摘要
研究背景
伴随着人们医疗卫生意识的不断提高,整形美容外科领域也日渐发展壮大,特别是近十年,当温饱问题不再是人们最关心的基本生活问题时,当缺医少药已经成为历史时,人们开始追求生活的质量,人们开始从仅仅追求生命的长度逐渐转变为既追求生命的长度也追求其宽度,如何在有限的生命历程中从美的角度提升自已的生活质量已经不再是少数人的奢望,如何让自己永远年轻美丽正在谱写着人们新一轮的生活追求,伴随着市场强烈的需求,整形美容外科领域的学者们专研着任何一个关于人体美的指标。如何使五官之首---眼睛永远保持年轻美丽就是广大爱美人士和整形美容外科医疗工作者们共同关心关注的话题之一。
眼睛作为五官之首---心灵之窗,对于一个人的容貌有着极其重要的影响。不管与生俱来的双眸多么的美丽迷人,不管我们是否采用各种化妆品和健身保养,我们都无法真正的抗拒衰老的自然规律,我们可以延缓衰老的过程,但无法阻止它的到来,更不可能使它停止,而心灵之窗—五官之首—眼睛,常常首当其冲表现出衰老的迹象。对于下眼睑,眼袋和鱼尾纹就成为爱美人士最大的困扰。由此,下睑年轻态越来越受到人们的重视,通常年轻下睑一个最明确的特征是更短、更饱满、皮肤细滑无皱纹。这与老化的下睑形成鲜明的对比,老化的下睑在临床上常表现为更长、且缺乏弹性。还表现出下睑松弛、眶周容积减小、眶隔脂肪经薄弱的眶隔疝出等解剖特征。下睑袋和鱼尾纹等典型的下睑老化征象随着时间流逝逐渐表现出来。
那么下睑袋的形成原因到底有哪些?
近年来对下睑袋形成的原因不断有新的认识,目前认为下睑袋形成的原因主要有：①眶内脂肪球过多；②眼轮匝肌肥厚而造成；③皮肤及眼轮匝肌张力下降；④眶隔膜的退变松弛,弹性丧失,支持力减弱,致眶内脂肪膨出、移位、脱垂；⑤眶周组织包括各支持韧带的松弛、萎缩及解剖位置的改变,使眶内脂肪量与下睑支持结构间的平衡关系受到破坏,眶周骨轮廓逐渐明显,眶下缘有不同程度的凹陷；⑥也有研究表明,骨骼重塑在面中部老化进程中起了重要作用,随着机体的自然老化,面部骨骼会出现不同程度的移位,骨骼重塑加重了眶隔脂肪继续脱垂、疝出的趋势；⑦眼轮匝肌下脂肪垫肥大或局部组织的松弛使该脂肪垫突出也可使下睑呈睑袋样畸形。其中①②常见于年轻人,多与遗传因素有关。关于下睑袋的临床分型提法很多,目前尚无统一标准,依据其临床表现和解剖学特点可分为四种：①皮肤松驰型；②隔内脂肪脱垂型；③眼轮匝肌肥厚型(特殊型)；④混合型。
关于下睑袋的治疗有非手术和手术两种类型,而在实践中看来非手术疗法的有效性远远不及手术疗法,临床上对于手术疗法的研究也越来越多,传统的下睑袋手术疗法有内入路和外入路,内入路也即结膜入路,此手术方法术后无皮肤切口瘢痕、极少并发下睑退缩或睑外翻等并发症。但由于不切除下睑皮肤,也存在不少缺点,如不能同时处理松弛的下睑皮肤、轮匝肌、眶隔膜,故适用范围小。外入路也即皮肤入路,传统的下睑袋修复手术主要是经下睑睫毛下皮肤切口切除多余的皮肤、部分眼轮匝肌和膨出的眶隔脂肪,如单纯眼轮匝肌切除术、单纯皮肤切除术、皮肤切除+眶脂去除术、这些术式都没有特意处理松弛薄弱的下睑支持结构。而近年来认识到下睑袋的形成并非眶隔脂肪增多(不包括先天性眶隔脂肪过多的睑袋患者)。相反,Camirand等的研究指出：人的眶隔肪脂含量是恒定的或随年龄的增长逐渐减少的,而下睑支持结构松弛、薄弱是继发性下睑袋形成的主要原因,自20世纪70年代以来,一些旨在加强下睑支持结构、不强调切除眶隔脂肪、甚至主张保留与利用眶隔脂肪的下睑袋整复术不断涌现。传统的手术方法虽然可以解决爱美人士的一些基本问题,但是在这个人们对美的追求越来越苛刻的新时代,爱美人士多以一种更苛求的眼光审视手术效果,追求更完美的容貌个性已经是当今时代爱美人士的普遍心理。故此,传统的手术方法已经远远不能满足爱美人士渴望拥有完美双眸的心理需求,对临床整形美容医疗工作者提出更高的要求。同时,整形美容医疗工作者们,在积累了多年的临床工作经验和收集了丰富病例的基础上,也不断地回顾和检查以往工作的得失和不足,对相关的手术术式提出质疑。
所以,伴随着整形美容外科事业的不断壮大,如何最大限度地满足广大爱美人士如此苛求的审美心里需求,如何在尽量减小手术创伤的同时,使术后外观更自然,效果更持久,渐渐成为整形美容医疗工作者追求的终极目标。本课题就是在传统手术的基础上,对下眼睑眶隔脂肪和眼轮匝肌进行特殊的处理,以术后形成年轻、美丽、自然的下眼睑外观,从医学美学的角度对下眼睑的美丽外观更好定位,如何使手术之后,受术者在拥有年轻下眼睑的同时,还可以拥有视觉上立体感更强,更自然美丽的下眼睑外观也是本课题研究的最终目的。
第一部分：眶隔后脂肪的处理：眶隔后脂肪移位睑袋整形术
目的：通过解剖及临床实践探索眶隔后脂肪移位睑袋整形的手术方法。
