米拉德缝合技巧要点

1、（米拉德）缝合技巧先把如题的米拉德整形外科原则的缝合技巧内容奉上：无论手术设计的如何巧妙， 手术操作的技巧， 包括缝合技巧， 在伤口愈合和最终效果方面将是一个重要的因素。某些缝合技巧会使缝合更便利。1 良好的皮下和皮内埋置， 缝合位置有助于死腔的关闭和消除皮肤的缝合张力。 同样皮肤缝合也可以消除组织死腔。2 一个最有效的皮肤间断缝合， 是在近皮缘处垂直或最好向外侧转动进针， 包括真皮的良好缝合和确保创缘外翻。3 由松弛侧向固定侧缝合， 即首先由游离皮片边进针， 然后经受植区皮肤缺损之固定边缘出针。这种顺序比由固定边缘进针，然后试图用针钩缝不稳定游离皮片边缘更好。4 将薄皮缘与厚皮缘缝合时，在薄

2、皮缘处浅层进针要稍深些，然后在厚皮缘处浅些出针，这样可使双侧皮缘平整对合。5 当一侧创缘比另一侧要低时， 由高侧创缘浅层进针， 然后在低侧创缘稍深位置出针缝合。由低向高缝合造成缝线由低侧穿出。 缝线长端向上牵拉打第一个结时， 就会使低侧创缘向上与对侧创缘处于同一水平。（植皮缝合时， 有时皮片与切口要不不能完全覆盖较厚的瘢痕切口， 要不覆盖太多， 造成部分皮片重叠或皮片多出瘢痕切缘太多，一皮源浪费，二切缘植皮成活不好， 这时， 充分拉直缝线两端，稍微抖动几下，很可能皮片与受区就很好的贴牢了，而且皮缘不太宽的情况下，该法可使皮缘与切缘很好重叠， 没有皮片游离于创缘， 也可使较厚的瘢痕切缘不因皮片未

3、能完全覆盖贴牢而影响外观， 此为导师实践摸索的很灵光、 很实用有效的经验方法， 各位和本人一样的新手可慢慢摸索、体会）6 为获得最整齐的创缘缝合， 精细的缝线比金属夹或微孔胶带更为有效。 金属线很少产生异物反应， 丝线更易于缝合操作，涤纶、 普洛灵及尼龙线则稳定而富有弹性。单线针比褥式缝合更好，因为 2 个针眼通常好于4 个针眼。除此通常情况外，对于足底、手掌、阴囊、耳后区和斜形切开的创缘，褥式缝合会起到较有效的作用。根据力学的微型lillputian 分布，用缝线在靠近皮缘处缝合伤口是有益的。 如果缝线距离创缘太远， 就会遗留阶梯状的缝线压痕，要去除这种压痕，就需牺牲太多的组织。 对关闭伤口

4、时有张力，且需保留缝线较长时间的部位，在某些特别要避免缝线压痕的部位，最好用得麦隆（ dermalon ）缝线形皮内缝合。这样不但可保留较长时间，也无缝线压痕的危险。皮内缝合线最好以每隔 5.08cm （ 2 英寸）或小于 5.08cm（ 2 英寸）的距离穿出皮肤后再进入皮内，这样可缩短拆线时间，拆线也更容易些。仔细观察瘢痕整形技艺大师，弗吉尼亚州福尔斯彻奇的alfred f. borges的w-整形术缝合操作，就会知道应该怎样更好的学习技艺。在全面认识到高超技艺的重要价值后， borges4982年写道：最佳的手术技术本身不是成功的保证， 在一项手术后， 要获得细小缝线瘢痕的决定因素之一，不

5、是如此之多的有特点的缝合技术，而是切口是否与皮肤张力松弛线行走一致。ri源的制断维合法之正确的瓦断货门法不止礴的间断鞋合法之deep inverted suture九3%i.这里是borges技术的一些基本规则沿皮肤张力线"rstl"( relaxed skin tension line)行走方向选择手术切口，其瘢痕将痕；3.对抗张力线的瘢痕可通过锯获得最佳美观和功能效果；2.对于张力线(alt, antitension line )的外壳显露手术切口，曲线的皮肤切口在愈合方面 优于直线alt切口，因为其可提供更宽大的显露和形成一条良好的富有弹性的术后曲线瘢z改形术)加以改

