额顶部扩张带蒂皮瓣整复儿童颈部烧伤后瘢痕挛缩畸形的效果

夏成德; 薛继东; 邢培朋; 郭海娜; 曹大勇; 谢江帆; 韩大伟; 狄海萍

doi:10.3760/cma.j.cn501120-20210507-00172

额顶部扩张带蒂皮瓣整复儿童颈部烧伤后瘢痕挛缩畸形的效果

doi: 10.3760/cma.j.cn501120-20210507-00172

郑州市第一人民医院烧伤科，郑州　　450004

基金项目:

河南省科技发展计划 192102310368

详细信息

通讯作者:
狄海萍，Email：390289311@qq.com

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出版历程
- 收稿日期: 2021-05-07
- 网络出版日期: 2022-07-20
- 刊出日期: 2022-05-20

Effects of expanded frontal-parietal pedicled flap in reconstructing cervical scar contracture deformity in children after burns

Department of Burns, Zhengzhou First People's Hospital, Zhengzhou 450004, China

Funds:

Science and Technology Development Program of Henan Province of China 192102310368

More Information

Corresponding author: Di Haiping, Email: 390289311@qq.com

摘要

摘要:
目的探讨额顶部扩张带蒂皮瓣整复儿童颈部烧伤后瘢痕挛缩畸形的效果。
方法采用回顾性观察性研究方法。2015年1月—2020年12月，郑州市第一人民医院收治18例符合入选标准的颈部烧伤后瘢痕挛缩畸形男性患儿，年龄4~12岁，其中颈部瘢痕挛缩畸形程度为Ⅱ度者10例、Ⅲ度者8例，均应用额顶部扩张带蒂皮瓣整复。手术分3期进行，Ⅰ期于额顶部埋置1个额定容量为300~500 mL的圆柱形皮肤软组织扩张器（以下简称扩张器），扩张时间为4~6个月，总注射生理盐水量为扩张器额定容量的2.1~3.0倍。Ⅱ期行扩张器取出+瘢痕切除+挛缩松解+皮瓣转移，其中皮瓣面积为18 cm×9 cm~23 cm×13 cm，瘢痕切除、挛缩松懈后继发创面面积为16 cm×8 cm~21 cm×11 cm。3~4周后行Ⅲ期皮瓣断蒂及蒂部复位。记录置入扩张器额定容量，注射生理盐水量，皮瓣血管蒂类型，Ⅱ期术后皮瓣存活及瘢痕整复情况。测量术前、术后1年颈部活动度和颈颏角，随访术后颈部外观、供受区常见并发症发生情况，患儿家属对治疗效果的满意度。对数据行配对样本t检验。
结果患儿均顺利完成3期手术，置入扩张器额定容量为300 mL者6例、400 mL者9例、500 mL者3例，注射生理盐水量630~1 500 mL。13例患儿皮瓣血管蒂类型为双蒂、5例患儿皮瓣血管蒂类型为单蒂。17例患儿皮瓣全部存活，颈部瘢痕切除、挛缩松解后继发创面均一次性整复；1例患儿单蒂皮瓣Ⅱ期术后远端血运欠佳，坏死长度约2.5 cm，术后10 d去除远端坏死组织，重新调整皮瓣位置后创面完全封闭。术后随访6个月~3年，18例患儿颈部瘢痕挛缩畸形得到矫正且未复发，皮瓣不臃肿、质地柔软，颏颈外观良好，术后1年颈部前屈活动度、后屈活动度、左侧屈活动度、右侧屈活动度和颈颏角均较术前明显改善（t值分别为43.10、22.64、27.96、20.59、88.42，P<0.01）。额部供瓣区切口位于发际线内，瘢痕轻微且隐蔽。扩张器置入部位未观察到颅骨凹陷等并发症，患儿家属对整复效果满意。
结论采用额顶部扩张皮瓣带蒂转移整复儿童颈部烧伤后瘢痕挛缩畸形能够明显改善颈部外观和功能，术后瘢痕挛缩不易复发，是一种较为理想的整复方法。
- 儿童 /
- 颈 /
- 瘢痕 /
- 扩张术 /
- 外科皮瓣 /
- 颞浅血管
Abstract:
Objective To explore the effects of expanded frontal-parietal pedicled flap in reconstructing cervical scar contracture deformity in children after burns.
Methods A retrospective observational study was conducted. From January 2015 to December 2020, 18 male children with cervical scar contracture deformity after burns who met the inclusion criteria were admitted to Zhengzhou First People's Hospital, aged 4 to 12 years, including 10 cases with degree Ⅱ cervical scar contracture deformity and 8 cases with degree Ⅲ scar contracture deformity, and were all reconstructed with expanded frontal-parietal pedicled flap. The surgery was performed in 3 stages. In the first stage, a cylindrical skin and soft tissue expander (hereinafter referred to as expander) with rated capacity of 300 to 500 mL was placed in the frontal-parietal region. The expansion time was 4 to 6 months with the total normal saline injection volume being 2.1 to 3.0 times of the rated capacity of expander. In the second stage, expander removal, scar excision, contracture release, and flap transfer were