摘要
一、目的和意义
临床上面部老化的类型各不相同，有的以皱纹出现为主，有的以皮肤松垂为主，有的集中在眼部，面部除皱术不是解决面部老化的唯一选择。针对不同类型面部老化的解剖学特点和临床处理方法进行系统研究，有助于我们采用综合性手段来更好地解决面部老化。
1、研究面部皱纹形成与面部表情肌的解剖学关系，采用处理表情肌的年轻化手术解决面部皱纹问题，包括：表情肌部分去除除皱法、表情肌阻隔除皱法和表情肌麻痹除皱法。重点研究：微创技术——用金属软组织解剖刀对表情肌进行松解、阻隔除皱的方法；下睑外侧眼轮匝肌部分去除矫正该部位皱纹的方法。
2、研究与面部皮肤松垂密切相关的解剖学结构——面部表浅肌肉筋膜系统(SMAS)的解剖学特点，采用提紧皮肤的年轻化手术解决面部皮肤松垂问题，包括：常规切口皮肤提紧法、小切口皮肤提紧法和无切口皮肤提紧法。重点研究：采用常规切口标准SMAS剥离的面部提升术与金属丝解剖刀除皱术相结合的办法矫正中面部皮肤松垂(鼻唇沟过深)；无切口微创技术——植入锯齿线提升面部的方法。
3、研究眼周老化与眼周脂肪垫的解剖学关系，采用对眼周脂肪垫综合处理的年轻化手术解决眼周老化问题。重点研究：对眼周脂肪垫(眉皮下脂肪层、眉脂肪垫、上眼轮匝肌下脂肪、上睑眶隔脂肪、下睑眶隔脂肪、颧脂肪垫)进行全面的解剖学研究；对上睑眶隔脂肪和上眼轮匝肌下脂肪的综合处理来解决上睑臃肿肥厚松垂。
二、材料与方法
(一)面部老化形态学及解剖学观察
1、材料
(1)面部老化形态学观察：①皱纹型，以额纹、眉间纹、鼻背横纹、鱼尾纹、鼻唇沟过深、颈横纹等动力性皱纹表现为主，18例，29～66岁，男3例，女15例；②皮肤松垂型，以上睑皮肤松驰、面颊部皮肤松垂、鼻唇沟加深、颏颈部皮肤松垂、颏颈角消失等皮肤松垂表现为主，21例，32～67岁，男4例，女17例；③眼周老化型，以眉外侧下垂、上睑臃肿肥厚松垂、下睑袋状突起、颧袋突现等眼周老化表现为主，32例，30～67岁，男6例，女26例。
(2)尸体标本解剖学观察：选用15例(30侧)10％福尔马林防腐固定，经动脉灌注的成人头部标本，30～70岁。
(3)临床手术解剖学观察：15例传统手术除皱术，额颞部除皱术2例，额颞面部4例，颞面部8例，颞面颈部1例，32～62岁，男1例，女14例。提眉术5例，切坏眉+提眉术7例，28～55岁，均为女性。经下睑缘切口入路眼袋整复术22例，30～65岁，男3例，女17例。
2、方法
(1)采用肉眼观察并照相的方法进行面部老化形态学观察；采用由表及里逐层解剖的方法进行尸体标本解剖学观察；对手术中涉及面部组织的结构、层次进行临床解剖学观察。
(2)观察全面部皮下脂肪的分布、厚薄，比较皱纹型面部老化与皮肤松垂型面部老化皮下脂肪的特点：观察面部表情肌(额肌、皱眉肌、降眉肌、眉间降肌、眼轮匝肌、口轮匝肌、笑肌、颧大小肌、颈阔肌等)止点与皱纹处皮肤真皮层的附着情况，比较皱纹型与皮肤松垂型表情肌的紧张度。
(3)观察SMAS的起止、范围，与颈阔肌、颞浅筋膜、眼轮匝肌、帽状腱膜、额肌等结构的移形关系，检测SMAS在各区的厚薄、致密度。
(4)将眼周分为眉区、上睑区、颞区、下睑区和颧区，观察眼周各区脂肪垫分布、移位与眼周老化的关系，观察眉皮下脂肪、眉脂肪垫、上睑眼轮匝肌下脂肪垫、下睑眼轮匝肌下脂肪垫的位置、界限、毗邻关系及血管构筑；观察上睑眼轮匝肌下脂肪垫范围，与眶隔脂肪的关系并做个体间的比较。
(二)年轻化手术的临床应用
1、皱纹型：
(1)表情肌部分去除除皱法：①额部冠状切口除皱术，对6例额纹、眉间纹、鼻背横纹表现明显者，利用额部冠状切口直视下对额肌、皱眉肌、降眉肌进行部分切除而除皱。②下眼轮匝肌部分去除除皱术，经下睑缘切口入路眼袋整复术病例中，其中5例下睑外眦部皱纹表现明显者，利用下睑缘切口对下睑眼轮匝肌外侧部肌肉进行去除而除皱。
