应用预扩张胸廓内动脉穿支皮瓣修复41例胸部大面积瘢痕疙瘩手术创面

时间：2023-07-24

　　戚征1 孟湉1 宋可新1 冯程1 梁铮韵1 李文博2 张福泉2

　　孔令燕3 丁宁3 王友彬1

　　本文来源：《中华整形外科杂志》2022年06月第38卷第06期

　　DOI:10.3760/cma.j.cn114453-20211228-00488

　　作者单位：1中国医学科学院北京协和医学院北京协和医院整形美容科，北京100031；2中国医学科学院北京协和医学院北京协和医院放射治疗科，北京100031；3中国医学科学院北京协和医学院北京协和医院放射科，北京100031

　　通信作者：王友彬，Email：wybenz@sina.com

　　引用本文

　　戚征, 孟湉, 宋可新, 等. 应用预扩张胸廓内动脉穿支皮瓣修复41例胸部大面积瘢痕疙瘩手术创面 [J] . 中华整形外科杂志, 2022, 38(6) : 635-639. DOI: 10.3760/cma.j.cn114453-20211228-00488.

　　【摘要】

　　目的探讨应用预扩张胸廓内动脉穿支皮瓣修复胸部大面积瘢痕疙瘩手术创面的临床效果。

　　方法对2017年1月至2021年9月北京协和医院应用预扩张胸廓内动脉穿支皮瓣修复胸部大面积瘢痕疙瘩手术创面患者的临床资料进行回顾性分析。治疗分为2个阶段：第1阶段，将皮肤软组织扩张器置入胸部胸廓内动脉穿支供血区正常皮肤深层，扩张器每周注水；第2阶段，扩张量达到预期扩张目标后取出扩张器，同时切除瘢痕疙瘩，并以相应的胸廓内动脉穿支血管为蒂形成预扩张胸廓内动脉穿支皮瓣，修复切除后创面。术后围手术期进行辅助放疗和高压氧治疗。术后随访治疗效果，分析术后并发症，记录复发率和患者满意率。

　　结果共纳入41例患者，男20例，女21例，年龄24~64岁，平均32.1岁。平均患病时间11.9年；瘢痕疙瘩大小平均约9 cm×8 cm；置入扩张器数量1~4枚，容量80~600 ml, 平均300 ml；平均注水时间约3个月。术中切取扩张穿支皮瓣大小平均约9 cm×8 cm。术后随访4~19个月，平均8.6个月，2例（4.9%）合并小面积皮瓣远端皮肤坏死；5例（12.2%）出现部分切口瘢痕增生，随访期内无完全复发病例出现。36例（87.8%）患者认为手术效果满意，5例（12.2%）患者认为手术效果可以接受。

　　结论预扩张胸廓内动脉穿支皮瓣是治疗胸部大面积瘢痕疙瘩手术创面的有效方法，可为创面修复提供足够的皮肤组织量，其血液供应稳定，效果满意。

　　【关键词】瘢痕疙瘩；胸部；外科皮瓣；预扩张胸廓内动脉穿支皮瓣；放射治疗

　　基金项目：北京市科委首都临床诊疗技术研究及示范项目（Z191100006619009）

　　Reconstruction of 41 cases of large chest keloids with the pre-expanded internal mammary artery perforator flap

　　Qi Zheng1, Meng Tian1, Song Kexin1, Feng Cheng1, Liang Zhengyun1, Li Wenbo2, Zhang Fuquan2, Kong Lingyan3, Ding Ning3, Wang Youbin1

　　1Department of Plastic Surgery，Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100031, China; 2Department of Radiotherapy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100031, China; 3Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100031, China

　　Corresponding author: Wang Youbin, Email:wybenz@sina.com

　　【Abstract】

　　Objective To analyze the clinical effects of the pre-expanded internal mammary artery perforator flap in large chest keloids surgical treatment.

　　Methods Patients with large chest keloid were treated with the pre-expanded internal mammary artery perforator flap between January 2017 and September 2021. The surgical treatment was divided into two different phases. In the first phase, a tissue expander was implanted beneath the skin within the angiosome of the internal mammary artery perforator. The expander was injected with normal saline once a week. In the second phase, the expander and the keloid tissue were removed, and a pre-expanded internal mammary artery perforator flap was designed to cover the wound. Radiotherapy and hyperbaric oxygen therapy were performed in the postoperative period. The treatment effect was followed up. The postoperative complications were analyzed, and the recurrence and patient satisfaction rates were recorded.

　　Results A total of 41 patients were enrolled, including 20 male and 21 female patients. The patients’ age ranged from 24 to 64, with a mean disease history of 11.9 years. The mean size of the keloid was 9 cm × 8 cm. Some patients were treated with one expander, but four expanders were needed in some extensive cases. The volume of the expander ranged from 80 to 600 ml. The mean volume was 300 ml, with a mean expansion time of 3 months. The mean flap size was 9 cm × 8 cm. Two cases with distal necrosis were observed. Five cases suffered from partial incision scar hyperplasia. No recurrence occurred during the followed-up period. Thirty-six patients (87.8%) were satisfied with the operation effect, and five (12.2%) thought the effect was acceptable.

