二氧化碳点阵激光联合自体脂肪注射治疗烧伤后增生性瘢痕效果的前瞻性随机对照临床研究

A prospective randomized controlled clinical study on the treatment of hypertrophic scar after burn by fractional carbon dioxide laser combined with autologous fat injection

目的探讨二氧化碳点阵激光联合自体脂肪注射治疗烧伤后增生性瘢痕的临床疗效。方法2018年4月—2019年4月,徐州仁慈医院整形烧伤科收治符合入选标准的12例烧伤后增生性瘢痕患者,纳入此前瞻性随机对照临床研究。患者中男7例、女5例,年龄(32±11)岁,瘢痕面积为(612±195)cm2。每例患者选取1处瘢痕均分为2个等面积瘢痕,采用随机数字表法分别纳入联合治疗组和单纯激光组,每组12个瘢痕。单纯激光组瘢痕仅行二氧化碳点阵激光治疗;联合治疗组瘢痕每次先予注射自体颗粒脂肪,再行二氧化碳点阵激光治疗。2组瘢痕均每2个月治疗1次,共治疗3次。首次治疗前、末次治疗后6个月,对2组瘢痕行改良温哥华瘢痕量表(mVSS)评分、行苏木精-伊红染色、彩色多普勒超声观察;末次治疗后6个月,对2组瘢痕评定疗效,计算瘢痕治疗有效数;记录整个治疗过程中不良反应情况。对数据行独立样本t检验、配对样本t检验、McNemar确切概率法检验。结果末次治疗后6个月,联合治疗组瘢痕mVSS评分为(4.5±0.4)分,明显低于单纯激光组的(7.8±0.6)分(t=10.000,P<0.01)。联合治疗组、单纯激光组瘢痕末次治疗后6个月mVSS评分均明显低于首次治疗前[(13.5±0.7)、(13.8±0.6)分,t=8.805、9.010,P<0.01]。联合治疗组瘢痕治疗有效数明显多于单纯激光组(P<0.05)。2组瘢痕治疗过程中均未出现瘢痕加重、感染等不良反应。首次治疗前,2组瘢痕均有胶原粗大、排列紊乱,毛细血管增生,部分炎症细胞浸润,皮肤附属器消失。末次治疗后6个月,2组瘢痕胶原稀疏、排列较整齐,血管密度降低,联合治疗组较单纯激光组改善更加明显。末次治疗后6个月,联合治疗组瘢痕厚度明显小于单纯激光组(t=2.657,P<0.05)。首次治疗前,2组瘢痕内血流丰富;末次治疗后6个月,联合治疗组瘢痕血流较单纯激光组明显减少。结论二氧化碳点阵激光联合自体脂肪注射治疗烧伤后增生性瘢痕可明显减轻患者瘢痕的疼痛、瘙痒症状及改善瘢痕的厚度、质地及充血情况。两者联合治疗具有协同作用,且不良反应少,为增生性瘢痕患者提供一种更为有效的治疗手段。

Objective To explore the clinical effects of fractional carbon dioxide laser combined with autologous fat injection in the treatment of hypertrophic scar after burn.Methods From April 2018 to April 2019,12 patients with hypertrophic scar after burn who met the inclusion criteria were admitted to the Department of Plastic Surgery and Burns of Xuzhou Renci Hospital,and were included in this prospective randomized controlled clinical study.There were 7 males and 5 females with age of(32±11)years and scar area of(612±195)cm2.One scar was selected from each patient and divided into two equal area scars,and they were divided into combined treatment group and laser alone group with 12 scars in each group according to the random number table.The scar in laser alone group was only treated with fractional carbon dioxide laser,while the scar in combined treatment group was injected with autologous granular fat and then treated with fractional carbon dioxide laser.Scars in the two groups were treated once every 2 months,totally 3 times.Before the first treatment and 6 months after the last treatment,the scars in the two groups were evaluated by modified Vancouver Scar Scale(mVSS),hematoxylin-eosin staining and color Doppler ultrasound.Six months after the last treatment,the curative effect of scars in the two groups was evaluated,and the effective number of scar treatment was calculated.The adverse reactions during the whole treatment were recorded.Data were statistically analyzed with independent sample t test,paired sample t test,and McNemar exact probability method test.Results Six months after the last treatment,the mVSS score of scars in combined treatment group was(4.5±0.4)points,which was significantly lower than(7.8±0.6)points in laser alone group(t=10.000,P<0.01).Six months after the last treatment,the mVSS scores of scars in combined treatment group and laser alone group were significantly lower than those before the first treatment((13.5±0.7)and(13.8±0.6)points,t=8.805,9.010,P<0.01).The effective number of scar treatment in combined treatment group was significantly more than that in laser alone group(P<0.05).There was no scar aggravation,infection,or other adverse reactions during the treatment of scars in both groups.Before the first treatment,the scars in both groups had large collagen,disordered arrangement,proliferation of capillaries,infiltration of some inflammatory cells,and disappearance of skin appendages.Six months after the last treatment,the scar collagen in both groups was sparse and orderly arranged,and the vascular density was reduced.The improvement of scars in combined treatment group was more obvious than that of laser alone group.Six months after the last treatment,the scar thickness in combined treatment group was significantly smaller than that in laser alone group(t=2.657,P<0.05).Before the first treatment,the blood flow of scars in both groups was abundant;6 months after the last treatment,the blood flow of scars in combined treatment group was significantly less than that in laser alone group.Conclusions Fractional carbon dioxide laser combined with autologous fat injection in the treatment of hypertrophic scar after burn can significantly reduce the pain and itching symptoms of scar,and improve the thickness,texture,and congestion of scar.The combined treatment has synergistic effect and less adverse reactions,providing a more effective treatment for patients with hypertrophic scar.