米拉德縫合技巧

1、（米拉德）縫合技巧先把如題的米拉德整形外科原則的縫合技巧內(nèi)容奉上：無論手術(shù)設(shè)計的如何巧妙，手術(shù)操作的技巧，包括縫合技巧，在傷口愈合和最終效果方面將是一個重要的因素。某些縫合技巧會使縫合更便利。1  良好的皮下和皮內(nèi)埋置，縫合位置有助于死腔的關(guān)閉和消除皮膚的縫合張力。同樣皮膚縫合也可以消除組織死腔。2  一個最有效的皮膚間斷縫合，是在近皮緣處垂直或最好向外側(cè)轉(zhuǎn)動進針，包括真皮的良好縫合和確保創(chuàng)緣外翻。3  由松弛側(cè)向固定側(cè)縫合，即首先由游離皮片邊進針，然后經(jīng)受植區(qū)皮膚缺損之固定邊緣出針。這種順序比由固定邊緣進針，然后試圖用針鉤縫不穩(wěn)定游

2、離皮片邊緣更好。4  將薄皮緣與厚皮緣縫合時，在薄皮緣處淺層進針要稍深些，然后在厚皮緣處淺些出針，這樣可使雙側(cè)皮緣平整對合。5  當一側(cè)創(chuàng)緣比另一側(cè)要低時，由高側(cè)創(chuàng)緣淺層進針，然后在低側(cè)創(chuàng)緣稍深位置出針縫合。由低向高縫合造成縫線由低側(cè)穿出?？p線長端向上牽拉打第一個結(jié)時，就會使低側(cè)創(chuàng)緣向上與對側(cè)創(chuàng)緣處于同一水平。（植皮縫合時，有時皮片與切口要不不能完全覆蓋較厚的瘢痕切口，要不覆蓋太多，造成部分皮片重疊或皮片多出瘢痕切緣太多，一皮源浪費，二切緣植皮成活不好，這時，充分拉直縫線兩端，稍微抖動幾下，很可能皮片與受區(qū)就很好的貼牢了，而且皮緣不太寬的情況下，該法可使

3、皮緣與切緣很好重疊，沒有皮片游離于創(chuàng)緣，也可使較厚的瘢痕切緣不因皮片未能完全覆蓋貼牢而影響外觀，此為導(dǎo)師實踐摸索的很靈光、很實用有效的經(jīng)驗方法，各位和本人一樣的新手可慢慢摸索、體會）6  為獲得最整齊的創(chuàng)緣縫合，精細的縫線比金屬夾或微孔膠帶更為有效。金屬線很少產(chǎn)生異物反應(yīng)，絲線更易于縫合操作，滌綸、普洛靈及尼龍線則穩(wěn)定而富有彈性。單線針比褥式縫合更好，因為2個針眼通常好于4個針眼。除此通常情況外，對于足底、手掌、陰囊、耳后區(qū)和斜形切開的創(chuàng)緣，褥式縫合會起到較有效的作用。根據(jù)力學(xué)的微型Lillputian分布，用縫線在靠近皮緣處縫合傷口是有益的。如果縫線距離創(chuàng)緣太遠，就會遺留

4、階梯狀的縫線壓痕，要去除這種壓痕，就需犧牲太多的組織。對關(guān)閉傷口時有張力，且需保留縫線較長時間的部位，在某些特別要避免縫線壓痕的部位，最好用得麥?。―ermalon）縫線形皮內(nèi)縫合。這樣不但可保留較長時間，也無縫線壓痕的危險。皮內(nèi)縫合線最好以每隔5.08cm（2英寸）或小于5.08cm（2英寸）的距離穿出皮膚后再進入皮內(nèi)，這樣可縮短拆線時間，拆線也更容易些。仔細觀察瘢痕整形技藝大師，弗吉尼亞州福爾斯徹奇的Alfred F. Borges 的W-整形術(shù)縫合操作，就會知道應(yīng)該怎樣更好的學(xué)習(xí)技藝。在全面認識到高超技藝的重要價值后，Borges4982年寫道：最佳的手術(shù)技術(shù)本身不是成功的保證，在一項手

