应用榫卯结构原理修复体表增宽瘢痕的临床效果

应用榫卯结构原理修复体表增宽瘢痕的临床效果

赵英楠施婧陈文

本文来源：《中华整形外科杂志》2023年8月第39卷第8期

DOI:10. 3760 / cma.j.cn114453-20230222-00039

作者单位：中国医学科学院北京协和医学院整形外科医院面颈整形三科，北京100144

通信作者：陈文，Email：chenwencw@163.com

引用本文

赵英楠,施婧,陈文. 应用榫卯结构原理修复体表增宽瘢痕的临床效果[J]. 中华整形外科杂志,2023,39(08)：838-843.DOI:10.3760/cma.j.cn114453-20230222-00039

【摘要】

目的探讨在体表增宽瘢痕修复中采用榫卯结构原理进行切缘以外的皮下真皮内缝合的临床效果。

方法回顾性分析2017年1月至2022年1月就诊于中国医学科学院整形外科医院进行体表增宽瘢痕修复术患者的临床资料。采用真皮内榫卯结构缝合对瘢痕进行修复，术中沿瘢痕外缘梭形切开，去除瘢痕表皮及真皮层浅层瘢痕组织。在保留的真皮层深层瘢痕组织上设计连续榫头结构，在对侧切缘同层真皮内设计与榫头相对应的连续卯眼结构。将所形成榫卯结构样真皮相互嵌插缝合，最后间断缝合皮肤。随访观察切口愈合情况，术后6个月采用温哥华瘢痕量表(VSS)评估瘢痕外观，评分越高表明瘢痕越严重，同时测量瘢痕宽度，并记录患者满意度。

结果共纳入32例患者，男性8例，女性24例，年龄8~44岁，平均34岁；术前瘢痕均为条索样，VSS评分3~7分，平均4.6分；瘢痕宽度2~11 mm，平均4 mm。术后随访6~24个月，所有患者切口均为一期愈合，4例(12.5%)出现一定程度的瘢痕增生，给予局部压迫和药物治疗后增生有所缓解，其余28例(87.5%)可见切口瘢痕细小，外观平整，较术前明显改善。此28例患者术后VSS评分0~2分，平均0.9分；瘢痕宽度0.1~1.0 mm，平均0.3 mm，其中11例瘢痕宽度<0.3 mm，8例为0.3~0.5 mm，9例为>0.5~1.0 mm。满意度评价显示，满意28例(满意率为87.5%)，良好4例。

结论瘢痕修复中真皮层缝合时保留真皮层深层瘢痕组织进行榫卯样缝合能够有效降低皮肤缝合张力，最终形成的切口瘢痕细微。

【关键词】瘢痕；皮肤张力；缝合技术；榫卯结构

A new method for repair of superficial widened scars by applying the Chinese wood joinery mortise-and-tenon principle

Zhao Yingnan, Shi Jing, Chen Wen

The Third Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, China

Corresponding author: Chen Wen, Email: chenwencw@163.com

【Abstract】

Objective To investigate the clinical effect of intradermal suturing using the principle of mortise-and-tenon suture in repair of superficial widened scars.

Methods A retrospective analysis was performed on the clinical data of patients with superficial widened scars repaired in the Plastic Surgery Hospital, Chinese Academy of Medical Sciences from January 2017 to January 2022. All patients were treated with this mortise-and-tenon method. During the operation, a pike incision was made along the outer margin of the scar to remove the top half of the dermal scar tissue, along with the epidermis. Serial tenon structures were created on the retained dermal scar tissue. Corresponding serial mortise structures were created by the removal of identically shaped blocks of dermal tissue opposite to the corresponding tenon structures. By suturing each tenon into its corresponding mortise, tensionless incision closure was readily achieved. Then, the skin was intermittently sutured. The incision was observed at postoperative follow-up, the Vancouver scar scale(VSS) was used to assess scar appearance, while higher scores indicated more severe scars; the scar width was measured, and patient satisfaction was recorded at 6 months postoperatively.

