整形重建手術成果分析及降低併發症之研究

邱文寬

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整形重建手術成果分析及降低併發症之研究

A research on outcome analysis and complications reduction in plastic reconstructive surgery

邱文寬 , Ph.D　　Advisor：楊騰芳　　

繁體中文

併發症；整形重建手術；頭頸癌；乳癌；慢性傷口； Complication ； Plastic reconstructive surgery ； Head and neck cancer ； Breast cancer ； Chronic wound

Abstract │ Reference (129) │ Altmetrics

Abstract 〈TOP〉

1.    研究壹: 多次游離皮瓣手術在同一患者的口腔癌重建中是否安
全？ ：結果和併發症分析
頭頸癌患者的游離皮瓣重建可以提供可靠而有效的傷口覆蓋。在此，我們將介紹成果並分析多次游離皮瓣重建手術的併發症及危險因子。總共分析了40位共接受92個游離皮瓣的患者(42個初次游離皮瓣和50個二次游離皮瓣)。最常見的顯微吻合血管是對側表淺甲狀腺血管（68％）。初次和二次游離皮瓣最常使用的皮瓣是大腿前外側皮瓣（64.3％和62％）。二次游離皮瓣的成功率為92.0％，而初次游離皮瓣的成功率為92.9％，無統計學意義差異。女性與傷口延遲癒合，OR為90.91（95％CI 0.001-0.17，p = 0.001），糖尿病也有獨立相關性OR為31.14（95％CI 2.60-373.19，p = 0.007）。二次游離皮瓣並非任何併發症的危險因素。與初次的游離皮瓣重建手術相比，二次游離皮瓣手術是一種可靠的頭頸部重建手術方法，沒有造成更高併發症發生率。
2.    研究貳:義乳重建中的義乳不正常運動(Animation deformity)之概述
義乳不正常運動是一種以胸大肌收縮造成植入物變形移位的難看併發症。由於最近對該現象的重視提高，也引起了對胸大肌上乳房重建的風氣。但有關義乳不正常的原因和影響的研究有限。具體而言，沒有發現特定於患者的危險因素可導致義乳不正常運動。放置在胸大肌下和胸大肌切斷是與義乳不正常運動嚴重程度相關的唯一圍術期因素。我們對義乳不正常運動的定量分析進一步讓我們對這種現象的有更多理解，在此我們結合當前的分類標準對此進行介紹。我們還將更廣泛地回顧有關義乳不正常運動的當前文獻，包括其成因，風險因素
，對患者預後的影響以及當前的治療選擇。總體結論，在此類患者身上會造成情緒困擾的併發症，且大多數患者希望接受手術的方法，以免出現義乳不正常運動。治療選擇的方法從將義乳轉換到胸大肌上、或胸大肌分段切開術、或選擇性神經切斷，或肉毒桿菌毒素注射。
3.    研究參:乳房重建中義乳不正常運動變形的定量分析
義乳不正常運動的特徵在於，胸大肌下植入物的乳房重建術後，因胸大肌收縮造成植入物變形。由於現有文獻缺乏客觀，定量的數據，無法測量和分析義乳不正常運動變形，我們試圖通過深入的客觀定量分析來補充主觀評估的誤差，對接受胸大肌下義乳重建術的患者進行前瞻性視頻動畫性分析。使用成像軟體對靜止和收縮狀態下的乳頭位移和輪廓變形的表面積進行定量。將動畫程度與乳房大小，身體質量指數，胸大肌切斷，併發症和放射治療進行比較。結果：分析了一百四十五例乳房重建（88位病患），乳頭平均位移為2.12±1.04 cm
，乳頭平均位移向量為62.5±20.6度，皮膚輪廓不規則區域的平均面積比例為16.4±15.41％。術中胸大肌切開，平滑/圓形植入物和雙側重建與義乳不正常運動變形相關。我們以乳頭淨移位2公分為閾值和皮膚輪廓不規則25％為閾值進行三級評分系統，在1級，2級和3級中分別佔41.4％和35.9％，在3級中佔22.8％。且不同評分者之間的認可度為89.5％（kappa = 0.84）。結論：本研究首次提出了乳房重建中義乳不正常運動的定量分析。由乳頭位移向量的幾何分析暗示了下側胸大肌肌節是導致義乳不正常運動畸形的主要來源。我們開發了相應的分級方式，提供一個標準化的方法，未來藉此方法來客觀討論不同研究。
4.    研究肆:新穎的肌切開-莢膜切開術和肌肉內脂肪移植（簡稱McFat）治療
胸大肌上義乳重建的軟組織缺損
以義乳為主的乳房重建是美國最受歡迎的乳房重建方式，佔2017年進行的106295例乳房重建的82％。歷史上，義乳為主的乳房重建最初是在胸大肌上進行的，但由於高的皮膚壞死率，植入物的露出率和美容性差，因此不受歡迎。在過去的40年中，胸大肌下植入義乳法一直是首選的治療方法。然而，近年來
，人們對胸大肌上重建很感興趣是由於胸大肌下重建的某些不良後遺症，即義乳不正常運動和術後疼痛增加，使得胸大肌上的乳房重建術重新出現。幸運的是，伴隨我們的新技術使胸大肌上重建成為可行的選擇，包括降低併發症發生率和改善外觀。
胸大肌上重建在美學上的一個關鍵缺點是在乳房上方會有挖空的變形。傳統解決方案是將脂肪轉移到上方的皮下空間。但是，在胸大肌上乳房重建中上軟組織極少（無胸肌），並限制了可以注射的脂肪數量，又會降低脂肪的存活使得脂肪很難掩蓋植入物邊緣。為了改善這個美學問題，我們描述了一種新穎的肌切開-莢膜切開術和肌肉內脂肪移植（簡稱McFat）技術來解決此問題。具體來說，我們進行了結合莢膜切開術和胸大肌切開術，創建了一個高度血管化的新空腔，比傳統的薄且血管化程度低的乳房切除術上方皮瓣更適合脂肪移植。其次，為了能夠有更大的脂肪移植空間，本技術還因結合掀起胸大肌肌肉方式，而一併達到美化胸前上緣挖空變形。
5.    研究伍:經足背蹠骨切除術治療慢性足底傷口的初步研究
慢性足底潰瘍的臨床十分難處理的問題。壓力負荷常常是最需要解決的問題。在本文中，我們報告了一種降低足底壓力的手術方法：經足背蹠骨切除術。 2011年3月至2016年10月，台北萬芳市立醫院（台北醫學大學）對16例患有慢性足底潰瘍的患者進行了蹠骨切除術。通過足背切除約0.5〜1 cm長的骨頭。足底傷口僅用清創術治療或同時用皮膚移植。總共納入了16例平均年齡為57.81歲（標準差為11.6）歲的患者（男12例，女4例）。 15例患者（93.75％）被診斷出患有第2型糖尿病，平均診斷糖尿病時間為20.66年（5-30年）。平均糖化血紅蛋白為9.14（範圍5.2〜13.2）g / dL。平均足底傷口尺寸為5.72 cm2。四名患者（25％）需要接受平均植皮大小為8.13平方公分。平均術後追蹤時間為15.2個月。足底傷口完全治癒共14例（87.5％），平均癒合時間為2.14個月，併發症部分，沒有足底潰瘍復發，但是兩名患者於術後平均7.5個月發生了轉移性潰瘍（12.5％）。結論:經足背蹠骨切除術是減少慢性足底傷口壓力負荷的有效方法。我們的研究提供了此方法來解決難題，傷口癒合率高，復發少。

