PLA Medical Journal, Vol. 36, No. 9, September 1, 2011 "ChinPLA, Vol36Na9Sepiember 1, 2011
Xing Xin
[Abstract Objective: To summarize the research status and development trends of plastic surgery at home and abroad, and to put forward the development direction, goals and priorities of plastic surgery in our army in the future.] MethodsThe relevant literature published in the past five years was searched in PubMed, Medline and Chinese Biomedical Journal Literature Database (CMCC), and the achievements of military plastic surgery in the past five years were statistically investigated. ResultsIn the past five years, plastic surgery has made gratifying progress in basic research and clinical treatment, and its role and status in the early treatment of war trauma have also been valued and recognized. The plastic surgery department of our army has made remarkable achievements in chronic wound repair, injury mechanism and prevention methods of skin and soft tissue explosion injuries and seawater immersion injuries, new technologies for the treatment of facial deformities in war wounds, and allogeneic facial composite tissue transplantation. Clinical treatment problems such as extensive full-thickness defects of the thoracic and abdominal wall, chronic ulcers and abnormal scarring At the same time, we should pay attention to giving full play to professional expertise and actively participate in the early treatment of war trauma
[Keywords: Surgery, Plastic Surgery; military medicine; progress
[Literature Marker Code.]
[CLC Number: 1R622:R8268.]
Article Number: 0577-7402 (2011) 09-0886-04
1 New progress in plastic surgery at home and abroad since the "Eleventh Five-Year Plan".
1 1 Development Trend and Progress of Skin Flap Transplantation Skin flap transplantation is one of the most basic and commonly used treatment methods in plastic surgery, and it plays an irreplaceable role in repairing and repairing defects and rebuilding organs. In recent years, the craze for discovering new flaps has gradually subsided, and the selection and improvement of previously applied flaps to optimize and standardize flap transplantation technology, optimize the treatment effect and minimize the damage to the donor area have become the main direction of flap research.
11.1 The development of axial flaps has entered the stage of refinement In recent years, the mainstream of research on axial flaps has shifted from the discovery of new flaps to the optimization of flaps. Through the comprehensive comparison of different parts and different types of flaps, some flaps with reliable blood supply, simple and easy operation, concealed donor area, and little damage to the donor area after incision have gradually become the first choice for clinical application, while some flaps with poor comprehensive effect and excessive incision value have gradually decreased or even been eliminated in clinical application! As one of the contents of the fine research on axial flaps, perforator flap has gradually become a hot spot in recent years. A variety of perforator flaps, such as inferior abdominal wall artery perforator, superior gluteal artery perforator flap, thoracodal dorsal artery perforator flap, anterolateral femoral perforator flap, fascia lata perforator flap, medial sural artery perforator flap, etc., have been widely used in clinical practice, and have achieved more satisfactory results than traditional axial flaps
11.2 The application of local flaps in facial cosmetic reconstruction still pays attention to the research Although the scope of medium-sized wounds on the face is not large, it is still a challenging problem to obtain the ideal repair effect if the two factors of appearance and function are taken into account. Because the local flap is prepared in the adjacent part of the defect area, it is the closest to the recipient area in terms of skin color, texture, thickness, hair growth, etc., so it has important cosmetic value for the repair of facial wounds. In recent years, some authors at home and abroad have studied the functional and cosmetic reconstruction methods of tissue defects in different aesthetic units of the face in accordance with the principle of partitioned repair of facial esthetic units, and have set the incision scar in the direction of the demarcation line, contour line or skin texture of the facial aesthetic unit as much as possible by improving the traditional flap, inventing a new type of flap and combining multiple or multiple flaps, which has significantly improved the function and cosmetic effect of the reconstructionFlap repair programs for skin and soft tissue defects of different sizes.
12 Advances in Wound Healing Research The scope of orthopedic surgery includes not only the repair of acute wounds, but also the two extremes of wound healing, namely non-union or slow healing (chronic wounds) and excessive healing (hypertrophic scars and keloids). Both of these issues are very difficult to deal with and have been a difficult problem for scholars for many years.
