本文選題：三維數(shù)字化技術(shù) + 耳廓再造�。� 參考：《北京協(xié)和醫(yī)學(xué)院》2017年博士論文

【摘要】：耳廓再造是整形外科最困難和精細(xì)的手術(shù)之一。耳支架的雕刻制作是耳廓再造手術(shù)的基礎(chǔ)和核心。先天性小耳畸形患者雖然具有一定的共性特征,因?yàn)槊總�(gè)人的耳廓形態(tài)各異,很難制定一個(gè)適用于所有人的耳支架雕刻的精確標(biāo)準(zhǔn),對(duì)于外傷性耳缺損患者,常因外傷原因不同而造成不同部位不同程度的缺損,這更加給醫(yī)生的治療增加了難度,需要個(gè)性化的術(shù)前評(píng)估和術(shù)中設(shè)計(jì)。肋軟骨作為耳支架雕刻的主體材料,其發(fā)育好壞是決定耳廓再造手術(shù)時(shí)機(jī)的關(guān)鍵因素,同時(shí)采取肋軟骨對(duì)患者的創(chuàng)傷較大,術(shù)后還會(huì)造成不同程度的胸廓畸形;考慮到畸形對(duì)患兒心理發(fā)育的影響,許多學(xué)者傾向于6歲左右進(jìn)行治療,但是手術(shù)時(shí)機(jī)的選擇仍然存在著巨大的爭(zhēng)議。因?yàn)槭中g(shù)技術(shù)難度大,這就要求醫(yī)生有過(guò)硬的操作技術(shù)、精準(zhǔn)的完成手術(shù)的各個(gè)步驟,傳統(tǒng)的治療方法也不再能滿足患者個(gè)性化治療的需求。三維數(shù)字化技術(shù)快速發(fā)展及在醫(yī)學(xué)中的廣泛應(yīng)用使得精準(zhǔn)個(gè)性化的治療成為可能,讓耳廓再造也向著更加系統(tǒng)、精準(zhǔn)、個(gè)性化的方向發(fā)展。研究目的:1.應(yīng)用三維數(shù)字化技術(shù)輔助小耳畸形患者手術(shù)時(shí)機(jī)的選擇。2.應(yīng)用三維數(shù)據(jù)化技術(shù)制作肋軟骨模型模擬耳支架雕刻輔助手術(shù)方案的設(shè)計(jì)及手術(shù)教學(xué)。3.應(yīng)用三維數(shù)字化重建技術(shù)輔助外傷性耳缺損患者的個(gè)性化治療。研究方法:1.收集2016年1月-2016年6月在中國(guó)醫(yī)學(xué)科學(xué)院整形外科醫(yī)院耳再造一中心治療的6歲單側(cè)先天性小耳畸形患者,通過(guò)術(shù)前胸廓CT掃描三維重建和耳廓表面掃描獲取相應(yīng)數(shù)據(jù),測(cè)量雙側(cè)6、7、8肋軟骨的長(zhǎng)、寬和健側(cè)耳廓有效耳輪的長(zhǎng)度,評(píng)估軟骨量能否實(shí)現(xiàn)耳支架的雕刻。2.選擇2016年2月2016年6月就診于中國(guó)醫(yī)學(xué)科研院整形外科醫(yī)院耳再造一中心的病人10例,通過(guò)術(shù)前CT掃描和三維重建,構(gòu)建肋軟骨的數(shù)字化模型。選取合適的材料,應(yīng)用增材制造技術(shù)制作出實(shí)體肋軟骨模型,應(yīng)用模具進(jìn)行術(shù)前手術(shù)設(shè)計(jì)并模擬雕刻過(guò)程,優(yōu)化手術(shù)方案。3.收集2015年3月-2016年2月于中國(guó)醫(yī)學(xué)科學(xué)院整形外科醫(yī)院耳再造一中心入院治療的單側(cè)外傷性耳缺損患者12例,術(shù)前進(jìn)行三維掃描獲取患者耳廓三維數(shù)據(jù)信息,通過(guò)患側(cè)與健側(cè)對(duì)比,評(píng)估缺損量,制作個(gè)性化耳廓模型,制定個(gè)性化的手術(shù)方案,術(shù)后半年再次行三維掃描獲取術(shù)后雙側(cè)耳廓三維數(shù)據(jù)信息,測(cè)量健側(cè)耳廓與患側(cè)再造耳長(zhǎng)寬高及周長(zhǎng),兩組數(shù)據(jù)進(jìn)行配對(duì)T檢驗(yàn),進(jìn)行術(shù)后評(píng)估。結(jié)果:1.右側(cè)6、7、8肋軟骨的平均長(zhǎng)度分別為76.1 ±9.2mm(61.1mm-94.9mm),102.6±9.9mm(84.5mm-119.1mm),75.4±19.3mm(47.3mmm-118.5mm)。