预扩张肩胛皮瓣游离移植整复颈部瘢痕挛缩畸形的临床疗效

Clinical effects of free transplanted pre-expanded scapular flap in reconstructing scar contracture deformity of neck

目的探讨采用预扩张肩胛皮瓣游离移植整复颈部瘢痕挛缩畸形的临床疗效。方法采用回顾性观察性研究方法。2010年2月—2020年8月,空军军医大学第一附属医院收治17例(男9例、女8例,年龄8~42岁)符合入选标准的颈部瘢痕挛缩畸形患者,均于Ⅰ期行肩胛区域皮肤软组织扩张器(以下简称扩张器)置入术+Ⅱ期行预扩张肩胛皮瓣游离移植整复颈部瘢痕切除后创面。颈部瘢痕切除后的创面面积为12.0 cm×6.0 cm~30.0 cm×24.0 cm,皮瓣切取面积为13.0 cm×7.5 cm~31.5 cm×25.0 cm。15例患者供区创面直接拉拢缝合,2例患者供区创面移植腹部全厚皮片。Ⅱ期术后观察皮瓣存活情况。Ⅱ期术后6个月,对出现切口瘢痕挛缩的2例患者行Z成形矫正术。Ⅱ期术后6~9个月,对于体态偏胖或皮瓣近1/3处臃肿的5例患者行去脂修薄术。Ⅰ期术前及末次(Ⅱ期或Ⅲ期)术后6个月,测量患者颏颈角和颌颈角,以其角度值评价颈部瘢痕改善程度。随访时,观察颈部运动功能,受区皮瓣色泽、质地,供区瘢痕情况[采用温哥华瘢痕量表(VSS)进行评估]。对数据行配对样本t检验。结果Ⅱ期术后,15例患者皮瓣存活良好;2例患者皮瓣于术后24 h内出现静脉危象,行紧急探查并清除血栓+重新吻合血管后皮瓣存活良好。与Ⅰ期术前患者的颏颈角[(126±12)°]和颌颈角[(148±13)°]角度相比,末次术后6个月患者的颏颈角[(107±12)°]和颌颈角[(123±11)°]角度均明显减小(t值分别为10.68、6.54,P<0.05)。随访2年,患者颈部背伸、侧弯等运动功能无受限;受区皮瓣色泽、质地与颈部正常皮肤接近;供区瘢痕VSS评分为3、4、5、6、7分者,分别为1、3、7、5、1例。结论游离移植的预扩张肩胛皮瓣可为颈部瘢痕挛缩畸形松解后创面提供充足的组织量;扩张后的肩胛皮瓣软组织薄、顺应性好,有利于颈部形态重塑;供区相对隐蔽且切口张力小,因而该方法是矫正颈部瘢痕挛缩的有效方法之一。

Objective To investigate the clinical effects of free transplanted pre-expanded scapular flap in reconstructing scar contracture deformity of neck.Methods A retrospective observational study was conducted.From February 2010 to August 2020,17 cervical scar deformity patients(9 males and 8 females,aged 8-42 years)who met the inclusion criteria were admitted to the First Affiliated Hospital of Air Force Medical University.The patients underwent skin and soft tissue expander(hereinafter referred to as expander)implantation in scapular region in stage Ⅰ procedures,and the free transplanted pre-expanded flaps were used to resurface the wounds followed by neck scar resection in the stage Ⅱ procedures.The wound size after neck scar release was 12.0 cm×6.0 cm-30.0 cm×24.0 cm,and the size of the flap ranged from 13.0 cm×7.5 cm to 31.5 cm×25.0 cm.The wounds in donor site of 15 patients were sutured directly,and the wounds in donor site of 2 patients were covered with full-thickness skin graft from abdominal area.The survival of flaps was observed after the operation of stage Ⅱ.Six months after stage Ⅱ surgery,Z plasty was performed to treat the incision scar contracture in 2 patients.For the 5 patients of overweight or bloating appearance in the 1/3 proximal flap underwent debulking procedures in 6-9 months after stage Ⅱ surgery.Before the stage Ⅰ surgery and six months after the last procedure(stage Ⅱ or stage Ⅲ),mental cervical angle(MCA)and cervical mandibular angle(CMA)were measured and the improvement of neck scar was evaluated by the angle values.The cervical motor function,skin color and texture in recipient areas,and scar in the donor sites assessed by Vancouver scar scale(VSS)were observed during follow-up.Data were statistically analyzed with paired sample t test.Results After stage Ⅱ surgery,15 patients'flaps survived well;venous crisis occurred in 2 flaps within 24 h after operation,and the flaps survived well after emergency exploration and thrombus removal+vascular re-anastomosis.Compared with the angle values of MCA of(126±12)°and CMA of(148±13)°of patients before the stage Ⅰ surgery,the angle values of MCA of(107±12)°and CMA of(123±11)°of patients in six months after the last procedure were significantly decreased(with t values of 10.68 and 6.54,respectively,P<0.05).After 2 years of follow-up,the patient's neck dorsiflexion,lateral bending,or other motor functions were not restricted;the color and texture of the flap in recipient site were close to those of the normal neck skin;the patient cases with VSS scores of scarring of 3,4,5,6,and 7 were 1,3,7,5,and 1 case,respectively.Conclusions The free transplantation of the pre-expanded scapular flaps can provide sufficient tissue for wound coverage after the release of cervical scar contracture deformity;the expanded skin tissue is featured by thin soft tissue and good pliability,which is conducive to restore the neck appearance;the donor sites are relatively covert with less tension,therefore,the treatment is an effective method for correcting the contracture in the neck.