1, the principle of surgical treatment in addition to some superficial scars generally do not need to be treated, all kinds of scar tissue d
1, the principle of surgical treatment in addition to some superficial scars generally do not need to be treated, all kinds of scar tissue due to the presence of varying degrees of contracture deformity and dysfunction and the need for treatment. Facial and neck scar, in addition to deformity and dysfunction, but also because of the impact of the appearance of patients with mental and psychological burden. The scar of the hand is the main cause of dysfunction. Hand scar contracture, can cause a long time of metacarpophalangeal joint flexion and adduction deformity thumb, resulting in the so-called "claw hand", the hand function was almost completely lost. Scar contracture of other parts of the body, can also affect the normal activities of the limbs or joints.
All kinds of cicatricial contracture associated with dysfunction need to be treated. From the point of view of the current technical conditions, this treatment is only limited to the application of surgical resection of scar, and the application of various surgical methods (including skin) to repair the wound and deformity correction. Although some scars do not produce symptoms of contracture, but because it causes persistent itching, pain symptoms, or often broken, should also be considered to be removed repair. Deep scar tissue may also be due to contraction and pull around the organs, resulting in neurological symptoms. This symptom is not easy to diagnose, but if confirmed, the effect of surgical treatment is quite satisfactory.
The effect of functional activities or the formation of a smaller area of deformity of hypertrophic scars, especially the face and hands, should be considered with surgery, to skin grafting. But this surgery should not be carried out in the early stage of scar hyperemia, otherwise it may cause more scar tissue hyperplasia (especially in the area of the edge of the skin). General should be waiting to enter the stage of degradation after excision and skin grafting was done.
For the treatment of atrophic scar, should be removed as soon as possible, in order to relieve the contraction of the state, so that normal tissue reset, and then in the wound on the thick skin graft. If the area is large, and is not suitable for all, can be partial excision and skin grafting in the most severe contracture of the site, to promote the surplus continues to shrink gradually into a stable state. In the presence of ulcers often do not need to wait for the wound healing, and should be removed early surgery.
In addition to the use of free skin grafting, when close to the bone surface of atrophic scar, or basal blood supply range, should consider the application of pedicle flap, to prevent the re rupture. Pedicled flap transplantation including local flap, distal skin tube transplantation, limb cross flap.
Severe trauma with deep tissue defects such as subcutaneous tissue, muscle or bone, after the wound healing, the formation of a lower than normal skin surface depression scar. Only when the lighter sag on the surface caused by groove shaped or disc like tissue low, serious person can interfere with the beautiful; and the tendon, muscle or bone, or with neural stem tissues such as direct adhesion, sometimes causing serious dysfunction or rupture after prolonged does not heal, or cause pain and other symptoms.
2, before the operation of a few points of attention to the treatment of scar, especially for severe burns after leaving a wide range of scars, in consideration of surgery before, must pay attention to the following points.
(1) generally hypertrophic scar should not be treated as early as possible. However, when there is a scar contracture in the whole part, there is a severe ectropion or small hole. In this case, in order to prevent excessive exposure of the cornea and cause serious consequences, or to eat, should be carried out as early as possible partial correction of ectropion or open the mouth. The scar of the other parts of the face, after waiting for the proliferative phase subsided in the surgical treatment. In addition, for the scar contracture of the hand, the author advocates the earlier operation. The operation can be chosen in wound healing 2 - 3 months, the local has no residual infection, while patients with systemic conditions permit to. In this way, the severe secondary deformities of joints and tendons are prevented.
(2) in the early formation of wound healing scar contracture, often starts to happen. At this time, the most obvious part of the contracture can be considered. And in order to reduce skin graft contracture. In the case of the rest of the treatment. After the above treatment, the remaining part of the scar may gradually become a stable state, and may not be treated further.
(3) before surgery, physical therapy and sports can give proper treatment, such as ultrasonic, wax etc., to soften the scar. The application of physical therapy and training, often can narrow the scope of scar resection. Other such as pressure dressing, traditional Chinese medicine treatment can also be used.
