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Chinese Journal of Burns and Wounds logoLink to Chinese Journal of Burns and Wounds
. 2022 Mar 20;38(3):251–255. [Article in Chinese] doi: 10.3760/cma.j.cn501120-20201201-00510

原位保留打孔断层瘢痕基质联合头皮移植与负压封闭引流治疗烧伤后非功能部位增生性瘢痕的临床效果

Clinical effects of in situ perforation of preserved split scar matrix in combination with scalp transplantation and vacuum sealing drainage in the treatment of hypertrophic scar in non-functional sites after burns

Yanbin Meng 1, Jin Lei 1, Hairui Zhang 1, Zhenming Hao 1, Peiyi Bai 1, Peng Duan 1,*
PMCID: PMC11705263  PMID: 35325970

Abstract

Objective

To investigate the clinical effects of in situ perforation of preserved split scar matrix in combination with scalp transplantation and vacuum sealing drainage in the treatment of hypertrophic scar in non-functional sites after burns.

Methods

A retrospective observational study was used. From June 2017 to June 2019, 33 patients (24 males and 9 females, aged 8-50 years) who met the inclusion criteria with hypertrophic scars in non-functional sites outside the face after burns were treated in General Hospital of TISCO (the Sixth Hospital of Shanxi Medical University). All patients underwent scalp transplantation after perforation of retained split scar matrix in situ (with scar thinning area of 90-500 cm2), and then the vacuum sealing drainage was performed. The hematoma and infection of wounds were observed on the 7th day after operation. At the same time, the survival rate of skin grafting was observed and calculated. The flatness and thickness of the scar in the operative area were observed in 12 months after operation, and the itching and pain of the patients were recorded. Vancouver Scar Scale was used to score the scar of patients before operation and at 3, 6 and 12 months after operation. The healing time and hair growth of donor site were observed. Data were statistically analyzed with repeated analysis of variance, paired sample t test and bonferroni correction.

Results

On the 7th day after operation, local subcutaneous hematoma appeared in the wound of 2 patients, which healed after dressing change; no infection occurred. On the 7th day after operation, the survival rate of skin grafting of patients was 94.6%-99.0%(96.8±1.2)%. Scar flatness was well, the thickness of scar was not significantly higher than that of normal skin in 12 months after operation, and the symptoms of itching pain of patients disappeared or significantly relieved. Vancouver Scar Scale scores of patients before operation and at 3, 6, and 12 months after operation were 12.1±2.8, 8.5±1.5, 7.6±1.6, 6.7±1.3, respectively, and the scores of 3, 6, and 12 months after operation were all significantly lower than that before operation (with t values of 4.48, 4.06, and 3.97, respectively, P < 0.01). All the donor sites of the head healed well in 4-7 days after operation. By 3-6 months after operation, all patients had good hair growth in the donor site and achieved no scar healing.

Conclusions

The treatment of hypertrophic scar in non-functional sites outside the face after burns by in situ perforation of preserved split scar matrix in combination with scalp transplantation and vacuum sealing drainage can effectively improve the appearance of hypertrophic scar in non-functional areas after burn and reduce its degree of hyperplasia, with scar-free donor site healing.

Keywords: Cicatrix, Skin transplantation, Negative-pressure wound therapy, Scar matrix, Hypertrophic scar

增生性瘢痕（HS）由烧伤后组织过度修复所致。在烧伤创面愈合的过程中, 胶原合成与降解之间的平衡被破坏, 如果胶原的合成超过降解, 就会有大量不规则组织堆积, 进而形成HS[1-2]。

HS会导致一系列身体不适, 如疼痛瘙痒以及反复破溃等使患者生活质量受到影响, 同时HS还可能引发严重的心理问题。所以, HS的防治一直是重点研究和探讨的热门课题。

目前国内外瘢痕治疗方法比较成熟的包括压力治疗、放射治疗、超声波治疗及激光治疗等[3-7]。如果瘢痕发生在关节部位, 可导致关节畸形、功能障碍等问题, 严重影响患者生活质量, 为患者首先选择处理的瘢痕, 一般采用手术的方法矫正畸形, 包括中厚皮移植术、全厚皮移植术、刃厚皮片联合人工真皮移植术以及皮肤扩张术等[8-9]。

