Clinical efficacy of W-plasty resection combined with remote tension-reducing suture in upper limb scars revision
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摘要:
目的 探讨W改形切除联合远位减张缝合整复上肢瘢痕的临床疗效。 方法 该研究为回顾性队列研究。2023年6月—2023年12月,空军军医大学第二附属医院烧伤整形外科收治69例符合入选标准的上肢瘢痕患者,根据采用的瘢痕整复术将患者分为行W改形切除联合远位减张缝合的W改形缝合组[36例,其中男6例、女30例,年龄（28±4）岁]、行常规梭形切除后局部减张缝合的常规减张缝合组[33例,其中男5例、女28例,年龄（29±6）岁]。术前及术后6、12个月,统计瘢痕的观察者瘢痕评估量表（POSAS）评分、温哥华瘢痕量表（VSS）评分、瘢痕宽度,并筛选上肢瘢痕患者术后12个月瘢痕POSAS评分、VSS评分的独立影响因素。统计术后12个月内手术相关并发症发生情况。 结果 W改形缝合组患者术后12个月瘢痕POSAS评分和VSS评分分别为（31.6±2.0）、（3.3±0.8）分,均明显低于常规减张缝合组（33.5±2.7）、（4.0±1.6）分（均数差值分别为-1.9、-0.7分,95%CI分别为-3.0~-0.8、-1.3~-0.1分,t值分别为3.22、2.63,P<0.05）。2组患者术后6、12个月瘢痕POSAS评分、VSS评分均明显低于术前（P<0.05）。常规减张缝合组患者术后12个月瘢痕POSAS评分明显高于术后6个月（P<0.05）,2组患者术后12个月瘢痕VSS评分均明显高于术后6个月（P<0.05）。多元线性回归分析显示,整复方法是患者术后12个月瘢痕POSAS评分的独立影响因素（标准化回归系数为0.38,t=3.26,P<0.05）,整复方法、年龄和术前瘢痕宽度均是患者术后12个月瘢痕VSS评分的独立影响因素（标准化回归系数分别为0.32、-0.32、0.27,t值分别为2.93、-2.86、2.49,P<0.05）。W改形缝合组患者术后12个月瘢痕宽度为（1.04±0.27）mm,明显窄于常规减张缝合组的（1.23±0.22）mm（均数差值分别为-0.19 mm,95%CI为-0.31~-0.07,t=3.17,P<0.05）。2组患者术后6、12个月瘢痕宽度均较术前明显变窄（P<0.05）。术后12个月内,2组患者切口均愈合,未见感染或明显瘢痕增生等并发症发生。 结论 W改形切除联合远位减张缝合整复上肢瘢痕的疗效更好,具有更显著的长期效果,患者自觉症状和瘢痕外观均获得了更好改善。 Abstract:Objective To investigate the clinical efficacy of W-plasty resection combined with remote tension-reducing suture in upper limb scar revision. Methods This study was a retrospective cohort study. From June 2023 to December 2023, 69 patients with upper limb scars who met the inclusion criteria were admitted to Department of Burn and Plastic Surgery of the Second Affiliated Hospital of Air Force Medical University. According to the scar revision technique adopted, the patients were divided into the W-plasty suture group of 36 cases (6 males and 30 females, aged (28±4) years) and conventional tension-reducing suture group of 33 cases (5 males and 28 females, aged (29±6) years). Patients in W-plasty suture group received W-plasty resection combined with remote tension-reducing suture, and patients in conventional tension-reducing suture group received conventional fusiform excision followed by local tension-reducing suture. Before surgery and at 6 and 12 months after surgery, the patient and observer scar assessment scale (POSAS) scores, Vancouver scar scale (VSS) scores, and width of scars were recorded. The independent influencing factors for the POSAS and VSS scores at 12 months after surgery in patients with upper limb scars were screened. Surgery-related complications were recorded within 12 months after surgery. Results At 12 months after surgery, the POSAS and VSS scores of scars in W-plasty suture group of patients were 31.6±2.0 and 3.3±0.8, respectively, which were