Youmans神经外科学专栏 | 第二期：手术切口及皮瓣设计

切口与愈合

Elizabeth G. Zellner and John A. Persing

译者：澳门科大医院,神经外科,谭林琼

所有手术伤口愈合所形成的疤痕或畸形越小越好。但愈合的好坏也取决于伤口对周围组织的影响和手术计划。即便是一个非常成功的神经外科手术，伤口迁延不愈、感染或遗留明显的疤痕会明显降低病人及家属的满意度。了解伤口愈合基本知识、头皮解剖和整形手术的原则，有益于实现伤口稳定、良好的愈合。

上期回顾

Youmans神经外科学专栏 | 第一期：伤口愈合与手术解剖

手术切口及皮瓣设计

Elizabeth G. Zellner and John A. Persing

译者：澳门科大医院,神经外科,谭林琼

切口

神经外科手术选择合适的切口，不仅需要仔细分析要处理的潜在组织，还要有头皮神经血管供应方面的知识，才能确保手术切口的血供、感觉和良好的伤口愈合。一般来说，所有的切口必须平行皮肤张力线，也就是常说的Langer’s线。也就是说，这些线的方向是与切口下肌肉的收缩方向相互垂直。就头皮而言，枕部、颞顶部和顶部前后的头皮Langer’s线方向是按圆周形走行，如图23-15所示。

图23-15:最小的皮肤张力线图示，即 Langer’s线。(改编自Seery GE. Surgical anatomy of the scalp. Dermatol Surg. 2002;28:581-587.)

无损伤器械以及适当的技巧可以减少伤口愈合不良的发生。主张使用有齿颞和有齿拉钩，以减少皮肤的压榨伤。身体大多数手术切口，都会要求手术刀垂直皮肤切开，以避免倾斜破坏临近的皮肤。而头皮是事关头发生长的组织，改良切开的技巧会更为有利。切开头皮时，为避免损伤毛囊，稍倾斜切开为最好，即手术刀与头皮呈80度角或平行头发。毛囊损伤可能导致瘢痕性脱发17 。不同区域头皮的头发倾斜度不同，前部的头发一般是朝前生长，后部和颞部的朝下，靠近顶部的呈螺旋状或放射状30。一般来说，看到的疤痕是唯一的考量因素，疤痕线垂直于临近“瀑布型”的毛囊时，头发就可以遮挡住疤痕。还有一个重要因素要考虑，就是发际线会随着时间发生很大的变化，尤其是男性患者会随着年龄的增长而脱发增多30。发际线不是固定的，而有一个过渡带，细发向前生长，粗发靠后生长。青少年发际线位于额肌上缘，成年人的发际线较青少年后退约一指宽，大多数中老年男性的发际线在上额纹之上1.5cm。额颞部发际线的后移是中年人的特征，设计隐蔽性好的手术切口需要考虑这一点。

前额部是关乎美学最敏感的区域，由几个不同的美学单元构成，设计跨额部的手术切口时需要关注。分类方案不少，大多数是把眼眶区作为一个独立的单元，然后将额部分成几个垂直带，新的称谓如旁正中、外侧和颞外侧单元(图23-16)3。生发的头皮是一个独立单元。规范的重建原则是：美学单元50%或以上发生改变时主张替换整个单元，以避免出现补丁样外观。当仅作部分替换时，就会出现补丁样外观19 。如果位置在额肌/皱眉肌和额部神经，还需要尽量减少眼睑运动单元的影响。

图23-16: 前额的美容单元—前额部、眉部及眶周区域。(改编自 Wells M. Scalp reconstruction. In: Mathes SJ, ed. Plastic Surgery. Philadelphia: Saunders; :607-610.)