头皮是人体天然的宝贵皮库, 供皮后毛发仍可自然生长。受韩军涛等[10]报道的以断层瘢痕组织支架结合自体刃厚皮整复后期大面积烧伤畸形取得良好效果的启发, 本研究团队对前述术式进行改良, 设计原位保留打孔断层瘢痕基质联合头皮移植与VSD治疗非功能部位HS, 患者以供皮区无瘢痕愈合的最小代价获得瘢痕外观及增生程度的改善, 临床效果佳。

1. 对象与方法

本回顾性观察性研究符合《赫尔辛基宣言》的基本原则, 所有入选患者均签署知情同意书。

1.1. 入选标准

纳入标准：患者年龄为3~60岁, HS面积为1%~5%TBSA, 温哥华瘢痕量表评分为13~15分, 位于面部及关节以外非功能部位的HS行原位保留打孔断层瘢痕基质头皮移植术治疗者。排除标准：合并精神障碍、凝血功能障碍、内分泌系统疾病、严重脏器疾病者。

1.2. 临床资料

2017年6月—2019年6月, 太钢总医院（山西医科大学第六医院）收治符合入选标准的患者33例, 其中男24例、女9例, 年龄8~50岁。患者HS部位：前臂7例、上臂3例、后背5例、小腿5例、大腿13例, 其中3例患者瘢痕表面有溃疡, 溃疡面积2~6 cm2。33例患者的瘢痕削薄面积为90~500 cm2。本次入院时间为创面愈合后1~2年, 患者均有不同程度的瘙痒或疼痛感, 瘢痕表面颜色部分为深红色、质地偏硬、厚度高于周围皮肤。

1.3. 手术方法

在全身麻醉下进行手术, 四肢部位的手术在止血带下进行；后脊部位的手术于躯干或臀部注射含肾上腺素生理盐水（配置比例为1∶50万）肿胀液, 一般每1%瘢痕面积注射200 mL。然后用滚轴刀削除HS, 直至基底保留1~2 mm厚度的平整瘢痕基质为止, 在此平面用23号手术刀片间隔0.5~1.0 cm密集网状戳直径5~10 mm小孔, 使挛缩的瘢痕基质松解、小孔张开, 似网状人工真皮支架状即可, 至此打孔断层瘢痕基质制备完成。瘢痕基质中没有大的血管, 表现为密集广泛的点状渗血, 可先用含肾上腺素生理盐水（配置比例为1∶10万）浸湿的纱布轻微加压5~10 min, 再精确电凝止血, 确保彻底止血后进行植皮。头部取皮前预先注射含肾上腺素生理盐水（配置比例为1∶30万）肿胀液以减少出血, 一般每次注射900~1 000 mL。用电动取皮刀切取厚度为0.15~0.25 mm的大张自体刃厚皮片, 移植于瘢痕基质, 采用订皮机固定。应用负压泵或医院中心负压将外覆负压材料固定, 行持续VSD治疗, 压力设置为-10.6 kPa。头部供皮区内层应用凡士林油纱, 外层应用无菌棉垫加压包扎, 并于术后第2日去除外层敷料, 待其自然愈合。瘢痕植皮区域一般在植皮术后7 d换药, 换药时去除植皮区负压材料并拆除订皮机皮钉。术后3~6个月内, 植皮区进行弹力压迫治疗及应用抗瘢痕药物。

1.4. 观测指标

1.4.1. 创面愈合情况及自体植皮成活率

术后7 d换药时, 观察受区创面有无血肿及感染, 同时计算植皮成活率。用无菌透明膜覆盖于植皮后创面上, 用画线笔沿植皮创面边缘画线, 标记创面植皮范围和植皮成活区域范围, 将薄膜取下, 转移到面积计算网格纸上, 计算植皮成活面积, 植皮成活率=植皮成活面积÷植皮面积×100%。

