趙亞楠 康曉靜 于世榮 安彩霞 羅東 張景展

[摘要]目的：探討頭面部皮膚惡性腫瘤及癌前病變手術(shù)切除和創(chuàng)面修復(fù)的方法。方法：58例頭面部惡性腫瘤及癌前病變患者，根據(jù)惡性腫瘤手術(shù)原則，徹底切除病灶，應(yīng)用原位縫合9例，游離皮片18例，局部皮瓣31例的方法進(jìn)行修復(fù)。結(jié)果：本組58例，除1例皮片移植表皮部分壞死，經(jīng)換藥治療傷口二期愈合外，其余植皮及皮瓣均一期修復(fù)，供區(qū)均一期愈合，顏面部外觀滿意。完成隨訪的42例中，1例面部鱗癌經(jīng)局部皮瓣修復(fù)術(shù)后1年復(fù)發(fā)，再次擴(kuò)大切除行皮片移植術(shù)后隨訪3年未見復(fù)發(fā)，其余41例均未見復(fù)發(fā)。結(jié)論：對(duì)于頭面部惡性腫瘤及癌前病變應(yīng)早期診斷，依據(jù)惡性腫瘤的治療原則徹底切除病灶，術(shù)中快速冰凍切片可降低復(fù)發(fā)率，修復(fù)缺損應(yīng)最大程度兼顧缺損區(qū)域功能和外形。

[關(guān)鍵詞]創(chuàng)面修復(fù)；惡性腫瘤；癌前病變；頭面部；皮瓣；植皮修復(fù)；手術(shù)切除

[中圖分類號(hào)]R622 [文獻(xiàn)標(biāo)志碼]A [文章編號(hào)]1008-6455（2018）12-0028-03

Surgical Resection and Wound Repair for Cutaneous and Malignant Precancerous Lesions of the Head and Face

ZHAO Ya-nan，KANG Xiao-jing，YU Shi-rong，AN Cai-xia，LUO Dong，ZHANG Jing-zhan

（Department of Dermatology，the Xinjiang Uygur Autonomous Region People's Hospital，Urumqi 830001，Xinjiang，China）

Abstract： Objective To investigate the methods of resection and wound repair of skin malignant tumor and precancerous lesions in the head and face. Methods There were 58 patients with head and face malignant tumors and precancerous lesions， according to the principle of malignant tumor surgery， the focus were thorough excision， 9 cases were repaired with orthotopic suture， 18 cases with free skin grafting and 31 cases with local skin flap. Results All the cases in this group were primary repair and primary healing， except for one case of which the skin grafting surface was partly necrosis，and healed in secondary. Among 42 cases with foIlow up， one case of facial squamous cell carcinoma recurred 1 year after local skin flap repair， no recurrence was found in 3 years of follow-up after extended resection and skin graft， and no recurrence was found in the remaining 41 cases. Conclusion For head and face malignant tumors and precancerous lesions， it should be early diagnosed and completely resected according to the treatment principle of malignant tumors. Rapid frozen section during surgery can reduce the recurrence rate， and the function and shape of the defect area should be taken into account to the greatest extent for the repair of defects.

Key words： wound repair； malignant tumor； precancerous lesions； head and face； skin flap； skin graft repair； surgical resection

2013年3月-2017年6月，筆者醫(yī)院共收治頭面部皮膚惡性腫瘤及癌前病變58例，病灶經(jīng)根治性手術(shù)切除后分別采用原位縫合、皮片移植、局部皮瓣的方法進(jìn)行修復(fù)，42例患者術(shù)后獲得1～3年的隨訪，取得了比較滿意的治療效果，現(xiàn)報(bào)道如下。

1 資料和方法

1.1 臨床資料：58例頭面部惡性腫瘤患者，男32例，女26例，年齡44～82歲，病程3個(gè)月～4年。病變部位：頭皮6例、眼瞼3例、眉部1例、鼻部6例、顳部9例、鼻唇溝8例、內(nèi)眥3例、額部5例、頰部7例、下頜部4例、顴部6例。修復(fù)缺損范圍5mm×7mm～55mm×65mm，病變均未發(fā)生局部淋巴及遠(yuǎn)位器官轉(zhuǎn)移。臨床表現(xiàn)：頭面部腫物部伴有潰瘍、結(jié)痂、接觸性出血。

1.2 方法：術(shù)前全部經(jīng)皮膚病檢或皮膚共聚焦顯微鏡檢查明確診斷。在局部阻滯麻醉下行皮膚惡性腫瘤根治切除術(shù)，嚴(yán)格遵守?zé)o瘤、無菌操作要求。術(shù)前根據(jù)腫瘤類型、分化程度及有無復(fù)發(fā)等因素確定切除廣度[1]。一般情況下切口距腫瘤外緣：基底細(xì)胞癌為5～10mm，鱗狀細(xì)胞癌為10～20mm，日光性角化病3～5mm。復(fù)發(fā)病例切除范圍30mm。切除深度根據(jù)術(shù)中具體情況決定，需超出腫瘤侵犯層次至正常組織層。一般腫瘤在面部的切除深度達(dá)淺筋膜層，位于頭皮淺表局限的腫瘤一般切至帽狀腱膜層[2]。腫瘤切除后用雙極電凝或電刀徹底止血，必要時(shí)可縫扎血管，以生理鹽水沖洗創(chuàng)面，更換紗布刀片。采用個(gè)體化修復(fù)方案，根據(jù)缺損大小、組織損傷程度及切口周圍皮膚的具體情況進(jìn)行修復(fù)，分別采用：①原位縫合9例；②游離皮片18例；③局部皮瓣31例，包括改良菱形皮瓣12例、鼻唇溝皮瓣5例、旋轉(zhuǎn)皮瓣3例、風(fēng)箏皮瓣1例，Burow楔形皮瓣4例，雙蒂推進(jìn)皮瓣3例（見圖1～2），“A-T”皮瓣3例（見圖3～4）。術(shù)前病理活檢確診為惡性腫瘤的患者，術(shù)中行快速冰凍切片病理檢查，以判斷手術(shù)切緣是否徹底，如邊緣未切凈，在殘留腫瘤一側(cè)擴(kuò)大2～5mm范圍再次切除。原位縫合常用可吸收縫合線行減張縫合。游離皮片移植可選擇四肢屈側(cè)皮膚或腹部皮膚，取皮區(qū)略大于創(chuàng)面，將所取全厚皮片修剪成刃厚皮片備用，取皮區(qū)一般直接縫合，將游離皮片放置于創(chuàng)面，打包縫合，加壓包扎。局部皮瓣修復(fù)需根據(jù)病變大小及位置合理設(shè)計(jì)皮瓣，按設(shè)計(jì)線切開并掀起皮瓣覆蓋創(chuàng)面，分層縫合，供皮區(qū)創(chuàng)面直接縫合。術(shù)后切除標(biāo)本送病理檢查，以明確腫瘤類型、分化程度及切緣是否殘留腫瘤組織。