皮瓣设计

过了解局部的解剖，就能选择一个显露最好、愈合稳定的手术切口。病人的最佳开颅入路一般要求是脑组织损伤最少，到达病变的距离最短。额颞或翼点开颅的切口历来都是经颧弓根到跨过额部中线的切口，适用于前部的病变。冠状切口通常在翼点切口之上，显露以及美容效果更好，前额部所有的美容单元都得以保留(图23-17)，缺点是切口长、缝合起来耗时多。为追求最佳的美容效果，我们一度将冠状切口更靠后，甚至在顶点之后。这是考虑未来脱发的因素，尤其是男性病人，切口自然还会在头发的覆盖之下(图23-18)32。切开骨膜后颅骨就显露出来，而颞顶区是颞肌覆盖着颅骨。将颞肌与皮瓣一并抬起能保护面神经，而游离颞肌就需要将颞肌向下牵开，牺牲了颞部的暴露。将分离的肌肉跟骨膜缝起来、用骨螺钉加固等多种方法可重建颞肌33。

图23-17:神经外科传统的额部切口：翼点、冠状和颞下。

图23-18: 改良靠后的冠状切口美容效果更好。(获Dr. John A. Persing, Yale School of Medicine授权使用.)

经典的颞下开颅是马蹄形皮瓣，适用于处理天幕、斜坡和基底动脉病变，如图23-19所示34。皮瓣主要以颞浅动脉、耳后动脉为基底。这些动脉不能切断，以保护皮瓣丰富的血供。

中线的枕下开颅历来主要用于后颅窝，优点包括中线两侧枕肌间无血管，特别利于伤口的愈合34。虽然手术切口跟头发下垂的方向平行，但枕部的头发密集，可很好地遮挡疤痕。颈后部项上线之下是由颈夹肌和斜方肌的穿支供血23。

图23-19:颞下开颅切口需要注意颞浅动脉的走行和发际线的位置。a.：动脉。(引自 Sughrue ME, Parsa AT. Temporopolar (half-and-half) approach to the basilar artery and the retrosellar space. In: Jandial R, McCormick P, Black PM, eds. Core Techniques in Operative Neurosurgery. Philadelphia: Elsevier; :111-116.)

切除任何小的圆形病灶，切口都要转换为一个椭圆形，切口长度是宽度的2到3倍，愈合时就不会出现难看的皱褶，也就是伤口末端的“折角”（dog ears） (图23-20)35。这样的切口疤痕长，但是愈合后轮廓会更漂亮。要达到切除的组织最多、疤痕最小，椭圆形的长轴就得尽量沿Langer’s线方向，同时还要考虑头发生长的方向。

图23-20: 椭圆形切口切除圆形病灶，理想的长宽比是3:1，夹角30度，可以避免缝合时出现皱褶。(引自Alam M. Basic excisional surgery. <http:// /article/1818482-overview#a 15>; updated July 30, Accessed 17.03.16.)

影响伤口稳定愈合的因素多而且复杂，包括放射治疗、手术后的疤痕、糖尿病、高龄（65岁以上）等。如果先前的手术或栓塞已经破坏了颞浅动脉，那么以颞浅动脉为基底的皮瓣就有会坏死的风险，这样的病人设计皮瓣时最好包括其它的血管。放疗组织的皮瓣设计也要遵守类似的原则。对于辐照组织或老年人，由于组织血供差，皮瓣的长度要保守，不要超过中线。

推荐读物

Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plast Reconstr Surg. ;116:54e-72e.

Mendes M, Moore P, Wheeler CB, et al. Susceptibility of brain and skin to bacterial challenge. J Neurosurg. 1980;52:772-775.

Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg. ;30:331-342.

Wang HT, Erdmann D, Olbrich KC, et al. Free flap reconstruction of the scalp and calvaria of major neurosurgical resections in cancer patients: lessons learned closing large, difficult wounds of the dura and skull. Plast Reconstr Surg. ;119:865-872.

Whetzel T, Mathes S. Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous vessels. Plast Reconstr Surg. 1992;89:591-603, discussion 604-605.

参考文献

1.Broughton G, Janis JE, Attinger CE. The basic science of wound healing. Plast Reconstr Surg. ;117(7 suppl):12S-34S. doi:10.1097/ 01.prs.0000225430.42531.c2.

2.Miller E, Gay S. Collagen Structure and Function. Philadelphia: Saunders; 1992.

3.Madden JW, Peacock EE Jr. Studies on the biology of collagen during wound healing. 3. Dynamic metabolism of scar collagen and remodeling of dermal wound. Ann Surg. 1971;174:511-520.

4.Lorenz P, Longaker MT. Wound healing: repair biology and wound and scar treatment. In: Mathes S, ed. Plastic Surgery. Philadelphia: Saunders; :209-234.

