本文關(guān)鍵詞： 皮下 遠(yuǎn)位 減張 縫合 張力 切口 效果 臨床 用的 研究　出處：《山東大學(xué)》2017年博士論文　論文類型：學(xué)位論文

【摘要】：研究背景及意義:傷口或手術(shù)切口愈合后不可避免的產(chǎn)生不同程度瘢痕,瘢痕的形成與損傷程度、局部炎癥、免疫反應(yīng)、皮膚張力等眾多因素有關(guān)。其中張力因素和愈合后瘢痕程度具有密切關(guān)系。如何充分減張,使得切口不但獲得快速良好的愈合和不明顯的術(shù)后瘢痕,仍然是一項具有挑戰(zhàn)性的課題。近年改良的縫合技術(shù)研究的主要角度是觀察相應(yīng)新縫合技術(shù)對病理性瘢痕即增生性瘢痕和瘢痕疙瘩的治療及預(yù)防,而對皮下縫合技術(shù)的減張程度研究較少,也較少涉及對生理性瘢痕程度評估觀察和相關(guān)對比研究。我們在本研究中提出一種新的切口遠(yuǎn)位皮下減張縫合理念和皮下遠(yuǎn)位橫向褥式減張縫合技術(shù),通過體外減張實驗與傳統(tǒng)的減張縫合技術(shù)進(jìn)行對比研究,證實皮下遠(yuǎn)位橫向褥式減張縫合技術(shù)對張力性刀口具有可靠、持久的減張效果,我們將該減張縫合技術(shù)應(yīng)用于面部瘢痕整形,對相應(yīng)縫合切口的術(shù)后瘢痕外觀進(jìn)行評估、對比。使用近年最新國際上較廣泛使用的瘢痕評估量表--患者與觀察者瘢痕評估量表(POSAS量表,Patient and Observer Scar Assessment Scale)對我們應(yīng)用的新縫合技術(shù)遠(yuǎn)期瘢痕情況進(jìn)行了相關(guān)觀察和評估,并和傳統(tǒng)方法縫合切口的瘢痕情況進(jìn)行了相關(guān)對比分析。第一部分研究目的:離體皮膚構(gòu)建體外張力性切口模型,以切口皮下減張縫合后皮緣裂隙寬度、皮紋方向為觀察指標(biāo),研究皮下遠(yuǎn)位橫向褥式減張縫合對張力性刀口的減張效果。研究方法:腹壁整形切除的多余皮膚制作體外皮膚切口模型。將對稱標(biāo)本分為A、B兩組,對A組切口行皮下埋沒垂直褥式縫合,B組行皮下遠(yuǎn)位橫向褥式減張縫合:于皮下脂肪面距離切緣2mm處進(jìn)針,向外上勾住基底部分真皮組織后向外下彎轉(zhuǎn),從進(jìn)針點向遠(yuǎn)處走行1cm出針,于經(jīng)過出針點旁(平行于切緣方向)1cm處反向路徑回針,出針點應(yīng)位于切緣底部最初進(jìn)針點旁1 cm,以同樣方法于對側(cè)做鏡像操作,縫線打結(jié)。分別對兩組切口給以2N、5N及100次最大值5N的周期性張力,測量兩組切口裂隙寬度,固定張力方向定位近焦拍照,紋理浮雕處理觀察切口兩側(cè)1cm范圍內(nèi)皮紋方向。研究結(jié)果:在不施加拉力時,兩組縫合后切口均能較好的對合,切緣無縫隙。2N拉力下A組切口均出現(xiàn)裂隙,寬度0.6-1.5mm,平均寬度1.07mm,而B組仍然均無裂隙,對合良好,裂隙寬度記錄為0mm。5N拉力下;A組標(biāo)本切口裂隙寬度均增大,寬度1.1-2.8mm,平均寬度2.05mm,而B組切口僅有4例出現(xiàn)細(xì)小裂隙,寬度0.1-0.4mm,平均寬度0.08mm。100次周期性5N拉力作用后,A組切口裂隙均增寬,3.2-6.5mm,平均寬度4.84mm,B組仍然維持原來4例裂隙,裂隙寬度0.2-0.6mm,平均寬度0.10mm。切口皮紋經(jīng)紋理浮雕效果處理后,皮膚皮紋方向可清晰可見。A組切口兩側(cè)1cm范圍內(nèi)皮紋松弛、無明顯優(yōu)勢方向;B組切口兩側(cè)鄰近及周邊1cm范圍內(nèi)絕大多數(shù)皮紋呈現(xiàn)與拉力方向一致的拉伸。第一部分研究結(jié)論:遠(yuǎn)位皮下橫向褥式減張縫合能使得張力性切口較好的減張對合。