significantly lower than 33.5±2.7 and 4.0±1.6 in conventional tension-reducing suture group (with mean differences of -1.9 and -0.7, 95% CI of -3.0 to -0.8 and -1.3 to -0.1, t values of 3.22 and 2.63, respectively, P<0.05). At 6 and 12 months after surgery, the POSAS and VSS scores of scars in both groups of patients were significantly lower than those before surgery (P<0.05). The POSAS score of scars in conventional tension-reducing suture group of patients at 12 months after surgery was significantly higher than that at 6 months after surgery (P<0.05), while the VSS scores of scars in both groups of patients at 12 months after surgery were significantly higher than those at 6 months after surgery (P<0.05). Multivariate linear regression analysis showed that the revision method was an independent influencing factor for the POSAS score of scars in patients at 12 months after surgery (with standardized regression coefficient of 0.38, t=3.26, P<0.05). The revision method, age, and preoperative scar width were the independent influencing factors for the VSS score of scars in patients at 12 months after surgery (with standardized regression coefficients of 0.32, -0.32, and 0.27, t values of 2.93, -2.86, and 2.49, respectively, P<0.05). At 12 months after surgery, the scar width in W-plasty suture group of patients was (1.04±0.27) mm, which was significantly narrower than (1.23±0.22) mm in conventional tension-reducing suture group (with mean difference of -0.19 mm, 95% CI of -0.31 to -0.07 mm, t=3.17, P<0.05). At 6 and 12 months after surgery, the scar widths in both groups of patients were significantly narrower than those before surgery (P<0.05). Within 12 months after surgery, the incisions in all patients of both groups healed, and no complications such as infection or significant scar hypertrophy were observed. Conclusions W-plasty resection combined with remote tension-reducing suture demonstrates superior efficacy in upper limb scar revision and more significant long-term efficacy, and both the patients' subjective symptoms and the scar appearance achieved better improvement. -
Key words:
- Cicatrix /
- Wound closure techniques /
- Surgery, plastic /
- Upper extremity /
- W-plasty /
- Remote tension-reducing suture /
- Scar revision
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参考文献
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图 1 W改形切除联合远位减张缝合技术示意图。1A、1B.分别为术前瘢痕和术中按W形切除瘢痕后示意图；1C、1D、1E.分别为远位真皮深层减张缝合、皮下组织缝合（箭头指示缝线走向）和表皮精细缝合示意图
图 2 采用W改形切除联合远位减张缝合整复例1患者右前臂瘢痕的效果。2A.术前可见一条线性、略凹陷、肤色不均的瘢痕,且瘢痕两侧存在初次手术遗留的针孔及线痕；2B.术中在瘢痕表面设计的W形切口线；2C.术后1个月,切口愈合后呈线性、色红,隆起显著；2D.术后12个月,切口外观明显改善,变得平整,颜色接近肤色,且未见遗留针孔及线痕