5.Baumann DP, Crosby MA, Selber JC, et al. Optimal timing of delayed free lower abdominal flap breast reconstruction after post- mastectomy radiation therapy. Plast Reconstr Surg. ;127:1100- 1106. doi:10.1097/PRS.0b013e3182043652.

6.Momoh AO, Colakoglu S, de Blacam C, et al. Delayed autologous breast reconstruction after postmastectomy radiation therapy: is there an optimal time? Ann Plast Surg. ;69:14-18. doi:10.1097/ SAP.0b013e31821ee4b6.

7.Larson BJ, Longaker MT, Lorenz HP. Scarless fetal wound healing: a basic science review. Plast Reconstr Surg. ;126:1172-1180. doi:10.1097/PRS.0b013e3181eae781.

8.Hu MS, Maan ZN, Wu J-C, et al. Tissue engineering and regenera- tive repair in wound healing. Ann Biomed Eng. ;doi:10.1007/ s10439-014-1010-z.

9.Edlich R, Kenney J. Antimicrobial treatment of minor soft tissue lacerations: a critical review. Emerg Med Clin North Am. 1986;4: 561-580.

10.Brown LL, Shelton HT, Bornside GH, et al. Evaluation of wound irrigation by pulsatile jet and conventional methods. Ann Surg. 1978; 187:170-173.

11.Edlich RF. The biology of wound repair and infection: a personal odyssey. Ann Emerg Med. 1985;14:1018-1025.

12.Mendes M, Moore P, Wheeler CB, et al. Susceptibility of brain and skin to bacterial challenge. J Neurosurg. 1980;52:772-775. doi:10.3171/ jns.1980.52.6.0772.

13.Broekman ML, van Beijnum J, Peul WC, et al. Neurosurgery and shaving: what’s the evidence? J Neurosurg. ;115:670-678. doi:10 .3171/.5.JNS10.

14.Tanner J, Woodings D. Preoperative hair removal to reduce surgical site infection: review. Cochrane Database Syst Rev. ;(3):CD004122.

15.Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: update. Infect Control Hosp Epidemiol. ;35:605-627. doi:10.1086/676022.

16.Mueller R. Facial trauma: soft tissue injuries. In: Mathes S, ed. Plastic Surgery. Philadelphia: Saunders; :1-45.

17.Seery GE. Surgical anatomy of the scalp. Dermatol Surg. 2002;28: 581-587.

18.Beran S. Scalp reconstruction. Select Reading Plast Surg. 1999;9: 23-35.

19.Wells M. Scalp reconstruction. In: Mathes S, ed. Plastic Surgery. Philadelphia: Saunders; :607-632.

20.Tremolada C, Candiani P. The surgical anatomy of the subcutaneous fascial system of the scalp. Ann Plast Surg. 1994;32:8-14.

21.Taylor GI. The angiosomes of the body and their supply to per- forator flaps. Clin Plast Surg. ;30:331-342. doi:10.1016/S0094 -1298(03)00034-8.

22.Tolhurst D. The surgical anatomy of the scalp. Plast Reconstr Surg. 1991;87:603-612.

23.Whetzel T, Mathes S. Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous vessels. Plast Reconstr Surg. 1992;89:590-603. Available at: </ plasreconsurg/Abstract/1992/04000/Arterial_Anatomy_ of_the_Face __An_Analysis_of.1.aspx>; Accessed 22.07.14.

24.Tubbs RS, Salter EG, Wellons JC, et al. Landmarks for the identifi- cation of the cutaneous nerves of the occiput and nuchal regions. Clin Anat. ;20:235-238. doi:10.1002/ca.20297.

25.Abul-Hassan H. Surgical anatomy and blood supply of the fascial layers of the temporal region. Discussion. Plast Reconstr Surg. 1986;7. Available at: <http://pdfs.journals. /plasreconsurg/1986/ 01000/00005.pdf>; Accessed 22.07.14.

26.Har-Shai Y, Fukuta K. The vascular anatomy of the galeal flap in the interparietal and midline regions. Plast Reconstr Surg. 1992;89. Available at:</ plasreconsurg/abstract/1992/01000/the_vascular_anatomy_of_the_galeal_flap_in_the.12.aspx>; Accessed 22.07.14.