(2)表情肌阻隔除皱法：①膨体聚四氟乙烯(ePTFE)薄片皮下置入除皱术，额颞部除皱术或额颞面部除皱术病例中，其中3例鱼尾纹表现明显者，术中将ePTFE薄片置入眼轮匝肌外眦部表面以阻隔鱼尾纹的形成。②金属软组织解剖刀除皱术，利用金属软组织解剖刀皮下切割开表情肌与皮肤真皮层之间的附着，并将2％透明质酸钠注入皮下隧道阻碍表情肌与皮肤发生愈合性粘连，从而达到除皱的目的。用此法处理眉间纹5例，鼻背横纹4例，鼻唇沟12例。
(3)表情肌麻痹除皱法：对10例额纹、眉间纹、鼻背横纹、鱼尾纹表现明显者，注射A型肉毒毒素麻痹额肌、皱眉肌、降眉肌、眼轮匝肌等以去除相应部位皱纹。
2、皮肤松垂型：
(1)常规切口皮肤提紧法：常规切口面部提升术，涉及额颞面部4例，颞面部8例，颞面颈部1例，术前临床共同特点：中面部皮肤松垂明显，鼻唇沟过深。采用耳前切口标准SMAS剥离的面部提升术，术后2～4周，鼻唇沟处再行金属软组织解剖刀除皱术。
(2)小切口皮肤提紧法：①颞部小切口面部提升术，有2例病例手术范围本应包括颞面部，因担心耳前会遗留切口瘢痕，只同意接受在颞部做切口，术中对面部进行潜行剥离提紧。②小切口提眉术，12例眉部位置偏低、下垂或洗眉后遗留明显瘢痕，同时伴上睑皮肤松垂者，在眉部做切口提升眉部并矫正上睑松垂。其中单纯提眉5例，切坏眉+提眉7例。
(3)无切口皮肤提紧法：①锯齿线植入面部提升术，将两端呈倒齿状的锯齿线通过中空的导引针引导植入皮下，利用锯齿线产生的张力将松驰皮肤上提。用此法处理眉下垂、上睑皮肤松垂8例，颞部皮肤松垂伴鱼尾纹明显2例，面颊部皮肤松垂3例，颌面部皮肤松垂2例。②金丝皮下植入术(资料来源于外院)，将直径0.1mm金丝剪成3～5mm长的小段，植入受术者额部、眼周、鼻唇沟、面颊部、颈部等部位，试图达到提紧皮肤并预防皮肤松垂的目的。
3、眼周老化型：
(1)去除脂肪法：①上睑松垂整复术，上睑臃肿肥厚松垂12例，其中2例已行上睑松垂整复术，术后仍觉上睑臃肿要求再次手术，通过对上睑眶隔脂肪、上眼轮匝肌下脂肪两类脂肪的综合处理行上睑松垂整复术。②去除眶隔脂肪的眼袋整复术，经结膜入路眼袋整复术8例，经下睑缘切口入路眼袋整复术20例，术中去除下睑眶隔脂肪。
(2)保留脂肪法：保留眶隔脂肪的眼袋整复术，经下睑缘切口入路眼袋整复术病例中，有2例采取保留眶隔脂肪、加强眶隔的做法。
三、结果
(一)面部老化形态学及解剖学观察结果
1、皱纹型：以额纹、眉间纹、鼻背横纹、鱼尾纹、鼻唇沟过深、颈横纹等表现为主。皱纹的位置、数目与表情肌的分布密切相关；皱纹的走向与表情肌肌纤维的走势相垂直；皱纹出现处的皮下脂肪少或无，或者是无脂区和多脂区的交界；皱纹处皮肤真皮层与表情肌止点有附着关系，表情肌的紧张度较强。
2、皮肤松垂型：以上睑皮肤松驰、面颊部皮肤松垂、鼻唇沟加深、颏颈部皮肤松垂、颏颈角消失等表现为主。皮肤松垂型皮下脂肪较皱纹型厚，而表情肌的紧张度较皱纹型弱。
3、眼周老化型：以眉外侧肥厚下垂、上睑臃肿肥厚松垂、下睑袋状突起、颧袋突现等表现为主。眼周老化与眼周脂肪垫的存在或改变密切相关。眉外侧易松垂与两个解剖因素有关：①眉外侧2／3骨膜之上有一明显脂肪层——眉脂肪垫存在；②眉区皮下脂肪层比较厚，但结构疏松。上睑易肥厚臃肿松垂的解剖学因素：①上睑眶隔筋膜松驰、眶隔脂肪脱垂；②睑板上方上眼轮匝肌下脂肪的存在和肥厚。眼袋的形成与下睑眶隔脂肪移位、脱垂密切相关。颧脂肪垫肥厚、脱垂、隆起造成了颧袋的形成、下睑凹陷的出现。
4、SMAS起自颈阔肌，向上越过颧弓和颞浅筋膜、帽状腱膜相连续，向前包绕眼轮匝肌、额肌，SMAS在腮腺区最厚，在颊区最薄弱。
(二)年轻化手术临床应用结果
1、皱纹型：
(1)表情肌部分去除除皱法：①额部冠状切口除皱术，术后额纹、眉间纹、鼻背横纹基本消除或明显变浅，连续观察长达3～5年，变化不大。②下眼轮匝肌部分去除除皱术，术后下睑外眦部皱纹基本消失，笑时也不明显，连续观察长达3～5年，变化不大。