6.    研究陸:富含血小板血漿治療萎縮性痤瘡疤痕的輔助治療的
Meta-analysis
大量研究調查了富含血小板血漿（PRP）作為萎縮性痤瘡疤痕的輔助治療方法的作用。但結果卻不太一樣，並且沒有最新的Meta-analysis證實萎縮性痤瘡疤痕的治療。所以我們針對萎縮性痤瘡疤痕進行Meta-analysis，評估以PRP為輔助治療的副作用及改善效果。該研究遵循PRISMA指南至2018年9月，使用PubMed，EMBASE，MEDLINE和Cochrane圖書館的電子數據庫對文獻進行了全面搜索。這篇評論包括七篇文章。所有已發表的研究都將PRP用作輔助療法。主要療法包括部分雷射療法和微針療法。改善效果評估可分為改善程度極改善分數。以改善程度來分析的文章共有五篇研究（249名參與者），改善程度有四個程度的改善（在此分析中，第3級和第4級被視為改善）。以改善分數來分析的文章共有四項研究（200名參與者），其中報告了平均改善得分。與對照組相比，PRP組的改善程度明顯較高（WMD = 8.19； 95％CI，4.32至15.52； p <0.00001）；相同地，平均改善分數也較高（WMD = 21.78； 95％CI ，從9.95到33.60； p = 0.0003）。在改善程度（I2 = 54％，p = 0.07）和平均改善分數（I2 = 75％； p = 0.008）中都看到異質性。副作用部分，在PRP組中，總體監測到的副作用較少，包括紅斑和浮腫（以天為單位），但是沒有發現任何意義。這項研究表明，PRP是一種治療萎縮性痤瘡疤痕的有用輔助療法，可以達到更好的改善治療。

