超量扩张皮肤的血流量改变与安全性的实验研究

目的通过动物实验，研究不同扩张量的皮肤血流量的变化与皮瓣存活的关系。方法以小型猪（香猪）为动物模型，实验分为7组：①1／2注水量组；②3／4注水量组；③注水满量组；④注水量超50％组；⑤注水量超100％组；⑥埋置扩张器不扩张的延迟对照组；⑦正常皮肤的空白对照组。测量不同注水量时皮肤的血流量及其波幅的变化和皮瓣成活的长度，进行比较和统计学分析。结果随着注水量的增加，扩张皮肤的血流量和皮瓣的成活长度均增加，但微血管的运动波和不稳定性亦同时增加。尤其是超量注水100％后，皮肤的血流量和皮瓣的成活长度反而下降。结论在皮肤软组织扩张术中，适度的超量扩张能增加任意型皮瓣的成活长度，增加修复缺损的面积。但过度扩张，注水量超过100％时皮瓣的成活反而下降，影响修复的效果。     

扩张皮肤中b-FGF和EGF的含量与扩张量的关系

目的　研究皮肤软组织扩张术中 ,扩张程度对皮肤中碱性成纤维细胞生长因子 (b FGF)和表皮生长因子 (EGF)含量的影响。方法　以香猪为动物模型 ,实验分为 7组 :注水 1 2量组、注水 3 4量组、注水满量组、注水超量 5 0 %组、注水超量 10 0 %组、手术对照组、空白对照组。各实验组的注水时间均为 10周 ,测量各组皮肤中b FGF和EGF含量并进行统计学处理。结果　扩张皮肤中b FGF和EGF含量增加 ,与正常皮肤相比差异有显著性意义 (P <0 0 5 ) ,超量扩张后其增加更加显著 ,与正常皮肤相比差异有非常显著性意义 (P <0 0 1)。结论　皮肤扩张可引起皮肤b FGF和EGF含量增加 ,其所导致的生物学效应 ,应可能与表皮细胞的增生和扩张皮瓣的血管化程度有关。     

扩张皮瓣注水量与安全性的实验研究

目的 研究不同注水量的扩张皮瓣组织学变化与皮瓣存活率的关系.方法 以中国小型猪为动物模型,实验分为5组:①标准注水组;②超量50％注水组;③超量100％注水组;④不扩张对照组;⑤正常皮肤对照组.每头猪分别在背部两侧共设计4个5 cm×7 em埋植100 ml圆柱形扩张器的手术区域和1个正常皮肤对照区域,测量不同注水量对皮肤和皮瓣存活率的影响,并应用SPSS 13.0软件,行多因素方差分析.结果 随着注水量的增加,皮瓣的存活率亦增加,但超量注水100％后,扩张皮瓣的存活率反而下降.结论 在皮肤软组织扩张术中,适度的超量扩张能提高皮瓣的存活率,增加修复缺损的面积.但注水量超过100％时皮瓣的存活反而下降,影响修复的效果.     

超量扩张在修复面部软组织缺损中的应用分析

目的:利用皮肤软组织扩张器的弹性以及皮肤在持续外力作用下的舒张性,探讨使用小额定容量的扩张器超量扩张在修复面部软组织缺损中的可行性。方法:将23枚扩张器埋入19例患者面部待修复的区域周围,注水量达到额定容量后仍继续注水超量扩张,直至扩张皮肤量能满足二期手术的需要。扩张完成后取出扩张器并手术修复缺损。结果:全部患者术后皮瓣均存活,效果满意,随访1个月~2年,皮瓣的外观、颜色、质地均与周围皮肤无明显差异。结论:选择小额定量的扩张器能减少术区的损伤范围,超量扩张能较常规扩张提供更多的额外皮肤,在面部创面修复中具有其独特的优势。     

超量扩张皮瓣修复大面积皮肤缺损

目的：讨论超量扩张皮瓣用于修复大面积缺损的可行性和风险。方法：24例患者置入83枚扩张器，进行超过额定容积的注水扩张。对注水过程、并发症和术后效果进行分析评价。结果：随扩张器注水增加，皮瓣面积也有增加。扩张皮瓣转移后成尊尚好，效果较满意，但是当超额定容积后并发症有所增多。结论：超量扩张是获得大面积皮瓣的有效方法，但应注意防治并发症。     

