微粒皮漂浮与皮浆移植修复特重度烧伤患者创面的疗效对比

背景:采用微粒皮漂浮的方法行微粒皮移植已成为近30年来修复特重度烧伤创面经典术式,并取得了良好的临床疗效.然而,采用皮浆涂抹的方法行微粒皮移植也能取得较好的治疗效果,但对此两种疗效办法的对比尚无报道.目的:观察皮浆移植法行微粒皮移植的临床疗效,并与常规微粒皮漂浮移植法进行对比.方法:选取特重烧伤患者72例,采用自身对照的方法,每例患者选取较为对称、创面性质相同的2处Ⅲ度烧伤切痂创面进行对照.皮浆移植组采用皮浆涂抹的方法行微粒皮移植,微粒皮漂浮组采用微粒皮漂浮的方法行微粒皮移植.应用网格计数法统计微粒皮移植后3,4和5周末2组创面愈合率.结果与结论:移植后第3,4和5周末扩张比在12.5:1以下的2段,两组创面愈合率基本相近(P0.05),提示微粒皮漂浮与皮浆移植均为治疗大面积深度烧伤的良好方法.扩张比在12.6:1以上的2段,微粒皮漂浮组明显优于皮浆移植组(P<0.05或P<0.01),表明当扩张比超过12.5:1的情况下,有必要选用微粒皮漂浮法行微粒皮移植.     

交联型猪脱细胞真皮基质与自体微粒皮复合移植的临床应用

目的:观察交联型异种(猪)脱细胞真皮基质与自体微粒皮复合移植修复大面积深度烧伤早期切痂创面的疗效。方法:选择2001-09/2006-10在珠海市人民医院暨南大学医学院第三附属医院整形烧伤科就诊的中面积和大面积深度烧伤患者16例共48个观测创面,患者均知情同意。患者于伤后3～5d休克期平稳渡过后行肢体创面切痂术,自体微粒皮移植组观测24个创面,均位于复合皮移植组创面的邻近或对侧肢体相同部位。①复合皮移植组:切痂创面用交联型异种(猪)脱细胞真皮基质(由江苏启东医疗用品研究所提供) 自体微粒皮复合移植 异体皮覆盖。②自体微粒皮移植组:切痂创面用自体微粒皮移植 异体皮覆盖。术后6周异体皮脱落,两组散在肉芽创面行小邮票状皮片补充移植修复创面。术后定期观察创面愈合情况,计算创面愈合率及收缩率,并行创面组织学检测。结果:两组48个创面均进入结果分析,无脱落。①两组异体皮成活情况相近。②术后6周,复合皮移植组患者的创面愈合率均显著低于自体微粒皮移植组(P<0.05);经补充植皮后即术后8周两组创面愈合率差异无显著性意义(P>0.05)。③移植术后6,8,12周,复合皮移植组患者的移植创面收缩率均显著低于自体微粒皮移植组[(10.28±2.36)%,(16.25±3.78)%;(15.68±1.79)%,(30.42±3.65)%;(22.07±1.39)%,(42.83±2.74)%(P<0.05)]。④术后8周组织学观察结果显示,复合皮移植组创面愈合处上皮化良好,胶原纤维排列有序,基底膜结构完整;自体微粒皮移植组上皮层仍较薄,细胞分化不良,真皮内胶原排列较紊乱。结论:交联型异种(猪)脱细胞真皮基质与自体微粒皮复合移植修复大面积深度烧伤早期切痂创面,能够抑制瘢痕增生,改善创面愈合质量,疗效满意。     

同基因异体皮肤移植在危重烧伤病人治疗中的应用

目的：探讨同基因异体皮临床应用效果。方法：经术前准备，l例严重烧伤病人双手背深度创面切痴后，用同卵孪生子异体皮覆盖；其余切痴创面植自体微粒皮加大张同种异体皮。结果：双手背植皮区未现察到排斥现象，而其余植皮区异体皮则最终排斥。结论：同基因异体皮移植后，皮片可长期存活。     

