三维数字化技术在耳廓再造临床应用中的探讨

发布时间：2018-04-24 11:41

本文选题：三维数字化技术 + 耳廓再造　；参考：《北京协和医学院》2017年博士论文

【摘要】：耳廓再造是整形外科最困难和精细的手术之一。耳支架的雕刻制作是耳廓再造手术的基础和核心。先天性小耳畸形患者虽然具有一定的共性特征,因为每个人的耳廓形态各异,很难制定一个适用于所有人的耳支架雕刻的精确标准,对于外伤性耳缺损患者,常因外伤原因不同而造成不同部位不同程度的缺损,这更加给医生的治疗增加了难度,需要个性化的术前评估和术中设计。肋软骨作为耳支架雕刻的主体材料,其发育好坏是决定耳廓再造手术时机的关键因素,同时采取肋软骨对患者的创伤较大,术后还会造成不同程度的胸廓畸形;考虑到畸形对患儿心理发育的影响,许多学者倾向于6岁左右进行治疗,但是手术时机的选择仍然存在着巨大的争议。因为手术技术难度大,这就要求医生有过硬的操作技术、精准的完成手术的各个步骤,传统的治疗方法也不再能满足患者个性化治疗的需求。三维数字化技术快速发展及在医学中的广泛应用使得精准个性化的治疗成为可能,让耳廓再造也向着更加系统、精准、个性化的方向发展。研究目的:1.应用三维数字化技术辅助小耳畸形患者手术时机的选择。2.应用三维数据化技术制作肋软骨模型模拟耳支架雕刻辅助手术方案的设计及手术教学。3.应用三维数字化重建技术辅助外伤性耳缺损患者的个性化治疗。研究方法:1.收集2016年1月-2016年6月在中国医学科学院整形外科医院耳再造一中心治疗的6岁单侧先天性小耳畸形患者,通过术前胸廓CT扫描三维重建和耳廓表面扫描获取相应数据,测量双侧6、7、8肋软骨的长、宽和健侧耳廓有效耳轮的长度,评估软骨量能否实现耳支架的雕刻。2.选择2016年2月2016年6月就诊于中国医学科研院整形外科医院耳再造一中心的病人10例,通过术前CT扫描和三维重建,构建肋软骨的数字化模型。选取合适的材料,应用增材制造技术制作出实体肋软骨模型,应用模具进行术前手术设计并模拟雕刻过程,优化手术方案。3.收集2015年3月-2016年2月于中国医学科学院整形外科医院耳再造一中心入院治疗的单侧外伤性耳缺损患者12例,术前进行三维扫描获取患者耳廓三维数据信息,通过患侧与健侧对比,评估缺损量,制作个性化耳廓模型,制定个性化的手术方案,术后半年再次行三维扫描获取术后双侧耳廓三维数据信息,测量健侧耳廓与患侧再造耳长宽高及周长,两组数据进行配对T检验,进行术后评估。结果:1.右侧6、7、8肋软骨的平均长度分别为76.1 ±9.2mm(61.1mm-94.9mm),102.6±9.9mm(84.5mm-119.1mm),75.4±19.3mm(47.3mmm-118.5mm)。左侧 6、7、8 肋软骨的平均长度分别为 78.0±9.6mm(63.2mmm-98.6mm),103.8±11.5mm(68.5mm-125.8mm),74.3±16.0mm(53.8mm-115.0mm)。左侧第 6 肋软骨较右侧第6软骨要更长和更宽,P值分别为0.004和0.007。右侧第7、8肋软骨的长度及第7肋软骨的宽度较左侧并没有显著差异,P值分别为0.464、0.763和0.693。耳轮的平均长度为90.5 ± 6.8 mm(76.9mm-101.5 mm),将右侧第7、8肋软骨长度与有效耳轮长度进行配对T检验,结果显示第7肋软骨要明显长于有效耳轮长度(P=1.2*10-4)可以实现耳廓支架耳轮的雕刻,而第8肋软骨无法满足需求,37例患者采用组织扩张法进行耳廓再造,手术效果满意。2.通过多种材料试验对比,TPU和聚氨酯材料可以进行肋软骨模具的制作。制作的类软骨模具与真实软骨形态相近,可以用于术前手术设计和手术模拟,聚氨酯材料雕刻难度小,更适于手术教学。10例病人在术前明确手术方案的情况下,均得到了一个满意的治疗效果。3.健侧耳廓平均长度、宽度、周长、高度分别为62.4±4.0mm(57.8mmm-68.8mm),30.7±2.3mmm(28.1mm-34.0mm),108.5±7.5mm(98.7mm-119.6mm),20.0±3.7mmm(14.2mm-25.6mm)。再造侧耳廓平均长度、宽度、周长、高度分别为63.4±5.1mm(55.6mm-71.4mm),32.5 ± 2.6mm(28.5mm-36.0mm),110.0 ± 7.9mm(96.lmmm-121.6mm),18.6±2.4mmm(13.Omm-21.6mm)。将健侧耳廓与患侧耳廓测量数据进行逐一配对T检验,耳廓长度P=0.3110.05,耳廓周长P=0.1530.05,耳廓高度P=0.1270.05,差异无统计学意义;耳廓宽度P=0.0010.05,差异有统计学意义。结论:1.胸部CT三维重建可有有效的评估患者的软骨量是否能满足耳廓再造手术需要,并且6岁患儿的软骨量足以满足组织扩张法耳廓再造的需要,综合患者生理和心理两方面的考虑,我们认为6岁是进行组织扩张法耳廓再造手术的最佳年龄。2.通过三维数字化重建和增材制造技术,可以制作出逼真的肋软骨实体模具,帮助医生在术前实现手术方案的设计、模拟手术雕刻过程,从而有效的减少设计误差,优化手术方案,达到一个更好的手术效果。同时还可以让年轻医生有机会进行耳支架雕刻实地操作练习,更加深刻生动的学习设计手术方案,锻炼操作技能。3.三维数字化技术可以为各种类型的外伤性耳缺损找到最合适的个性化治疗方案,同时还可以辅助手术中耳软骨支架的雕刻,并对术后效果作出客观的分析,对于辅助耳缺损患者的治疗作用显著。
[Abstract]:Auricle reconstruction is one of the most difficult and fine operations in plastic surgery. The engraving of the ear stents is the basis and core of the reconstruction of the auricle. Although the congenital microtia patients have some common characteristics, it is difficult to establish an accurate standard for the engraving of all the ears for everyone. Patients with traumatic ear defects, often caused by different causes of trauma, cause different degrees of defect in different parts. This adds to the difficulty of the doctor's treatment. It needs individualized preoperative assessment and intraoperative design. The rib cartilage is the main material for the engraving of the ear stents. The development of the rib cartilage is the key factor to determine the timing of the auricular reconstruction. The trauma of the costal cartilage to the patient is greater, and the thoracic deformity