皮肤扩张多因素分析

皮肤扩张多因素分析 第l4卷第4期 2OO4年2月 中国现代医学杂志 ChinaJournalofModernMedicine Vo1.14No.4 Ecb.2004 文章编号:1005—8982(2004)04—0057—03 皮肤扩张多因素分析 朱颉,贺全勇,彭浩 (中南大学湘雅三医院烧伤整形科,湖南长沙410013) ? 论着? ' 摘要:目的探讨皮肤组织扩张的最佳方法.方法从多方面对1996—2002年间118例患者221个扩 张器行皮肤软组织扩张术的回顾性分析.结果除头部外,面,颈,胸,肩背与四肢皮肤扩张的并发症发生率 无明显差异(P>O.O5),感染是威胁皮肤扩张的最常见因素.扩张速度以常规扩张为主.结论头部并发症 较少,皮肤软组织扩张围手术期要注重感染的预防和控帝1,同时要综合考虑I期手术的切口设计,囊腔分离的 层次,范围及扩张速度等多因素的共同作用. 关键词:皮肤扩张;并发症;防治 中图分类号:R622.I文献标识码:A Mulitiplefactorsanalysisofskintissueexpansion ZHUJie,HEQuan—yongandPENGHao (DepartmentofBurnandPlasticSurgery,the3rdAffiliatedHospital, CentralSouthUniversity,Changsha,Hunan410013,P-R.China) Abstract:Objective:Toexplorethebestwayofskintissueexpansion.Methods:Total221exp anderswere usedfor118patientsfrom1996to2002.RetrospectivestudyinseveralaspectsWasperformed .Results:Multiplefac- tomwereanalyzedintheretrospectivestudy.Incidencesofcomplicationswerenotsignifican tlydifferent(P>O.1O)a— rsongthegroupsofface,neck,chest,extremitiesandshoulderskintissueexpansion.Infection Wasthemostfrequent riskfactorofskintissueexpansion.TheroutineexpansionWasmainlype珊 ed.Conclusions:IncidenceofcompHca- tionsinscalpWaslowerthanthoseinothersites.Anti— infectionplaysamajorroleinpostoperationofskintissueex- pansionandmultiplefactorsshouldbeconsideredaswel1. Keyw0rds:skinexpansion;complications;preventionandcontrol CLCn~ber:R622,1Docmnentcode:A Tissueexpansionwaswidelyusedinclinicinthe worldsincethecontrolledskintissueexpanderwasde— velopedbyRadovanin1976….Withpatientshigher requirementtoplasticoperation,specialistsfoundthat skintissueexpandercansupplyskintissueandflap whicharesimilarwithtissueofacceptedregionincolor andluster,textureandthickness.Italsosuppliescom— poundskinflapcharacterizedbyplentifulbloodflow, strongabilityofplerosis,andmaximalrecoveryofout— lineformand/orfunction[.However.skinexpansion Receiveddate:Feb.11,2003 iSassociatedwithsometechniquedifficultiessuchas expansiontime,donorsiteselectionandprevention andcureofcomplications.Wemadearetrospectivea— nalysisof118casestreatedwithskinexpansioninre— centsixyearstoprimarilyinvestigatetheexperiencesof thistechnique. 1Materialsandmethods 1.1Generaldata Thisgroupconsistedof188hospitalizedpatients treatedwithskintissueexpansionfrom1996to2002, including68menand50women,withaverageageof ? 57? 参巍鋈}l越 ChinaJournalofModemMedicineV.14 (29.28?5.77)years.anddiseasecourse6months, 30years(average:9.05years).Therewere21lex- pandersdistributedatface(52),neck(56),head (37),chest(32),shoulderandback(34),extremi- ties(10).eaffusiontimerangedfrom24to92 days,withaveragetimeof48days.Accordingtothe durationoftime,53casesareover50days,65cases lessthan50days,withaverageoperativetimeofII phase:57days. 1.2Operationmethodsanddata Implantexpanderaccordingtooperationprinciples reportedbyRadovan(1976)andArgenta(1981): Caputexpanderswereimplantedunderepicranialapo- neurosis.Exceptfor2caseslowerlimbswereimplan- tedunderdescendingmusculo——cutaneousflapforex?? pansion,otherswereimplantedsubcutaneously.Ex- pansionsiteisgenerallyclosetolesion.Operativelayer detachedhomogenously,throughhemostasia,andsub— cutaneoustissuewassuturedatfirst.Administrateanti- bioticfromlhourbeforeoperationto3,5daysafter