performed, with the flap areas of 18 cm×9 cm to 23 cm×13 cm and the secondary wound areas of 16 cm×8 cm to 21 cm×11 cm after scar excision and contracture release. After 3 to 4 weeks, in the third stage, the flap pedicle was cut off and restored. The rated volume of placed expander, total normal saline injection volume, type of vascular pedicle of flap, survival of flap and reconstruction of scar after the second stage surgery were recorded. The neck range of motion and cervico-mental angle were measured before surgery and one-year after surgery. The appearance of neck, occurrence of common complications in the donor and recipient sites of children, and satisfaction of children's families for treatment effects were followed up. Data were statistically analyzed with paired sample t test.
Results All the patients successfully completed the three stages of operation. The rated volume of implanted expander was 300 mL in 6 children, 400 mL in 9 children, and 500 mL in 3 children, with the volume of normal saline injection being 630 to 1 500 mL. The type of vascular pedicle of flap was double pedicle in 13 cases and was single pedicle in 5 cases. All the flaps in 17 children survived well, and the secondary wounds after neck scar excision and contracture release were all reconstructed in one procedure. In one case, the distal blood supply of the single pedicled flap was poor after the second stage surgery, with necrosis of about 2.5 cm in length. The distal necrotic tissue was removed on 10 days after the operation, and the wound was completely closed after the flap was repositioned. In the follow-up of 6 months to 3 years post operation, the cervical scar contracture deformity in 18 children was corrected without recurrence. The flap was not bloated, the texture was soft, and the appearances of chin and neck were good. The range of motion of cervical pre-buckling, extension, left flexion, and right flexion, and cervico-mental angle in one year after operation were improved compared with those before operation (with t values of 43.10, 22.64, 27.96, 20.59, and 88.42, respectively, P<0.01). The incision in the frontal donor site was located in the hairline, the scar was slight and concealed. No complication such as cranial depression was observed in expander placement site, and the children's families were satisfied with the result of reconstruction.
Conclusions Application of expanded frontal-parietal pedicled flap in reconstructing the cervical scar contracture deformity in children after burns can obviously improve the appearance and function of neck, with unlikely recurrence of postoperative scar contractures, thus it is an ideal method of reconstruction.
- Child /
- Neck /
- Cicatrix /
- Dilatation /
- Surgical flaps /
- Superfical temporal vessels
夏成徳、薛继东、狄海萍：手术设计和操作、论文撰写；邢培朋、郭海娜、曹大勇、谢江帆、韩大伟：患者管理、手术操作

