摘要：
目的 探讨吻合血管的扩张皮瓣治疗大面积烧伤患者瘢痕挛缩畸形的效果. 方法 2016年4月-2018年2月,笔者单位收治大面积烧伤所致严重瘢痕挛缩畸形患者9例,其中男7例、女2例;年龄23 ～ 54岁;共14处瘢痕挛缩畸形及功能障碍,其中面颈部8处、肘部2处、腕及手部4处.于胸腹部置入扩张器,按扩张器额定容量的2～3倍注射生理盐水扩张,扩张满意后手术切除瘢痕,松解挛缩畸形.根据受区缺损所需切取扩张后皮瓣移植,吻合供受区动静脉.观察和记录扩张器个数、注射生理盐水量及扩张时间,皮肤软组织扩张术并发症,皮瓣个数、面积、厚度、转移方式,供区修复方法,皮瓣成活情况;随访瘢痕挛缩畸形整复效果,随访时参照李克特量表5级评分调查患者对各手术部位治疗效果的满意度,采用简明版烧伤专用健康量表评估患者治疗前及随访时的生活质量.对数据行配对样本t检验、Wilcoxon符号秩和检验. 结果 本组患者共置入扩张器16个,其中胸部6个、腹部10个.扩张结束时注射生理盐水量为(1 421±348)mL.扩张时间(8.1±2.6)个月.扩张期间发生扩张器渗漏1例、注射壶翻转不能注水1例.16处扩张区共切取皮瓣17个,面积为15 cm×13 cm ～30 cm ×25 cm,其中6个胸部皮瓣厚(0.49±0.06) cm,11个腹部皮瓣厚(0.76±0.15)cm.14个皮瓣采取吻合血管游离移植;3个皮瓣为带蒂转移及远端吻合血管增压,其中1个皮瓣2周后断蒂再与另侧受区血管吻合.除1个腹部皮瓣供瓣区另移植刃厚头皮外,其余供瓣区均直接缝合.术后2个皮瓣远端少许坏死,分别经换药及移植刃厚头皮后愈合;其余15个皮瓣全部成活.随访6～24个月,皮瓣质地柔软;1例患者手掌侧移植的腹部皮瓣因略显肥厚于首次皮瓣术后3个月修薄,其余皮瓣厚薄适宜.末次随访时,所有患者皮瓣修复处外观及功能均较术前明显改善;患者对手术部位治疗效果的满意度评分为(4.4±0.6)分;患者生活质量总分及热敏感、治疗反感、外貌与情感问题得分较治疗前有显著提高(t=3.232、2.683、3.969、2.884、2.588,P＜0.05),手功能、性能力、人际关系、简单活动能力、重新工作能力得分与治疗前相近(t =0.778、1.000、1.664,Z=1.826、1.633,P＞0.05). 结论 采用吻合血管的扩张皮瓣治疗大面积烧伤患者瘢痕挛缩畸形,皮瓣面积大且厚薄适宜,供区易于直接闭合,可明显改善外观和功能,提高患者生活质量,患者满意度较高.%Objective To explore the effect of expanded flaps with vascular anastomosis in the treatment of scar contracture deformities of extensively burned patients.Methods From April 2016 to February 2018,9 patients with severe scar contracture deformities caused by extensive burns were hospitalized in our unit,including 7 males and 2 females,aged 23-54 years.There were 14 sites of scar contracture deformities and dysfunction,including 8 in face and neck,2 in elbow,and 4 in wrist and hand.The expander was inserted into the chest or abdomen and was expanded by 2 to 3 times of its rated volume with injection of normal saline.After satisfied expansion,the expanded flap was harvested and transplanted with arteriovenous anastomosis onto the recipient site,where the scar was removed,the deformity was corrected,and the contracture was released.The number of expanders,the volume of normal saline injected,the period of expansion,the complications of skin and soft tissue expansion,the number,size,thickness,transplantation modes,and survival of flaps,and the repair method of donor site were observed and recorded.The reconstruction effect of scar contracture deformity was followed up.The patients' satisfaction with the therapeutic effect of various surgical sites during follow-up was investigated with a 5-point Likert Scale.The Burn Specific Health Scale-Brief was used to evaluate the quality of life of the patients pretreatment and during follow-up.Data were processed with paired sample t test or Wilcoxon signed-rank sum test.Results A total of 16 expanders were inserted in this group of patients,including 6 in the chest and 10 in the abdomen.The volume of normal saline injected at the end of expansion was (1 421 ± 348) mL.The expansion time was (8.1 ± 2.6) months.One case of expander leakage and one case of injection port turnover resulted in failure of water injection occurred during expansion.Totally 17 flaps were resected from 16 expanded areas.The size of flaps ranged from 15 cm × 13 cm to 30 cm ×25 cm.The thickness was (0.49 ±0.06) cm in 6 chest flaps and (0.76 ± 0.15) cm in 11 abdomen flaps.Free transplantation with vascular anastomosis was performed in 14 flaps,and pedicled transplantation supercharged with distal vascular anastomosis was performed in 3 flaps,one of which the vascular pedicle was divided and re-anastomosed to the other side of the recipient area 2 weeks later.Except for one donor site of abdomen flap which was transplanted with thin split-thickness scalp,the other donor sites were sutured directly.After operation,2 flaps were slightly necrotic at the distal end and healed after dressing change and thin split-thickness scalp transplantation respectively,while the remaining 15 flaps all survived.During the follow-up of 6-24 months,the texture of the flaps was soft.The abdomen flap transplanted to the palm of hand in one patient was slightly hypertrophic,which was thinned 3 months after operation,while the other flaps were good in thickness.At the last follow-up,the appearance and function of the sites repaired by flaps of all patients were obviously improved compared with those before operation,the satisfaction score of the patients with the therapeutic effect of the surgical site was (4.4 ± 0.6) points,the total score of quality of life and the scores of heat sensitivity,treatment antipathy,body image,and affect of patients were significantly higher than those before treatment (t =3.232,2.683,3.969,2.884,2.588,P ＜ 0.05),while the scores of hand function,sexuality,interpersonal relationship,simple function abilities,perception in returning to work of patients were close to those before treatment (t =0.778,1.000,1.664,Z =1.826,1.633,P ＞0.05).Conclusions Expanded flaps with vascular anastomosis are suitable for the treatment of scar contracture deformities of extensively burned patients.The flaps are large in size and suitable in thickness.The donor sites are easy to be closed directly.The treatment can obviously improve the appearance,function,and the quality of life of the patients,with a high satisfaction of patients.