(2)表情肌阻隔除皱法：①膨体聚四氟乙烯(ePTFE)薄片皮下置入除皱术，术后肿胀消除后，无论是静态或笑时鱼尾纹明显减少、变浅，连续观察长达3年半，鱼尾纹变化不大。②金属软组织解剖刀除皱术，术毕眉间纹、鼻背横纹、鼻唇沟处明显变浅，病例观察最长时间为2年半，为一例鼻唇沟受术者，效果保持良好。
(3)表情肌麻痹除皱法：注射后1～3天开始出现效果，7～14天达到高峰，皱纹基本消失，3～6个月后皱纹再现。
2、皮肤松垂型：
(1)常规切口皮肤提紧法：常规切口面部提升术，术后可见到明显的提升效果，面部松垂情况得到明显矫正，鼻唇沟变浅，整个人变年轻。鼻唇沟再经过金属软组织解剖刀的处理，鼻唇沟明显变浅。2～3年后随访，面部提升效果保持良好，鼻唇沟深浅变化不大。
(2)小切口皮肤提紧法：①颞部小切口面部提升术，术后早期可观察到上面部松垂得以明显矫正，中面部松垂得以改善。术后一年半再观察，提升效果保持欠佳，几乎恢复到术前的情况。②小切口提眉术，坏眉或多余皮肤得以切除，切口痕迹不明显，新眉形轻微上挑，重睑显宽，上睑皮肤松垂情况得以改善，整个人显年轻。术后随访2～3年，提升效果保持良好。
(3)无切口皮肤提紧法：①锯齿线植入面部提升术，术中锯齿线紧贴皮肤真皮层(额眉部除外，层次可稍深)植入，相应部位就出现明显的提升效果。术后随访6～24个月，提升效果仍保持良好，但除额眉外其它部位皮下易触及条索状异物，受术者难以接受。②金丝皮下植入术，术后随访2～3年，无法观察到对面部皮肤的提升效果，或者有预防面部松垂的功效。
3、眼周老化型：
(1)去除脂肪法：①上睑松垂整复术，术后上睑肥厚臃肿松垂得到明显改善，重睑形态自然流畅，眼部明亮有神显年轻。术后随访2～3年效果保持良好。②去除眶隔脂肪的眼袋整复术，术后下睑外观平滑，效果满意，无下睑凹陷的出现。术后随访2～3年效果保持良好。
(2)保留脂肪法：保留眶隔脂肪的眼袋整复术，术后效果欠佳，仍有眼袋的表现，患者不满意。
四、结论
1、皱纹型：
(1)面部皱纹形成与面部表情肌密切相关：a、面部表情肌在皮肤真皮层的直接附着。b、皱纹处皮下脂肪比较少甚至无，或者是无脂肪区与多脂肪区的交界。c、皮肤老化性萎缩、变薄。提示：任何削弱表情肌的处理措施、方法，对消除或减轻面部皱纹肯定都有效。
(2)治疗面部皱纹主要靠处理表情肌的年轻化手术来解决。表情肌部分去除除皱法效果最好且不容易复发，对额纹、眉间纹、鼻背横纹的同时处理，主张用此法。表情肌阻隔除皱法效果好、维持时间也长，主张用ePTFE薄片皮下置入去除鱼尾纹。表情肌麻痹除皱法，见效快，对额纹、眉间纹、鼻背横纹、鱼尾纹除皱效果都好，但维持时间短，需反复注射。
(3)新途径：通过松解并阻碍表情肌与皮肤真皮层之间的附着来除皱纹——改进后的金属软组织解剖刀除皱术，处理眉间纹、鼻背横纹和鼻唇沟过深效果好，维持时间也长。
(4)新方法：下眼轮匝肌部分去除除皱术，去除下睑外眦部皱纹效果好、维持时间长。
2、皮肤松垂型：
(1)治疗面部皮肤松垂主要靠提紧皮肤的年轻化手术来解决。对于面部大范围的皮肤松垂，主张采用常规切口皮肤提紧法的方式，此法效果好、维持时间长；小切口皮肤提紧法，提升效果有限、维持时间短。对于眉下垂伴上睑皮肤松垂，采用小切口提眉术或锯齿线植入提眉术，提升效果好，维持时间也长。
(2)综合应用：SMAS厚薄不均，颊区最薄弱，广泛剥离SMAS损伤面神经分支可能性大，我们主张采用标准SMAS剥离的面部提升术与金属丝解剖刀除皱术相结合的办法，既能有效矫正中面部皮肤松垂(鼻唇沟过深)，又能降低手术风险。
(3)锯齿线植入面部提升术只适宜在额眉部应用，不适合其它部位。
(4)金丝皮下植入对面部松垂的无明显治疗效果。
3、眼周老化型：