of different degrees will be caused after the operation. Considering the effect of the malformation on the psychological development of the children, many scholars tend to be treated around 6 years, but the choice of the timing of the operation still exists a huge controversy. Because the surgical technique is difficult, it requires the doctor to have excellent operation. Technology, the precise completion of the various steps of the operation, the traditional methods of treatment can no longer meet the needs of individual patients. The rapid development of 3D digital technology and the extensive application in medicine make it possible for the precise and personalized treatment to make the reconstruction of the auricle more systematic, accurate and individualized. 1. application of three-dimensional digital technology to assist the selection of the operation time of the patients with small ear malformation.2. application three-dimensional data technology to make the design of the rib cartilage model simulation ear stent engraving scheme and the operation teaching.3. application three-dimensional digital reconstruction technique to assist the individualized treatment of traumatic ear defect patients. Research methods: 1. collection of 2 In January, 016 years, 016 years -2016, a 6 year old single congenital microtia of congenital microtia treated with a central ear reconstruction in Plastic Surgery Hospital, CAMS, PUMC, the corresponding data were obtained by the preoperative thoracic CT scan three-dimensional reconstruction and the auricular surface scanning. The length of the bilateral 6,7,8 costal cartilage was measured, and the length of the effective ear auricle was measured, and the measurement of cartilage energy was evaluated. .2. selected 10 patients with a center of ear reconstruction in the plastic surgery hospital of Chinese Medical Scientific Research Institute in June 2016 February 2016. The digital model of costal cartilage was constructed by CT scanning and three-dimensional reconstruction before operation. Suitable materials were selected and the model of solid rib cartilage was made by using the technology of material adding, and the mold was applied. 12 cases of unilateral traumatic ear defect were collected in February March 2015 -2016 year in one center of the ear reconstruction of Plastic Surgery Hospital, CAMS, PUMC, 12 cases of unilateral traumatic ear defect were collected in February March 2015. The individual auricle model was made, individualized operation scheme was made, and three dimensional scan was performed half year after the operation to obtain the three dimensional data of bilateral auricle, and the height and circumference of the lateral auricle and the reconstructed ear were measured. The two groups of data were paired T test and the postoperative evaluation was performed. Results: the average length of the 1. right 6,7,8 costal cartilage. 