1.4.2. 瘢痕情况

术后12个月, 观察受区瘢痕平整度及厚度, 记录患者痒痛情况。术前及术后3、6、12个月, 采用温哥华瘢痕量表对患者瘢痕情况进行评分, 主要从瘢痕色泽（色泽与正常皮肤近似为0分、色泽较浅为1分、色泽介于较浅与较深之间为2分、色泽较深为3分）、厚度（0 mm为0分、 > 0且≤1 mm为1分、 > 1且≤2 mm为2分、 > 2且≤4 mm为3分、 > 4 mm为4分）、血管分布（瘢痕红润程度与正常皮肤近似为0分、肤色偏粉红为1分、肤色偏红为2分、肤色呈紫色为3分）、柔软度（正常为0分、柔软为1分、柔顺为2分、质硬为3分、弯曲为4分、挛缩为5分）共4个方面进行评估, 量表最高分为15分, 评分越高表示瘢痕越严重。

1.4.3. 供皮区愈合情况

观察术后供皮区愈合时间及头发生长情况。

1.5. 统计学处理

采用SPSS 21.0统计软件进行数据分析。计量资料数据均符合正态分布, 以x ± s表示, 总体比较行单组重复测量方差分析, 两两比较行配对样本t检验, 并对P值进行Bonferroni校正。P < 0.05为差异有统计学意义。

2. 结果

2.1. 创面愈合情况及自体皮成活率

术后7 d, 2例患者创面出现局部皮下血肿, 经外用重组人表皮生长因子凝胶换药后愈合；无感染病例, 未出现非计划二次手术情况。术后7 d, 33例患者植皮成活率为94.6%~99.0%（96.8±1.2）%。

2.2. 瘢痕情况

术后12个月, 瘢痕平整度可、厚度未见明显高于正常皮肤, 患者痒痛症状消失或较治疗前明显减轻。术前及术后3、6、12个月, 患者瘢痕的温哥华瘢痕量表评分分别为（12.1±2.8）、（8.5±1.5）、（7.6±1.6）、（6.7±1.3）分, 总体比较差异有统计学意义（F=1 253.04, P < 0.001）。与术前相比, 患者术后3、6、12个月的瘢痕温哥华瘢痕量表评分均明显降低（t值分别为4.48、4.06、3.97, P值分别为0.003、0.001、0.001）。

2.3. 头部供皮区愈合情况

所有患者头部供皮部位均在术后4~7 d愈合良好, 头发正常生长, 长度为1~3 mm。术后3~6个月, 所有患者头部供皮区头发生长良好如前, 达到无瘢痕愈合。

2.4. 典型病例

患者男, 42岁, 双前臂火焰烧伤导致瘢痕增生1.5年收治入本研究单位。患者右前臂HS面积为210 cm2, 颜色暗红、压之不褪色, 伴痒痛, 温哥华瘢痕量表评分为15分。入院后4 d, 行右前臂瘢痕削薄、保留断层瘢痕基质, 间隔0.5~1.0 cm进行密集戳孔（孔径大小为5 mm）, 然后行大张头皮移植、VSD术。头部供皮区创面用纱布加压包扎, 患肢抬高制动。术后7 d, 自体皮成活率为99.1%, 植皮部位渗液细菌培养结果为阴性。患者于入院第19天痊愈出院, 术后6个月内常规外用抗瘢痕药物及弹力压迫治疗。术后3、6、12个月, 患者瘢痕情况的温哥华瘢痕量表评分分别为7、6、3分。术后1年复查, 瘢痕整体外观特别是厚度及痒痛等不适症状明显改善头发生长良好, 达到无瘢痕愈合。见图 1。

图 1.

图 1

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原位保留打孔断层瘢痕基质联合头皮移植与负压封闭引流治疗患者前臂烧伤后增生性瘢痕。1A.术前右前臂瘢痕外观；1B.右前臂瘢痕削薄即刻, 原位保留瘢痕基质进行打孔；1C.术后6个月复查, 瘢痕较术前变薄, 整体外观及瘢痕不适症状改善；1D.术后12个月复查, 瘢痕整体外观特别是厚度得到明显改善

3. 讨论

以往针对瘢痕患者只对影响功能的瘢痕进行进一步手术治疗, 而对于非功能部位的瘢痕往往采取传统的外用抗瘢痕药物、弹力压迫等进行治疗[11-14]。随着生活水平的提高, 患者希望所有瘢痕均得到有效的治疗, 特别是部分瘢痕患者难以长期忍受瘢痕痒痛刺激。以往的手术方法是将瘢痕组织全层切除, 并移植中厚皮或者全厚皮对创面进行修复, 但中厚皮及全厚皮对于烧伤面积较大的患者来说是十分宝贵的资源, 临床医师更希望将其留在患者面颈部等美容部位或关节等功能部位使用, 而且中厚皮及全厚皮供皮区在取用后会不可避免地再次留下瘢痕或者色素沉着, 从而对患者造成再次伤害。采用人工真皮支架联合自体薄皮片治疗HS也是一种有效的治疗方法[15-19], 但人工真皮支架来源有限、价格昂贵, 不属于医疗保险报销范畴, 对患者来说是不小的负担。