Results A total of 32 patients, 8 males and 24 females, aged from 8 to 44 years old (mean, 34 years old), were enrolled. All scars were elongated in shape and the VSS score was 3-7 (mean, 4.6). The scar width ranged from 2 to 11 mm (mean, 4 mm). The postoperative follow-up was 6 to 24 months. All incisions were healed by primary intention. 4 cases (12.5%) showed some degree of scar hyperplasia, which was improved by local compression and medication, and the remaining 28 cases (87.5%) showed small incision scars with a flat appearance, which were significantly improved compared with the preoperative period. Among these 28 cases, the VSS score was 0-2 (mean, 0.9). The scar width was 0.1-1.0 mm, (mean, 0.3 mm), including 11 cases with scar width <0.3 mm, 8 cases with scar width of 0.3-0.5 mm, and 9 cases with scar width of >0.5-1.0 mm. 28 patients were satisfied (satisfaction rate of 87.5%) and 4 cases were good.

Conclusion The proposed mortise-and-tenon scar repair technique can effectively reduce incision tension and thus the final incision scar is minimal.

【Key words】Cicatrix; Skin tension; Suture technique; Mortise-and-tenon structure

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: Ethical approval was given by the Medical Ethics Committee of Plastic Surgery Hospital, Chinese Academy of Medical Sciences (2023-14).

皮肤瘢痕不仅影响正常的皮肤生理功能，而且异常外观形态会对患者心理造成影响，往往需要考虑进行切除修复[ 1 , 2 ]。对于过宽瘢痕或瘢痕位置处于靠近关节等活动频繁部位，手术切除后会因为作用于皮肤缝合切口的张力过大引发缝合处瘢痕增宽[ 3 ]。研究证实，皮肤切口缝合后张力大小是影响切口愈合质量及后期瘢痕形成的最重要因素之一[ 4 ]。瘢痕切除缝合时最大程度地降低切缘皮肤缝合张力是防止瘢痕增生及变宽的关键[ 5 , 6 , 7 ]。本研究将中国古典木建筑中榫卯结构原理应用于真皮层缝合，术中保留两侧切缘真皮层深层瘢痕组织并交替嵌插缝合以获得持续和稳定的皮肤减张效果，减轻张力过大所引起的远期瘢痕变宽现象。

资料与方法

一、资料选择

回顾性分析2017年1月至2022年1月就诊于中国医学科学院整形外科医院进行体表增宽瘢痕修复术的患者临床资料。纳入标准：(1)确诊患条索样增生性瘢痕；(2)瘢痕位于面部、胸部、腹部、四肢等较高应力区域；(3)均采用真皮内榫卯结构缝合进行瘢痕修复；(4)自愿参加本研究，签署知情同意书并同意使用其照片。排除标准：(1)中途退出、放弃，或同时参与了其他临床研究者；(2)瘢痕稳定期未超过6个月；(3)瘢痕疙瘩或瘢痕癌患者。

本研究经中国医学科学院整形外科医院伦理委员会批准(2023-14)。所有受试者都提供了参与研究的书面知情同意书。

二、方法( 图1 ，图2 )

使用美蓝在瘢痕周缘标记梭形切口，标记范围涵盖了瘢痕边缘少量正常皮肤。用0.5%利多卡因混合1∶200 000肾上腺素在瘢痕内及周缘皮下组织内浸润麻醉。沿标记线切开皮肤至真皮层深层，完整去除切口内的表皮和真皮层浅层瘢痕组织( 图1A )。在保留的深层瘢痕组织上沿中央标记1条纵线，与该纵线垂直标记一系列间隔0.5~0.8 cm的横线( 图1B )。沿标记线切开瘢痕直达皮下组织。用眼科剪在皮下组织向切口两侧潜行分离，间断去除边长为0.5~0.8 cm的正方形瘢痕组织块，使两侧创缘保留的组织块相互交叉对应，形成连续榫头样结构( 图1C )。间断去除与榫头样结构平行对应的另一侧切缘的真皮层深层及皮下组织，形成与榫头样真皮结构大小相同的连续卯眼样结构( 图1D )。随后，用可吸收缝线将榫头样真皮缝合固定在相对应切缘内的卯眼结构内，皮肤切缘能够无张力自然对合。最后，间断缝合皮肤( 图1E )。术后用纱布覆盖切口，轻度加压包扎，切口涂抹红霉素眼膏。所有手术均由同一位资深外科医生操作。术后第3天换药，术后7~10 d拆线。

三、随访及观察

术后3、6、12、24个月通过门诊复查、电话或微信等方式随访观察切口瘢痕情况。所有患者均于术后6个月在门诊行标准摄像，并采用温哥华瘢痕量表(Vancouver scar scale，VSS)评估瘢痕外观(评分越高表明瘢痕越严重)，标尺测量瘢痕宽度，并记录患者满意度。

结果

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