12.1 Research Progress on Chronic Wounds Chronic wounds refer to wounds that persist for a long time, heal slowly or have no tendency to heal after high-quality, standardized and formal treatment. At present, the research on chronic wound treatment focuses on three aspects: wound debridement, inhibition of chronic inflammatory response and application of biological dressings, and hyperbaric oxygen therapy, electromagnetic therapy, negative pressure-assisted occlusion therapy, growth factor therapy, stem cell therapy and tissue engineering active skin therapy have been confirmed to have certain efficacy on clinical chronic wounds, among which negative pressure-assisted occlusion therapy has been highly regarded in recent years. However, the role of surgery in the treatment of chronic wounds is irreplaceable. The available data show that it is difficult to compare the advantages and disadvantages of various wound therapies alone, and the general consensus is that once a chronic wound is formed, it is often difficult to reverse, and a variety of methods should be used for treatment.
12.2 Research Progress on Abnormal Scars Abnormal scars mainly include proliferative scars and keloids. In recent years, the basic research on abnormal scars still focuses on its occurrence mechanism, and the relationship between a variety of cytokines and the formation and development of abnormal scars has attracted the most attention: Exploring the mechanism of abnormal scars from the perspective of genes has been paid attention to, and in recent years, more and more keloid families have been discovered, and "suspicious genes" have been locked or excluded: in-depth study of the mechanism of embryonic scarless healing is still an important idea to explore the causes of abnormal scars. In terms of the establishment of experimental animal models, the abnormal scar model of nude mice and the female red Duroc pig model constructed by tissue engineering technology in recent years are expected to become valuable research tools. In terms of clinical research, there is a consensus on the comprehensive treatment of abnormal scars, but there is no consensus on the specific treatment methods. In addition, in recent years, Mela analysis has become an important method for abnormal scar research, and it is hoped that through the scientific analysis of a large number of previous literatures, valuable clues for basic research and clinical research on abnormal scars can be obtained, so as to put forward stricter standardization requirements for related research in the future.
13 New Highlights of Plastic Surgery - Tissue Engineering and "Face Replacement" At present, reconstructive plastic surgery is still the main battlefield of plastic surgery. In this field, the main treatment method is still autologous tissue transplantation, which is a method of "digging up flesh to repair sores, treating injuries with injuries, and tearing down the east wall to make up for the west wall", which can repair or correct a defect or deformity in one part at the same time, it will cause different degrees of morphological and functional damage in the donor area. In addition, when the amount of tissue loss is large, autologous tissue transplantation is often impossible or ineffective due to the absence of an appropriate donor or insufficient donor area. In order to overcome the inherent defects and limitations of autologous tissue transplantation, a large number of studies have been carried out by scholars at home and abroad for a long time, and the research on tissue engineering and allogeneic composite tissue transplantation has attracted the most attention.
13.1 Progress in Tissue Engineering Research In recent years, some encouraging progress has been made in tissue engineering research, not only the types of tissue construction are increasing, but also some tissue engineering products such as skin, bone, trachea, etc. have been preliminarily used in clinical practice, and have achieved good results, showing the broad application prospects of tissue engineering. Advances in stem cell research have broadened the source of seed cells, bringing new hope to solve this bottleneck. Biological scaffold materials are three-dimensional scaffolds that seed cells rely on to survive and attach to before forming tissues. In recent years, from traditional polymer degradable polymers to natural biomaterials such as various decellularized matrices, they have been widely used in the construction of a variety of tissues. The organic combination of synthetic materials and natural materials to complement each other's strengths has become a new trend in the development of tissue engineering materials in the future.
In recent years, tissue engineering has received more and more attention internationally, and the International Foundation for Regenerative Medicine has clearly defined tissue engineering as a branch of regenerative medicine. The research projects funded by the U.S. military include the construction and repair of tissue defects from bone marrow mesenchymal stem cells, which makes tissue engineering research have a strong military medical color, which deserves our attention.
