超脉冲二氧化碳点阵激光联合脂肪干细胞胶移植治疗瘢痕

超脉冲二氧化碳点阵激光联合脂肪干细胞胶移植治疗瘢痕

樊华刘杜鹃刘凤彬张九文

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.cn114453-20221216-00383

作者单位：吉化集团公司总医院烧伤整形科与整形美容激光中心，吉林132022

通信作者：张九文：Email:572047763@qq.com

引用本文

樊华,刘杜鹃,刘凤彬,等. 超脉冲二氧化碳点阵激光联合脂肪干细胞胶移植治疗瘢痕[J]. 中华整形外科杂志,2023,39(08)：830-837.DOI:10.3760/cma.j.cn114453-20221216-00383

【摘要】

目的探讨超脉冲二氧化碳点阵激光联合脂肪干细胞胶(SVF-Gel)移植治疗瘢痕的临床效果。

方法回顾性分析2018年1月至2022年1月吉化集团公司总医院治疗的瘢痕患者的临床资料。应用超脉冲二氧化碳点阵激光进行治疗：增生性瘢痕采用Scaar FX模式治疗，能量80~150 mJ,频率250 Hz，密度3%；浅表性和萎缩性瘢痕采用Deep FX模式治疗，能量30~50 mJ，频率300 Hz,密度为5%；增生性瘢痕、萎缩性瘢痕存在瘢痕挛缩的位置，采用超脉冲模式进行人工点阵技术治疗，能量150~175 mJ，频率40 Hz，孔与孔间距离为4~5 mm，每孔治疗时间2~3 s。浅表性和萎缩性瘢痕上述治疗共进行2次，增生性瘢痕上述治疗共进行3次，每次间隔2个月。首次激光治疗后30 d左右移植SVF-Gel治疗瘢痕：抽取大腿脂肪组织制备成SVF-Gel，于瘢痕基底层和瘢痕内深层进行多点多隧道注射。于全部治疗结束后6个月复诊并评价治疗效果，采用温哥华瘢痕量表(VSS)进行评分，同时测定治疗后瘢痕皮肤与邻近正常皮肤经皮水分丢失(TEWL)差值，与治疗前进行对比。应用SPSS 20.0软件进行统计分析，数据以x±s表示，治疗前、后VSS评分和TEWL差值比较采用配对t检验，P<0.05为差异有统计学意义。

结果共纳入30例患者，男17例，女13例，年龄(32.7±11.2)岁。30例中浅表性瘢痕10例、增生性瘢痕10例、萎缩性瘢痕10例，瘢痕形成时间(17.5±4.5)个月。(1)浅表性瘢痕治疗后VSS评分为(1.8±0.7)分，低于治疗前的(4.7±0.8)分(t＝9.26，P＝0.001)；治疗后瘢痕皮肤与正常皮肤TEWL差值为(2.48±0.61)g·m－2·h－1，低于治疗前的(6.85±1.17) g·m－2·h－1(t＝13.28，P<0.001)。(2)增生性瘢痕治疗后VSS评分为(3.9±1.1)分，低于治疗前的(10.6±1.7)分(t＝9.37，P＝0.001)；治疗后瘢痕皮肤与正常皮肤TEWL差值为(4.91±0.87) g·m－2·h－1，低于治疗前的(9.92±0.75) g·m－2·h－1(t＝18.22，P<0.001)。(3)萎缩性瘢痕治疗后VSS评分为(3.5±1.2)分，低于治疗前的(7.7±2.3)分(t＝5.81，P＝0.005)；治疗后瘢痕皮肤与正常皮肤TEWL差值为(3.73±1.22) g·m－2·h－1，低于治疗前的(6.52±1.51) g·m－2·h－1(t＝9.52，P＝0.001)。

结论超脉冲二氧化碳点阵激光联合SVF-Gel移植治疗瘢痕效果确切，对瘢痕的色泽、厚度、血管分布、柔软度以及瘢痕皮肤屏障功能均有改善作用。

【关键词】瘢痕；超脉冲二氧化碳点阵激光；脂肪干细胞胶；再生

基金项目： 吉林省卫生健康委科技项目（2013ZC027）

Ultrapulse fractional carbon dioxide laser combined with stromal vascular fraction gel transplantation in the treatment of scars

Fan Hua, Liu Dujuan, Liu Fengbin, Zhang Jiuwen

Burn and Plastic Surgery Department and Plastic Surgery Cosmetology Laser Center, General Hospital of Jilin Chemical Industry Group, Jilin 132022, China

Corresponding author: Zhang Jiuwen, Email: 572047763@qq.com

【Abstract】

Objective To investigate the clinical effect of ultrapulse fractional carbon dioxide laser combined with stromal vascular fraction gel (SVF-Gel) transplantation in the treatment of scars.

