累及颅内结构的头部难愈性创面的修复方法及其临床效果

王梦娜; 梁鹏飞; 毕长龙; 黄覛韬; 何志友; 张丕红; 周捷; 曾纪章; 兰松; 刘劲芳

doi:10.3760/cma.j.cn501225-20250106-00008

累及颅内结构的头部难愈性创面的修复方法及其临床效果

doi: 10.3760/cma.j.cn501225-20250106-00008

1.
中南大学湘雅医院烧伤整形外科，长沙 410008
2.
中南大学湘雅医院神经外科，长沙 410008

基金项目:

湖南省自然科学基金面上项目 2023JJ30909

详细信息

通讯作者:
梁鹏飞，Email：liangpengfeijbm@163.com

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出版历程
- 收稿日期: 2025-01-06

Repair methods for refractory head wounds involving intracranial structures and their clinical effectiveness

1.
Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
2.
Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha 410008, China

Funds:

General Program of Hunan Natural Science Foundation of China 2023JJ30909

More Information

Corresponding author: Liang Pengfei, Email: liangpengfeijbm@163.com

摘要

摘要: 目的探讨累及颅内结构的头部难愈性创面的修复方法及其临床效果。方法该研究为回顾性观察性研究。2020年9月—2024年7月，中南大学湘雅医院（以下简称本院）烧伤整形外科收治68例符合入选标准的累及颅内结构的头部难愈性创面患者，与本院神经外科医师共同管理，其中男38例、女30例，年龄1~76岁。根据创面难愈合的原因，将累及颅内结构的头部难愈性创面分为5类：单纯组织缺损创面、单纯感染性创面、植入物相关创面、与副鼻窦贯通创面、放射性损伤创面，并根据创面情况采用相应处理方案。创面床准备完成后，根据创面位置、大小、血供条件、是否需要软组织填充以及患者全身情况等因素，结合损伤最小化原则，对无明显头皮软组织缺损者，予以直接缝合；对缺损较大无法直接缝合者（创面面积为8 cm×3 cm~28 cm×13 cm），设计最合适的组织瓣（包括头部带蒂皮瓣和游离组织瓣）修复创面。将头部皮瓣供区创面直接缝合或移植全厚皮片修复，游离组织瓣供区创面直接缝合。术前记录难愈性创面的类型、创面分泌物标本微生物培养结果，术中记录创面修复方式、游离组织瓣类型、受区血管及供受区血管吻合方式，术后观察头部创面及组织瓣供区恢复情况。随访受区外观、血运、创面复发情况以及后续处理情况。结果 68例患者中，单纯组织缺损创面者2例、单纯感染性创面者15例、植入物相关创面者43例、与副鼻窦贯通创面者4例、放射性损伤创面者4例。术前创面分泌物标本微生物培养结果为阳性者28例。创面床准备完成后，17例患者的创面予以直接缝合，31例患者的创面采用头部带蒂皮瓣转移予以修复，20例患者的创面采用游离组织瓣移植予以修复。采用游离组织瓣移植修复创面的20例患者中，12例患者的受区血管为颞浅动静脉、8例患者的受区血管为面动静脉；其中2例患者采用血流桥接方式吻合血管，其余18例患者行供受区血管端端吻合。术后，66例患者头部创面愈合，2例患者头部创面未愈合、再次行清创手术后愈合；组织瓣供区均恢复良好。随访6~32个月，所有患者受区血运良好，头部外形可，创面无复发；其中4例患者后期行头皮扩张后再次植入钛网，2例患者出现新发癫痫后行服药控制。结论在充分评估创面难愈合原因的基础上，针对性去除影响创面愈合的因素，采用直接缝合、头部带蒂皮瓣转移或游离组织瓣移植修复累及颅内结构的头部复杂难愈性创面，可获得较佳临床治疗效果。
- 头部 /
- 外科皮瓣 /
- 感染 /
- 假体和植入物 /
- 难愈性创面 /
- 创面修复
Abstract: Objective To investigate the repair methods for refractory head wounds involving intracranial structures and their clinical effectiveness. Methods This study was a retrospective observational study. From September 2020 to July 2024, 68 patients with refractory head wounds involving intracranial structures who met the inclusion criteria were admitted to the Department of Burns and Plastic Surgery of Xiangya Hospital of Central South University (hereinafter referred to as our hospital) and were co-managed with neurosurgeons from our hospital. Among them, 38 were male and 30 were female, aged 1 to 76 years. Based on the causes of difficult wound healing, the refractory head wounds involving intracranial structures were classified into 5 categories: simple tissue defect wounds, simple infectious wounds, implant-related wounds, wounds communicating with paranasal sinuses, and radiation-damaged wounds. Corresponding management plans were adopted according to the wound condition. After wound bed preparation was completed, according to factors such as wound location, size, blood supply condition, need for soft tissue filling, and the patient's general condition, and also following the principle of minimizing damage, patients with no obvious scalp soft tissue defect were sutured directly. For patients with large defects that could not be sutured directly (with wound area of 8 cm×3 cm to 28 cm×13 cm), the most suitable tissue flaps (including pedicled scalp flaps and free tissue flaps) were designed to repair the wounds. The donor site wounds of scalp flaps were directly sutured or repaired by full-thickness skin grafting and the donor site wounds of free tissue flaps were directly sutured. Before surgery, the types of refractory wounds and the microbial culture results of wound exudate specimens were recorded. During surgery, the wound repair methods, types of free tissue flaps, recipient vessels, and vascular anastomosis methods between donor and recipient sites were recorded. After surgery, the recovery of the head wounds and the tissue flap donor sites was observed. The recipient site appearance, blood supply, wound recurrence, and subsequent management were followed up. Results Among 68 patients, 2 cases had simple tissue defect wounds, 15 cases had simple infectious wounds, 43 cases had implant-related wounds, 4 cases had wounds communicating with paranasal sinuses, and 4 cases had radiation-damaged wounds. Before surgery, the microbial culture results of wound exudate specimens were positive in 28 cases. After wound bed preparation was completed, the wounds of 17 patients were sutured directly, the wounds of 31 patients were repaired with pedicled scalp flap transfer, and the wounds of 20 patients were repaired with free tissue flap transplantation. Of the 20 patients who underwent free tissue flap transplantation for wound repair, 12 patients had the superficial temporal arteries and veins as the recipient vessels and 8 patients had the facial arteries and veins as the recipient vessels. Among them, 2 patients had their blood vessels anastomosed using a flow-through technique, while the remaining 18 patients underwent end-to-end anastomosis between donor and recipient vessels. After surgery, the head wounds of 66 patients healed, and the head wounds of 2 patients did not heal, which healed after undergoing debridement surgery again. All tissue flap donor sites recovered well. During follow-up of 6 to 32 months, all patients had good blood supply in the recipient sites, acceptable head shape, and no wound recurrence. Among them, 4 patients underwent titanium mesh reimplantation after scalp expansion at a later stage, and 2 patients developed new-onset epilepsy which was controlled with medication. Conclusions Based on an adequate assessment of the causes of difficult wound healing, targeted removal of factors affecting wound healing, and use of direct suture, pedicled scalp flap transfer, or free tissue flap transplantation to repair complex refractory head wounds involving intracranial structures can achieve favorable clinical treatment outcomes.
- Head /
- Surgical flaps /
- Infection /
- Prostheses and implants /
- Refractory wounds /
- Wound repair
本文亮点
(1) 根据创面难愈合的原因，将累及颅内结构的头部难愈性创面分为5类：单纯组织缺损创面、单纯感染性创面、植入物相关创面、与副鼻窦贯通创面、放射性损伤创面，并明确不同创面的处理。