operation.Adoptingdrainageornotdependsonthe conditionduringoperation.GenerMlynegativepressure tubeisplacedfordrainageandremovedafter48hours. Stitchestakenoutin7—-14daysandpouredinitially4 , 7daysafteroperation.Everyaffusionoccupied10% oftheexpandervolume,onceitdesignedamountstop affusion.Thetreatmentforcomplicationswas:decrea- singdose,draining,anti—inflammation,andtaking outandpressinglocaUy.ThemethodforphaseII叩一 erationincludeddrivingskinflap,conbolution,trans- locationormakingskintubetodelayetc.Calculating theareaofexpandedskinaccordingtoNiuXingtaofor- mula:A=0.152V一0.151ortheratioofareastovo1. ume:lcm/9m1.emaximaldesignvolumewas 130%,l80%ofexpander.Thenumberandsizeof expanderwereselectedaccordingtothesize,site,are- aandshapeofthetreatedregion.Expanderswereall domesticallysuppliedbyShanghaiXingshengMedical InstrumentCompanyandShanghaiWeiningMedical InstrumentCompany. 2Results 221expandersweresetin118patients,inwhich 21casespresentedcomplications,accountedfor 9.50%ofallequipments;4casespresentedsevere complications,accountedfor1.81%andtheirexpand- ersweretakenoutinadvance.Othercomplicationsdid notaffectthetreatmentobviouslyafterconservative treatment. Theincidenceofcomplicationvariedwiththedif- ferentexpanderslocations. edmostcomplications. Expandersinfaceasaoeiat- accountedfor9cases (17.31%);1caseinextremities(10.00%);3ca- sesinchest;5casesinneck(8.93%);3casesin shoulderandback(8.82%);andnoctl,~sinhead. SeeTable. TableComplicationsofskinexpansionindI磊e--眦location Nete:Exce~forhead.P>O.m(x~--2.34s)eTI伽叩.哪6棚-—瞄b|p eaffusingtimeofdifferentlocationswereasfol- 13.12)days;neck:(56.88? lows:face:(43.25? 17.42)days;'shoulderandback:(61.24?14.73) days;limb:(69.1l?26.72)days;head:(47.22? l4.67,days.Ithadnoobvioussignificancetocom- pareaffusingtimeindependently,sincetheaffusing timeofdifferentlocationsvariedgreatly.Butwecan makecomparativeanalysiswithhomologouscasesof otherhospitals. 3Discussion Skinsoft—tissuedilatationneedsatleast2opera- tionsandcomparativelylongtimeexpansion.Theinci- dencerateofcomplicationishigh.reportedfrom5% to60%[. Chiefcomplicationsincludeinfection,he. matoma,exposureofexpandercapsule,bloodflowob- stacle,dilatationcapsuleleakage,pain,foreignbody rejectionandpsychologicalintolerance. Theimplantationlocationandlayerselectionhave greateffectonexpansion.Theincidencerateoftom- plicationsbetweengroupshasnoobviousdifference. Theskinofheadexpanders,becauseofitshealsolid base,thicknessofskintissueclearl矗瞧._ibeiIlgde- ? 58? No.4ZHUJie.etal:Mulitiplehct0rsanalysisofskintissueexpansion tachedeasily,plentifulsurroundingbloodtransporta— tionandstronganti—inflammation,haveleastcompli— cations.Wealsoconsiderthatthefaceandneckhas itslocationspecialty:thinskintissue,strongertension infacethaninneck,andinhomogeneousthicknessof skinlayerwhendetachedinoperation.Inadditionto thelimitationofcompartmentsize,expanderstendto befoldedintoangles.Italsotendstocompressskin andbeassociatedwithbloodflowobstacleresultingin possibleexposure.Oncecomplicationsoccur,plerosis effectisseverelyaffected. Fromthisgroup,wedemonstratedthatinfectionis animportantfactoraffectingexpanderimplantationand anurgentproblemtoberesolveinclinicalapplica— tion[引.Thecausesareasfollows:basicallyimplanting