纤维蛋白黏合剂的止血作用对烧伤修复植皮的影响

目的:观察纤维蛋白胶应用于烧伤深二度植皮手术中的削痂创面和供皮区创面渗血的止血效果。方法:随机选择2003-01/05第三军医大学西南医院烧伤研究所烧伤后需行植皮手术患者24例,术中选取相邻部位或对称部位的供皮区及削痂创面,进行自身同体对照,实验组创面使用纤维蛋白胶;对照组使用生理盐水,观察并记录创面出血量及止血时间。结果:实验组24例平均出血量为1.04g,出血时间为5.71s,对照组24例平均出血量3.46g,出血时间为86.58s。试验组的止血效果显著优于对照组(P<0.01)。结论:纤维蛋白胶运用于烧伤植皮手术削痂创面及供皮区时,有确切的止血效果。     

大面积Ⅲ度烧伤三种植皮方法的临床效果比较

【目的】探讨大面积Ⅲ度烧伤三种手术方法的效果和特点。【方法】1985年1月至2008年12月应用保痂肉芽创面植皮、切痂微粒皮植皮、削痂微粒皮植皮三种治疗方法,处理156例大面积Ⅲ度烧伤创面并对治疗结果进行分析。【结果】创面平均愈合时间：保痂肉芽创面植皮组（65．6±9．8）d,切痂微粒皮植皮组（53．8±9．2）d,削痂微粒皮植皮组（45．5±9．5）d。保痂组病程长,病人消耗大,并发症发生率高,死亡几率增大;切痂组手术损伤重,对病人烧伤后第二次打击大,愈后外形和功能差,丧失了皮肤附属器,对功能康复影响大;削痂组创面愈合快,并发症少,疤痕平坦、柔软。【结论】伤后及时清除坏死组织,对创面进行有效的覆盖,对加快创面愈合,减少创面侵袭性感染,减少脓毒症的发生,保护各脏器的功能,缩短病程,减少医疗费用非常重要。削痂微粒皮植皮治疗大面积Ⅲ度烧伤,可保留皮肤组织的部分功能,减少疤痕,愈后外形和功能良好。     

脱细胞异体真皮在功能部位深度烧伤早期治疗中的应用

12例III度烧伤创面早期切削痂,采用脱细胞异体真皮+自体薄皮复合移植固定,与创面行刃厚皮片移植做对照观察。随访4～12个月,证实复合移植皮肤愈合质量优于对照部位创面。     

纤维蛋白黏合剂的止血作用对烧伤修复植皮的影响

目的：观察纤维蛋白胶应用于烧伤深二度植皮手术中的削痂创面和供皮区创面渗血的止血效果。方法：随机选择2003-01／05第三军医大学西南医院烧伤研究所烧伤后需行植皮手术患者24例，术中选取相邻部位或对称部位的供皮区及削痂创面，进行自身同体对照，实验组创面使用纤维蛋白胶；对照组使用生理盐水，观察并记录创面出血量及止血时间。结果：实验组24例平均出血量为1.04g，出血时间为5．71s，对照组24例平均出血量3．46g，出血时间为86．58s。试验组的止血效果显著优于对照组(P&;lt;0．01)。结论：纤维蛋白胶运用于烧伤植皮手术削痂创面及供皮区时，有确切的止血效果。     

异种(猪)脱细胞真皮与自体微粒皮复合移植的疗效观察

目的用异种(猪)脱细胞真皮与自体微粒复合移植解决烧伤患者自体微粒皮移植术后功能欠佳的问题。方法5例男性,TBSA50％～95％,Ⅲ度30％～70％,异种脱细胞真皮移植100～150cm2,采用两步法,外层覆盖异体皮。结果术后4～6周异体皮脱落,创面愈合80％左右,复合皮移植处外观平整,皮肤弹性及关节功能较对照部位好。半年后复诊关节功能正常,疤痕增生不明显。结论异种(猪)脱细胞真皮来源容易、价格低廉,与自体微粒皮复合移植,疗效满意。     