方法：采用睑缘切口,显露眶隔及眶隔后脂肪,将内侧脂肪团释放并向下睑中央拉拢缝合于睑囊筋膜的弓状扩张部,以横向收紧眶隔,然后再纵向褥式缝合加强眶隔,在此基础上再适当合理处理眼轮匝肌和下睑皮肤,修复下睑袋。
结果：本组38例,手术后5d拆线,除下睑皮肤有轻度瘀血外,下睑均为平整,无凹陷,睑外翻及下睑退缩。血肿及球结膜出血等并发症发生。随访：术后3个月随访28例,术后3年随访5例,5例失访,医患双方对手术效果均感满意。
结论：眶隔后脂肪移位消除下睑袋整形的方法,可以减少出血,防止眼球内陷,根据受术者具体情况适量去除部分眼轮匝肌和下睑皮肤,也可做眼轮匝肌的折叠或切断悬吊术,切除轮匝肌和皮肤时不可超量,以免出现睑外翻等并发症。本组除少数患者有术区轻度淤血青紫外无1例出现并发症,降低术后复发率,远期效果更较理想,医患双方均满意,值得推广应用。
第二部分：睑缘眼轮匝肌的处理：保留“眼台”的睑袋修复术
目的：探讨保留“眼台”的下睑袋修复方法及其效果。
方法：通过睑缘切口,采用皮瓣与肌皮瓣联合的方法适当保留睑板前眼轮匝肌,并对眶隔前眼轮匝肌和眼轮匝肌眶部、眶隔及眶隔脂肪作适当的处理,去除适量的皮肤,在保留“眼台”的同时修复睑袋。
结果：本组58例,其中10例眼轮匝肌肥厚,术中去除部分眼轮匝肌后,效果满意。28例有不同程度的眶隔脂肪疝出,经还纳并加强眶隔后睑袋修复效果满意。10例眼轮匝肌肥厚者在去除适量眼轮匝肌后下眼睑臃肿外观得到改善。本组受术者均保留睑板前眼轮匝肌3-5mm,形成“眼台”。术后睑袋消失,睑颊区过度自然,形态良好。无一例出现并发症。所有受术者术后随访6个月-2年,眼袋明显改善,下睑缘饱满轮廓流畅,下睑形态良好,外观自然,富有立体感,微笑时“眼台”显现更明显,医患双方均满意。
结论：保留“眼台”的睑袋修复方法,在传统的睑袋修复术的基础上,保留睑板前眼轮匝肌,形成“眼台”,在解决下睑袋状突出问题的同时,能使下睑外观更自然,表情生动,富有立体感,更符合美学要求,使眼部更年轻美观。医患双方均满意。
第三部分眼轮匝肌眶部的处理：钳夹破坏眼轮匝肌的鱼尾纹去除术
目的：探索一种通过破坏眼轮匝肌来去除鱼尾纹的手术方法。
方法：通过睑缘切口在修复眼袋的同时钳夹破坏外眦部眼轮匝肌,减少外眦动力性皱纹的形成。
结果：本组36例,术后均按期拆线,7-15天肿胀消退,除了有3例颞部及外眦角处出现瘀斑,于术后12天左右渐消退外,无一例出现其他并发症。所有受术者于术后4月～18个月得到随访,鱼尾纹明显改善,眼袋、外眦角下移得以修复,外眦形态良好,切口瘢痕不明显,面部年轻化效果理想。
结论：钳夹破坏眼轮匝肌去除鱼尾纹的手术方法简单可行,效果可靠,可与眼袋手术同时进行。
Background
As the medical and health-care cause is improved together with people's health consciousness. Aesthetic Plastic Surgery is also developing and expanding with times. In particular, when the problem of food and clothing has no longer been the basic living issue people extremely concerned and the shortage of doctors and medicine has become past records, people get to pursue the quality of life, varying from length of life to length of life plus width of life, namely, it's no longer wide wish for a few people to improve their own life quality within limit life cause. With the intense demand of market, scholars and professionals in Aesthetic Plastic Surgery is studying the each esthetical index of human body. It is one of the topics to maintain beautiful eyes forever for enthusiasts in cosmetic beauty and surgeons in Aesthetic Plastic Surgery are concerned.