無論是靜態(tài)性張力還是周期性動態(tài)張力下,遠(yuǎn)位皮下橫向褥式減張縫合較皮下埋沒垂直褥式縫合,都可有效的保持對合后切緣及兩側(cè)鄰近皮膚較大范圍的無張力狀態(tài)。第二部分研究目的:將皮下遠(yuǎn)位橫向褥式減張縫合技術(shù)應(yīng)用于面部瘢痕整形,觀測瘢痕寬度,并使用患者與觀察者瘢痕評估量表(POSAS量表)對遠(yuǎn)期瘢痕情況進(jìn)行了相關(guān)觀察和評估,并和傳統(tǒng)方法縫合切口的瘢痕情況進(jìn)行相關(guān)對比分析。研究方法:隨機(jī)選取面部瘢痕一次性切除或分次切除縫合患者作為研究對象。分為治療組和對照組。瘢痕切除后,治療組進(jìn)行遠(yuǎn)位皮下橫向褥式減張縫合切口;對照組采用皮下埋沒垂直褥式縫合切口。術(shù)后拆線時觀察刀口愈合情況。術(shù)后3月、6月進(jìn)行瘢痕情況隨訪,對每位患者兩組瘢痕瘢痕寬度測量、P0SAS瘢痕量表評分。研究結(jié)果:縫合后所有切口均能嚴(yán)密外翻性對合,治療組患者切口縫合后隆起、外翻更加明顯。瘢痕寬度的比較:術(shù)后3月治療組瘢痕平均寬度1.02mm對照組1.32mm.兩組設(shè)計定理資料的t檢驗。術(shù)后6月治療組瘢痕平均寬度1.25mm對照組1.66mm.兩組設(shè)計定量資料的t檢驗,差異均有計學(xué)意義(P0.05)。術(shù)后3月POSAS瘢痕量表評分:治療組患者評分的各項評分之和均值14.56對照組18.91,總體印象分2.94對照組3.59。分別比較設(shè)計定量資料的秩和檢驗差異均有計學(xué)意義(P0.05)。觀察者評分各項評分之和均值14.73對照組16.85,總體印象分1.94對照組3.28。分別比較設(shè)計定量資料的秩和檢驗差異,各項評分之和均值差異無統(tǒng)計學(xué)意義。但總體印象分差異有明顯計學(xué)意義(P0.05).術(shù)后6月P0SAS瘢痕量表評分:治療組患者評分的各項評分之和均值10.05對照組14.76,總體印象分2.1對照組2.96。分別比較設(shè)計定量資料的秩和檢驗差異均有計學(xué)意義(P0.05)。觀察者評分各項評分之和均值9.89對照組13.33,總體印象分1.61對照組13.33。分別比較設(shè)計定量資料的秩和檢驗差異,各項評分之和均值差異和總體印象分差異均有明顯計學(xué)意義(P0.05)。第二部分研究結(jié)論:皮下遠(yuǎn)位橫向褥式減張縫合技術(shù)應(yīng)用于面部瘢痕整形,能有效減小刀口張力,使得切緣良好的外翻和對合,大大減少真皮層縫線,與傳統(tǒng)減張縫合相比,瘢痕寬度及P0SAS瘢痕量表評分顯示術(shù)后瘢痕程度更輕,且瘙癢、疼痛等不適癥狀輕。本課題的研究結(jié)論:遠(yuǎn)位皮下橫向褥式減張縫合能使得張力性切口較好的減張對合。無論是靜態(tài)性張力還是周期性動態(tài)張力下,遠(yuǎn)位皮下橫向褥式減張縫合較皮下埋沒垂直褥式縫合,都可有效的保持對合后切緣及兩側(cè)鄰近皮膚較大范圍的無張力狀態(tài)。該縫合方法可應(yīng)用于于面部瘢痕整形,能有效充分減小刀口張力,使得切緣良好的外翻和對合,大大減少真皮層縫線,與傳統(tǒng)減張縫合相比,瘢痕寬度及P0SAS瘢痕量表評分顯示術(shù)后瘢痕程度更輕,且瘙癢、疼痛等不適癥狀輕。
[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.

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R622

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