相邻接轴型皮瓣间血管交通支于皮肤扩张术后变化的定量研究

目的以血管造影的方法，观察相邻接轴型皮瓣间血管交通吻合支于皮肤扩张术后变化的定量分析研究，为皮瓣的血供提供更加确凿的依据。方法于巴马猪双侧侧腹壁形成以旋髂深血管为蒂的轴型皮瓣，并分别与双侧的腹壁上动静脉轴型皮瓣相连，一侧于血管交接部位埋置皮肤扩张器为实验组，另一侧为非扩张对照组。扩张完成后，于颈动脉灌注明胶一氧化铅混悬液，获得皮肤血管的x线影像。在该图像上两血管大致的交通部位设计等距的3条平行线垂直于两血管的长轴方向，总的宽度以能覆盖所有的交通支为准，计数平行线与该区域内的血管支的切割数，并进行统计学分析。结果实验组平行线与交接区动脉切割数为81．20±10．33，对照组为22．40±5．41，两组之间比较差异有统计学意义（P〈0．01）。结论血管交通支的计量方法能真实反映血管交通支的改变，并可运用于其他实验和临床的相关研究。     

围术期体温维护对移植皮瓣成活影响的临床研究

目的 探讨皮瓣移植围术期体温维护对皮瓣成活的影响。方法 2005年7月～2006年11月，对择期行皮瓣移植修复术、美国麻醉医师协会分级Ⅰ～Ⅱ级的50例患者，分为试验组和对照组（n=25）。试验组采用变温水毯和加压空气加热器维持患者体温正常，对照组不作任何处理，仅监测温度。每隔15min记录患者鼻咽温度（pharyngeal temperature，PT）和皮肤温度（skin temperature，ST），此外记录手术室温度、手术时间、麻醉时间、术毕至拔管时间、术中输血量、术中补液量及术后7d皮瓣成活情况。结果试验组与对照组手术室温度、麻醉时间、手术时间、术中输血量及补液量，各指标组间差异均无统计学意义（P〉0．05）。麻醉后45min，试验组与对照组PT均下降，与插管时比较差异有统计学意义（P〈0．05），但组间比较差异无统计学意义（P〉0．05）；试验组与对照组ST均升高，与插管时比较差异有统计学意义（P〈0．05）。麻醉45min后，试验组PT维持在36C，而ST与插管时比较，差异无统计学意义（P〉0．05）；对照组PT和ST随时间延长而逐渐下降，与插管时比较差异有统计学意义（P〈0．05）；试验组各监测时间点PT和sT均高于对照组（P〈0．05）。试验组皮瓣均成活，对照组2例皮瓣发生坏死。结论术中维护患者的正常体温有助于提高皮瓣成活率，麻醉医师在皮瓣移植术中应进行体温监测并应积极维持正常体温。     

乳突区超量扩张皮瓣与颞浅筋膜瓣联合包裹多孔高密度聚乙烯支架全耳廓成形术

目的 探讨应用乳突区超量扩张皮瓣联合颞浅筋膜瓣包裹多孔高密度聚乙烯( Medpor)支架行全耳廓成形术的效果.方法 手术分三期进行:第Ⅰ期在乳突区置入皮肤软组织扩张器,并超量注水扩张;第Ⅱ期将扩张器取出并形成蒂在前的扩张皮瓣、掀起以颞浅血管为蒂的颞浅筋膜瓣,应用乳突区超量扩张皮瓣与颞浅筋膜瓣联合由里至外包裹Medpor耳支架完成全耳廓成形术,第Ⅲ期为残耳处理及耳垂再造.结果 临床应用12例,随访3个月至1年,耳支架外露发生1例,形成的耳廓外形逼真,轮廓分明,肤色与周围正常皮肤一致.结论 应用乳突区超量扩张皮瓣与颞浅筋膜瓣双层组织瓣联合包裹Medpor耳支架,可以获得更多的皮肤面积并提高Medpor耳支架置入的安全性,避免发生外露,又不影响支架外形和轮廓的显现,制作的耳廓表面皮肤的色泽与周围皮肤一致.     