(1)眼周老化与眼周脂肪垫的存在或改变密切相关，治疗眼周老化要注意对眼周脂肪垫的综合处理才能获得最佳效果。眉外侧易松垂与眉脂肪垫存在、眉区皮下脂肪层厚而疏松有关。颧脂肪垫肥厚、脱垂、隆起造成了颧袋的形成、下睑凹陷的出现。
(2)上睑肥厚臃肿松垂的解剖学因素：上睑眶隔筋膜松驰、眶隔脂肪脱垂；睑板上方眼轮匝肌下脂肪的存在和肥厚。眼轮匝肌下脂肪薄者，眶隔脂肪则多而突出，而眼轮匝肌下脂肪肥厚者，则眶隔脂肪反而少而不突出。上睑松垂整复术中，对上睑眶隔脂肪、上眼轮匝肌下脂肪进行综合处理，才能充分纠正上睑肥厚臃肿松垂的现象。
(3)眼袋的形成与下睑眶隔脂肪移位、脱垂密切有关。在眼袋整复术中，去除眶隔脂肪的做法，效果好；采取保留下睑眶隔脂肪、加强眶隔的做法，效果不好，可能不适宜东方人。
1. ObjectiveThere are various types of the aging face, such as the face dynamic wrinkle, the face flabby skin and the periorbital aging several categories of etc. Rhytidectomy is not only way to treat the aging face. To study the anatomic characteristics of different type of the aging face, and to investigate the results of the operations or methods for facial rejuvenation, it will help us treat the face aging more effectively.2. Materials and methods(1) Basic partThe way that adopts the clinical face observation, the corpse specimen anatomy observation to combine together with the face surgical operation anatomy observation, to study the anatomy characteristics of the face dynamic wrinkle, the face flabby skin and the periorbital aging.(2) Clinical partTo observe the actual results of treating the face dynamic wrinkles with different methods, and to adopt new method or micro-traumatic technique to treat the dynamic wrinkles. To observe the actual results of treating the face flabby skin with small incision or micro-traumatic technique, and to treat the central face flabby skin with the way that the classical face lift combined together with micro-traumatic technique. To treat the periorbital aging effectively with the way of dealing with the periorbital fat pads.