6、善。该技术可以改变瘢痕的方向， 并将其分割成短小的直线瘢痕。 任何面部没有按rstl 行走的瘢痕， 都可经 w 成形术或 z 成形术进行修正而加以改善，条件是先前没有太多的皮肤缺损。4 皮肤张力是瘢痕形成的基本因素， 皮肤张力的形成受皮肤缺损里昂、 区域、 走向、 类型、瘢痕长度及病人年龄的影响；5 在大部分情况下，宽大和（或）增生的瘢痕不适合用任何瘢痕修整手术。简单切除一条因伤口自行愈合和棱形切除瘢痕后关闭创面所形成的宽大和 （或） 增生性瘢痕， 将不可避免地在手术后再次形成一条宽大和（或）增生的瘢痕；6 不要轻易去行瘢痕修整， 除非你有理由确定， 你可以部分或全部改变形成不理想瘢痕的因素，

7、或你可以承担整修术可能会导致比原先瘢痕更差的风险；7 当处理一条严重凹陷瘢痕或一条绞索状突起瘢痕是， z 改形术首选方法， 因为 z 改形术可以通过组织的交叉插入，消除和改变张力，达到明显的平衡作用；8 在纠正半环状隆起瘢痕畸形是， 治疗目标不应包括正常皮下脂肪组织的隆起， 而应针对弧形皮肤瘢痕所致的束带状收缩；9 缝合时最常见的技术过错是皮肤缝线结扎得太紧。约翰霍普金斯医院的 william s. halstead 在 1890 年就提醒外科医生： “由缝合合结扎而造成的血循环障碍，常常是感染创面化脓的直接原因。 ”注意张力缝线痕迹在缝合时，可在缝线的小范围内形成张力环。尽管撕裂伤、手术切口

8、所形成的瘢痕无法避免，但永久的缝线痕迹是可以避免的。犹如猎人可依据脚印寻找到一只野兽一样，人们可以通过缝线痕迹来认识一位外科医生。如果别人将通过这些缝线痕迹来认识我们，这表明我们应该仔细检讨一下，这种因缝合而造成的潜在皮肤血循环不良的原因。当将缝线的结大得太紧时，不但会切割皮肤，而且会形成炎性水肿，并将导致压力性皮肤坏死、感染可能。1 .施行间断缝合时，对于一个较短的直线形伤口，可先在伤口的两端各做一个缝合, 再将两端的缝线拉紧，使伤口两侧的皮肤自然队合，然后再在两端之间进行间断缝合。 对于一个不规则的伤口，应该先选尖角或突出部分进行缝合，以后再用等分缝合法将 全部伤口缝合。2 .有些伤口，例

9、如切削伤伤口，其边缘的厚度常在两侧各不相同，即有时一侧较厚, 而另一侧较薄。这时，为了求得进针的深度能在伤口两侧彼此相同，其与伤口的距离 亦不相同。通常皆需在较厚侧距离伤口边缘较近，在较薄侧距伤口边缘较远。切削伤的缝合3.缝合的伤口如较深且稍有张力，则在缝合时最好采用褥式缝合法或远-近、近-远缝合法，垂直褥式缝合法亦称在端”褥式缝合法（mcmillen氏法），它在缝合皮肤边缘同时可以将皮下组织缝合。远 -近、近-远缝合法亦称翎翼缝合法（bolster氏法），它在缝 合皮肤边缘以后再在距离皮肤边缘较远处再作一个缝扣，减少皮肤边缘的张力。vertical mattress:far-near/nea

10、r-farvera te: classical, (far-far/near-near耳,:蝎指外理z：,* i_b q. "w -r .一jv,* c,.i «/a-七 1rvertical mattress:near-far/neanfar各种褥式缝合法或远-近、近-远缝合法续前，尽管整形科使用该类方法不多，一起带上。vertical mattress:near-far/far-near真皮缝合法及皮下缝合法1.真皮缝合和皮下缝合的区别1）真皮缝合是选择性缝合真皮的方法。其目的是减张，以防止一期愈合后的瘢痕在 形成稳定性瘢痕前的数个月期间因持续的张力作用而变宽。2）皮下