所有作者均声明不存在利益冲突

血管渗漏引起的烧伤休克是严重烧伤患者病死率较高的主要原因之一。然而，血管渗漏的病理生理机制尚不清楚。南京医科大学附属苏州医院孙炳伟教授团队在《Burns & Trauma》发文《Neutrophil-derived heparin binding protein triggers vascular leakage and synergizes with myeloperoxidase at the early stage of severe burns (with video)》。该研究团队分离人外周血中性粒细胞，采用ELISA法检测血浆中性粒细胞来源的颗粒蛋白和糖萼损伤产物，采用小鼠激光共聚焦活体成像评估血管渗漏和中性粒细胞运动，采用实时荧光定量RT-PCR检测黏附相关分子表达，采用透射电镜和扫描电镜观察血管内皮细胞糖萼的损伤。采用蛋白质组学、流式细胞术和免疫荧光技术进一步研究人外周血中性粒细胞来源的次氯酸盐与人血管内皮细胞CD44的关系。该研究团队观察到，在严重烧伤后，迅速增加的活化中性粒细胞分泌肝素结合蛋白(HBP)和髓过氧化物酶(MPO)，HBP升高与MPO协同引发血管渗漏，导致全身水肿和烧伤休克；MPO的催化产物次氯酸盐能触发CD44胞外结构域从血管内皮细胞脱落，从而损伤糖萼；糖萼的损伤导致中性粒细胞的粘连，增加血管渗漏。该研究认为这2种生物分子的靶向干预可能会引入新的减少大量液体流失和随后的烧伤休克的策略。

李江锋，编译自《Burns Trauma》, 2021, 9:tkab030；郇京宁，审校

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1 儿童额顶部扩张带蒂皮瓣供区的皮肤软组织扩张器埋置范围和切口位置标记图

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2 额顶部扩张单蒂皮瓣整复例1患儿火焰烧伤后颈部瘢痕挛缩畸形。2A.颈部瘢痕挛缩畸形1年，颈部后仰受限，左口角向下移位；2B.额顶部埋置皮肤软组织扩张器后5个月；2C.Ⅱ期术中皮瓣切取，皮瓣最宽处达9 cm；2D.Ⅱ期术中，皮瓣切取长度为18 cm，额顶部皮瓣供区拉拢缝合后；2E.Ⅱ期术中颈部瘢痕切除、挛缩松解；2F.Ⅱ期术后即刻，创面封闭；2G、2H.分别为断蒂术后1年头后仰和左侧观，颈部外观明显改善，头后仰及颈部活动功能恢复

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3 额顶部扩张双蒂皮瓣整复例2患儿热水烧伤后颈部瘢痕挛缩畸形。3A.4岁时颈部Ⅳ度挛缩畸形，颏颈胸粘连、下唇外翻；3B.颈部大张中厚皮移植后4年，8岁时颏颈胸再次粘连，右侧口角向下牵拉；3C.第2次大张中厚皮移植后4年，12岁时颈部再次挛缩；3D.额顶部皮肤软组织扩张器置入后5个月；3E.Ⅱ期术中切取双蒂皮瓣，皮瓣切取宽度为13 cm；3F.Ⅱ期术后10 d，断蒂前；3G、3H.分别为断蒂术后1年右侧位和正位观，颈部外观改善，额顶部皮瓣供区恢复良好

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表1 18例颈部瘢痕挛缩畸形患儿额部扩张带蒂皮瓣整复手术前后颈部活动度及颈颏角比较（°， $\bar{x} \pm s$ ）

指标	术前	术后1年	t值	P值
前屈活动度	15.1±1.8	46.4±2.5	43.10	<0.001
后屈活动度	12.4±3.7	35.1±2.1	22.64	<0.001
左侧屈活动度	27.3±1.9	44.1±1.7	27.96	<0.001
右侧屈活动度	26.9±2.2	42.7±2.4	20.59	<0.001
颈颏角	154.6±2.5	90.4±1.8	88.42	<0.001

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