通过削除部分瘢痕制备成打孔断层瘢痕基质, 这一点在以往治疗瘢痕的文献中鲜见报道。前述术式可彻底松解瘢痕基质, 同时1~2 mm瘢痕基质厚度类似人工真皮, 具有成熟、韧实的特点, 可起支撑固定作用, 形成一个网状瘢痕支架, 有效避免了瘢痕再次挛缩。韩军涛等[10]报道的瘢痕整复方法也取得了良好效果, 但断层的瘢痕组织有失活坏死的可能。本研究中将打孔断层瘢痕基质保留在原位, 不存在坏死风险, 而且基质本身是有血运的, 这使得头皮移植后更容易成活, 植皮成功率更高。植皮术后, 传统方法中采用包扎或局部打石膏实现对皮片加压, 但这种方法会使受区压力分布不均匀, 可能会产生死角, 导致部分皮片成活较差；负压治疗使移植皮片与基底紧密贴合, 封闭了无效腔, 对于植皮创面分泌物的引流、皮片的固定均具有良好作用。持续负压抽吸可以充分、及时地将皮片下积血积液引流出来, 且用于密封伤口的半透膜可将伤口与外界隔离, 降低皮片下组织感染的发生率[20-22]。此外, 负压抽吸的作用还有利于毛细血管生成和组织愈合, 增加创面血流灌注, 抑制创面感染, 减轻组织水肿, 改善局部微循环, 促进新生血管生长[23-25], 这些保证了植皮成活率, 特别适用于躯干、臀部等不易包扎的非功能部位。本研究中, 术后3、6、12个月, 患者痒痛等不适感均较治疗前有明显改善, 瘢痕的温哥华瘢痕量表评分均较术前明显降低。头皮是全身皮肤最厚的部位, 毛囊深、数量多, 血液供应丰富, 抗感染能力强, 愈合快, 不留瘢痕, 能反复供皮10次以上[26-28], 因此本研究选用头皮作为供皮区, 避免了切取中厚皮或全厚皮“拆东墙补西墙”带来的损失, 供皮区可无瘢痕愈合, 最大限度减少手术不良反应, 可以最小成本给患者带来最大收益。本组患者对手术效果均表示非常满意。本研究不足之处：样本量偏少, 未与传统的瘢痕全层切除移植全厚皮以及人工真皮联合自体刃厚皮进行对照研究。

该手术注意事项：（1）适合面部以外非功能部位的瘢痕。（2）尽量一次削除瘢痕到位, 避免反复削薄, 可以先进行小片瘢痕削薄以调整滚轴刀刻度。（3）瘢痕基质打孔的长轴方向应选择垂直于瘢痕挛缩应力线, 以彻底松解瘢痕基质。（4）术中瘢痕基质应止血彻底, 防止术后形成皮下血肿, 影响皮片成活。（5）术毕, 患者从手术室到病房的转运过程中, 应使用可移动便携式负压泵对术区进行持续负压固定皮片, 防止转运过程中皮片移位。

综上, 原位保留打孔断层瘢痕基质联合头皮移植与VSD治疗面部以外非功能部位HS能以供皮区无瘢痕愈合的最小代价, 改善患者整体外观及不适症状, 值得临床进一步推广。本技术在使用时要严格掌握其适应证, 目前仅适用于因痒痛不适, 或瘢痕反复溃破等影响患者生活质量, 且处于成熟期、非功能部位的HS。

Footnotes

利益冲突  所有作者均声明不存在利益冲突

作者贡献声明  孟艳斌、段鹏：负责本研究相关人员的工作分配及文章撰写、数据整理和提交；雷晋：提供了本研究的实验思路、数据处理方法等指导性工作；张海瑞：负责本研究的数据整理和分析；郝振明、白培懿：负责病例的收集和汇总

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