双扩张器重叠埋置与单扩张器埋置术皮肤扩张率与即刻回缩率的比较研究

目的 对比研究单腔双扩张器重叠埋置与单个扩张器埋置术的皮肤扩张率与即刻扩张皮瓣回缩率的差别.方法 2009年3月至2012年3月,对22例共39处需行扩张器埋置术者,于24处单腔重叠埋置2个扩张器,15处单腔埋置1个扩张器.采用“湿布样”法测量扩张皮瓣的面积,同时测量手术时需要分离的皮下囊腔面积大小,即扩张皮肤的面积,并计算单位面积皮肤的扩张率.二期手术前在扩张皮瓣的中央取两定点距离5 cm,取出扩张器后,再次测量这两定点的距离,采集数据并计算扩张皮瓣的即刻回缩率.结果 在扩张周期(P=0.06)无明显差异的情况下,单腔重叠埋置双扩张器组与单腔单扩张器埋置组的皮肤扩张率分别为(3.5±0.9)％和(2.6±0.6)％,差异有统计学意义(P=0.002);二者的扩张皮瓣即刻回缩率分别为(30.3±0.8)％和(32.3±0.9)％,差异无统计学意义(P=0.47).扩张皮瓣即刻回缩率与扩张周期呈现负相关性,相关系数r=-0.768.结论 重叠埋置双扩张器的手术方法增加了单位面积皮肤的扩张率,扩张皮瓣即刻回缩率较传统方法相差无异,所以可供利用的扩张皮肤量绝对数增加了,同时减少大面积缺损时反复扩张的次数,特别适用于乳突区,超过周径一半的四肢缺损以及大面积躯干病变等.     

多个皮肤扩张器包绕式埋置修复颈胸部瘢痕畸形

目的:探讨利用多个皮肤扩张器包绕式埋置修复颈胸部瘢痕畸形的临床效果。方法:本组28例患者,根据颈胸部瘢痕周围正常皮肤面积及形状,埋置不同容量的多个扩张器,共72枚,定期注水扩张,掌握好扩张速度,扩张期2~4个月,超量扩张不超过扩张器容量的2.2倍;当达到每8~10ml注水量对应1cm~2瘢痕的比例时停止注水,7~14d后行二期手术,纤维包膜适当处理后,扩张皮瓣交错转移修复瘢痕。结果:本组除1例因对扩张器过敏,改为其他术式,其余均完成二期手术,皮瓣血运良好,外观改善明显。结论:多个皮肤扩张器包绕式埋置修复颈胸部瘢痕畸形,在注重细节基础上,均可完成手术预期目的,疗效满意。     

Continuous perioperative monitoring of microcirculatory blood flow in pectoralis musculocutaneous flaps

Hypovolemia and hypotension in traumatized patients as well as those undergoing long-lasting surgical procedures lead to hypoperfusion of tissues. Combined with the trauma of flap elevation and the warm ischemia during performance of the anastomoses, hypoperfusion of flap tissues may lead to flap failure. The influence of hypovolemia, ischemia and reperfusion on flap macro- and microcirculation was studied in an acute experiment on a new musculocutaneous pectoralis flap developed in minipigs. Using a multichannel laser Doppler system we studied, simultaneously and continuously, microcirculatory flow (MBF) in both the skin and muscle of the flap as well as in the contralateral control skin and muscle in anesthetized minipigs (n = 7). Measurements were done before and after raising the flap, after 90 min of flap ischemia, during mild to moderate hypovolemia (5%, 10%, 15%, and 20% blood loss) and during and after restoration of blood volume. Electromagnetic flowmetry was used to measure total blood flow (TBF) to the flap. All animals remained hemodynamically stable during the experiment. The flap MBF decreased by 20% in the skin and 25% in the muscle after flap elevation with no changes in the control skin and muscle. After flap ischemia and reperfusion, MBF returned to post-elevation values while TBF showed a significant increase as compared to MBF (P<0.05). Hypovolemia caused a gradual drop in cardiac output (25%) and mean arterial pressure (40%), but both recovered above the baseline after reinfusion of shed blood. Hypovolemia also caused a 60% reduction in MBF in both flap skin and muscle, and only 20–23% in control skin and muscle (P<0.01). After reinfusion of shed blood the MBF in the flap remained 30–40% below and the TBF increased 20% over the baseline. The MBF in control skin and muscle increased more than 20% over baseline (P<0.01). It was concluded that MBF in flap skin and muscle decreased by approximately 20–25% as a consequence of flap elevation, while central parameters remained normal. It was shown that even during moderate hypovolemia, MBF in the flap might decrease to critical levels. We suggest that intensive monitoring of central hemodynamics and continuous LDF monitoring of the flap during and after surgery should be performed in order to restore the blood volume expeditiously and prevent irreversible damage to flap tissues. © 1995 Wiley-Liss, Inc.     

