Boston, Mass. From Brigham and Women's Hospital.
Plast Reconstr Surg. 2013 Nov;132(5):1280-1290. doi: 10.1097/PRS.0b013e3182a4c3a9.
The application of a new approach is presented, percutaneous aponeurotomy and lipofilling, which is a minimally invasive, incisionless alternative to traditional flap reconstructions.
The restrictive subdermal cicatrix and/or endogenous aponeurosis is punctured, producing staggered nicks. Expansion of the restriction reconstructs the defect and creates a vascularized scaffold with micro-openings that are seeded with lipografts. Wide subcutaneous cuts that lead to macrocavities and subsequent graft failure are avoided. Postoperatively, a splint to hold open the neomatrix/graft construct in its expansive state is applied until the grafts mature. Thirty-one patients underwent one to three operations (average, two) for defects that normally require flap tissue transfer: wounds where primary closure was not possible (n=9), contour defects of the trunk and breast requiring large-volume fat grafts (n=8), burn contractures (n=5), radiation scars (n=6), and congenital constriction bands (n=3).
The regenerated tissue was similar in texture and consistency to the surrounding tissues. Wider meshed areas had greater tissue gain (range, 20 to 30 percent). There were no significant wound-healing issues, scars, or donor-site morbidities. Advancement tension was relieved without flap undermining or decreased perfusion.
Realizing that, whether scar or endogenous fascia, the subdermal aponeurosis limits tissue stretch and/or its three-dimensional expansion, a minimally invasive procedure that expands this cicatrix into a matrix ideally suited for fat micrografts was developed. Grafting this scaffold applies tissue-engineering principles to generate the needed tissue and represents a regenerative alternative to reconstructive flap surgery.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
本文提出了一种新方法，经皮腱膜切开术和脂肪填充术，这是一种微创、无切口的替代传统皮瓣重建的方法。
对限制皮下的疤痕和/或固有腱膜进行穿刺，产生交错的切口。限制的扩张重建了缺陷，并创建了一个带有微开口的血管化支架，这些微开口中种植了脂肪移植物。避免了导致大腔和随后移植物失败的广泛皮下切口。术后，使用夹板将新基质/移植物构建体保持在扩张状态，直到移植物成熟。31 名患者接受了 1 至 3 次手术（平均 2 次），用于需要皮瓣组织转移的缺陷：无法进行一期缝合的伤口（n=9）、需要大容量脂肪移植的躯干和乳房轮廓缺陷（n=8）、烧伤挛缩（n=5）、放射性瘢痕（n=6）和先天性缩窄带（n=3）。
再生组织的质地和一致性与周围组织相似。网眼较大的区域有更大的组织增益（范围为 20%至 30%）。没有明显的伤口愈合问题、疤痕或供区并发症。在不进行皮瓣减张或降低灌注的情况下，缓解了推进张力。
认识到无论是疤痕还是固有筋膜，皮下腱膜都会限制组织拉伸和/或其三维扩张，因此开发了一种微创程序，将这种疤痕扩展成一个非常适合脂肪微移植物的基质。移植这种支架应用组织工程学原理来生成所需的组织，是对重建皮瓣手术的一种再生替代。
临床问题/证据水平：治疗，V。
