皮下远位减张缝合对张力性切口减张效果及临床应用的研究

发布时间：2018-01-22 05:24

本文关键词： 皮下远位减张缝合张力切口效果临床用的研究　出处：《山东大学》2017年博士论文　论文类型：学位论文

【摘要】：研究背景及意义:伤口或手术切口愈合后不可避免的产生不同程度瘢痕,瘢痕的形成与损伤程度、局部炎症、免疫反应、皮肤张力等众多因素有关。其中张力因素和愈合后瘢痕程度具有密切关系。如何充分减张,使得切口不但获得快速良好的愈合和不明显的术后瘢痕,仍然是一项具有挑战性的课题。近年改良的缝合技术研究的主要角度是观察相应新缝合技术对病理性瘢痕即增生性瘢痕和瘢痕疙瘩的治疗及预防,而对皮下缝合技术的减张程度研究较少,也较少涉及对生理性瘢痕程度评估观察和相关对比研究。我们在本研究中提出一种新的切口远位皮下减张缝合理念和皮下远位横向褥式减张缝合技术,通过体外减张实验与传统的减张缝合技术进行对比研究,证实皮下远位横向褥式减张缝合技术对张力性刀口具有可靠、持久的减张效果,我们将该减张缝合技术应用于面部瘢痕整形,对相应缝合切口的术后瘢痕外观进行评估、对比。使用近年最新国际上较广泛使用的瘢痕评估量表--患者与观察者瘢痕评估量表(POSAS量表,Patient and Observer Scar Assessment Scale)对我们应用的新缝合技术远期瘢痕情况进行了相关观察和评估,并和传统方法缝合切口的瘢痕情况进行了相关对比分析。第一部分研究目的:离体皮肤构建体外张力性切口模型,以切口皮下减张缝合后皮缘裂隙宽度、皮纹方向为观察指标,研究皮下远位横向褥式减张缝合对张力性刀口的减张效果。研究方法:腹壁整形切除的多余皮肤制作体外皮肤切口模型。将对称标本分为A、B两组,对A组切口行皮下埋没垂直褥式缝合,B组行皮下远位横向褥式减张缝合:于皮下脂肪面距离切缘2mm处进针,向外上勾住基底部分真皮组织后向外下弯转,从进针点向远处走行1cm出针,于经过出针点旁(平行于切缘方向)1cm处反向路径回针,出针点应位于切缘底部最初进针点旁1 cm,以同样方法于对侧做镜像操作,缝线打结。分别对两组切口给以2N、5N及100次最大值5N的周期性张力,测量两组切口裂隙宽度,固定张力方向定位近焦拍照,纹理浮雕处理观察切口两侧1cm范围内皮纹方向。研究结果:在不施加拉力时,两组缝合后切口均能较好的对合,切缘无缝隙。2N拉力下A组切口均出现裂隙,宽度0.6-1.5mm,平均宽度1.07mm,而B组仍然均无裂隙,对合良好,裂隙宽度记录为0mm。5N拉力下;A组标本切口裂隙宽度均增大,宽度1.1-2.8mm,平均宽度2.05mm,而B组切口仅有4例出现细小裂隙,宽度0.1-0.4mm,平均宽度0.08mm。100次周期性5N拉力作用后,A组切口裂隙均增宽,3.2-6.5mm,平均宽度4.84mm,B组仍然维持原来4例裂隙,裂隙宽度0.2-0.6mm,平均宽度0.10mm。切口皮纹经纹理浮雕效果处理后,皮肤皮纹方向可清晰可见。A组切口两侧1cm范围内皮纹松弛、无明显优势方向;B组切口两侧邻近及周边1cm范围内绝大多数皮纹呈现与拉力方向一致的拉伸。第一部分研究结论:远位皮下横向褥式减张缝合能使得张力性切口较好的减张对合。无论是静态性张力还是周期性动态张力下,远位皮下横向褥式减张缝合较皮下埋没垂直褥式缝合,都可有效的保持对合后切缘及两侧邻近皮肤较大范围的无张力状态。第二部分研究目的:将皮下远位横向褥式减张缝合技术应用于面部瘢痕整形,观测瘢痕宽度,并使用患者与观察者瘢痕评估量表(POSAS量表)对远期瘢痕情况进行了相关观察和评估,并和传统方法缝合切口的瘢痕情况进行相关对比分析。研究方法:随机选取面部瘢痕一次性切除或分次切除缝合患者作为研究对象。分为治疗组和对照组。瘢痕切除后,治疗组进行远位皮下横向褥式减张缝合切口;对照组采用皮下埋没垂直褥式缝合切口。术后拆线时观察刀口愈合情况。术后3月、6月进行瘢痕情况随访,对每位患者两组瘢痕瘢痕宽度测量、P0SAS瘢痕量表评分。研究结果:缝合后所有切口均能严密外翻性对合,治疗组患者切口缝合后隆起、外翻更加明显。瘢痕宽度的比较:术后3月治疗组瘢痕平均宽度1.02mm对照组1.32mm.两组设计定理资料的t检验。术后6月治疗组瘢痕平均宽度1.25mm对照组1.66mm.两组设计定量资料的t检验,差异均有计学意义(P0.05)。术后3月POSAS瘢痕量表评分:治疗组患者评分的各项评分之和均值14.56对照组18.91,总体印象分2.94对照组3.59。分别比较设计定量资料的秩和检验差异均有计学意义(P0.05)。观察者评分各项评分之和均值14.73对照组16.85,总体印象分1.94对照组3.28。分别比较设计定量资料的秩和检验差异,各项评分之和均值差异无统计学意义。但总体印象分差异有明显计学意义(P0.05).术后6月P0SAS瘢痕量表评分:治疗组患者评分的各项评分之和均值10.05对照组14.76,总体印象分2.1对照组2.96。分别比较设计定量资料的秩和检验差异均有计学意义(P0.05)。观察者评分各项评分之和均值9.89对照组13.33,总体印象分1.61对照组13.33。分别比较设计定量资料的秩和检验差异,各项评分之和均值差异和总体印象分差异均有明显计学意义(P0.05)。第二部分研究结论:皮下远位横向褥式减张缝合技术应用于面部瘢痕整形,能有效减小刀口张力,使得切缘良好的外翻和对合,大大减少真皮层缝线,与传统减张缝合相比,瘢痕宽度及P0SAS瘢痕量表评分显示术后瘢痕程度更轻,且瘙痒、疼痛等不适症状轻。本课题的研究结论:远位皮下横向褥式减张缝合能使得张力性切口较好的减张对合。无论是静态性张力还是周期性动态张力下,远位皮下横向褥式减张缝合较皮下埋没垂直褥式缝合,都可有效的保持对合后切缘及两侧邻近皮肤较大范围的无张力状态。该缝合方法可应用于于面部瘢痕整形,能有效充分减小刀口张力,使得切缘良好的外翻和对合,大大减少真皮层缝线,与传统减张缝合相比,瘢痕宽度及P0SAS瘢痕量表评分显示术后瘢痕程度更轻,且瘙痒、疼痛等不适症状轻。
[Abstract]:The research background and significance, have different degrees of scar inevitable wound or wound healing, scar formation and the degree of injury, inflammation, immune response, related to many factors. The skin tension tension factors and the scar degree has a close relationship. How to reduce tension, which not only get good incision healing and fast no obvious postoperative scar, is still a challenging task. The main point of the modified suture technique in recent years is a new technique to observe the corresponding suture pathological scar treatment and prevention of hypertrophic scar and keloid, and the subcutaneous suture technique for reducing tension of less degree, are less involved in physiological assessment of the degree of scar was observed and related to comparative study. We propose a new incision distal subcutaneous and distal subcutaneous reduction of Zhang Fenghe's idea of transverse mattress in this study Suture technique, through in vitro reduction suture technology experiment and comparing to the traditional research, confirmed that the subcutaneous distal