(4) the extent of resection of scar should be limited to the most severe site, especially for patients with extensive scar contracture and skin defects. If the scar area is removed, or an attempt is made to remove all the scar areas, there is often a problem of insufficient donor site.
3, surgical treatment of surgical treatment of scar, according to the characteristics of scar and choose different methods.
(1) superficial scar treatment for most superficial scars without treatment, as described above. But if anything happens in the facial appearance intact, can consider surgery. If the area is small, it can be resected and sutured directly in one operation. Whether one or more removed, should pay attention to the incision and suture in the design along the direction of striae; and in case of skin were rectangular staggered, should be designed "Z" incision to repair, otherwise it will affect the final effect, even lead to another deformity. Treatment of large area superficial scar is difficult to be free skin graft after resection results in color is not satisfactory, sometimes because of adverse consequences of skin graft contraction occurs.
(2) for the treatment of depressed scar, the scar tissue usually has the defects of subcutaneous tissue, muscle or bone tissue when the scar tissue is deformed. Simple depressed scar is only linear scar and the local area of a wide depression; is widely spread, the depth is deeper. To correct this deformity, not only to deal with the scar on the skin, but also in accordance with the severity of depression using different methods to fill the defect in order to restore the normal shape.
Simple line like depressed scar, before resection of scar surface of a thin layer of epithelial tissue, and the deep scar left in the skin; on both sides of a transverse incision, dissect subcutaneous tissue on both sides, draw a margin, above the suture in deep scar tissue. The scar is not deep in the general application of this method can be repaired. If the depression is deep, this method will not work. 1 - to 2 pedicle fat tissue flaps were designed in the subcutaneous tissue around the incision. However, attention should be paid not to cause another depression in the nearest neighbor.
In the treatment of a wide range of depressed scars, in addition to the removal of scar tissue, but also need to be transplanted in the depression or fill in a tissue, in order to achieve the purpose of improving appearance. In addition to the transplanted tissue, we should also pay attention to the problem of the tissue tension after skin excision. At the top of the transplanted tissue, if the blood supply to the skin is not good, there is a chance of failure. At this time, local transfer flap is a good method, but should pay attention to avoid another deformity. Transplantation of distant skin flap or skin graft can only be considered in the case of the lack of adjacent skin tissue. The structure can be filled according to the needs, such as leather, fascia, fat, cartilage or bone can be used. Sometimes it can also be used to carry on the transplantation of the complex belt fat or fascia fat. In the design of a large area of the sunken deformity, it is possible to design a pedicled fat tissue graft to fill the subcutaneous defect. Because of bone defect caused by the low, can be applied to cartilage or bone transplantation. Non biological substances such as hydroxyapatite, silicone rubber can be used.
(3) the treatment of linear scar often occurs in the suture of wound or surgical incision. Clinically, we often see a number of incision scar after suture, not only has a wide range of hypertrophic scar in the middle, but also has a row on both sides of a significant and prominent point like scar. This scar is sometimes only a defect of form, but sometimes it is also caused by a straight scar. The symptoms of itching, pain and scar period intolerable. The processing method is linear scar excision, and then the application of "Z" shaped operation principle to form one or several triangles, so the lifting of the contracture, but also to prevent the wound healing after new scar contracture. Such as scar on both sides with prominent punctate scar, multiple W can be taken to repair.
(4) treatment of webbed cicatricial contracture in flexion of the suspension of scar contracture strips, such as after a long time, then the scar contracture on both sides of the skin and subcutaneous tissue can be lengthened, webbed scar contracture. This scar is big is small, large webbed scar is common in the front of the neck, armpits, cubital fossa, popliteal and ankle joints and other parts of the front; small webbed scar can be seen in the inside and outside canthus, nasolabial fold, mouth, fingers and the palm surface, refers to the web site.
Some webbed scar is annular, opening in the surface channel, such as the mouth, urethra, vagina, mouth, nose, trachea artificial anus mouth etc., the main symptoms are caused by the narrow caliber influence normal function.