复合皮片移植治疗烧伤后功能部位瘢痕20例

目的:观察复合皮片移植对烧伤后功能部位瘢痕的修复效果。方法:选择2002-05/2005-12在柳州医学高等专科学校第一附属医院烧伤整形科住院的复合皮片移植治疗烧伤功能部位瘢痕患者20例,患者均知情同意。所有病例均在全麻下行功能部位瘢痕切除,将脱细胞异体真皮(广西北生药业北京桀亚莱福生物技术有限公司生产,物理性能柔软、有弹性、弯曲不易断裂、乳白色、呈网状、分光洁面与粗糙面)移植于创面上,异体真皮粗糙面紧贴创面,光洁面朝上,缝合创周。取自体薄皮片(取自头皮、躯干或四肢)移植于异体真皮上,皮片间隙尽量小,以减少异体真皮外露。术后2周换药,术后定时随访。观察术后2周~1年复合皮的移植成活率、挛缩率、平整光滑度、皮肤弹性、关节部位功能恢复情况及供皮区愈合情况。结果:20例患者复合皮移植后随访时间1个月~1年,1~3个月4例,4~6个月3例,7个月~1年13例。31个部位复合皮移植一期成活30个部位,另1个部位创面因自体皮片间隙过大异体真皮外露影响皮片成活,植皮成活率达93.00%。植皮区外观平整,较光滑,弹性尚可,挛缩轻,关节功能活动良好。供皮区愈合良好。结论:复合皮片移植成活率高,能明显改善烧伤功能部位瘢痕所致功能障碍及外观畸形。     

保留部分真皮微粒皮浆移植对深Ⅱ度创面愈合的影响

深Ⅱ度烧伤创面愈合时间长,愈合后多产生不同程度的瘢痕及瘢痕挛缩而导致的功能障碍和外观异常。贾赤宇等[1]认为,能否明显地加速创面愈合和有效地控制后期瘢痕增生是目前烧伤治疗的重点和难点,同时也是烧伤治疗水平高低的质量指标。鉴此,作者设计了深Ⅱ度烧伤创面削痂保留部分自体真皮后行微粒皮浆移植对深Ⅱ度创面愈合时间、愈合瘢痕等进行了前瞻性研究,以寻找一种可解决深Ⅱ度创面愈合时间长及愈合后功能障碍和外观异常的方法。1临床资料与方法入选标准:①住院年轻病人;②热液烫伤或火烧伤;③烧伤后7 d内创面;④创面未感染或溶痂;⑤同侧…     

Acellular porcine dermal matrix produced with different methods and an experimental study on its transplantation to skin wound.]

OBJECTIVE: To observed the effect of healing quality of composite skin grafting consisting of acellular porcine dermal matrix combined with autologous split-thickness skin graft. METHODS: Porcine skin was treated with dispase II/triton X-100 or hyperosmotic saline/sodium-dodecyl-sulfate (SDS) respectively, and acellular porcine dermal matrix I (APDMI) and APDM II were obtained. Sixty-three Sprague-Dawley rats with full-thickness skin defects on the back were separately covered with APDMT + split-thickness autologous skin, or APDM II + split-thickness autologous skin. The quality of wound healing was observed, the rates of survival and contraction of the grafts were calculated, the tissue samples were harvested for histological examination, and compared with that of autologous split-thickness skin graft. RESULTS: The wound healing quality of composite skin I, and II was good. There was no significant difference in the rate of survival and contraction of the grafts between the two composite skin grafting groups. It was indicated by histological examination intact basal membrane. There was no significant difference in the survival rate between composite skin grafting groups and autologous split-thickness skin at the 6 th week after operation, but the contraction rates of the grafts in the composite skin groups were lower. CONCLUSION: Full-thickness skin defect can be healed by covering with acellular porcine dermal matrix produced by two methods combined with split-thickness autolograft, and it can help improve the quality of wound healing.     

