摘要
目的：探讨预制以扩张器植入机体后形成的纤维包膜作为衬里的推进皮瓣,修复完全性上睑缺损的可行性。
背景：完全性上睑缺损在临床上是比较罕见的难题,主要见于肿瘤切除、外伤以及先天性畸形。重建完全性上睑缺损包括两个基本层次：外层富于弹性的皮肤和内层滑润的结膜。笔者观察到皮肤软组织扩张器植入机体后形成的纤维包膜,具有光滑、湿润的滑膜样外观,和正常的睑结膜相似。于是设计了预制以纤维包膜为衬里的推进皮瓣重建实验动物兔的完全性上睑缺损。
方法：31只新西兰白兔分别在额部皮下植入10ml圆形扩张器,持续扩张6到8周。应用额部推进皮瓣(带扩张器植入后形成的纤维包膜)修复全层上眼睑的矩形缺损。观察纤维包膜作为眼睑衬里的转归：分别在3天、1周、2周、1个月、2个月、4个月取标本进行组织学检测。在推进皮瓣修复兔完全性上睑缺损2个月以后,我们选择从内眦点到外眦点上睑缘长度的改变,作为反映皮瓣挛缩的一维参数。
结果：大体观察术后2个月：眼裂水平距离缩短,球结膜和角膜无损伤,作为衬里的纤维包膜表面湿润、光滑,较正常睑结膜颜色略白。组织学检测可见,推进皮瓣术后1周包膜层有大量炎症细胞浸润；术后1个月有单层扁平样上皮形成；术后2个月纤维包膜转化为复层柱状上皮,并且可以发现杯状细胞,接近正常的睑结膜层。上睑缘长度平均回缩率不明显为10.9±6.7%。
结论：扩张器包膜为衬里的推进皮瓣重建实验动物兔的大面积上睑缺损是可行的,重建的眼睑呈现令人满意的皮瓣颜色和厚度。纤维包膜作为睑结膜的替代物为大面积全层眼睑缺损的修复提供了细胞重建的平台、抗感染的屏障。
目的：探讨一种在眼轮匝肌悬吊法下睑袋切除术中,通过完全松解眼轮匝肌支持韧带,使附着在眶缘骨膜上松弛的皮肤、皮下组织得以充分释放,达到下睑组织和眶颧组织整体提紧效果的改良手术方法。
方法：对409例具有较明显沟槽畸形的患者,行眼轮匝肌悬吊法下睑袋切除术过程中,增加了眼轮匝肌支持韧带离断、眼轮匝肌支持韧带断端上提与眶隔筋膜固定的手段,改进眼轮匝肌悬吊法下睑袋切除术。
结果：2006年开始应用本法治疗下睑袋共409例,女391例,男18例,年龄在31-75岁,术后随访1-3年。其中轻度者16例下睑皮肤和眼轮匝肌松弛完全平复,外观良好。中度者354例中,352例下睑皮肤和眼轮匝肌松弛完全改善,外观良好,2例皮肤仍有轻度松弛,但较术前明显改观。重度者39例中,36例下睑皮肤和眼轮匝肌松弛完全改善,3例仍有皮肤轻度松弛及眶脂膨出,但较术前明显改善。390例沟槽畸形术后明显改观,无一例增多,其中有3例眼袋较严重者,在半年内感到下眼袋尚未完全去除,5例行第二次手术。约1/6患者术后早期外眦部可扪及一小硬结(线结),1-2个月左右消除。术后一般常见有闭眼时外眦部牵扯感,数日内缓解。术后下睑区皮肤平坦,鼻颊沟和眶颊沟消失。全部手术效果满意,无一例出现睑外翻及凹陷畸形等术后并发症。
结论：这种改良的下睑袋切除术,松解了眶颧部皮肤,有利于恢复睑颊复合体的平整自然,对解决沟槽畸形尤其有效。此方法简单易行,安全性高,可作为下睑袋年轻化手术很好的选择。
Reconstruction of Total Upper Eyelid with Prefabricated, Capsule-Lined Advancement Flaps:A Preliminary Study in Rabbit Model
Objective:to repaire total upper eyelid defects with prefabricated capsule-lined advancement flaps in a experimental model in rabbits.
Background:Total upper eyelid defect is a rare problem following tumor excision, trauma, and burns. Reconstruction of a total upper eyelid defect involves the reconstruction of two fundamental elements:anterior and posterior lamellae. The authors have observed that an expander capsule looks like the palpebral conjunctiva with a moist, smooth, white glistening appearance. The authors, therefore, experimentally repaired total upper eyelid defects with prefabricated capsule-lined advancement flaps in rabbits.