13.2 Progress of Allogeneic Composite Tissue TransplantationWith the advancement of surgical technology, the advent of new immunosuppressants, and the improvement and perfection of organ preservation methods, allogeneic organ transplantation has become the main means of treating end-stage diseases of heart, liver, kidney and other organs, saving the lives of millions of patients. Encouraged by this, in the past 10 years, reconstructive and reconstructive surgeons have begun to try to use allogeneic composite tissue transplantation to repair extremely serious tissue surface defects, clinical conductor hand transplantation, abdominal wall transplantation, facial transplantation and even penis transplantation have been reported4, among which allogeneic hand transplantation and facial composite tissue transplantation have the largest number and have attracted the most attention. In 1998, the world's first allogeneic hand transplant was performed in France, and a total of 38 (52) allogeneic hand transplants have been performed worldwide. There are no less than 11 cases and 14 allogeneic hand transplants in China (3 cases of both hands, 8 cases of one hand, and only 1 case is alive so far). In 2005, France successfully performed the world's first allogeneic facial composite tissue transplantation, which the media called "face swapping". In April of the following year, our army's Xijing Hospital successfully carried out the world's second case. To date, a total of 7 cases have been carried out worldwide, with 2 deaths.
After clinical allogeneic hand transplantation and facial composite tissue transplantation were reported, they sparked extensive and fierce debates in the academic community and society. The debate is about the risk-beneli balance and psychological ethics. In 2009, the American College of Surgeons conducted a survey of surgeons' attitudes towards allogeneic composite tissue transplantation, and the results showed that most physicians believe that the current time for allogeneic composite tissue transplantation is not ripe enough to wait for the emergence of new highly effective and low-toxicity immunosuppressive therapies. Nevertheless, this kind of exploratory study is still of very positive significance, which verifies that it is technically feasible to repair severe and complex tissue defects by allogeneic composite tissue transplantation under the condition of effective control of immune rejection, and can obtain satisfactory morphological results, showing good application prospects. However, there is still a lot of work to be done to make allogeneic composite tissue transplantation a routine treatment, among which the development of new immunosuppressants or the induction of immune tolerance are key issues that must be solved.
14 The Role of Plastic Surgery in the Early Treatment of War Trauma It is an indisputable fact that plastic surgery plays a major role in the repair and reconstruction of deformities in the late stage of war trauma. In recent years, there has been increasing evidence that plastic surgery also plays a very important role in the early treatment of soft tissue injuries caused by natural disasters such as explosions, car accidents, and earthquakes.
According to foreign data, more than 50% of the casualties caused by explosions and earthquakes have skin and soft tissue injuries. Liu Zhou et al. reported that after the Wenchuan earthquake, 1,205 (64%) of the 1,874 injured patients admitted to the Sichuan Provincial People's Hospital had soft tissue injuries; Chen Aimin et al.2 reported that 66% of the 629 hospitalized wounded admitted to Jiangyou Field Hospital in the first week after the Wenchuan earthquake had soft tissue injuries. In 2009, Professor Rohrich, the former president of the American Society of Plastic Surgery, pointed out that plastic surgeons play an important role in the early treatment of trauma, especially in the first aid of skin and soft tissue injuries, limb injuries, and craniomaxillofacial trauma, so it is suggested that: (1) the government should pay attention to the role of plastic surgery when formulating disaster medical rescue plans. Orthopedic surgeons should be included in the formation of medical detachments; (2) Orthopedic surgeons should receive disaster medicine education and related skills training.
15 Advances in Cosmetic Surgery As a part of plastic surgery, cosmetic surgery has become the most active sub-discipline in the field of plastic surgery, with the highest public attention and the most market potential, which has injected new vitality into plastic surgery and broadened the development space of plastic surgery. In recent years, facial contouring cosmetic surgery has been widely carried out in China; Minimally invasive or non-invasive cosmetic procedures, such as botulinum toxin injection cosmetic, hyaluronic acid and new porcine collagen injection filling cosmetology, radiofrequency cosmetology, etc., have become a new trend: some traditional cosmetic procedures, such as face lifting, are improving in the direction of minimally invasive; Breast augmentation and soft tissue filling using adipose-derived stem cells have also been clinically successful.
