本文來源：《中華整形外科雜志》2023年6月 第39卷 第6期

DOI:10. 3760 / cma.j.cn114453-20220320-00075

作者單位：空軍軍醫(yī)大學(xué)第一附屬醫(yī)院燒傷與皮膚外科， 西安710032

通信作者：李娜,，Email：linaxjss@163.com

【摘要】 

目的 探討20 MHz高頻超聲在瘢痕厚度及形態(tài)學(xué)評(píng)估中的作用,。

方法 對(duì)2019年4月至2020年12月空軍軍醫(yī)大學(xué)第一附屬醫(yī)院燒傷與皮膚外科診治的燒創(chuàng)傷后瘢痕形成初期（<1個(gè)月）、增生期（1~6個(gè)月）和消退期（>6個(gè)月）患者的臨床資料進(jìn)行回顧性分析,。全部納入患者均進(jìn)行了20 MHz高頻超聲,、溫哥華瘢痕量表（VSS）及病理組織學(xué)3種方式的評(píng)估。超聲檢查時(shí)在瘢痕處選擇3個(gè)點(diǎn)進(jìn)行瘢痕厚度測量,，記錄平均值,；在超聲測量部位的瘢痕組織取標(biāo)本，進(jìn)行HE染色和Masson染色,，觀察并測量瘢痕厚度；由2名醫(yī)生采用VSS對(duì)瘢痕的厚度進(jìn)行評(píng)估,，記錄平均值,。分別比較瘢痕形成初期、增生期,、消退期采用上述3種方式測評(píng)的瘢痕厚度的差異,；同時(shí)，對(duì)比高頻超聲聲像圖特征與病理組織形態(tài)學(xué)的關(guān)系,。正態(tài)分布計(jì)量資料以±s表示,，3組間比較采用單因素方差分析，組間兩兩比較采用SNK-q檢驗(yàn),；計(jì)數(shù)資料采用卡方檢驗(yàn)進(jìn)行分析,。

結(jié)果 共納入224例患者，男91例,， 女133例,，年齡1~34歲，平均25.7歲,；瘢痕形成初期患者79例,、增生期102例,、 消退期43例。（1）在瘢痕形成初期,，20 MHz超聲測量的瘢痕厚度為（2.01±0.68）mm,，VSS評(píng)估厚度為（1.72±0.49）mm，病理測量厚度為（2.11±0.45）mm,；在增生期瘢痕,，20 MHz超聲測量厚度為（4.11±0.73）mm，VSS評(píng)估厚度為（3.02±0.47）mm,，病理測量厚度為（4.27±0.44）mm,；在消退期瘢痕，20 MHz超聲測量厚度為（1.74±0.64）mm,，VSS評(píng)估厚度為（1.77±0.61）mm,，病理測量厚度為（1.71±0.67）mm。對(duì)于3個(gè)時(shí)期的瘢痕,，20 MHz高頻超聲測量的瘢痕厚度與病理測量厚度的差異均無統(tǒng)計(jì)學(xué)意義（P均>0.05）,；而在瘢痕形成初期及增生期，VSS評(píng)估的厚度值與20 MHz高頻超聲,、病理測量厚度的差異均有統(tǒng)計(jì)學(xué)意義（P均<0.05）,。（2）在瘢痕形成初期，高頻超聲顯示表皮厚度與正常表皮接近且呈高亮強(qiáng)回聲,，但表皮與真皮層之間有約<1 mm厚的條形低回聲或無回聲區(qū),，形似真皮水腫；病理組織學(xué)顯示,，該期瘢痕的表皮有棘皮樣改變,，真皮層內(nèi)有豐富的毛細(xì)血管，并有少量膠原纖維組織,。在增生期瘢痕,，表皮仍呈強(qiáng)回聲，真皮層內(nèi)呈不均勻回聲,，真皮淺層呈明顯等回聲,，而深層表現(xiàn)無回聲或低回聲；病理顯示,，表皮薄而光滑,，角化明顯，真皮淺層可見與表面平行,、排列規(guī)則的膠原纖維,，真皮深層可見膠原纖維增多增厚，呈結(jié)節(jié)狀,、漩渦狀,。在消退期瘢痕,，表皮呈強(qiáng)回聲，真皮層與皮下組織之間無明顯分界,，呈均勻等回聲,；病理顯示，表皮變薄,，出現(xiàn)“皮釘”樣結(jié)構(gòu),，真皮淺、深層交界不明顯,，膠原纖維呈平行或斜向排列,，表面分界不清。

結(jié)論 20 MHz高頻超聲對(duì)瘢痕厚度的評(píng)估較VSS更準(zhǔn)確,，且可反映瘢痕內(nèi)膠原分布,、水分比例情況，相較于病理檢查具有無創(chuàng),、快捷的優(yōu)點(diǎn),，是評(píng)估瘢痕厚度及形態(tài)學(xué)的有效手段。

Application of 20 MHz high-frequency ultrasound in scar evaluation 

Bai  Lu, Shi  Xueqin, Yang  Li, Zhao  Wenli, Li  Na, Han  Juntao, Hu  Dahai

Department of Burn and Cutaneous Surgery, the First Affiliated Hospital of Air Force Medical University, Xi’an 710032, China

Corresponding author: Li Na, Email:  linaxjss@163.com

  【Abstract】

Objective To investigate the role of 20 MHz high-frequency ultrasound in evaluating scar thickness and morphology.