As first one of five sense organs, the eye can be deemed as window of heart and place great impact on the one's appearance. no matter the eyes are born with beautifulness and charm and whatever cosmetics and fitness maintenance we adopted, we can't manage to resist the natural law of aging completely, but we can postponing the process of aging. As preventing the arrival of aging and stopping aging are impossible, the aging signs firstly appears on our eyes-our window of heart-first one of five sense organs. For lower eyelid, eye bag and crow's feet turn into the supreme perplex for beauty lover. So the youth of lower eyelid is gathering more and more attention. One of the most defining features of a youthful lid is a shorter, fuller eyelid.2 This is in stark contrast with the aged eyelid, which clinically appears longer and deflated and demonstrates anatomic features such as laxity, loss of volume, and pseudoherniation of orbital fat through a weakened orbital septum. The aging signs of the lower eyelid, including lower eye bag and crow's feet, emerge gradually with time.
What are causes to formation of lower eyelid bag?
There are many fresh opinions on the cause of formation of lower baggy eyelids recently, among which the main causes are concluded as below:
①redundant orbital fat;
②thick orbicularis oculi muscle;
③declined muscular tension of skin and orbicularis oculi muscle;
④the bulging, transposition and prolapsus of orbital fat caused by degeneration relaxation, loss of resilience, weaken bearing capacity of orbital septum;
⑤The orbitofrontal organization consists of relaxation and contraction of supportive ligament and change of anatomy location, which destroy the balanced relation between orbital fat volume and supportive structure of lower eyelid and make orbitolfrontal bone outline obvious and various sag under infraorbital rim;
⑥Many researches show that bone remodeling plays an important role in the aging process of mid-facial fracture. Various displacement of facial bone will emerges with natural aging of organism. Bone remodeling aggravates the tendency of orbital fat prolapse and herniation;
⑦Thick fat pat under orbicular muscle or the relaxation of partial tissue make fat pat protruding and lower eyelid deformed (lower baggy eyelids).
Among which①②are common in young people with respect to genetic factor. There are a lot of Clinical classification formulations on lower baggy eyelids; however, there is no unified standard at present. The formulations can be classified into four groups according to its clinical manifestation and anatomy features:①skin flabby type;②orbital fat prolapse type;③thick orbicular muscle(special pattern);④mixed type.
There are non-surgical and surgical type on treatment of lower baggy eyelids, the effectiveness of non-surgical type is not as good as that of the surgical treatment in practice. More and more clinical researches on surgical treatment are emerging. The traditional surgical treatment on lower baggy eyelids contains trans-conjunctival approach and extradural approach. The trans-conjunctival approach refers to trans-conjunctival route, leaving no skin incision scar, with rarely eruption of lower eyelid retraction or eyelid ectropion. However, because of no resection of eyelid skin, there are many drawbacks:narrow applicable range because that this approach can not deal with flabby lower eyelid skin, orbicular muscle, orbitofrontal diaphragm simultaneously. The extradural approach refers to skin incision. The traditional lower lid blepharoplasty mainly cut off redundant skin, partial orbicular muscle and bulging orbital fat through skin incision under lower eyelash. Such as Pure resection of the orbicularis muscle, pure resection of skin, skin resection + resection of orbital fat, all the approaches haven't disposed with flabby and frail supportive structure of lower eyelid in special way. It has been known recently that the formation of the lower baggy eyelids is not caused by increased orbital fat (excluding the congenital eyelid bag patient who has redundant orbital fat). On the contrary, Camirand points out in his study:the orbital fat content is constant or decreasing with aging, but the loose and frail supportive structure of lower eyelid are main causes to formation of secondary lower baggy eyelids. Since the 1970s, the lower lid blepharoplasty which reserves and utilizes lower baggy eyelids of orbital fat emerges gradually to strengthen supportive structure of lower eyelid but not to strengthen the excision of orbital fat. Although the traditional operation can resolve many basic questions from beauty-lovers, they examine operation effect in fastidious attitude for the reason of the new age in which people pursue the beauty in more and more fastidious way, so it's very common mentality of beauty-lovers to chase after more perfect and individual face at present. Consequently, traditional operation has no longer satisfied the psychological demand from beauty-lovers who desire for perfect eyes, putting forward higher requirement for workers in Clinical and Aesthetic & Plastic Surgery. Based on long-term accumulation of clinical experience and collection of rich cases, workers in Aesthetic & Plastic Surgery also take a review and check advantages and disadvantages in past meanwhile propose queries to the relevant operations.