(2) 根据创面床准备完成后创面位置、大小、血供条件、是否需要软组织填充及患者全身情况等因素，结合损伤最小化原则，采用直接缝合、头部带蒂皮瓣转移或游离组织瓣移植修复创面。

利益冲突 所有作者声明不存在利益冲突

作者贡献声明 王梦娜：患者管理、数据收集与分析、文章撰写；梁鹏飞、毕长龙：指导手术的设计与实施过程、指导文章撰写、研究经费支持、对文章的知识性内容作批评性审阅；黄覛韬、何志友：患者管理、手术实施、数据收集；张丕红、周捷、曾纪章、兰松、刘劲芳：手术实施、研究指导、对文章的知识性内容作批评性审阅

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图 1 股前外侧穿支皮瓣移植修复例1脑外伤患者左侧额颞部钛网外露且与额窦贯通的创面及再次植入钛网的效果。1A.清创前，左侧额颞部钛网外露创面；1B.清创中见钛网下颅骨缺损处与额窦贯通；1C.清创后拆除的钛网；1D.术中设计左侧股前外侧穿支皮瓣；1E.术中皮瓣移植修复创面后即刻，皮瓣血运良好；1F.术后18个月，头部置入皮肤软组织扩张器扩张头皮；1G.再次植入钛网术前，CT示左侧额颞部颅骨缺损；1H.头部再次植入钛网重建颅骨1年后情况；1I.再次植入钛网术后1年，CT示钛网固定在位

Figure 1. The effects of anterolateral thigh perforator flap transplantation and titanium mesh reimplantation in repairing the exposed titanium mesh and wounds communicating with frontal sinus in the left frontotemporal region of patient 1 with traumatic brain injury

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图 2 背阔肌肌皮瓣移植填塞例2患者颅内腔隙并修复头部放射性损伤创面的效果。2A.术前头部放射性损伤创面情况；2B、2C.分别为术前头部CT显示的颅脑的横断面和矢状面，可见颅前窝脑组织缺损，额部及前颅底颅骨缺损，右侧脑室与颅前窝脑组织缺损处贯通；2D.术中清创见颅前窝脑组织大量坏死，颅前窝内脑脊液积聚，前颅底缺损与鼻腔贯通；2E.术中设计背阔肌肌皮瓣；2F.术中切取肌皮瓣；2G.术中移植肌皮瓣至头部缺损处修复创面；2H.术后复查头部CT示无创面残留，颅内无窦道与外界贯通；2I.术后6个月，头部外形可，溃疡无复发，无脑脊液漏

Figure 2. The effects of latissimus dorsi myocutaneous flap transplantation in filling intracranial cavities and repairing the radiation-damaged wound on the head of patient 2

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