 27 patients, the VSS scores of scar in the donor sites of tissue flaps were 2 in 16 cases, 3 in 7 cases, 5 in 2 cases, and 7 in 2 cases, and the VSS scores of scar in the recipient sites of tissue flaps were 3 in 17 cases, 4 in 8 cases, and 5 in 2 cases; the VSS scores of scar were 5 in 2 cases and 7 in 2 cases in cervico-occipital region among the other 4 patients. In the evaluation of rehabilitation function in cervico-occipital region, all patients were evaluated as excellent in terms of pain and muscle strength; 22 patients were evaluated as excellent, and 9 patients were evaluated as good in terms of activity and daily living ability. Among the patients, twenty-three patients were very satisfied with the therapeutic effect, 7 patients were relatively satisfied, and 1 patient was generally satisfied. Conclusions A precise diagnosis and treatment system and personalized repair strategies based on multidisciplinary team collaboration, combined with postoperative systematic functional rehabilitation training and comprehensive scar management plan, can effectively promote the healing of complex wounds, improve the function of the cervico-occipital region, alleviate scars, and improve patient satisfaction, demonstrating significant clinical application value. -
参考文献
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图 1 采用游离腹壁下动脉穿支皮瓣联合腹直肌肌瓣修复例1患者颈胸部放射性溃疡的效果。1A.清创前颈胸部溃疡创面,创面边缘瘢痕增生,创面中心可见锁骨骨质外露；1B.Ⅱ期术中,用肌瓣填塞保护外露锁骨及神经；1C.腹壁下动脉穿支皮瓣联合腹直肌肌瓣切除术后；1D.术后6个月随访时,皮瓣受区愈合良好；1E.术后6个月随访时,皮瓣供区遗留线性瘢痕,未见切口疝
图 2 采用游离腹壁下动脉穿支皮瓣联合腹直肌肌瓣修复例2患者颈胸部电烧伤的效果。2A.入院时急诊行床旁气管切开术后；2B.Ⅰ期清创后颈胸部缺损范围情况；2C.Ⅱ期设计腹壁下动脉穿支皮瓣联合腹直肌肌瓣；2D.腹壁下动脉穿支皮瓣联合腹直肌肌瓣切取后；2E.Ⅱ期术后拆除负压材料后见皮瓣成活；2F.Ⅱ期术后气管CT三维重建显示,第7颈椎和第1胸椎水平偏左侧局部气管壁缺损；2G.Ⅲ期术中用腹直肌肌瓣修复气管缺损后；2H.术后4年随访时,颈部皮瓣周围轻度瘢痕增生,未见切口疝
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