皮肤扩张术机理探讨

目的 探讨皮肤扩张术（Ｓｋｉｎ ｅｘｐａｎｓｉｏｎ ｔｅｃｈｎｉｑｕｄｅ,ＳＥＴ）的机理。方法 以家犬为动物模型,应用显微分光光度计及放射微球技术,对扩张后皮肤表皮有丝分裂及皮瓣微循环进行了测定。结果 （１）被扩皮肤表皮明显增厚;（２）基底细胞有丝分裂较对照组显著增强;（３）皮瓣微循环较即刻皮瓣显著增强。结论 （１）ＳＥＴ并非仅以代偿为基础,而复制了新的“剩余”皮肤。（２）增强了皮瓣微循环,增大皮     

Haemodynamic enhancement in perforator flaps: the inversion phenomenon and its clinical significance. A study of the relation of blood velocity and flow between pedicle and perforator vessels in perforator flaps.

Perforator flaps are perfused through a long vessel whose calibre decreases from its origin to the skin, because all branches have been sealed, resulting in a conduit with resistances in series, rather than a tree with resistances in parallel, as in the normal systemic circulation. This study was planned to assess whether the differences between perforator flap and normal systemic vasculature have an impact on haemodynamic parameters in perforator flaps and on their clinical significance. The study was performed on 10 patients. Echo-colour-Doppler measurement of diameters, velocity of flow and calculations of flow rate were made at the level of flap pedicle artery and skin perforator artery, pre- and post-operatively in each patient. Statistical analysis used the Wilcoxon matched pairs signed sum rank test. Our data show that in the donor area pre-operatively, blood velocity in skin artery perforator is lower that in the corresponding pedicle artery, whereas post-operatively, in perforator flaps, blood velocity in the perforator is higher than in the pedicle. The difference was statistically significant (P<0.01). There is an inversion of the gradient of blood velocity between pedicle artery and perforator artery compared to normal circulation. Furthermore, in normal circulation flow through the perforator was found smaller than that at the pedicle, whereas in perforator flaps, flow through the perforator is smaller but is a greater proportion of the flow through the pedicle and the difference is statistically significant (P<0.01). Therefore, the velocity of blood and the rate of flow reaching the skin are higher in perforator flaps than in normal circulation.     

组织扩张对预构轴型皮瓣血供影响的实验研究

目的　研究组织扩张对预构轴型皮瓣血供范围的影响 ,为临床上获取更大面积的预构轴型皮瓣提供理论指导。方法　在同一只兔子腹部的左右侧分别设计、完成以股动、静脉为轴型血管的预构皮瓣 ,右侧腹部仅预构皮瓣未埋置扩张器 (未扩张组 ) ,左侧预构皮瓣下埋置扩张器进行扩张 (扩张组 ) ,分别于预构术后 1、3、5、7、10、14、2 1、2 8、5 6天对扩张组与未扩张组预构皮瓣血供范围进行相关检测。结果　预构皮瓣经扩张后其轴型血管供血范围明显大于未经扩张的预构皮瓣 (P <0 .0 5 )。结论　扩张术可加速皮瓣预构进程 ,增加预构轴型皮瓣的存活面积     

带导药系统的快速扩张器的临床研究

目的探索快速组织扩张和提高皮瓣扩张质量的方法.方法对15例不同部位应用带导药(罂粟碱)系统的扩张器进行皮肤软组织扩张.结果新型扩张法(下简称NEM)和普通扩张法(下简称GEM)扩张至额定容量所需要的平均时间分别为26d和51d;全部扩张完成后两种扩张法扩张器的实际注水量超过额定容量的百分比分别为92.41%和27.12%.扩张区皮肤血流量的比较(V),NEM1.27±0.28;GEM0.64±0.11.扩张表面积即时回缩率的比较(%),NEM20.17±1.74;GEM38.26±2.01.结论采用此种方法,扩张速度快,皮瓣的即时回缩率低,血运好.     