Methods The clinical data of patients with the initial stage of scar formation after burn trauma (<1 month), hypertrophic scar (1-6 months) and atrophic scar (>6 months) treated by the Department of Burn and Cutaneous Surgery, the First Affiliated Hospital of Air Force Medical University from April 2019 to December 2020, were retrospectively analyzed. All patients were evaluated by 20 MHz high-frequency ultrasound, histopathology and Vancouver scar scale (VSS). Three measurement points were randomly selected at the scar during ultrasonic examination, and the average value was recorded as the ultrasonic thickness measurement value. The scar tissue samples were collected from the site of ultrasonic examination, and HE staining and Masson staining were performed. At the same time,scar thickness was evaluated by two physicians using VSS. The difference of scar thickness assessment result  among the 3 method  in patients at the initial stage of scar formation, hypertrophic scar and atrophic scar was compared. Meanwhile, the relationship between the characteristics of 20MHz high-frequency ultrasound and histopathology was compared. The measurement data of normal distribution were expressed as Mean±SD. One-way ANOVA was used for comparison among three groups, and SNK-q test was used for pairwise comparison between groups. Counting data were analyzed by Chi-square test.

Results A total of 224 patients were included, including 91 males and 133 females, aged from 1 to 34 years, with an average age of 25.7 years. There were 79 patients at the initial stage of scar formation, 102 at the hypertrophic stage, and 43 at the atrophic stage. (1) In the initial stage of scar formation, the thickness measured by 20 MHz ultrasound was about (2.01±0.68) mm, the thickness evaluated by VSS was (1.72±0.49) mm, and the thickness measured by pathological section was (2.11±0.45) mm. In the hyperplastic scar stage, the thickness measured by 20 MHz ultrasound was (4.11±0.73) mm, the thickness evaluated by VSS was (3.02±0.47) mm, and the thickness measured by pathological section was (4.27±0.44) mm. In the atrophic scar stage, the thickness measured by 20 MHz ultrasound was (1.74±0.64) mm, the thickness measured by VSS was (1.77±0.61) mm, and the thickness measured by pathological section was (1.71±0.67) mm. For scars in the above three periods, there was no statistical significance between scar thickness measured by 20 MHz high-frequency ultrasound and that measured by pathological sections(all P<0.05). In the initial stage of scar formation and hypertrophic stage, the thickness evaluated by VSS was significantly different from that measured by 20 MHz high-frequency ultrasound and pathology (all P<0.05), respectively. (2) Echo intensity was evaluated by ultrasound. In the initial stage of scar formation, the thickness of the epidermis shown by high-frequency ultrasound was close to that of the normal epidermis and presented a high-intensity echo, but there was a strip of echoless or no echo zone of <1mm between the high-intensity echo epidermis and dermis, which looked like dermal edema. Pathology showed that there were acanthoid changes in the epidermis of the scar at this stage, rich capillaries and a small amount of collagen fibrous tissue in the dermis. In the hyperplastic scar stage, the scar epidermis still showed strong echo, while the dermis showed uneven echo, the superficial dermis showed obvious isoecho, and the deep dermis showed no echo or hypoecho. Pathology showed that the epidermis was thin and smooth, and keratosis was obvious. Collagen fibers parallel to the epidermis could be seen in the superficial layer of the dermis, with regular arrangement. Collagen fibers were increased and thickened in the deep layer of the dermis, in the shape of nodules and swirls. In the atrophic scar stage, the scar epidermis presented a strong echo, and there was no obvious demarcation between the dermis and subcutaneous tissue, presenting a uniform echo. Pathological findings showed that the epidermis became thinner with a “skin nails”-like structure, the junction between the superficial and deep dermis was not obvious, and the collagen fibers were arranged in parallel or oblique direction, and the surface boundary was unclear.

Conclusion 20MHz high-frequency ultrasound is more accurate than VSS in the assessment of thickness of hypertrophic scar, and can reflect the collagen content and moisture ratio in scar. Compared with pathological examination, it has the advantages of non-invasive and fast, and is an effective means to evaluate scar thickness and morphology.

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: This study was conducted in accordance with the Helsinki Declaration.