[Clinical effects and mechanism of treating extensive deep burns by stage-Ⅱ Meek skin grafting on adipose tissue after tangential excision].

Objective: To observe the clinical effects of stage-Ⅱ Meek skin grafting on adipose tissue after tangential excision in patients with extensive deep burns, and to explore the functional mechanism. Methods: The medical records of 26 extensively burned patients who met the inclusion criteria and were admitted to the Department of Burns and Plastic Surgery of the Fourth Medical Center of PLA General Hospital from May 2015 to December 2017 were retrospectively analyzed. According to the treatment methods, 14 patients were enrolled in stage-Ⅰ skin grafting group (10 males and 4 females, aged 27 to 75 years), and 12 patients were enrolled in stage-Ⅱ skin grafting group (10 males and 2 females, aged 31 to 76 years). Patients in the 2 groups all underwent debridement of tangential excision, and their healthy adipose tissue was preserved. Meek skin grafting was performed just after tangential excision in patients in stage-Ⅰ skin grafting group. In patients in stage-Ⅱ skin grafting group, porcine acellular dermal matrix (ADM) was applied to cover the wound after tangential excision, and 3 days later, it was removed and Meek skin grafting was performed. The times of complement skin grafting and the wound basic healing time of patients in the 2 groups were observed and recorded. In the stage-Ⅱ skin grafting group, the adipose tissue of patients were taken from the wound center immediately after tangential excision and immediately after the removal of porcine ADM, for the observation of structure of the fault surface of adipose tissue through hematoxylin and eosin staining and microvessel density (MVD) through immunohistochemical staining. Data were processed with independent sample t test and Fisher's exact probability test. Results: (1) The times of complement skin grafting of patients in stage-Ⅱ skin grafting group was (1.83±0.17) times, which was obviously less than (3.36±0.63) times in stage-Ⅰ skin grafting group (t=2.19, P<0.05). The wound basic healing time of patients in stage-Ⅱ skin grafting group was (35.1±2.3) d, which was obviously shorter than (48.8±4.9) d in stage-Ⅰ skin grafting group (t=2.27, P<0.05). (2) Immediately after tangential excision, the intercellular substance was few between the adipose cells in adipose tissue of patients in stage-Ⅱ skin grafting group. Immediately after the removal of porcine ADM, there was regenerated granulation tissue in the intercellular space of adipose cells of adipose tissue of patients in stage-Ⅱ skin grafting group. Immediately after tangential excision, the MVD of adipose tissue of patients in stage-Ⅱ skin grafting group was 20.2±1.3 under per 400-time field, which was obviously less than 32.2±1.9 under per 400-time field immediately after the removal of porcine ADM (t=-5.38, P<0.01). Conclusions: Meek skin grafting on the adipose tissue in stage-Ⅱ surgery after tangential excision could reduce the times of complement skin grafting and shorten wound healing time of patients with extensive deep burns. The mechanism may be related to the improvement of the recipient condition of adipose tissue.目的： 观察大面积深度烧伤患者削痂后于脂肪组织层行Ⅱ期Meek植皮的效果并探讨其作用机制。 方法： 回顾性分析解放军总医院第四医学中心烧伤整形科2015年5月—2017年12月收治的26例符合入选标准的大面积深度烧伤患者的病历资料，将患者按采用的治疗方法分为Ⅰ期植皮组14例(男10例、女4例，年龄为27～75岁)、Ⅱ期植皮组12例(男10例、女2例，年龄为31～76岁)。2组患者均行削痂术清创，保留健康脂肪组织。Ⅰ期植皮组患者在削痂后即行Meek植皮术；Ⅱ期植皮组在削痂后采用猪脱细胞真皮基质(ADM)覆盖创面，3 d后揭去猪ADM再行Meek植皮术。观察并记录2组患者补充植皮次数、创面基本愈合时间。于削痂术后即刻、揭去猪ADM后即刻，取Ⅱ期植皮组患者创面中心脂肪组织，行苏木精－伊红染色观察脂肪组织断层表面结构，行免疫组织化学染色观测脂肪组织微血管密度(MVD)。对数据行独立样本t检验、Fisher确切概率法检验。 结果： (1)Ⅱ期植皮组患者补充植皮次数[(1.83±0.17)次]明显少于Ⅰ期植皮组[(3.36±0.63)次，t＝2.19，P<0.05]，创面基本愈合时间[(35.1±2.3)d]明显短于Ⅰ期植皮组[(48.8±4.9)d，t＝2.27，P<0.05]。(2)Ⅱ期植皮组患者削痂术后即刻脂肪组织的脂肪细胞间隙间质成分少，揭去猪ADM后即刻脂肪组织的脂肪细胞间隙有新生肉芽组织增生。Ⅱ期植皮组患者削痂术后即刻脂肪组织MVD为每400倍视野下(20.2±1.3)个，明显少于揭去猪ADM后即刻的每400倍视野下(32.2±1.9)个(t＝－5.38，P<0.01)。 结论： 对大面积深度烧伤患者，采取削痂后Ⅱ期在脂肪组织层行Meek植皮，可减少补充植皮次数、缩短创面愈合时间，其机制可能与改善脂肪组织层受皮条件有关。.