3. Results
(1) Basic part
The position, number and trend of the face dynamic wrinkles were all invariable. There was a little or no fat under the dynamic wrinkle skin, or it was the boundary of no-fat area and greasy area under the wrinkle skin. The facial muscles adhered to the subcutaneous tissue under the wrinkle skin. Superficial muscular aponeurotic system (SMAS) arose from platysma, and SMAS was continuous with superficial temporal fascia and epicranial aponeurosis cross zygomatic arch, investing orbicularis oculi and frontal muscle. SMAS was thick in the parotid area, but weak in the cheek area. The morphologic characteristics of the periorbital aging was determined by the local soft tissue's anatomic constructive characteristics, especially related with periorbital fat pads. External eyebrow was easy to loose due to two anatomic factors: the existence of brow fat pad, and subcutaneous brow fat was thick but flaccid. The observation of anatomy and clinic showed that the suborbicularis oculus fat and the orbital fat of the upper eyelid were both contributing factors to lateral upper eyelid fullness and heaviness and ptosis. The orbital fat and the suborbicularis oculus fat pad were the main anatomic components of the aesthetic changes and aging of the lower eyelid and malar area.
(2) Clinical part
We could achieve the best result to treat the face dynamic wrinkles with the method of removing or cutting off muscle. The result of the method of A-botox injection was good, but maintaining time was short. Placing ePTFE thin slice to baffle the formation of the wrinkles, the result was good and maintaining time was long. The result of the method of removing the external part of the lower canthus muscle to treat lateral canthus wrinkle was good, and the region of lateral canthus wrinkle contracted almost 3/5～2/3. After some improvements were made during the operating process of treating the face dynamic wrinkles with special steel wire instrument, it was proved to be a kind of new micro-traumatic, safe, effective practical method.
Adopting the method of the classical face lift combined together with micro-traumatic technique could treat the central face flabby skin (deep nasolabial fold) effectively, and avoiding the various risks of other methods. Apparent lifting results were achieved immediately during the operating process if the serrated sutures were implanted at the proper level of structure under the skin. There was no lifting result if the serrated sutures were implanted at the level of the fat layer or SMAS. Promoting brow skin-subcutaneous fat aponeurosis flap was used to correct the external flabby brow, it could gain a good result and keep good result for long term.
The suborbicularis oculus fat and the orbital fat of the upper eyelid were both contributing factors to lateral upper eyelid fullness and heaviness and ptosis. We could acquire the good surgical operation result by dealing with both kinds of fat. The results of orbital fat preservation for lower eyelid pouches were not good, the result of orbital fat excision for lower eyelid blepharoplasty were satisfactory.
4. Conclusions
The anatomic factors of the dynamic wrinkles formation: The superficial situated mimetic muscles adhered to the subcutaneous tissue under the wrinkle skin, and there was a little or no fat under the dynamic wrinkle skin, or it was the boundary of no fat area and greasily area under the skin. We could achieve the best result to treat the face dynamic wrinkles with the method of removing or cutting off muscle. The result of the method of A-botox injection was good, but maintaining time was short. Placing material to baffle the formation of the wrinkles, the result was good and maintaining time was long. The result of the method of removing the external part of the lower canthus muscle to treat lateral canthus wrinkle was good, and the region of lateral canthus wrinkle contracted almost 3/5～2/3. After some improvements were made during the operating process of treating the face dynamic wrinkles with special steel wire instrument, it was proved to be a kind of new micro-traumatic, safe, effective practical method.
SMAS was thick in the parotid area, but weak in the cheek area. Adopting the method of the classical face lift combined together with micro-traumatic technique could treat the central face flabby skin (deep nasolabial fold) effectively, and avoiding the various risks of other methods. There was no consistent or obvious lifting result if the method of small incision or gold silk implanting was adopted to treat the face flabby skin. The method of implanting special serrated sutures under the face skin to tighten the flabby tissue was only fit for correcting external eyebrow ptosis.
The periorbital aging was especially related with periorbital fat pads. External eyebrow was easy to loose due to two anatomic factors: the existence of brow fat pad, and subcutaneous brow fat was thick but flaccid. The suborbicularis oculus fat and the orbital fat of the upper eyelid were both contributing factors to lateral upper eyelid fullness and heaviness and ptosis. The orbital fat and the suborbicularis oculus fat pad were the main anatomic components of the aesthetic changes and aging of the lower eyelid and malar area.
We could acquire the good surgical operation result by dealing with both kinds of fat. The results of orbital fat preservation for lower eyelid pouches were not good, the result of orbital fat excision for lower eyelid blepharoplasty were satisfactory.
引文
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