Methods Retrospective analysis of the clinical data of patients with scars treated at the General Hospital of Jilin Chemical Industry Group from January 2018 to January 2022. Application of ultrapulse fractional carbon dioxide laser for treatment: Scaar FX mode treatment for hypertrophic scars, micro FX energy: 80-150 mJ, frequency: 250 Hz, density: 3%. Deep FX mode treatment for superficial scars and atrophic scars, micro FX energy: 30-50 mJ, frequency: 300 Hz, density: 5%. Manual fractional technology(MFT) mode treatment for hyperplastic scars, atrophic scars with scar contracture site, energy: 150-175 mJ, frequency: 40 Hz, distance between holes: 4-5 mm, treatment time 2-3 s. Superficial scar and atrophic scar were treated 2 times, hypertrophic scar was treated 3 times, and the time interval was 2 months. Transplantation of SVF-Gel for scar treatment around 30 days after the first laser treatment. Thigh fatty tissue was extracted to prepare SVF-Gel. The SVF-Gel was injected into the basal layer and deep layer of inside the scar by multi-point and multi-tunnel injection. All patients were followed up for 6 months to evaluate the therapeutic effect. Assess the Vancouver scar scale (VSS) score and the difference of transepidermal water loss (TEWL) between scar skin and adjacent normal skin was measured after treatment, compared with before treatment. The data were analyzed by SPSS 20.0, data in Mean±SD represents. Paired t-test was used to compare the difference between the VSS score and TEWL before and after treatment. P<0.05 indicates a statistically significant difference.

Results A total of 30 patients were enrolled, including 17 males and 13 females, aged (32.7 ± 11.2) years old. Among the 30 patients, 10 patients were superficial scars, 10 patients were hypertrophic scars, 10 patients were atrophic scars. The scars’ formation time was (17.5 ± 4.5) months. (1) The VSS score of superficial scars after treatment was 1.8±0.7, which was lower than 4.7±0.8 before treatment(t=9.26, P=0.001). The difference in TEWL after treatment was (2.48±0.61) g·m-2·h-1, which was lower than (6.85±1.17) g·m-2·h-1 before treatment(t=13.28, P<0.001). (2) The VSS score of hyperplastic scars after treatment was 3.9±1.1, which was lower than 10.6±1.7 before treatment(t=9.37, P=0.001). The difference in TEWL after treatment was (4.91±0.87) g·m-2·h-1, which was lower than (9.92±0.75) g·m-2·h-1 before treatment(t=18.22, P<0.001). (3) The VSS score of atrophic scars after treatment was 3.5±1.2, lower than 7.7±2.3 before treatment (t=5.81, P=0.005). The difference in TEWL after treatment was (3.73±1.22) g·m-2·h-1, lower than (6.52±1.51) g·m-2·h-1 before treatment (t=9.52, P=0.001).

Conclusion Ultrapulse fractional carbon dioxide laser combined with SVF-Gel transplantation is effective in the treatment of scars. It can improve the color, thickness, vascular distribution, softness, and skin barrier function of scars.

【Key words】Cicatrix; Ultrapulse fractional carbon dioxide laser; Stromal vascular fraction gel; Regeneration

Fund program: Science and Technology Project of Health Commission of Jilin Province(2013ZC027)

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

Ethical Approval: This study was conducted in accordance with the Helsinki Declaration.

治疗瘢痕的方法主要包括手术、光电、药物注射、外用药物、压力疗法、物理及康复治疗、放射治疗等，根据瘢痕的特点和对人体的影响，往往需要选择综合的治疗方法才能取得较好的效果[ 1 ]。随着瘢痕治疗理念的更新，不仅要矫正畸形、改善功能，还要力求达到瘢痕组织的再生性修复[ 2 ]，缩小瘢痕皮肤与正常皮肤外观和功能上的差距。我们对浅表性、增生性、萎缩性瘢痕患者应用超脉冲二氧化碳点阵激光联合脂肪干细胞胶(stromal vascular fraction gel，SVF-Gel)移植治疗，取得了较好的效果。

资料与方法

一、资料选择

回顾性分析2018年1月至2022年1月于吉化集团公司总医院就诊的瘢痕患者的临床资料。纳入标准：(1)各类原因皮肤损伤后形成的浅表性、增生性、萎缩性瘢痕；(2)自愿接受全程治疗，并完成全部随访；(3)年龄16~60岁，性别不限；(4)瘢痕形成时间12~24个月，范围、部位不限；(5)应用二氧化碳点阵激光联合SVF-Gel移植进行治疗。排除标准：(1)瘢痕疙瘩等其他类型的瘢痕；(2)已经过手术、光电、注射、弹力加压、放射等治疗的瘢痕；(3)存在系统性基础疾病影响本治疗方案实施者。本研究已参考赫尔辛基宣言，患者对本研究完全知情，并同意将其资料用于本研究。