expanderstIIincisionclosetosearinthepatientsof thegroup,ofwhich2casesimplantedinthedeeppart oflimbpreparedforsearvalveexpansion;thebacteria remainedinscarcanonlymakethestandardofincision inthelevelof11grade,andithastheconditionofin— fectionunderoperationstress;expandersareforeign bodycomparingwithorganism,whichcaninducenon — bacterialinflammationunderstimulation;edemapro— videsopportunityforinfection. Topreventdamagingtissuesclosetoaxio——vessel andproducingscarinsurroundingsandaffectingfol— lowingflaptransplant,expandersfromscapulashould beplacedindeepfascialayerandkeptsomedistance fromthevesselstalkofskinflap.Andtheexpansion cavityshouldbeslightlybiggerthanexpandercapsule. Butthesizeofskinflapislimitedbybloodflow,and sometimesskinflapbloodflowobs~c!eOCCUrseven thoughtheskinflapinthenorma1.Itisallduetothe pathologicalstatusofhyperplasticvesselsinskinflap, whichwinds,reflowsslowly,andhaspoorneurohu— moralregulationofmicrocirculation5j.Moreover, addingincisionwillaggravatebloodflowobstaclein transfer.Papaverineandhyperbaricoxygenwerea— doptedin4casesofthegroup,and3caseswerealive andrecurrent,1casefailed. Comparingexpansionspeed,otherlocationsofthe patientsinthisgroupwereallsuitableforquickexpan— sionexceptforthepoorintoleranceofface.Itmightbe relatedtothinskintissueofface,strongexpansionten— sionandobviousdistentionpaincomparedtoother1o— cations.Butwethinkthatpurequickexpansiononly suitsfortheplerosisareanotmorethan5cmx10cm. Sincethegreatretractionofskinafterexpansion,we donotdeliberatelypursueswiftnessinclinic. Skincontractureisusuallyachieffactorthataf- fectsoperationeffectafterexpansion,particularly quickexpansion.Toreducethecontracturerateofskin flap,weoftenadoptconventionaldistention.Whenit achievestheaimofexpectationdesign,keepdistention instillfor1—2weeks.Excessiveexpansionwasa— doptedintimebeforeextractingexpansion'capsuledur— ingthephase11operationtohavetheeffectofflaccid subdermalandincreasethespringandutilizationof skin.Whenprocessingfiberenvelope,weremovedfi_ berenvelopetolessencontractureofskinflapifthe skinflagissmallexpanded.Whenthedesignofskin flapwasrelativelybig,wekeptfiberenvelopeand looseditby"#"topreventthebloodflowobstacleof remotepartofskinflap.Intransferofpartialskinflap, thesurrounding thebasementof tissueoffabricenvelopewasincisedat expandertosmoothtrauma,andnot treatthecentertospontaneousdegeneration. Inaword,expansiontechniqueofsofttissueCall reachgoodcosmeticresult[引. However,itishindered bylong—termtreatment,multiplecomphcationsand otherfactors.Weneedtofurtherresearchonhowto increaseexpansioneffectandreduceincidencerateof complications. References: [1]RadovanC.Tissueexpansioninsoft—tissuereconstruction[J].Plast RvconstrSurg,1984,74:482—492. [2]罗志军,吴德勇.皮瓣及复合皮瓣移植治疗功能部位深度烧伤 [J].中国现代医学杂志,2001,l】(6):48—86. [3]BrownMD,JohnsonTM.Complicationsoftissueexpansion[J].J DermatolSurgOncol,l993,19:l12O—l122. [4]展望,吴念.扩张囊内注入抗生素控制感染的临床作用 [J].中国现代医学杂志,2002,12(11):4. [5]MehmetMura1.Venouschangesinexpandedskin:amicroangio- graphicandhistologicalstudyinrabbits[J].AnnSury,1996,37:75 — 83. [6]MandersEK,GrahamWT,SchendenMJ,eta1.Skinexpansionin headandneckreconstruction[J].AnnPlastSurg,1984,12:305— 3l2. (EditedbyZOUXian—de) ? 59? 婆E