Parallel Abstract 〈TOP〉

Research 1:
Is Sequential Free Flap Safe in Oral Cancer Reconstruction in the Same Patient? : An Outcome and Complication Analysis
Sequential free flap reconstruction in patient with head and neck cancer can provided reliable and effective wound coverage. Herein, we presented the outcome and analysed the risk factors for complications in sequential free flap reconstruction. In total, 40 patients with 92 free flaps were analyzed; 42 initial and 50 sequential free flaps. The most common recipient vessels for sequential flap were contralateral superficial thyroid vessels (68%). The most common flap for both initial and sequential free flap was anterolateral thigh flap (64.3% and 62%). The success rate of sequential free flap was 92.0% compared to 92.9% for initial free flap, which showed no statistically significant difference. Female was independently associated with delayed wound healing with an OR of 90.91 (95% CI 0.001-0.17, p=0.001), as well as diabetes with an OR of 31.14 (95% CI 2.60-373.19, p=0.007). Sequential free flap was not a risk factor for any complication. Sequential free flap is a reliable method for head and neck surgery without more complication rate comparing to initial free flap reconstruction.
Research 2:
An overview of animation deformity in prosthetic breast reconstruction
Animation deformity is an unsightly complication after sub-pectoral breast reconstruction characterized by implant displacement with pectoralis muscle contraction. Recent increased awareness of this phenomenon has driven interest in pre-pectoral breast reconstruction but research is limited regarding the causes and implications of animation deformity. Specifically, no patient-specific risk factors have been identified as contributing to animation deformity. Placement in a sub-pectoral plane and division of the pectoralis are the only peri-operative factors associated with severity of animation deformity. Our own quantitative analysis of animation deformity has further refined our understanding of this phenomenon, which we present here along with a review of current grading scales. We also more broadly review the current literature surrounding animation deformity, including its causes, risk factors, impact on patient outcomes and current treatment options. Overall, patients find this to be an emotionally distressing complication and most patients would like to be educated on alternative surgical options to avoid animation deformity. Treatment options range from conversion to a pre-pectoral plane to muscle-splitting techniques to selective nerve ablation to Botox injections. Further research into causes, implications and ways to enhance pre-pectoral reconstruction are needed to improve patient outcomes with this phenomenon.
Research 3:
A Quantitative Analysis of Animation Deformity in Prosthetic Breast Reconstruction
Animation deformity is characterized by implant deformity with pectoralis contraction after subpectoral implant-based breast reconstruction. Extant methods to measure and analyze animation deformity are hampered by the paucity of objective, quantitative data. The authors endeavored to supplement subjective measures with an in-depth quantitative analysis. Patients undergoing subpectoral implant-based breast reconstruction were followed prospectively with video analysis of animation deformity. Nipple displacement and surface area of contour deformity in resting and contracted states were quantified using imaging software. Degree of animation was compared to breast size, body mass index, division of pectoralis muscle, complications, and radiation therapy. One hundred forty-five reconstructed breasts (88 patients) were analyzed. Mean nipple displacement was 2.12 ± 1.04 cm, mean vector of nipple displacement was 62.5 ± 20.6 degrees, and mean area of skin contour irregularity was 16.4 ± 15.41 percent. Intraoperative pectoralis division, smooth/round implants, and bilateral reconstructions were associated with greater deformity. A three-tiered grading system based on thresholds of 2-cm net nipple displacement and 25 percent skin contour irregularity placed 41.4 percent of breasts in grade 1, 35.9 percent in grade 2, and 22.8 percent in grade 3. Inter-rater variability testing demonstrated 89.5 percent overall agreement (kappa = 0.84).This study presents the first quantitative analysis of animation deformity in prosthetic breast reconstruction. Geometric analysis of nipple displacement vector and increasing animation with pectoralis division both implicate the inferior pectoralis myotome as a primary driver of animation deformity. A concomitant grading schema was developed to provide a standardized framework for discussing animation from patient to patient and from study to study.
Research 4:
Myotomy-Capsulotomy With Intramuscular Fat Grafting: A Novel Technique for Secondary Treatment of Prepectoral Upper Pole Defects in Breast Reconstruction
Implant-based breast reconstruction is the most popular mode of breast reconstruction in the United States, accounting for 82% of the 106,295 breast reconstructions performed in 2017. Historically, implant-based breast reconstruction was initially performed in the prepectoral plane, but due to high rates of skin necrosis, implant extrusion, and poor cosmesis, it fell out of favor. The subpectoral approach has been the preferred technique for the last 40 years. In recent years, however, interest in prepectoral implant-based breast reconstruction has reemerged given certain undesirable sequela of subpectoral reconstruction, namely animation deformity and increased postoperative pain. This interest has fortuitously been accompanied by new technologies and techniques that now make prepectoral reconstruction a viable option involving reduced complication rates and improved appearance.