二、方法

(一)治疗方法

1．激光治疗

应用美国科医人公司Ultra Pulse超脉冲二氧化碳点阵激光进行治疗：增生性瘢痕采用Scaar FX模式(能量80~150 mJ，频率250 Hz，密度3%)，浅表性瘢痕、萎缩性瘢痕采用Deep FX模式(能量30~50 mJ，频率300 Hz，密度为5%)，增生性瘢痕、萎缩性瘢痕存在瘢痕挛缩的位置采用超脉冲模式以人工点阵技术(manual fractional technology，MFT)治疗(能量150~175 mJ，频率40 Hz，孔间距离为4~5 mm,每孔治疗时间2~3 s)。浅表性瘢痕、萎缩性瘢痕上述治疗共进行2次，增生性瘢痕上述治疗共进行3次，每次间隔2个月。

2．SVF-Gel移植治疗

首次激光治疗后30 d移植SVF-Gel治疗瘢痕。手术方法：(1)SVF-Gel制备。配置麻醉肿胀液：2%盐酸利多卡因20 ml+0.1%肾上腺素1 ml+5%碳酸氢钠注射液5 ml+0.9%氯化钠注射液500 ml。使用20 ml注射器在大腿标记区域的皮下组织脂肪层内缓慢、均匀扇形注射肿胀麻醉液，稍大于吸脂范围，当皮肤表现为苍白色、轻微橘皮样改变即可，轻按注射区域以便使麻醉肿胀液均匀弥散。使用20 ml一次性医用螺口注射器预留5 ml负压，连接直径为3 mm、侧孔直径为1.2 mm的多侧孔吸脂针，扇形均匀抽吸脂肪组织，将抽取出的脂肪组织静置15 min,排掉下层麻醉肿胀液。将收集到的脂肪组织装入脂肪离心机器平衡放置，以1 200×g离心3 min,排掉下层液体，保留注射器中脂肪组织(Coleman脂肪)。将中层脂肪组织转移至20 ml注射器中，接鲁尔转换头后，推注至对侧空的注射器中，反复推注使脂肪呈乳糜化，拉开注射器针栓以保持负压，轻微震荡后可观察到絮凝现象。将乳糜化脂肪以1 600×g离心3 min，离心后分3层，弃去顶层油脂、底层残留肿胀液，中间层黄白色黏性凝胶样物质即为SVF-Gel。(2)SVF-Gel移植。将制备的SVF-Gel转移至1 ml注射器中，瘢痕基底应用内径为1.2 mm的脂肪注射针、瘢痕内应用21 G针头进行注射移植，按照先深层后浅层顺序，在瘢痕基底层和瘢痕内深层多点、多隧道扇形注射移植，边退针边注射，使移植的SVF-Gel均匀分布于瘢痕基底和瘢痕组织内，每条隧道SVF-Gel注射量为0.05~0.10 ml,每次移植注射量根据瘢痕范围确定。

(二)疗效评估指标

1．温哥华瘢痕量表(Vancouver scar scale，VSS)评分

对患者治疗前和全部治疗结束后6个月分别应用VSS对瘢痕的色泽、厚度、血管分布、柔软度4个方面进行评估并计分。色泽由接近正常肤色至颜色较深(0~3分)；厚度由正常到大于4 mm(0~4分)；血管分布由瘢痕红润程度与正常皮肤接近到瘢痕呈紫色(0~3分)；柔软度由正常到挛缩(永久性缩短导致残废与畸形)(0~5分)[ 3 ]。评估和计分由5位未参与治疗、具备10年以上工作经验、主治医师以上职称的整形外科医生进行，对瘢痕分别评分后取平均值。

2．瘢痕皮肤及正常皮肤经皮水分丢失(transepidermal water loss, TEWL)检测

患者治疗前及全部治疗结束后6个月分别行瘢痕皮肤TEWL检查。检查方法：患者置身于恒温、恒湿[温度(24±1)℃，相对湿度(45±5)%)]环境中30 min，应用德国Courage Khazaka公司TM300水分流失测试仪连续记录瘢痕被测部位TEWL值1 min，收集结果曲线，并计算TEWL平均值；应用同样方法，测试被测瘢痕邻近正常皮肤(距离瘢痕边缘约1 cm)或对侧相同部位的TEWL值；计算瘢痕皮肤和正常皮肤TEWL差值，并做记录。

三、统计学分析

应用SPSS 20.0软件进行统计学分析，数据以x±s表示，治疗前、后VSS评分和TEWL差值比较采用配对t检验，P<0.05为差异有统计学意义。

结果

一、一般资料

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