5、術(shù)后，要獲得細小縫線瘢痕的決定因素之一，不是如此之多的有特點的縫合技術(shù)，而是切口是否與皮膚張力松弛線行走一致。這里是Borges技術(shù)的一些基本規(guī)則：1  沿皮膚張力線“RSTL”（Relaxed Skin Tension Line）行走方向選擇手術(shù)切口，其瘢痕將獲得最佳美觀和功能效果；2  對于張力線（ALT, Antitension line）的外殼顯露手術(shù)切口，曲線的皮膚切口在愈合方面優(yōu)于直線ALT切口，因為其可提供更寬大的顯露和形成一條良好的富有彈性的術(shù)后曲線瘢痕；3  對抗張力線的瘢痕可通過鋸齒狀瘢痕修整手術(shù)（W或Z改形術(shù)）加

6、以改善。該技術(shù)可以改變瘢痕的方向，并將其分割成短小的直線瘢痕。任何面部沒有按RSTL行走的瘢痕，都可經(jīng)W成形術(shù)或Z成形術(shù)進行修正而加以改善，條件是先前沒有太多的皮膚缺損。4  皮膚張力是瘢痕形成的基本因素，皮膚張力的形成受皮膚缺損里昂、區(qū)域、走向、類型、瘢痕長度及病人年齡的影響；5  在大部分情況下，寬大和（或）增生的瘢痕不適合用任何瘢痕修整手術(shù)。簡單切除一條因傷口自行愈合和棱形切除瘢痕后關(guān)閉創(chuàng)面所形成的寬大和（或）增生性瘢痕，將不可避免地在手術(shù)后再次形成一條寬大和（或）增生的瘢痕；6  不要輕易去行瘢痕修整，除非你有理由確定，你可以

7、部分或全部改變形成不理想瘢痕的因素，或你可以承擔(dān)整修術(shù)可能會導(dǎo)致比原先瘢痕更差的風(fēng)險；7  當處理一條嚴重凹陷瘢痕或一條絞索狀突起瘢痕是，Z改形術(shù)首選方法，因為Z改形術(shù)可以通過組織的交叉插入，消除和改變張力，達到明顯的平衡作用；8  在糾正半環(huán)狀隆起瘢痕畸形是，治療目標不應(yīng)包括正常皮下脂肪組織的隆起，而應(yīng)針對弧形皮膚瘢痕所致的束帶狀收縮；9 縫合時最常見的技術(shù)過錯是皮膚縫線結(jié)扎得太緊。約翰霍普金斯醫(yī)院的William S. Halstead在1890年就提醒外科醫(yī)生：“由縫合合結(jié)扎而造成的血循環(huán)障礙，常常是感染創(chuàng)面化膿的直接原因。”注意張力縫線痕跡在縫合

8、時，可在縫線的小范圍內(nèi)形成張力環(huán)。盡管撕裂傷、手術(shù)切口所形成的瘢痕無法避免，但永久的縫線痕跡是可以避免的。猶如獵人可依據(jù)腳印尋找到一只野獸一樣，人們可以通過縫線痕跡來認識一位外科醫(yī)生。如果別人將通過這些縫線痕跡來認識我們，這表明我們應(yīng)該仔細檢討一下，這種因縫合而造成的潛在皮膚血循環(huán)不良的原因。當將縫線的結(jié)大得太緊時，不但會切割皮膚，而且會形成炎性水腫，并將導(dǎo)致壓力性皮膚壞死、感染可能。1  施行間斷縫合時，對于一個較短的直線形傷口，可先在傷口的兩端各做一個縫合，再將兩端的縫線拉緊，使傷口兩側(cè)的皮膚自然隊合，然后再在兩端之間進行間斷縫合。對于一個不規(guī)則的傷口，應(yīng)該先選尖角或突

9、出部分進行縫合，以后再用等分縫合法將全部傷口縫合。2  有些傷口，例如切削傷傷口，其邊緣的厚度常在兩側(cè)各不相同，即有時一側(cè)較厚，而另一側(cè)較薄。這時，為了求得進針的深度能在傷口兩側(cè)彼此相同，其與傷口的距離亦不相同。通常皆需在較厚側(cè)距離傷口邊緣較近，在較薄側(cè)距傷口邊緣較遠。3  縫合的傷口如較深且稍有張力，則在縫合時最好采用褥式縫合法或遠-近、近-遠縫合法，垂直褥式縫合法亦稱“在端”褥式縫合法（Mcmillen氏法），它在縫合皮膚邊緣同時可以將皮下組織縫合。遠-近、近-遠縫合法亦稱翖翼縫合法（Bolster氏法），它在縫合皮膚邊緣以后再在距離皮膚邊緣較遠處再