组织工程皮肤修复皮肤缺损成功率与手术方法的相关性

背景:皮肤缺损的常规修复方法多采用自体皮肤移植,需要健康供皮区且会遗留不同程度的瘢痕畸形。组织工程皮肤的成功构建并应用于临床,标志着皮肤缺损治疗的重大突破。目的:通过组织工程皮肤修复皮肤缺损,分析手术方法与愈合率的关系,为组织工程皮肤的临床应用提供实验依据。设计:随机对照观察。单位:解放军第四军医大学口腔医学院口腔颌面外科,组织病理学教研室,组织工程实验中心。材料:实验于2003-10/2004-03在解放军第四军医大学口腔医学院口腔组织工程实验中心完成。选用2.5～3月龄健康清洁级约克猪6只,随机分为3组:组织工程全层组、组织工程真皮 自体表皮组、自体移植组,2只/。每只猪制作8个直径50mm的圆形皮肤缺损创面,16个创组面/组,共48个创面。方法:①制备组织工程全层皮肤和组织工程真皮。②组织工程全层组:沿画线自脂肪层切除全厚皮肤,彻底止血,以湿生理盐水纱布覆盖创面备用,此时取出组织工程全层皮肤并于组织工程皮肤上均匀打引流孔以利引流,用生理盐水冲去组织工程皮肤表面的培养液,使表皮层向上平铺于创面上,注意与创面间不能产生气泡。其上分别覆盖单层油纱布,生理盐水纱布、无菌干纱布、弹性海绵垫,每层厚度约为3～5mm,常规打包包扎,最后再以弹性绷带加压包扎。③组织工程真皮 自体表皮组:以同样方法切除全厚皮肤,将取下的皮肤用取皮鼓反取厚约0.1～0.2mm的刃厚表皮泡于生理盐水中备用。以同样方法取出处理组织工程真皮后覆盖于创面上,即刻覆盖自体刃厚表皮。其余处理同组织工程全层组。④自体移植组:切除全厚皮肤并去除脂肪组织后,回植于自体创面,覆盖各层敷料,加压包扎。⑤每次换药打开创面时,移植皮肤无感染、坏死、脱落且直径不小于3mm即为成活,否则即为失败。于术后4周统计各组创面成活率。主要观察指标:术后4周各组移植皮肤成活情况。结果:术后4周时,组织工程全层组移植皮肤成活率75%,组织工程真皮 自体表皮组移植皮肤成活率87%,自体移植组移植皮肤成活率94%,3组比较基本相似(χ2=2.34,P>0.05)。结论:组织工程皮肤移植修复皮肤缺损的效果与自体表皮移植接近,证明组织工程皮肤修复皮肤缺损是可行的。     

异种(猪)无细胞真皮基质与自体微粒皮复合移植修复深度烧伤创面的实验研究

目的　观察异种 (猪 )无细胞真皮支架与自体微粒皮加同种异体皮复合移植修复全层皮肤缺损的效果。方法　 4 8只 SD大鼠背部全层皮肤缺损创面 ,分别行异种 (猪 )无细胞真皮支架与自体微粒皮移植(复合皮组 )和单纯微粒皮移植 (对照组 ) ,术后定期观察创面愈合情况并行创面愈合率和收缩率的计算 ,同时取创面组织进行组织学观察。结果　复合皮组的创面愈合情况良好 ,未见明显挛缩 ,皮肤弹性较好 ,两组异体皮成活情况及创面愈合情况相近 ,但是复合皮组创面收缩率显著低于对照组。组织学观察复合皮组上皮化良好 ,胶原纤维排列有序 ,基底膜结构完整。结论　异种 (猪 )无细胞真皮支架与自体微粒皮复合移植能修复全层皮肤缺损 ,改善创面愈合质量。     

表皮干细胞联合脱细胞真皮构建人工皮肤促进创面愈合的实验研究

目的探讨表皮干细胞联合脱细胞真皮构建人工皮肤促进创面愈合的可行性。方法（1）用胰蛋白酶和EDTA联合消化法分离表皮,用Ⅳ型胶原快速黏附法分离、纯化人表皮干细胞,以含表皮生长因子、角质细胞无血清培养液等组成人表皮干细胞培养基进行体外培养,测定克隆形成率。（2）将培养人表皮干细胞接种于制备的脱细胞真皮支架中,构建组织工程人工皮肤,移植治疗兔全层皮肤缺损创面,观察创面修复效果。（3）取新西兰白兔常规制作背部全层皮肤缺损创面,随机分为4组：A、B、C组分别用含表皮干细胞的组织工程皮肤、含角质细胞的组织工程皮肤和单纯脱细胞真皮移植于皮肤缺损创面;D组用创面空置为对照。观察创面修复情况、局部炎症反应,并记录创面愈合时间。结果体外培养的人表皮干细胞增殖稳定,克隆形成率明显高于角质细胞对照组（P〈0．05）。移植后A组创面愈合良好,局部炎症反应轻微,无出血、积脓、坏死,创面愈合时间较B、C、D组明显缩短（P〈0．05或P〈0．01）。结论以表皮干细胞作为种子细胞联合脱细胞真皮构建人工皮肤可用于皮肤缺损创面的修复治疗。     