Although there are several putative advantages that prepectoral reconstruction has over a subpectoral approach, one key aesthetic disadvantage is the potential for hollowing and contour ledging at the upper pole. The conventional solution for contour ledging is fat transfer to the subcutaneous space of the upper pole. However, the paucity of upper pole soft tissue (sans pectoralis muscle) in a prepectoral reconstruction perforce limits the amount of fat that can be injected, which in turn may attenuate fat retention. Less soft tissue substrate for grafting will make it more difficult for the fat to camouflage the implant edge. To ameliorate this aesthetic problem, ideally there would be a way to supplement the soft tissue defect in the upper pole of prepectoral reconstructions. To this end, we describe a novel myotomy-capsulotomy and intramuscular fat grafting (colloquially termed McFat) technique to address this issue. Specifically, we performed a conjoint capsulotomy and pectoralis myotomy, creating a highly vascularized neo-subpectoral space isolated to the upper pole that is more favorable for fat graft insertion and take than a traditional thinner and less vascularized upper pole mastectomy skin flap. Secondarily to abetting greater fat grafting, this technique also incorporates the elevation of an additional bulk of soft tissue—namely a slip of the pectoralis muscle—to soften the natural prepectoral upper pole step off that may occur.
Research 5:
Assessment of Outcomes of a Metatarsal Bone Ostectomy for Chronic Plantar Ulcers-a Preliminary Study
Clinical management of chronic plantar ulcers is a difficult issue in medical practice. Pressure overloading is a problem that needs to be resolved. Herein, we report a surgical method to reduce plantar pressure: a dorsal approach to a metatarsal ostectomy. From March 2011 to October 2016, 16 patients suffering from chronic plantar ulcers underwent ostectomy procedures at Taipei Wan-Fang Municipal Hospital (Taipei Medical University). A bone segment about 0.5~1 cm long was removed via a dorsal foot approach. The plantar wound was treated with debridement only or was simultaneously covered with a skin graft. In total, 16 patients with an average age of 57.81 (standard deviation, 11.6) years (12 males and four females) were included; 15 patients (93.75%) had a diagnosis of type 2 diabetes for a mean of 20.66 (range, 5~30) years. The mean glycated hemoglobin was 9.14 (range, 5.2~13.2) g/dL. The mean plantar wound size was 5.72 cm2. Four patients (25%) needed to receive a skin graft with a mean skin graft size of 8.13 cm2. The mean follow-up time was 15.2 months. The plantar wounds completely healed in 14 patients (87.5%) in an average of 2.14 months. No plantar ulcer was complicated with recurrence, but transfer ulcers developed in two patients (12.5%) at an average of 7.5 months postoperatively. Metatarsal ostectomy surgery via a dorsal foot approach is an efficient way to reduce pressure overloading of chronic plantar wounds. Our study provides an alternative method to treat this difficult problem with a high wound healing rate and less recurrence.
Research 6:
A Meta-Analysis of the Evidence for Assisted Therapy with Platelet-Rich Plasma for Atrophic Acne Scars
A number of studies have investigated the role of platelet-rich plasma (PRP) as an assisted therapy for atrophic acne scars. However, the results are diverse, and no up-to-date meta-analysis was found that exclusively examined atrophic acne scar treatment. To perform a meta-analysis to assess improvements in side effects of PRP and the effect of assisted therapy for atrophic acne scars. This study followed PRISMA guidelines. A comprehensive search of the literature was carried out in September 2018 using the electronic databases of PubMed, EMBASE, MEDLINE, and the Cochrane Library. Seven articles were included in this review. All of the studies published utilized PRP as additive therapy. The major therapies included fractional carbon laser therapy and microneedling. Five studies (249 participants) reported four degrees of improvement on an improvement scale (degrees 3 and 4 were considered improvement in this analysis). Four studies (200 participants) reported mean improvement scores. A significantly higher degree of improvement was shown in the PRP group compared to the control group (WMD=8.19; 95% CI, 4.32 to 15.52; p<0.00001), as well as better mean improvement score (WMD=21.78; 95% CI, 9.95 to 33.60; p=0.0003). Substantial heterogeneity was seen in the degree of improvement (I2=54% p=0.07) and the mean improvement score (I2=75%; p=0.008). There were overall fewer monitored side effects, including erythema and edema (in days), in the PRP groups; however, no statistical significance was found. This review shows that PRP is a useful assisted therapy for atrophic acne scars, which can achieve better improvement.

Reference ( 129 ) 〈TOP〉

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[2]. Blackwell KE. Unsurpassed reliability of free flaps for head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1999; 125:295-9.
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