10、作一個縫扣，減少皮膚邊緣的張力。各種褥式縫合法或遠-近、近-遠縫合法續(xù)前，盡管整形科使用該類方法不多，一起帶上。真皮縫合法及皮下縫合法1  真皮縫合和皮下縫合的區(qū)別:1）  真皮縫合是選擇性縫合真皮的方法。其目的是減張，以防止一期愈合后的瘢痕在形成穩(wěn)定性瘢痕前的數(shù)個月期間因持續(xù)的張力作用而變寬。2）  皮下縫合：一般并非單純的真皮縫合，而是包括皮下組織的縫合，主要作用是為了閉合死腔。雖有一定的減張作用，但達不到減張縫合的減張效果。真皮縫合中縫線的位置：初學(xué)者最容易犯的錯誤是真皮縫合的位置過淺(如下圖A)。雖然這種縫合方法稍微帶有真皮，

11、并可很好地對合傷口邊緣，但縫線易外露。最理想的縫合方法如圖B，使縫線位于較深位置，并呈松弛的橢圓形。（我們平時在縫合張力較大部位如腹部取皮處，采取與切口平行而不是垂直的方法進針做真皮縫合應(yīng)該基于此道理）不必要進行真皮縫合的部位：手掌，足底，眼瞼及與皮紋相平行的部位粘膜，陰囊等處。應(yīng)該形真皮縫合部位：頭皮、軀干多處及下肢等。4  Stair-Step Technique of Repaira.  The Stair-step resection of scars of lesions, and the stair-step incision to expo

12、se and to carry out procedures such as the augmentation mammaplasty enable one to repair in a stair-step fashion with a sound layer closure. This makes for a safer wound closure, especially when there is tension on the edges, and makes exposure of foreign implants or grafts (such as breast prosthese

13、s, bone grafts, and cartilage grafts) less likely. Interruption of the continuity of the healing wound external to the graft or implant is not likely with this repair because it distributes and shares the tension in each layer.b.   This technique may be applied to any wound closure and in

14、resection of superficial lesions or scars, as is demonstrated. The tissue usually keep their normal thickness to give a level skin surface, with less likelihood of spreading or depression of the scar line. 上段文字并不難理解，做了個參考翻譯a. 階梯形切除瘢痕，階梯狀切開并暴露深層組織，例如隆乳術(shù)，這樣，我們以同樣階梯形式縫合，可安全放心的閉合切口。這種切口修復(fù)方法相對更安全，特別是切緣張力

15、較大時，階梯狀縫合使外源性植入物或自身移植物（如乳房假體、移植骨、軟骨）更不容易外露。由于階梯狀縫合使張力能夠分布并分散到不同的層面，切口在不同的層面修復(fù)，故植入或移植物幾乎不可能外露。b. 臨床應(yīng)用證實，該方法或許可擁有任何表淺傷口或瘢痕切口的修復(fù)。由于該方法降低了瘢痕的攣縮力的擴展或凹陷幅度，故愈合后局部組織通常可維持原來正常的厚度，保持一個平整的外觀?！半A梯形”切口應(yīng)用a. The inframammary and the ancillary incisions allow for an incision through the skin, then dissection downwar

16、d, before penetrating more deeply to the retromammary area. This creates a stair-step type of approach, which permits a more thorough closure by pulling the subcutaneous fat flap down over the implant, to close beneath the lower skin flap. This stair-step repair gives a thick, secure closure over th

17、e implant and more nearly insures sound wound healing without danger of dehiscence of the wound. Obviously, this approach does not penetrate the breast tissue but skirts the underside (or the lateral side, for the axillary approach) of the breast.b. The periareolar (marginal areolar) approach for th

18、e small breast allows the surgeon to dissect inferiorly or laterally around the margin of the breast in the subcutaneous plane and to approach the retromammary space without penetrating the breast tissue. This is definitely preferable to a division of the breast tissue.c. The transareolar or periare

19、olar approach may penetrate and divide the breast tissue. This transaction may cut across the ducts, creating cysts or blockage of the duct. This approach is not favored by the author for this obvious reason and because it creates additional scar tissue in the breast which is difficult to evaluate i

20、n future breast examinations. The hazard of decreased somewhat, particularly but the transareolar approach and the nipple-splitting incision.Neither the technique of b nor c allows an adequate check for bleeding vessels and securing of these vessels, and for hemostasis one must depend primarily on i

21、nsertion of packs or of pressure before insertion of the augmentation prosthesis. Though the marginal areolar incision leaves little scarring in most instances, a heavy scar in this area is much more disturbing to the patient than one in the axilla or in the inframammary area.The Overlap Techniquea.