左側(cè) 6、7、8 肋軟骨的平均長(zhǎng)度分別為 78.0±9.6mm(63.2mmm-98.6mm),103.8±11.5mm(68.5mm-125.8mm),74.3±16.0mm(53.8mm-115.0mm)。左側(cè)第 6 肋軟骨較右側(cè)第6軟骨要更長(zhǎng)和更寬,P值分別為0.004和0.007。右側(cè)第7、8肋軟骨的長(zhǎng)度及第7肋軟骨的寬度較左側(cè)并沒(méi)有顯著差異,P值分別為0.464、0.763和0.693。耳輪的平均長(zhǎng)度為90.5 ± 6.8 mm(76.9mm-101.5 mm),將右側(cè)第7、8肋軟骨長(zhǎng)度與有效耳輪長(zhǎng)度進(jìn)行配對(duì)T檢驗(yàn),結(jié)果顯示第7肋軟骨要明顯長(zhǎng)于有效耳輪長(zhǎng)度(P=1.2*10-4)可以實(shí)現(xiàn)耳廓支架耳輪的雕刻,而第8肋軟骨無(wú)法滿足需求,37例患者采用組織擴(kuò)張法進(jìn)行耳廓再造,手術(shù)效果滿意。2.通過(guò)多種材料試驗(yàn)對(duì)比,TPU和聚氨酯材料可以進(jìn)行肋軟骨模具的制作。制作的類軟骨模具與真實(shí)軟骨形態(tài)相近,可以用于術(shù)前手術(shù)設(shè)計(jì)和手術(shù)模擬,聚氨酯材料雕刻難度小,更適于手術(shù)教學(xué)。10例病人在術(shù)前明確手術(shù)方案的情況下,均得到了一個(gè)滿意的治療效果。3.健側(cè)耳廓平均長(zhǎng)度、寬度、周長(zhǎng)、高度分別為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)。再造側(cè)耳廓平均長(zhǎng)度、寬度、周長(zhǎng)、高度分別為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)。將健側(cè)耳廓與患側(cè)耳廓測(cè)量數(shù)據(jù)進(jìn)行逐一配對(duì)T檢驗(yàn),耳廓長(zhǎng)度P=0.3110.05,耳廓周長(zhǎng)P=0.1530.05,耳廓高度P=0.1270.05,差異無(wú)統(tǒng)計(jì)學(xué)意義;耳廓寬度P=0.0010.05,差異有統(tǒng)計(jì)學(xué)意義。結(jié)論:1.胸部CT三維重建可有有效的評(píng)估患者的軟骨量是否能滿足耳廓再造手術(shù)需要,并且6歲患兒的軟骨量足以滿足組織擴(kuò)張法耳廓再造的需要,綜合患者生理和心理兩方面的考慮,我們認(rèn)為6歲是進(jìn)行組織擴(kuò)張法耳廓再造手術(shù)的最佳年齡。2.通過(guò)三維數(shù)字化重建和增材制造技術(shù),可以制作出逼真的肋軟骨實(shí)體模具,幫助醫(yī)生在術(shù)前實(shí)現(xiàn)手術(shù)方案的設(shè)計(jì)、模擬手術(shù)雕刻過(guò)程,從而有效的減少設(shè)計(jì)誤差,優(yōu)化手術(shù)方案,達(dá)到一個(gè)更好的手術(shù)效果。同時(shí)還可以讓年輕醫(yī)生有機(jī)會(huì)進(jìn)行耳支架雕刻實(shí)地操作練習(xí),更加深刻生動(dòng)的學(xué)習(xí)設(shè)計(jì)手術(shù)方案,鍛煉操作技能。3.三維數(shù)字化技術(shù)可以為各種類型的外傷性耳缺損找到最合適的個(gè)性化治療方案,同時(shí)還可以輔助手術(shù)中耳軟骨支架的雕刻,并對(duì)術(shù)后效果作出客觀的分析,對(duì)于輔助耳缺損患者的治療作用顯著。
[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.

【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R764.9

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