27.Becser N, Bovim G, Sjaastad O. Extracranial nerves in the posterior part of the head: anatomic variations and their possible clinical sig- nificance. Spine. 1998. Available at: </spinejournal/Abstract/1998/07010/Extracranial_Nerves_in_the _Posterior_Part_of_the.1.aspx>; Accessed 22.07.14.

28.Casanova R, Cavalcante D, Grotting JC, et al. Anatomic basis for vascularized outer-table calvarial bone flaps. Plast Reconstr Surg. 1985;78:300-308.

29.McCarthy J, Berenstein A. Blood supply of the upper craniofacial skeleton: the search for composite calvarial bone flaps. Plast Reconstr Surg. 1984. Available at: </plasreconsurg/ Abstract/1984/11000/Blood_Supply_of_the_Upper_Craniofacial _Skeleton_.3.aspx>; Accessed 22.07.14.

30.Bernstein RM, Rassman WR, Rashid N, et al. The art of repair in surgical hair restoration, part I: basic repair strategies. Dermatol Surg. 2002;28:783-794.

31.Seline P, Siegle R. Forehead reconstruction. Dermatol Clin. ;23: 1-11.

32.Pavri S, Arnaud E, Renier D, et al. The posterior coronal incision. J Craniofacial Surg. ;26:243-244.

33.Spetzler RF, Lee KS. Reconstruction of the temporalis muscle for the pterional craniotomy. Technical note. J Neurosurg. 1990;73:636- 637. doi:10.3171/jns.1990.73.4.0636.

34.Clatterbuck R, Tamargo R. Surgical positioning and exposures for cranial procedures. In: Winn HR, ed. Youmans Neurological Surgery. 5th ed. Philadelphia: Saunders; :623-630.

35.Cowan B. Twelve technical strategies to the perfect surgical scar. Skin Therapy Lett. ;10:9.

36.Venturi ML, Attinger CE, Mesbahi AN, et al. Mechanisms and clini- cal applications of the vacuum-assisted closure (VAC) device: a review. Am J Clin Dermatol. ;6:185-194.

37.Lorenz P, Bari AS. Scar prevention, treatment, and revision. In: Neligan PC, ed. Plastic Surgery. 3rd ed. Philadelphia: Elsevier; .

38.Atagi T, Young V. Alloplastic materials. In: Mathes S, ed. Plastic Surgery. Philadelphia: Saunders; :745-768.

39.Yaremchuk MJ, O’Sullivan N, Benslimane F. Reversing brow lifts. Aesthet Surg J. ;27:367-375. doi:10.1016/j.asj..05.008.

40.Raposio E, Santi P, Nordstrom REA. Effects of galeotomies on scalp flaps. Ann Plast Surg. 1998;41:17-21.

41.Furlanetti LL, de Oliveira RS, Santos MV, et al. Multiple cranial burr holes as an alternative treatment for total scalp avulsion. Childs Nerv Syst. ;26:745-749. doi:10.1007/s00381-010-1145-7.

42.Leedy JE, Janis JE, Rohrich RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plast Reconstr Surg. ;116:54e72e.doi:10.1097/01.prs.0000179188.25 019.6c.

43.Orticochea M. New three-flap scalp reconstruction technique. Br J Plast Surg. 1969;184-188.

44.Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg. 1984;74. Available at: </plasreconsurg/Abstract/1984/10000/Tissue_ Expansion_in_Soft_Tissue_ Reconstruction.5.aspx>; Accessed 22.07.14.

45.Milenović A, Virag M, Uglesić V, et al. The pectoralis major flap in head and neck reconstruction: first 500 patients. J Craniomaxillofac Surg. ;34:340-343. doi:10.1016/j.jcms..04.001.

46.Wang HT, Erdmann D, Olbrich KC, et al. Free flap reconstruction of the scalp and calvaria of major neurosurgical resections in cancer patients: lessons learned closing large, difficult wounds of the dura and skull. Plast Reconstr Surg. ;119:865-872. doi:10.1097/01. prs.0000240830.19716.c2.

未完待续

本文节选翻译自：Youmans and Winn Neurological Surgery-Incisions and Closures；版权归原出版社，翻译仅供学习。

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