76.1 + 9.2mm (61.1mm-94.9mm), 102.6 + 9.9mm (84.5mm-119.1mm), 75.4 + 19.3mm (47.3mmm-118.5mm). The average length of the left 6,7,8 costal cartilage was 78 + 9.6mm (63.2mmm-98.6mm), 103.8 + 11.5mm (68.5mm-125.8mm) and 74.3 + 16.0mm. The left sixth costal cartilage was longer and wider than the right of the sixth cartilage. The length of the 7,8 rib cartilage on the right side of 0.004 and 0.007. and the width of the 7 rib cartilage were not significantly different. The average length of the P value of the 0.464,0.763 and 0.693. auricle was 90.5 + 6.8 mm (76.9mm-101.5 mm). The length of the cartilaginous cartilage in the right part of the ribbed and the effective ear length were paired T. The results showed that the cartilage of the seventh rib was obvious. An effective ear wheel length (P=1.2*10-4) can be used to engraving the auricle of the auricular stents, while the eighth rib cartilage can not meet the needs. 37 cases of the auricle can be reconstructed by tissue expansion. The effect of the operation is satisfactory to.2. through a variety of materials test and comparison. TPU and polyurethane materials can be made of the rib cartilage mold. The true cartilage is similar and can be used for preoperative design and operation simulation. The urethane material is less difficult to engraving and is more suitable for the surgical teaching of.10 patients. The average length, width, and circumference of the.3. side auricle are 62.4 + 4.0mm (57.8mmm-68.8mm), with a satisfactory therapeutic effect. 30.7 + 2.3mmm (28.1mm-34.0mm), 108.5 + 7.5mm (98.7mm-119.6mm), 20 + 3.7mmm (14.2mm-25.6mm). The average length, width, and circumference of the reconstructed lateral auricle were 63.4 + 5.1mm (55.6mm-71.4mm), 32.5 + 2.6mm (28.5mm-36.0mm), 110 + 7.9MM (96.lmmm-121.6mm) and 18.6 +. According to one by one T test, the length of the auricle was P=0.3110.05, the perimeter of the auricle was P=0.1530.05, the height of the auricle was P=0.1270.05, and the difference was not statistically significant. The width of the auricle was P=0.0010.05, and the difference was statistically significant. Conclusion: 1. the three-dimensional reconstruction of the chest CT can effectively assess whether the cartilage volume of the patient can meet the needs of the auricle reconstruction, and the 6 year old child. The quantity of cartilage is sufficient to meet the needs of tissue expansion and auricle reconstruction. In combination with two aspects of physiological and psychological considerations, we think that 6 years old is the best age for tissue expansion of auricle reconstruction..2. can make realistic rib cartilage molds by three-dimensional digital reconstruction and material enhancement. The design of the operation plan, the simulation of the surgical engraving process, which can effectively reduce the design error, optimize the operation plan, achieve a better operative effect. At the same time, it also allows the young doctor to have the opportunity to carry out the field operation practice of the ear stent engraving, the more vivid study and the design of the operation plan, the exercise skills.3. three dimensional figures. The technology can find the most suitable individualized treatment for various types of traumatic ear defects, and can also assist the engraving of the ear cartilage scaffold in the operation, and make an objective analysis of the postoperative effect, and the therapeutic effect is significant for the patients with auxiliary ear defect.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R764.9

【相似文献】