22、  For depressed scars, defects in the underlying deeper soft tissues, and depressions in the underling skeletal tissues, there may be a need to build up the soft tissue and increase its thickness. The actual overlap of the deeper tissues is carried out rather than bring them together in st

23、air-step fashion as in Figure 1-6, or as a simple layer closure as shown in Figures 1-5. A resection is carried out both superficially and deeply as is required. Then the superficial and the deeper tissues are undermined separately to allow sliding together of the superficial tissues and overlapping

24、 of the deeper tissues.b.  This technique may be used to maintain or correct contour defects and to build up the thickness of the soft tissue when there are deficiencies of either soft tissue or underlying skeletal tissues. A layer repair is carried out as with all wound repairs. This tech

25、nique can cause exaggeration of the fullness when there is firm underlying skeletal support of the soft tissues such as over the forehead.“梯形”切口及“外翻”式切口前者我們在切除前額 中部、下巴及其他部位瘢痕，尤其是凹陷性瘢痕可靈活應(yīng)用。后者，我們在取全厚皮尤其是腹部供區(qū)脂肪較厚是可參考使用，減少修剪額外多出脂肪的時間，以便更好的縫合。“貓耳”的處理：（有趣的是，個人看來下面英文描述的方法很好的利用了皮膚有良好彈性這一特點，其“貓耳”的處理，似乎把切緣看成

26、了“橡皮筋”。Caveat 8: There Are Other Ways to Deal with Lines of Unequal Length    Often in plastic surgery an ellipse is designed, but because of the configuration of thelesion, the limbs of the ellipse have different lengths. A triangle of tissue (as describedabove) is one solution,

27、 but there are occasions where this is not desirable.    If the discrepancy between the limbs is not too big, differential suturing (“stealing stitches”)is all   that is required. When there is a greater discrepancy in length, in principle, one line can be made longer o

28、r the other can be made shorter, or both methods can be used (Fig. 1).Remember, dog-ears commonly arise from two situations: the angle of the ellipse is too obtuse,or the length discrepancy between the two limbs is too great to allow for a “stealing” stitch.順便學(xué)學(xué)上帖所提外國人頭頂植皮怎樣打包吧，結(jié)合我們實踐中確實有不少植皮皮緣與切緣原位

29、健康組織因打包縫線壓迫影響血運或打包時受力不均勻，致使周邊植皮活得更差甚至拆線后裂開，或因此而推遲部分拆線，某些部位（如血供好、組織不稚嫩或某些凹凸不平之處）植皮還是值得我們借鑒的，畫了個草圖（綠色標記線可能都是成對的），為方便理解，說明一下：植皮與切口正常組織的間斷縫合線（外人以可吸收線縫合）直接剪短，而在切口外圍約1cm的地方以絲線再次縫合，留長線打包，他們這種方式對創(chuàng)緣正常組織和植皮的血供影響要小些，而且植皮打包后受力更均勻，對植皮完全成活很有利。不規(guī)則創(chuàng)口“呈角”創(chuàng)口縫合：三角形尖端的縫合法：先從一側(cè)皮膚進針，從創(chuàng)緣內(nèi)出針后再橫行穿過三角形皮瓣尖端的真皮下或皮下，然后由對側(cè)創(chuàng)緣相應(yīng)厚度

30、進針，穿出皮膚，輕輕拉攏結(jié)扎，使三角瓣尖端與兩邊皮膚對合好。The corner suture is best initiated near an imaginary line that bisects the tissue opposite the tissue corner. This allows the pull of the tissue directly into the corner, and not off to one side. A plumb line drawn opposite the corner will help guide the start and fini

31、sh of the corner stitch (Figure 6). The needle enters the skin next to the plumb line (1 to 2 mm from the line) about 6 to 8 mm from the corner. The needle passes to the wound edge about 4 to 6 mm from the corner. It enters into the wound at the depth of the deep dermis, not beneath the dermis.The c

32、orner flap is elevated with Adson forceps (pick-ups), and the needle is passed from one edge of the flap to the opposite edge of the flap. The needle passes through the deepest portion of the flap dermis, about 4 mm from    the corner tip. After passing through the corner, the needle can be placed backward in the needle holder. The needle then passes about 4 to 6 mm from the corner into the dee