供皮区皮片打孔扩张原位回植取皮术的临床效果

Introduction of a kind of skin graft in situ replantation with punched skin grafting in donor site

目的探讨供皮区皮片打孔扩张原位回植取皮术在中小面积皮肤移植手术中的应用效果。方法选择2002年1月至2019年12月河南省人民医院整形美容外科收治的各种原因造成的皮肤软组织缺损患者为A组,以鼓式取皮机于供皮区切取一整鼓中厚皮片,面积200~220 cm^(2),取皮机根部皮片不予离断,根据所需面积获取取皮机游离部皮片,移植于术区创面,间断缝合,打包包扎;供皮区剩余皮片则以15号手术刀片均匀打孔后,覆盖所有供区创面,间断缝合,加压包扎。选择同期同一科室其他医疗组收治的同类患者,供皮区采用传统直接暴露法包扎,为B组。患者术后门诊随访,观察供皮区愈合情况及局部瘢痕增生程度,并参照温哥华瘢痕量表对瘢痕进行评分。应用SPSS 9.4软件进行数据统计学分析,定量资料以M(Q_(1),Q_(3))表示,采用Mann-WhitneyU检验进行分析;定性资料以卡方检验进行分析。P<0.05为差异有统计学意义。结果A组共纳入63例患者,男性45例,女性18例,年龄5~83岁,创面面积40~80 cm^(2),术后除1例患者面部植皮区皮片撕脱,2例皮片下血肿形成、皮片部分成活,1例术后感染、皮片成活不良外,其余患者受区皮片均成活良好,供区一期愈合。B组共纳入59例患者,男性38例,女性21例,年龄4~78岁,皮肤缺损面积为40~80 cm^(2)。2组患者术后均获7~12个月随访,A组供区愈合时间为11.1(10.2,12.2)d,未出现皮肤色素沉着、严重增生性瘢痕、供区延迟愈合等情况,4例出现轻度瘢痕增生,无瘢痕疙瘩发生,温哥华瘢痕量表评分为3(2,4)分。B组愈合时间为15.8(13.9,17.5)d,愈合后出现增生性瘢痕23例,瘢痕疙瘩2例,温哥华瘢痕量表评分为17(17,17)分。A组和B组患者愈合时间比较,差异有统计学意义(P<0.01);2组温哥华瘢痕量表评分比较,差异有统计学意义(P<0.01);2组增生性瘢痕发生率比较,差异有统计学意义(P<0.01)。结论改良的供皮区皮片打孔扩张原位回植取皮术与传统的取皮术相比,供皮区皮片完整,厚薄均匀,原位回植于供皮区创面后血运建立快,供皮区无创面裸露,一期愈合后肤色自然,瘢痕不明显,更加符合人体皮肤功能与美学要求。

Objective To investigate the effect of the replantation in situ of donor skin graft with perforation and expansion in small and medium-sized skin transplantation.Methods Patients were selected as group A with skin and soft tissue defects caused by various reasons treated in the Plastic and Aesthetic Surgery Department of Henan Provincial People’s Hospital from January 2002 to December 2019.A medium thick skin piece was harvested from the donor area with a drum dermatome,covering an area of 200-220 cm^(2).The skin piece at the root of the drum dermatome was not broken,but the free skin piece of the drum dermatome was removed to the required area,transplanted to the wound surface,stitched intermittently and dressed with packing heap.The remaining skin graft in the donor area was punctured evenly with No.15 surgical blade,then covered all the wounds in the donor area,sutured intermittently,and bandaged under pressure.The same kind of patients treated in other medical groups in our department in the same time were selected as group B.The skin donor area was not covered with skin graft in situ,but wrapped with traditional gauze.The patients were followed up in the outpatient department after operation,when the healing of the donor skin area and the degree of local scar was evaluated for data statistical analysis.The scars were scored according to Vancouver Scar Scale.The quantitative data were expressed in M(Q_(1),Q_(2)),and were analyzed by Mann-Whitney U test.The qualitative data were analyzed by Chi-square test.P<0.05 was statistically significant.Results Group A had 63 cases,except for 1 case of graft avulsion,2 cases of hematoma under the skin with partial survival of skin graft,1 case of poor survival of infected skin graft after operation,the other skin grafts in the recipient area survived well.Group B included 59 patients,38 males and 21 females,aged from 4 to 78 years old,with a skin defect area of 40 to 80 cm^(2).The patients in both groups were followed up for 7-12 months.The healing time in group A was 11.1(10.2,12.2)days.There were no skin pigmentation,severe hypertrophic scar and delayed healing of donor area.Four cases had mild scar hyperplasia and no keloid.The score of Vancouver Scar Scale was 3(2,4).The healing time of group B was 15.8(13.9,17.5)days with 23 cases of hypertrophic scar and 2 cases of keloid after healing.The score of Vancouver Scar Scale was 17(17,17).There was significant difference in healing time between group A and group B(P<0.01);there was significant difference in Vancouver Scar Scale scores between the two groups(P<0.01);what’s more,there was significant difference in the number of cases of hypertrophic scar between the two groups(P<0.01).Conclusions Compared with the traditional skin transplantation,the improved technology of the replantation in situ of donor skin graft with perforation and expansion has the advantages of intact skin,uniform thickness,timely blood circulation establishment after transplantation,no wound exposure in the donor area,natural skin color after primary healing,less scar and more in line with the skin function and aesthetic requirements of human body.