11、缝合：一般并非单纯的真皮缝合，而是包括皮下组织的缝合，主要作用是为 了闭合死腔。虽有一定的减张作用，但达不到减张缝合的减张效果。vertical mattress: pulley or lloopvertical mattress: half-buriedjmattress/ vertical shorthand regular真皮缝合中缝线的位置：初学者最容易犯的错误是真皮缝合的位置过浅（如下图a）。虽然这种缝合方法稍微带有真皮，并可很好地对合伤口边缘，但缝线易外露。最理想的 缝合方法如图b,使缝线位于较深位置，并呈松弛的椭圆形。（我们平时在缝合张力较大部位如腹部取皮处，采取与切口平行而不是

12、垂直的方法进针做真皮缝合应该基于此道理）'_- j于，乙七产 70=m送匕 b.vertical mattress:space-obliteratingwound /skin surfacesu be utd neo us tissue不必要进行真皮缝合的部位：手掌，足底，眼睑及与皮纹相平行的部位粘膜，阴囊等 处。应该形真皮缝合部位：头皮、躯干多处及下肢等。subcuticularabab4. stair-step technique of repaira. the stair-step resection of scars of lesions, and the stair-step

13、 incision to expose 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

14、 breast prostheses, 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 an

15、d in 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.上段文字并不难理解，做了个参考翻译a.阶梯形切除瘢痕，阶梯状切开并暴露深层组织，例如隆乳术，这样，我们以同样阶梯形 式缝合，可安全放心的闭合切口。这种切口修复方法相对更安全，特别是

16、切缘张力较大时，阶梯状缝合使外源性植入物或自身移植物（如乳房假体、移植骨、软骨）更不容易外露。由于阶梯状缝合使张力能够分布并分散到不同的层面，切口在不同的层面修复， 故植入或移植物几乎不可能外露。b.临床应用证实，该方法或许可拥有任何表浅伤口或瘢痕切口的修复。由于该方法降低了瘢痕的挛缩力的扩展或凹陷幅度，故愈合后局部组织通常可维持原来正常的厚度，保持一个平整的外观。阶梯形”切口应用a. the inframammary and the ancillary incisions allow for an incision through the skin, then dissection down

17、ward, 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

18、 the 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

19、 the 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 peri

20、areolar 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 evaluat

21、e in 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 o

22、n insertion 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.fig, 50.1. (lluttnti

23、on of thq an&tcmjc&l plant ofdistction;r励f图片弓| 自(subfascial brua&i augmcntauan)r. graf, d. t. pace. r.c. damesio, r. rippel, l*. araujo, lg. neto, t. al yaf1the overlap techniquea. for depressed scars, defects in the underlying deeper soft tissues, and depressions in the underling skelet

24、al 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 stair-step fashion as in figure 1-6, or as a simple layer closure as shown in figures 1-5. a resection is carried out bot

25、h 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 of the deeper tissues.b. this technique may be used to maintain or correct contour defects and to build up the thickne

26、ss 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 technique can cause exaggeration of the fullness when there is firm underlying skeletal support of the soft tissues such as over the f

27、orehead.梯形”切口及外翻”式切口前者我们在切除前额 中部、下巴及其他部位瘢痕，尤其是凹陷性瘢痕可灵活应用。后者，我们在取全厚皮尤其是腹部供区脂肪较厚是可参考使用，减少修剪额外多出脂肪的时间，以便更好的缝合。“梯形"切口"外部”式切口猫耳”的处理：(有趣的是，个人看来下面英文描述的方法很好的利用了皮肤有良好弹性这一特点，其猫耳”的处理，似乎把切缘看成了橡皮筋caveat 8: there are other ways to deal with lines of unequal lengthoften in plastic surgery an ellipse is d

28、esigned, but because of the configuration of the lesion, the limbs of the ellipse have different lengths. a triangle of tissue (as described above) is one solution, but there are occasions where this is not desirable.if the discrepancy between the limbs is not too big, differential suturing ( "

29、 stealingstitches " )is all that is required. when there is a greater discrepancy in length, in principle, one line can be made longer or 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 ob