扩张超薄皮瓣的血液循环变化规律

为了探索扩张超薄皮瓣的血液循环变化规律，对１７例耳廓缺损畸形患者，在耳区皮肤的真皮下血管网深层埋置扩张器，对皮肤进行预扩张，观察扩张的薄皮肤血运变化有一定规律性：当扩张容量过多时，局部皮肤变苍白，或出现青紫，皮肤表面血管呈瘀血性网状扩张等。只要能注意操作的要点，扩张皮肤均能顺利渡过血循环障碍。１７例应用扩张后的超薄皮瓣作耳廓成形术，成功１４例，失败３例。     

扩张后皮瓣修复面颈部瘢痕挛缩畸形

目的 了解扩张后皮瓣治疗面颈部烧伤后瘢痕挛缩畸形的效果.方法 利用83个皮肤扩张器对38例烧伤后面颈部瘢痕挛缩畸形患者进行治疗.扩张器容量为100～600 mL,扩张时间3～5个月.扩张器置入部位大部分为正常皮肤,但其中10个扩张器置入烧伤后稳定软化的瘢痕下.扩张后行皮瓣转移术.本组有3例患者的扩张器置于斜方肌下部深筋膜层内,行以颈横动脉深支为蒂的远位扩张皮瓣移植.结果 38例患者术后皮瓣均成活,效果满意.其中8例术后发生血肿、感染等并发症,经处理后均未影响治疗效果.30例患者随访3～24个月,皮瓣颜色、质地均佳,外形及功能明显改善.结论 扩张后皮瓣是治疗面颈部烧伤后瘢痕畸形的最佳方法.在局部无正常皮肤的情况下,扩张瘢痕皮肤及远位扩张也是良好的选择.     

Enhanced capillary blood flow in rapidly expanded random pattern flaps

We have quantitatively examined the effect of rapid sequential skin expansion on capillary blood flow in the porcine random flap model in order to determine the relation between the increased survivability of expanded random flaps and capillary blood flow. Three 6 X 20 cm random flaps were tattooed on the backs of six small (20-kg) pigs. One flap was not manipulated (control). A 450-ml expander was inserted at the base of the second flap and left in place (sham). At the base of the third flap a 450-ml expander was inserted and each day for 5 days sequentially filled to the limits of skin viability as determined by vital dye staining (expanded). Capillary blood flow was measured on day 8 by measurement of radioactivity after injection of 15-microns radiolabeled microspheres. Samples were taken at 4-cm intervals from the base of each flap. Rapid expansion led to significant increases in capillary blood flow in expanded skin and to enhanced preservation of capillary flow after elevation of random pattern flaps based on expanded skin compared to sham and to control tissues. This correlates with and explains at least in part our previous observation of improved length of survival of flaps raised on expanded skin.     

颞浅筋膜预构颈部扩张皮瓣修复大面积面部缺损的临床研究

目的 观察颞浅筋膜瓣预构颈部扩张皮瓣,修复大面积面部缺损的效果。方法 2013年6月至2015年3月,应用颞浅筋膜瓣预构颈部扩张皮瓣,治疗10例大面积面部缺损患者。分离颞浅筋膜瓣,返折后固定于颈部预扩张皮瓣下方,并放置扩张器;经5~6个月的扩张获得足够的新生皮肤后,设计皮瓣,形成以颞浅筋膜为蒂的岛状皮瓣,将皮瓣转移修复面部缺损。结果 颞浅筋膜瓣预构颈部皮瓣后,可使扩张量达到400~800 m L,平均修复面积为129 cm2,大小8 cm×9.5 cm~14 cm×14 cm。扩张过程中未出现缺血、坏死等并发症。本方法成功修复10例患者的面部缺损,术后随访6~12个月,皮瓣色泽、质地与面部皮肤接近。结论 采用颞浅筋膜瓣预构颈部扩张皮瓣,可有效增加扩张皮肤血液供应,从而获取较大面积的扩张皮肤进行面部修复。