Methods:Thirty-one tissue expanders were implanted into the foreheads of thirty-one rabbits. After 6 to 8 weeks, the prefabricated advancement flaps were designed to reconstruct rectangular excisions of the upper eyelid. Histopathology was evaluated at 3 days,1 week,2 weeks,1 month,2 months, and 4 months following reconstruction. The shortening of the upper palpebral edges was measured after 4 months of reconstruction as a one-dimension reference point of flap contracture.
Results:No edema, congestion, infection, corneal damage, or necrosis were observed during the reconstructions. Histopathologic studies revealed that the long-term capsule had a normal conjunctiva-like appearance with a stratified columnar epithelium. The average shortening, measured as the length between inner to outer canthal folds, was inconspicuous.
Conclusion:The capsule successfully served as a conjunctival substitute in a rabbit model of full-thickness lid defects after total eyelid excision. The eyelid appearance was satisfactory with ideal color and skin thickness. The expander capsule was a temporary conjunctiva/mucosa substitute providing a physical shield, an infection barrier, and a matrix for epithelialization simultaneously with a gradual capsular resolution.Within weeks, the capsules were transformed into a microscopically normal-appearing conjunctiva/mucosa.
Objective:To study a improved technique by releasing orbicularis retaining ligament in orbicularis oculi muscle supension blepharoplasty. Release orbicularis retaining ligament could cut off the contact between orbitomalar skin and periosteum at inferior orbital rim, and carry the point of tightening orbitomalar skin in orbicularis oculi muscle supension blepharoplasty.
Methods:There were 409 patients with apparent orbitmalar fold. The methods of releasing orbicularis retaining ligament and orbital septum fixation were added to advance the orbicularis oculi muscle supension blepharoplasty.
Results:409 cases were treated using this method over the past 3 years. All results were satisfactory. No complications were observed.
Conclusion:This improved method of orbicularis oculi muscle supension blepharoplasty is useful for orbitomalar skin rolling, especially for orbitmalar fold. The release allows effective redraping and upward mobilization of the orbicularis of the lower lid and the premalar soft tissues. This method is a simple and effective procedure for the correction of tear trough deformity and well-demarcated lid/cheek junction in lower eyelid belpharoplasty. This technique was easily performed with high security. It is one of the best choices for lower eyelid blepharoplasty.
引文
[1]黄一雄,侯明种.眼睑缺损的修复[J].实用美容整形外科杂志,2000,11(4)：221-222.
[2]Hewes EH, Sullivan JH, Beard C. Lower eyelid reconstruction by tarsal transposition[J]. Am J Ophthalmol,1976,81(4):512-4.
[3]Kersten RC, Kulwin DR, Levartovsky S, et al. Management of lower-lid retraction with hard-palate mucosa grafting[J]. Arch Ophthalmol, 1990,108(9):1339-43.
[4]Barbera C, Manzoni R, Dodaro L, et al. Reconstruction of the tarsus-conjunctival layer using a venous wall graft[J]. Ophthal Plast Reconstr Surg, 2008,24(5):352-6.
[5]Parodi PC, Faini G, De Biasio F, et al. Full-thickness lower eyelid reconstruction with a conchal chondro-perichondral graft and local coverage with Mio-cutaneous flaps--our divisional experience[J]. J Oral Maxillofac Surg, 2008,66(9):1826-32.
[6]Nigro MV, Friedhofer H, Natalino RJ, et al. Comparative analysis of the influence of perichondrium on conjunctival epithelialization on conchal cartilage grafts in eyelid reconstruction:experimental study in rabbits[J]. Plast Reconstr Surg, 2009,123(1):55-63.
[7]Li TG, Shorr N, Goldberg RA. Comparison of the efficacy of hard palate grafts with acellular human dermis grafts in lower eyelid surgery[J]. Plast Reconstr Surg,2005,116(3):873-8; discussion 879-80.
[8]Mullner K, Langmann G. Chondroplast:A new material for eyelid reconstruction [J]. Ophthalmologica,1999,213(3):189-93.
[9]Tan J, Olver J, Wright M, et al. The use of porous polyethylene (Medpor) lower eyelid spacers in lid heightening and stabilisation[J]. Br J Ophthalmol, 2004,88(9):1197-200.