30、tuse,or the length discrepancy between the two limbs is too great to allow for a“ stealing " stitchdog ear correctionm1114fi" ab njwrrrr，加用 ea! nib bhciwti nrlpfdrd ilfic itut'kll i i ihrn- 11111d3, w «t>uf ifu. 4ub«*j l h* imijaf dta? ril*gil fkty r- " /<1. a【rite

31、1 wifi b-fyrr. ih . «!nfwjmnr inrrih>«jimf.nnixhwi4 j aif .715,1 er 山 rw畤 jn *|4懵牛.i e.i - * f$r-" .de klilgf rflim qnit.4闭* w jm hlvs rwfi1 kneffcw rv "iw ilfttst drm&kc101alui /4 hiryif e5 icmfcirriiig live ?tprx pmfli dbr'm- i (-4ufea4 f jw op i% mcigrr th-an ux(fce

32、厂ilirthric ji|i liialkr ifwaiitabhl'hirilr lii'iiil'ril llit 111 i* thirarli jn whidiuw 刖i力 (jqwf*r)- tlw3h niuluir mr 闻& iilicririjffnj h ,«< lkijj4l t ijn h>ii-rfrilly ijil “f r gi”l j/-顺便学学上帖所提外国人头顶植皮怎样打包吧，结合我们实践中确实有不少植皮皮缘与切缘原位健康组织因打包缝线压迫影响血运或打包时受力不均匀，致使周边植皮活得更差甚至拆线后裂开，

33、或因此而推迟部分拆线， 某些部位（如血供好、组织不稚嫩或某些凹凸不平之处） 植皮还是值得我们借鉴的，画了个草图（绿色标记线可能都是成对的），为方便理解，说明一下：植皮与切口正常组织的间断缝合线（外人以可吸收线缝合） 直接剪短，而在切口外围约1cm的地方以丝线再次缝合，留长线打包，他们这种方式对创缘正常组织和植皮的血供 影响要小些，而且植皮打包后受力更均匀，对植皮完全成活很有利。不规则创口 呈角”创口缝合：三角形尖端的缝合法：先从一侧皮肤进针，从创缘内出针后再横行穿过三角形皮瓣尖端的真皮下或皮下，然后由对侧创缘相应厚度进针，穿出皮肤，轻轻拉拢结扎，使三角瓣尖端与两边皮肤对合好。the corne

34、r 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 finish of the corner stitch (figure 6). the

35、 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 corner flap is elevated with adson force

36、ps (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 t

37、hen passes about 4 to 6 mm from the corner into the deep dermis of the opposite edge from where the needle previously passed. the needle exits the skin on the opposite side of the plumb line, 6 to 8 mm from the corner. the suture is tied gently, allowing the tip to fit snugly into the corner. if the

38、 suture is tied too tightly, the corner tends to buckle.corner sutureflguht 4du+y w. nq h.ewl451dv th* wekjtsrrtolb ulur*fb>d4ntirwd by duct4d hn«t.fkiurf 5 euf拶 i.” 与g3 由川心山n. thwovyn nllth thi w mui 电川&m/te lam4y? li 胃-mitt l.tjf <kirtkl hn*s.figure c-. for net i 史 30 *n to bon the

39、cor rwt surttm-s drlsorki - drjuih 匚 a plunri3 hnoi ejhm bh*£ti ths sy片 口!，|2 1m 工口ptkt akimrd 111 will b曲 tcj«ki. feh&ah rofid4 next g iha linv，thff rweale n |me<i imo me wunci kt ihfli mm or iht at«p nmtha /m f er fwn cm lwnor. i'jb ite(口1tdp h dlwdldij mth qdmjh tthu4fjf

40、c 华ilk-unj.占 111d nha fwjulk- ij froin cri« 旬& of the filo h0 !& 值* -dtbar skid i<ft s中 心40出eili |t tha mihlid hmbdijk lilliu hit* wu-uhl-adg 而。m <4 k> & mrn frdf¥i thv tip*口他)事又, fh* -jlifi. thw iixur4 thr*iiil pacing b =b forn 的9 eeflap i? *用就内 b>' th? ngdk driverdhpm<nrtrtltn pyrp©安卜不规则创口 不等长或等高”创口缝合:figure 2. schematic illustrating the principle of halving sutures. simple interrupted sutures are used to bisect the side of excess tissue. additional sutures are used to equally divide the two