Split skin graft application over an integrating, biodegradable temporizing polymer matrix: immediate and delayed

The objective of this study is to further investigate the NovoSorb? biodegradable polyurethane in generating dermal scaffolds; to perform a pilot study comparing the previously used spun mat against a recently developed NovoSorb? foam, ascertaining the optimum structure of the matrix; and to evaluate the successful matrix as an immediate adjunct to split skin grafting and as a temporizing matrix in a prospective six-pig study. A pilot study comparing a previously investigated form of the polymer (spun mat) against a new structural form, a foam, was performed. This was followed by a six-pig study of the foam matrix with three treatment arms-autologous split skin graft alone, polymer foam with immediate engraftment, and polymer foam with delayed engraftment. The foams allowed less wound contraction than the spun mats. The foam structure is less dense (cheaper to produce and having less degradation products). The material remained in situ despite clinical wound infection. Proof of concept was achieved in both treatment modalities in the main study. Split skin graft applied immediately over the polymer foam was able to engraft successfully. The result was "thicker" to pinch and "flush" with the skin surrounding the wound. There was no significant difference in the degree of wound contraction between the graft alone and the polymer plus immediate graft groups. Split skin graft also "took" when applied to the surface of a polymer that had been applied to a wound 11 days earlier, again with a thicker result, flush with the surrounding skin. Split skin grafts alone left a persisting depression. However, a significant degree of wound contraction (compared with the other two groups) was observed in the polymer plus delayed graft group. This has prompted further investigation into "sealing" the polymer foam with a membrane, to prevent evaporative water loss, when the foam is to be used as a biodegradable temporizing matrix. The studies indicate that the NovoSorb? platform will allow the creation of two inexpensive dermal matrix products; an immediate scaffold to allow a thicker grafting result and a biodegradable temporizing matrix (BTM) for wound integration after burn debridement while donor sites become reharvestable. However, further modification on the BTM structure is necessary to further reduce wound contraction pregrafting.     

Reduced wound contraction after grafting of full-thickness burns with a collagen and chondroitin-6-sulfate (GAG) dermal skin substitute and coverage with biobrane

Full-thickness burns destroy both the epidermal and dermal tissues of the skin. This study evaluates a collagen and chondroitin-6-sulfate dermal skin substitute (graft) that was applied to excised full-thickness burns and covered with Biobrane. Experimental conditions included: (a) no burn, subcutaneous implantation of the graft; (b) burn, excision, graft, coverage with Biobrane and bandages; (c) burn, excision, no graft, coverage with Biobrane and bandages; (d) burn only. forty-one days post-surgery, subcutaneous implantation (N = 3) of the graft caused no detectable contraction or necrosis of the overlying skin, whereas all burn wounds contracted. Measurements of wounds (percentage of original wound size) showed statistically significant differences between the following treatments; (a) graft plus Biobrane (N = 10), 34%; (b) no graft plus Biobrane (N = 9), 25%; (c) untreated burns (N = 6), 16%. Semi-quantitative evaluation of time to healing indicated by spontaneous detachment of Biobrane from wounds showed that grafted, excised wounds healed in an average of 2.7 weeks, while ungrafted, excised wounds required an average of 4.3 weeks to heal. Histological appearance of healed wounds after grafting and coverage with Biobrane resembles undamaged skin without epidermal adnexal structures. Excision of full-thickness burn eschar, followed by grafting with a collagen and chondroitin-6-sulfate dermal skin substitute and coverage with Biobrane provides reduced wound contraction within a six-week period of observation compared to non-excised wounds. Both more rapid and more complete wound healing took place compared to excised wounds that were not grafted.     