　　Conclusions The pre-expanded internal mammary artery perforator flap is an effective treatment for the large chest keloid. It can provide sufficient skin tissue for wound repair, with a stable blood supply and an excellent curative effect.

　　【Key words】Keloid; Thorax; Surgical flaps; Pre-expanded internal mammary artery perforator flap; Radiotherapy

　　Fund program: Beijing Municipal Commission of Science and Technology (Z191100006619009)

　　Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

　　Ethical Approval: Ethical approval was given by the Medical Ethics Committee of Peking Union Medical College Hospital (ZS-3373).

　　瘢痕疙瘩是一种皮肤浅表的良性肿瘤，其病理特征是皮肤胶原蛋白过度沉积和局部成纤维细胞增生，常伴有瘙痒、疼痛症状，部分患者发生局部反复感染［1］。由于严重的美容损毁，患者常有极大的心理负担。瘢痕疙瘩的治疗方法有硅凝胶贴敷、压迫、冷冻、激光、药物注射、手术以及放疗等［2］。对于胸部大范围的瘢痕疙瘩，手术切除辅助术后放疗仍然是临床常用的有效治疗方法。手术治疗瘢痕疙瘩的方法有切除后直接缝合、局部皮瓣转移、胸廓内动脉穿支皮瓣移植［3-4］、预扩张皮瓣转移、吻合血管皮瓣移植［5］和皮片移植等。当瘢痕疙瘩体积巨大且形状不规则时，邻近往往缺乏足够的正常皮肤用于覆盖瘢痕疙瘩切除后的创面，给此类患者的治疗带来困难和挑战。近年我院应用预扩张胸廓内动脉穿支皮瓣的方法治疗了41例胸部大面积瘢痕疙瘩患者，为此类病例的治疗提供了新的思路和方案。

　　一、资料选择

　　回顾性分析2017年1月至2021年9月在北京协和医院整形外科接受治疗的胸部大面积瘢痕疙瘩患者的病历资料。纳入标准：胸部瘢痕疙瘩手术治疗病例，切除瘢痕疙瘩后创面无法用直接缝合、局部皮瓣转移或穿支皮瓣转移封闭且不宜用皮片移植或吻合血管游离皮瓣移植修复，需要用皮肤软组织扩张，且扩张皮肤需有知名肋间穿支携带才能达到需要修复的创面部位。排除标准：单纯通过扩张皮瓣直接推进旋转覆盖瘢痕疙瘩切除后创面的病例资料。

　　研究方案获得北京协和医院伦理委员会批准（ZS-3373），均已取得患者知情同意，患者信息已做隐匿。

　　二、方法

　　（一）手术方法

　　手术操作均由同一手术团队完成。手术分为两个阶段。第1阶段：根据瘢痕疙瘩大小和邻近可用正常胸部皮肤面积，选择合适大小的扩张器，用超声多普勒确定胸廓内动脉穿支血管的位置和走行，然后根据可用的胸廓内动脉穿支蒂确定扩张器埋置部位。全身麻醉满意后，切开扩张器置入位置的皮肤至胸大肌筋膜浅层。在胸大肌筋膜浅层剥离形成扩张器置入的腔穴。腔穴的分离也可通过内窥镜辅助完成。彻底止血后，在腔穴内置入一定大小的皮肤软组织扩张器，放置引流。切口拆线1周后开始注水，每周1次，每次注水量约为扩张器容量的10%。第2阶段：第2阶段手术在达到预期扩张目的后进行，术前用三维CT和超声多普勒再次确定胸廓内动脉穿支血管的位置和走行，然后切除瘢痕疙瘩，取出扩张器，根据瘢痕疙瘩切除后创面大小和形状在扩张皮肤上设计扩张皮瓣的大小和形状，由远及近分离皮瓣直到皮瓣可以无张力旋转至创面部位，观察皮瓣蒂部以确定胸廓内动脉穿支血管在皮瓣蒂内。用皮瓣覆盖创面，留置引流管后缝合切口。

　　（二）术后辅助治疗方法

　　所有患者在术后第1天进行第1次放疗，1周后进行第2次放疗，每次900 cGy。术后第2天开始进行高压氧治疗，每天1次至切口愈合拆线，方法是：采用3舱7门大型空气舱群，匀速升压30 min至0.2 Mpa（2个绝对大气压）后稳压，持续面罩吸氧60 min，氧气浓度100%，然后匀速减压30 min。术后持续弹力衣物局部加压6至12个月。

　　（三）随访评价方法

　　术后观察记录伤口愈合情况。所有患者术后每3至6个月进行1次随访。随访内容包括切口瘢痕复发情况和患者满意度等。评价方法如下。

　　 1. 复发情况判断：（1）全部伤口无超出原切口范围的瘢痕增生判为无复发；（2）全部伤口个别部位有超出原切口范围的瘢痕增生判为部分复发；（3）全部伤口出现超出原切口范围的瘢痕增生为完全复发［6］。

　　 2. 患者满意度判断：满意度分为结果满意、可以接受和不满意3个等级。随访时患者根据自己的判断进行评级。

　　三、结果

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