图 3 采用常规梭形切除后减张缝合整复例2患者左前臂瘢痕的效果。3A.术前可见一条线性、色红的增生性瘢痕,且瘢痕两侧存在初次手术遗留的针孔及线痕；3B.术中在瘢痕表面设计的梭形切口线；3C.术后1个月,切口愈合后呈线性、略发红、轻微隆起；3D.术后12个月,可见切口外观改善,变得平整,但宽度较术后1个月略有增宽,颜色略发红,仍可见初次手术遗留的针孔痕迹
Table 1. 2组上肢瘢痕患者一般资料比较
组别 例数 性别（例） 年龄（岁, 瘢痕长度[mm,M（Q1,Q3）] 瘢痕宽度[mm,M（Q1,Q3）] 瘢痕形成时间（月, 男 女 W改形缝合组 36 6 30 28±4 34.00（22.00,48.75） 8.50（5.00,14.00） 89±45 常规减张缝合组 33 5 28 29±6 31.00（19.50,50.00） 20.00（5.00,15.50） 97±49 统计量值 χ2=0.03 t=0.58 U=0.08 U=0.10 t=0.74 P值 0.864 0.561 0.933 0.923 0.461 注：对W改形缝合组患者瘢痕行W改形切除联合远位减张缝合,对常规减张缝合组患者瘢痕行常规梭形切除后局部减张缝合 
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Table 2. 2组上肢瘢痕患者各时间点POSAS评分比较（分,
组别 例数 术前 术后6个月 术后12个月 F值 P值 W改形缝合组 36 84.3±5.8 30.8±2.1a 31.6±2.0a 2 441.61 <0.001 常规减张缝合组 33 83.9±5.7 31.1±2.7a 33.5±2.7ab 1 896.94 <0.001 均数差值（95%CI） 0.4（-2.4~3.2） -0.3（-1.5~0.9） -1.9（-3.0~-0.8） t值 0.35 0.50 3.22 P值 0.726 0.619 0.002 注：POSAS为患者与观察者瘢痕评估量表；对W改形缝合组患者瘢痕行W改形切除联合远位减张缝合,对常规减张缝合组患者瘢痕行常规梭形切除后减张缝合；处理因素主效应,F=1.24,P=0.27；时间因素主效应,F=3 966.38,P<0.001；两者交互作用,F=1.49,P=0.232；与组内术前比较,aP<0.05；与组内术后6个月比较,bP<0.05
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Table 3. 影响69例上肢瘢痕患者术后12个月POSAS评分的多元线性回归分析结果
因素 标准化回归系数 t值 P值 方差膨胀因子 整复方法（以常规梭形切除后减张缝合为参照） 0.38 3.26 0.002 1.01 性别（以女性为参照） -0.04 -0.37 0.716 1.08 年龄（岁） -0.05 -0.38 0.705 1.09 术前瘢痕长度（mm） 0.10 0.85 0.401 1.08 术前瘢痕宽度（mm） 0.03 0.27 0.786 1.03 瘢痕形成时间（月） -0.14 -1.15 0.255 1.06 注：POSAS为患者与观察者瘢痕评估量表
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Table 4. 2组上肢瘢痕患者各时间点VSS评分比较（分,
组别 例数 术前 术后6个月 术后12个月 F值 P值 W改形缝合组 36 10.3±1.9 2.6±0.7a 3.3±0.8ab 416.53 <0.001 常规减张缝合组 33 10.9±1.6 2.8±1.1a 4.0±1.6ab 301.95 <0.001 均数差值（95%CI） -0.6（-1.5~0.3） -0.2（-0.6~0.2） -0.7（-1.3~-0.1） t值 1.61 1.07 2.63 P值 0.111 0.289 0.011 注：VSS为温哥华瘢痕量表；对W改形缝合组患者瘢痕行W改形切除联合远位减张缝合,对常规减张缝合组患者瘢痕行常规梭形切除后减张缝合；处理因素主效应,F=8.84,P=0.004；时间因素主效应,F=715.97,P<0.001；两者交互作用,F=0.83,P=0.440；与组内术前比较,aP<0.05；与组内术后6个月比较,bP<0.05
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Table 5. 影响69例上肢瘢痕患者术后12个月VSS评分的多元线性回归分析结果
因素 标准化回归系数 t值 P值 方差膨胀因子 整复方法（以常规梭形切除后减张缝合为参照） 0.32 2.93 0.005 1.01 性别（以女性为参照） -0.17 -1.53 0.132 1.08 年龄（岁） -0.32 -2.86 0.006 1.09 术前瘢痕长度（mm） 0.05 0.46 0.648 1.08 术前瘢痕宽度（mm） 0.27 2.49 0.015 1.03 瘢痕形成时间（月） 0.04 0.35 0.725 1.06 注：VSS为温哥华瘢痕量表
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Table 6. 2组上肢瘢痕患者各时间点瘢痕宽度比较（mm,
组别 例数 术前 术后6个月 术后12个月 F值 P值 W改形缝合组 36 9.81±5.49 0.88±0.20a 1.04±0.27a 93.15 <0.001 常规减张缝合组 33 9.97±5.90 0.88±0.24a 1.23±0.22a 75.18 <0.001 均数差值（95%CI） -0.16（-2.90~2.58） 0（-0.10~0.10） -0.19（-0.31~-0.07） t值 0.12 0.02 3.17 P值 0.905 0.985 0.002 注：对W改形缝合组患者瘢痕行W改形切除联合远位减张缝合,对常规减张缝合组患者瘢痕行常规梭形切除后减张缝合；处理因素主效应,F=0.07,P=0.797；时间因素主效应,F=167.39,P<0.001；两者交互作用,F=0.02,P=0.897；与组内术前比较,aP<0.05；与组内术后6个月比较,bP<0.05
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