transverse mattress suture technique for tension incision is reliable, long-lasting reduction effect, we will reduce the application of suture technique in a facial scar surgery, compared to the assessment the postoperative incision scar appearance. The use of the most recent international widely used scar assessment scale in patients with Observer Scar Assessment Scale (POSAS scale, Patient and Observer Scar Assessment Scale) of the new suture technique we used long-term scar was observed and assessed the situation and scar and the traditional method of suture of incision made comparative analysis. The first part of the study objective: in vitro in vitro skin incision tension model with incision subcutaneous suture after the skin edge crack width, The direction of striae was observed and the study of subcutaneous distal transverse mattress suture on the edge of the tension tension effect. Methods: abdominoplasty resection of redundant skin produced in vitro skin incision model. The symmetrical specimens were divided into A, B two groups, A group of incision of subcutaneous buried vertical mattress suture B group, subcutaneous distal transverse mattress suture in the distance: subcutaneous fat margin 2mm surface needle, outward hooked tissue basal portion of dermis outward bending, the needle from the needle points to walk away from 1cm, after the needle point adjacent (parallel to the cutting edge direction) 1cm reverse path back to the needle, the needle point should be located at the bottom of the initial margin entry point near 1 cm, in the same way as the mirror operation, to side suture. The two groups respectively with 2N incision, 5N and 100 times the maximum periodic tension of 5N, measuring the width of the two groups were fractured, fixed a force near focal orientation Take pictures, texture relief treatment observation of incision 1cm on endothelial grain direction. Results: in tension, two sets of stitched incisions were better on the cutting edge, seamless.2N tension A group incision appeared crack width of 0.6-1.5MM, the average width of 1.07mm, while the B group still had no crack the good, the width of the crack is recorded as 0mm.5N under tension; the width of A group were increased fracture incision, width of 1.1-2.8mm, the average width of 2.05mm, while the B group only 4 cases of small incision fissure, width of 0.1-0.4mm, the average width of 0.08mm.100 periodic 5N pulling force, A group were widened fracture incision, 3.2-6.5mm. The average width of 4.84mm, B group still maintain the original 4 cases of fracture, crack width of 0.2-0.6mm, the average width of 0.10mm. incision skin texture effect of relief after treatment, the skin striae direction can be clearly visible on both sides of the notch group.A 1cm range lines endothelial relaxation, no obvious The dominant direction; B group on both sides of the notch and the surrounding adjacent 1cm within the scope of the vast majority of dermatoglyphics show strain is consistent with the direction of pull. Conclusion: the first part of the study of distal subcutaneous transverse mattress suture can make the tension of reducing tension of incision better. Both static tension or periodic dynamic tension. The distal subcutaneous transverse mattress suture than the subcutaneous buried vertical mattress suture, can effectively maintain the state of tension free margin and a wide range of adjacent skin. The second part objective: subcutaneous distal transverse mattress suture technique applied to facial scar, scar width observation, and use patient and Observer Scar Assessment Scale (POSAS scale) on long-term scar were