New achievements made since the "Eleventh Five-Year Plan" of military plastic surgery
During the "Eleventh Five-Year Plan" period, the scientific research work of our army's plastic surgery department, especially in the research on the damage mechanism and prevention methods of chronic wound repair, skin and soft tissue explosion injuries and seawater immersion injuries, and new technologies for the treatment of facial deformities from war wounds, has achieved fruitful results, and has also made great progress in discipline construction and personnel training. According to incomplete statistics, in the past five years, the plastic surgery specialty of the whole army has won more than 40 projects of the National Natural Science Foundation of China (including 1 key project), more than 30 military and provincial and ministerial fund projects, 14 second-class or above achievement awards (including 1 first prize), 15 monographs edited (translated), and more than 600 papers (including more than 80 SCI papers). In 2006, Xijing Hospital successfully carried out the first case of allogeneic facial composite tissue transplantation in China and the second case in the world, which made the scientific research and clinical level of allogeneic facial composite transplantation of our army in the leading position in China, and entered the international advanced ranks, expanding the influence of plastic surgery of our army at home and abroad. During the "Eleventh Five-Year Plan" period, the Department of Plastic Surgery of Xijing Hospital and the Department of Plastic Surgery of Changhai Hospital successively became the Institute of Plastic Surgery and the Plastic Surgery Center of the Army, and the plastic surgery departments of the three military medical universities have entered the ranks of national key disciplines. At present, in the plastic surgery branch of the Chinese Medical Association, there are 9 members of the army, of which 3 are vice chairmen.
3. The development plan of the "Twelfth Five-Year Plan" discipline of plastic surgery
3 1 Guiding Ideology Guided by the Scientific Outlook on Development and guided by the preparations for military struggle, we should keep abreast of new developments, actively adapt to the new situation, take medical treatment as the center, and coordinate the development of medical education and research.
3 2 Basic Ideas Adhere to the surname of the army as the true character of the war, and improve the level of repair and reconstruction of war traumatic tissue defects and deformities as the main task: conform to the trend of the times, actively participate in market competition, and attach importance to the development of cosmetic surgery. Actively carry out new technologies and new treatments, and strive to improve the level of clinical treatment; Closely combine clinical research to seek innovation through scientific research, establish characteristics with innovation, and promote development with characteristics: strengthen foreign exchanges, attach importance to personnel training, strengthen professional skills training and continuing medical education, and establish a talent echelon with excellent technology, advanced concepts and reasonable structure.
3 3 Main research directions and construction priorities
33.1 Repair and Reconstruction of Skin and Soft Tissue Defects and Deformities from War Wounds The focus is on the repair of severe facial disfigurement, extensive full-thickness defects of the thoracic and abdominal walls, and avulsions of the skin of the extremities. The research to be carried out mainly includes: (1) research and development of new tissue substitutes and fillers with better biocompatibility, (2) the use of tissue engineering principles and technologies to construct tissue-engineered tissues and organs, (3) clinical exploration and basic research on allogeneic composite tissue flap transplantation, (1) refining, improvement and combined application of traditional skin flaps.
33.2 Repair of chronic wounds The focus is on the repair of traumatic ulcers and radiation ulcers. The research to be carried out mainly includes: (1) gene therapy, (2) stem cell therapy, and (3) the development of simple, convenient, inexpensive and effective negative pressure wound treatment devices.
33.3 Research on the mechanism and prevention measures of abnormal scar hyperplasia and contracture It is proposed to explore the formation mechanism of abnormal scar at the molecular and genetic levels, so as to provide a basis for seeking effective prevention and treatment methods.
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