重组人表皮细胞生长因子对供皮区创面的修复

背景:传统的供皮区创面修复以抗感染、支持及保护创面为主,最终为自然愈合,时间较长.研究表明,重组表皮生长因子促进皮肤切割、烧伤等动物模型创面的愈合,加速表皮再生的速度.目的:验证重组表皮生长因子对供皮区创面的修复效果.方法:选择泸州医学院附属医院整形烧伤科需要自体植皮修复创面的患者共32例,男18例,女14例.将32处新鲜供皮区创面随机均分为对照组和治疗组.治疗组将重组表皮生长因子药液(15 mL/支,2 000 IU/mL)直接喷洒于单层内敷纱布上直至浸透,然后覆盖到供皮区,2次/d;对照组将单层生理盐水纱布覆盖供皮区,外加敷料包扎,2次/d.48 h后,采用半暴露疗法.主要观察从治疗开始至供皮区完全愈合所需要的时间,不良事件及副反应,治疗前、后血常规及肝肾功能检测.结果与结论:在重组表皮生长因子喷洒组较生理盐水喷洒组明显缩短创面愈合时间,两组间比较具有显著差异(P<0.01).重组表皮生长因子喷洒组未见明显的不良事件及副反应发生.提示经重组人表皮细胞生长因子处理后,能明显缩短创面的愈合时间,减少了瘢痕的过度增生,在加速创面愈合及再上皮化中具有显著的促进作用.     

β射线照射皮肤损伤创面注射骨髓间充质干细胞后的创面愈合

背景：13射线皮肤损伤创面难愈,尚无有效的治疗方法。目的：观察骨髓间充质干细胞对13射线皮肤损伤创面愈合的影响。方法：①选用SD雌性大鼠3只分离培养骨髓间充质干细胞,传代细胞生长至第5代,DAPI标记细胞,制备骨髓间充质干细胞悬液。②选3月龄清洁级SD雌性大鼠47只,随机分为3组：治疗组应用直线加速器产生的β射线（45Gy）单次照射大鼠臀部皮肤40rnm×30mm,建立急性深Ⅱ度β射线皮肤损伤动物模型,创面出现后将骨髓间充质干细胞悬液注入大鼠创面皮下及真皮层;对照组13射线照射同治疗组,创面出现后注射安慰剂,用法同治疗组。正常组为正常大鼠。光镜下观察治疗后1,2,3,4周各组大鼠创面组织病理学变化,免疫组织化学方法检测CD31、CK4、成纤维细胞生长因子含量的动态变化。结果与结论：治疗组创面愈合时间比对照组明显加快（P〈0．05）。治疗组注射骨髓间充质干细胞细胞悬液后1-4周CD31、CK4、成纤维细胞生长因子阳性细胞值明显高于对照组（P〈0．05）。证实骨髓间充质干细胞能促进β射线皮肤损伤创面的愈合,缩短创面愈合的时间。     

Evaluation of new absorbable Lactomer subcuticular staple.

The most recent advance in skin sampling is the Auto Suture SQS -20 disposable stapler. It approximates and everts wound edges, placing one synthetic absorbable pin in the dermis each time the instrument handle is activated. Staple wound closure was accomplished four times faster than sutural closure of the dermis. Wounds with staple pin closure exhibit superior resistance to infection than wounds approximated by dermal sutures. Although sutures provide more immediate wound security, as measured by wound breaking strength, than dermal pins, the breaking strength of wounds subjected to either dermal pins or dermal sutures were not significantly different 14 days after wounding.     

网状中厚皮片移植联合负压封闭引流修复皮肤软组织缺损

目的：探讨网状中厚皮片移植联合负压封闭引流修复皮肤软组织缺损的疗效。方法：对19例皮肤撕脱伤创面及皮肤坏死创面患者均采用网状中厚皮片移植,以VSD材料覆盖植皮创面,修剪边缘后缝合固定于周围健康皮肤,封闭整个植皮区。24 h持续负压吸引5-7 d。结果：17例移植皮片全部存活,创面愈合。2例皮片存活95%以上,经换药后创面愈合。随诊0.5-1 a,创面外观、功能恢复良好。结论：网状中厚皮片移植联合负压封闭引流修复皮肤软组织缺损能及早封闭创面,降低感染的发生,促进皮片与创面良好贴附,有利于皮片存活,是一种简便、有效的修复皮肤软组织缺损创面的治疗方法。