Therefore, with the expansion of the Aesthetic & Plastic Surgery, it turns into the ultimate goal for workers in Aesthetic & Plastic Surgery to meet the fastidious Aesthetic psychological demand from vast beauty-lovers to a maximum, manage to lessen operational injury and keep more natural appearance and more enduring effect in the meantime. Based on traditional operation, the subject focuses on special treatment on orbital fat in lower eyelid and orbicular muscle, shaping young, pretty and natural appearance of lower eyelid after operation, positions beautiful appearance of lower eyelid from medical and aesthetic perspective. The final purpose of the subject lies in making the person who undergoes surgery have young lower eyelid and more natural and prettier and stronger 3D appearance of lower eyelid in vision in the meantime.
Part one:Treatment of after the orbital septum fat:Baggy eyelids anaplasty through posterior orbital septum fat displacement
Objective:To explore the baggy eyelids anaplasty through posterior orbital septum fat displacement.
Methods:Orbital septum and posterior orbital septum fat were exposed through palpebral margin incision, internal orbital fat was released and sutured with arcuate expansion of capsulopalpebral fascia at the middle lower eyelid, which was taken as the function of tighting the flaccid lower eyelid at transverse direction. On such a basis, the muscle and skin were repaired and so did orbital septum and baggy eyelids.
Results:Of the 38 patients with this operation,. In addition to the lower eyelid skin with mild bleeding, the lower eyelid are smooth, no depression, and lower eyelid ectropion back, hematoma and bleeding. follow-up:after 3 months follow up 28 cases,5 cases followed up after 3 years,5 cases were lost. baggy eyelids anaplasty were achieved satisfactory results.
Conclusion:The method of baggy eyelids plasty through posterior orbital septum fat displacement could reduce hemorrhage, prevent Enophthalmos and decrease baggy eye palindromia, with better long-term effects.
Part two:Treatment of pre-tarsal orbicularis oculi:Repair of baggy deformity with lower eyelid step reservation
Objective:To explore the operation method and effect of repairing baggy deformity with lower eyelid step reservation.
Methods:The method of skin flap and musculo cutaneous flap with pretarsal orbicularis oculi reservation was adopted through palpebral margin incision, then the preseptal orbicularis oculi muscle and orbital part, orbital septum and orbital septum fat of orbitalis muscle were treated suitably to remove appropriate amount of skin,the lower eyelid step was reserved and repair of blepharoptosis was performed simultaneously.
Results:The 58 cases, including 10 cases of orbicularis muscle hypertrophy, the part of orbicularis muscle was removed by surgery, the results were satisfactory.28 cases with different degrees of orbital fat herniation, repair of eyelid bags was satisfactory after the orbital septum is strengthened.10 cases of orbicularis muscle hypertrophy, the appearance of lower eyelids swollen was improved after the part of orbicularis muscle was removed. preservation tarsus orbicularis muscle 3～5mm in this group, so the formation of lower eyelid step in postoperation. eyelid bags is disappeared in postoperation, eyelid cheek area is natural, good shape. None of the complications.all of patients followed up for 6 months to 2 years, baggyeye taxis was achieved satisfactory results, lower eyelid shape was very nice, the eyes were natural and more three-dimensional appearance.
Conclusion:The method of repair baggy deformity with lower eyelid step reservation could not only solve problem of eye bags,which produces a more desirable appearance, but also meet aesthetic requirements and rejuvenative appearance.
Part three:Treatment of orbital of orbicularis oculi:Crow's feet ablation of clamp damage orbicularis oculi muscle
Objective:To explore a surgical method to remove crow's feet.
Methods:To repair baggy deformity by palpebral margin lower incision,at the same time clamp damage the department of outer canthal orbicularis oculi muscle and to reduce the external canthus dynamic formation of wrinkles.
Results:In 36 cases, On time for removal of stitches postoperation, swelling is dissipated after 7-15 days,3 cases of temporal and outer canthal corner bruising, in gradually subsided after 12 days, but no case of other complications occurred, all of patients followed up for 4 months to 18 months, crow's feet was improved significantly after surgery, outer canthal shape well, scar in not obvious, results were satisfactory.
Conclusions:to remove crow's feet surgical method through clamp damage orbicularis oculi muscle is simple, feasible, effective and reliable operation with bags under the eyes at the same time.
引文
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