Webbed scar generally can be used "Z" principle of operation to remove the contracture. The operation is simple and the effect is good. Design of "Z" shaped incision has been stretched to make full use of local skin and subcutaneous adipose tissue staggered swap position, make the web disappear, and also lifted the contracture. The suture of the wound margin is not right at the same time, thus preventing the occurrence of re contracture. In general, the two triangle flap swap position, can completely eliminate the wound; but the contracture of heavier, there are still some wounds exposed after translocation, the desirable thickness skin grafting or local skin flap.
Processing of various parts of the webbed scar, can refer to the relevant chapters.
Annular scar contracture can also be treated with a "Z" - shaped surgical procedure, but usually requires more than one "Z" - shaped incision. Congenital limb ring contracture is also a kind of contracture, can also be applied to the "Z" type operation principle to lift.
(5) treatment of large cicatricial contracture of scar contracture of large area treatment principle, is part or all of the parts of the scar resection, to contracture after release of skin graft or flap for wound repair. Generally lighter, not deep scar contracture cases were by free skin graft is appropriate. However, if the contracture is severe, the scar is close to the deep tissue such as muscle, tendon or bone, and the side is better with the skin flap. The flaps can be derived from adjacent tissues, or distant skin flaps or direct flap transfer. These must be prepared in advance, fully prepared, and then scheduled for surgery.
For a long time, the contraction of the scar, especially in the early childhood, can affect the development of the muscles, tendons, blood vessels, nerves and bones. In this case, it is often impossible to completely remove the contracture after excision of the scar. This should use violence reduction, in order to avoid damage in these tissues, or the diameter of vessels stretched thin, block the blood circulation or broken nerve and cause serious consequences. It should be placed in the body position for maximum function of skin grafting, after surgery with continuous traction and physical therapy to correct the. If necessary, it is feasible to extend the tendon, joint capsule incision, joint ligament resection and other auxiliary operations, to achieve a full release.
(6) the deep scar contracture of wound treatment and deep body, such as stabbing or shrapnel wounds, often may form a large number of scar tissue in deep tissue, it not only with the peripheral nerve and muscle adhesion, but also due to contracture of surrounding tissues can result, traction reflex and muscle pain disorders. When dealing with this scar, you should pay attention to two points:
1 the location, extent and depth of the scar is often difficult to estimate accurately before surgery. Sometimes scar and important organ adhesion, difficult for radical surgery, so must be fully prepared before surgery.
2 after the resection of the cavity, we should try to use tissue filling to eliminate it, otherwise it will form a new scar contracture. This kind of filling tissue is better with fat tissue transplantation; free fat block or pedicle fat tissue can achieve the purpose of treatment, and the latter is better.
(7) surgical treatment of hypertrophic scar is only used when there is dysfunction or morphological changes. The operation principle is to remove the scar, fully release, correct the deformity, and cover the wound with skin flap or skin flap. In the case of large scar area and lack of skin source, only partial or partial excision of the scar can be done, but the full release of the contracture is needed to repair the defect.
(8) keloid is known to be easy to recur after surgical excision of keloid, and it often increases after relapse. Therefore, many scholars believe that simple surgical excision of keloid is of no significance, and other methods should be combined to achieve a better therapeutic effect.
Hynes introduces the elimination of keloids to the skin around the skin, and then the thick skin graft. But he pointed out that the cut scar must be mature and pale; otherwise, the process will be re fibrosis. In order to prevent the formation of donor skin keloid Ketchum recommends the use of split thickness skin (0.02 - 0.025cm), and the donor site should be selected after the pressurized parts.
No matter what kind of surgical method in keloid resection of heirs, must try to reduce tissue injury, hematoma, infection, necrosis, die cavity and tension. Proliferation of fibroblasts can be stimulated by increased tension.
In the treatment of keloid, often using the following two methods: partial resection of the keloid lesions within the periphery retain a residual scar. Because there are indications that residual scar does not increase the recurrence rate, while greatly reducing the size and volume of the lesion, creating a condition for further local drug therapy. In the case of a larger range of keloids, the skin surface of keloid was used as the skin graft after the excision of keloid.
Chinese Academy of Medical Sciences; plastic surgery hospital
Dr Liu Xinhai