related to observation and assessment, and the scar and the traditional method of comparative analysis of suture of incision. Methods: a randomized study Select the disposable facial scar resection or partial excision suture patients as the research object. Divided into treatment group and control group. The treatment group after scar resection, distal subcutaneous transverse mattress suture incision; the control group by subcutaneous buried vertical mattress suture incision. Postoperative stitches observe wound healing after surgery. In March June, the scar follow-up for each of two groups of patients with scar width measurement, P0SAS scar score. Results: all incisions were sutured to the strict valgus of the patients in the treatment group, incision suture bulge, valgus more obvious. Comparison of scar width: t test for postoperative scar treatment group in March the average width of the 1.02mm control group 1.32mm. two group design theorem data. T test after June the average width of 1.25mm treatment group: the control group 1.66mm. two group design of quantitative data, the differences were statistically significant (P0.05) after operation. March POSAS scar scale score: treatment group scores in patients with the score of 14.56 and average of 18.91 in the control group, the overall impression is divided into 2.94 control group 3.59. compared the design of quantitative data test the differences were statistically significant (P0.05). The score of observer scoring average of 14.73 and 16.85 in the control group, the overall impression 1.94 the control group 3.28. compared the design of quantitative data test differences, no statistically significant difference between the score and mean. But the overall impression was statistically significant difference (P0.05). Postoperative June P0SAS scar scale score: treatment group scores in patients with the score of 10.05 and average of 14.76 in the control group, the overall the impression is divided into 2.1 control group 2.96. compared the design of quantitative data test the differences were statistically significant (P0.05). The score of observer scoring average of 9.89 and 13.33 in the control group, the overall impression is divided into 1.61 control group The rank sum test were compared between 13.33. quantitative data, the score and the mean difference and the overall impression of significant difference statistically significant (P0.05). The second part is the research conclusions: subcutaneous distal transverse mattress suture technique applied to facial scar, can effectively reduce the knife mouth tension, makes the cutting edge good valgus and involution, greatly reduce the dermal suture and traditional suture in scar width and P0SAS scar score showed that the postoperative scar less, and itching, pain and other symptoms of light. The research conclusion: the distal subcutaneous transverse mattress suture can make the tension of good for reducing tension of incision. Both static tension or periodic dynamic tension, distal subcutaneous transverse mattress suture than the subcutaneous buried vertical mattress suture, can effectively maintain the margin and adjacent to both sides No tension state wide range of skin. The suture method can be applied to the facial scar, can effectively reduce the impact of the full tension, good margin valgus and involution, greatly reduce the dermal suture and traditional suture in scar width and P0SAS scar score showed that the postoperative scar less, and itching, pain and other symptoms.

【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R622

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