[10]McCord C, Nahai FR, Codner MA, et al. Use of porcine acellular dermal matrix (Enduragen) grafts in eyelids:a review of 69 patients and 129 eyelids[J]. Plast Reconstr Surg,2008,122(4):1206-13.
[11]Verity DH, Collin JR. Eyelid reconstruction; the state of the art[J]. Curr Opin Otolaryngol Head Neck Surg; 2004,12(4):344-8.
[12]李江,鲁开化,等.扩张囊外纤维包膜的组织学结构及其意义[J].中华医学美学美容杂志,2001,7(4)：191-193.
[13]Scuderi N, Ribuffo D, Chiummariello S. Total and subtotal upper eyelid reconstruction with the nasal chondromucosal flap:a 10-year experience[J]. Plast Reconstr Surg,2005,115(5):1259-65.
[14]deSousa JL, Leibovitch I, Malhotra R, et al.Techniques and outcomes of total upper and lower eyelid reconstruction[J]. Arch Ophthalmol, 2007,125(12):1601-9.
[15]Thomson HG. The fate of the pseudosheath pocket around silicone implants[J]. Plast Reconstr Surg,1973,51(6):667-71.
[16]Friedman HI, Friedman AC, Carson K. The fate of the fibrous capsule after saline implant removal[J]. Ann Plast Surg,2001,46(3):215-21.
[17]Sarifakioglu N, Gokrem S, Bingul F, et al. The fate of transplanted fibrous capsule as an autogenous.graft[J]. Plast Reconstr Surg,2005,115(4):1087-94.
[18]Wieslander JB, Wieslander M. Prefabricated (expander) capsule-lined transposition and advancement flaps in reconstruction of lower eyelid and oral defects:an experimental study[J]. Plast Reconstr Surg,2000,105(4):1399-407.
[19]Herford AS, Cicciu M, Clark A. Traumatic eyelid defects:a review of reconstructive options[J]. J Oral Maxillofac Surg,2009,67(1):3-9.
[20]Haefliger 10, Trittibach P, Pimentel AR, et al. Large upper eyelid full-thickness defects reconstructed only with an anterior lamella[J]. Klin Monatsbl Augenheilkd,2009,226(4):341-3.
[21]Siggelkow W, Faridi A, Spiritus K, et al. Histological analysis of silicone breast implant capsules and correlation with capsular contracture[J]. Biomaterials, 2003,24(6):1101-9.
[22]Stump A,3rd HLH, Connor J, et al. The use of acellular dermal matrix to prevent capsule formation around implants in a primate model[J]. Plast Reconstr Surg,2009,124(1):82-91.
[23]王佳琦,王原路,罗家麟,等.眼轮匝肌悬吊法下睑袋切除术[J].中华整形烧伤外科杂志,1995,11(1)：66-67.
[24]王佳琦,贾致强,吕维.眼轮匝肌悬吊和眶隔固定法下睑袋修除术[J].中华整形外科杂志,1999,15(4)：265.
[25]高静,乔群,刘志飞,等.联合下睑袋整形的面部除皱术[J].中华医学美学美容杂志,2001,7(5)：242-243.
[26]邢新,薛春雨.睑袋整复术进展[J].中华医学美学美容杂志,2003,9(5)：318-320.
[27]张本寿,林子豪,陈淑章,等.睑袋成形术的几点改进[J].中华医学美学美容杂志,2003,9(1)：36-37.
[28]张海明,王佳琦,郑行跃,等.老年性上睑松垂和下睑袋的美容外科治疗[J].中华医学美学美容杂志,2003,9(5)：267-269.
[29]高兰香.睑袋手术的几个关键问题[J].中华医学美学美容杂志,2006,12(1)：54-55.
[30]邢新,杨超.睑袋整复术进展与需要把握的几个问题[J].中华医学美学美容杂志,2006,12(5)：257-259.
[31]Ghavami A, Pessa JE, Janis J, et al. The orbicularis retaining ligament of the medial orbit:closing the circle[J]. Plast Reconstr Surg,2008,121(3):994-1001.
[32]Kikkawa DO,Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament[J]. Ophthal Plast Reconstr Surg,1996,12(2):77-88.
[33]Muzaffar AR, Mendelson BC,. Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus[J]. Plast Reconstr Surg, 2002,110(3):873-84; discussion 897-911.
[34]Iwanami M, Tsurukiri K. Histological comparison between young and aged specimens of the Oriental lower eyelid using sagittal serial sections[J]. Plast Reconstr Surg,2007,119(7):2061-71.
