颞区、乳突区的解剖研究及其在耳廓再造手术中的应用
摘要
目的：
耳再造手术是整形外科中最具挑战性的手术之一,术中所涉及的解剖区域包括颞区和乳突区。本研究通过解剖尸头标本,明确颞区、乳突区层次及神经、血管分布和走行特点,并讨论其在手术中的应用。
方法：
采用一般解剖学方法,对4例(8侧)尸头标本的颞区和乳突区进行逐层解剖：1、由浅向深解剖颞区和乳突区的层次；2、解剖颞区和乳突区神经,观察其走行和分布；3、解剖耳周肌肉分布情况及耳后肌供血血管；4、解剖颞浅动脉、耳后动脉及其分支,观察耳后筋膜瓣中横行血管的走行、数量及其于耳后筋膜瓣上的分布特点；5、测量耳后筋膜瓣的厚度及范围。
结果：
1、颞区层次由浅至深为：皮肤、皮下浅筋膜脂肪层、颞浅筋膜层、筋膜下疏松结缔组织层、颞深筋膜、颞肌、骨膜层；乳突区层次为：皮肤、皮下浅筋膜脂肪层、乳突浅筋膜层、筋膜下疏松结缔组织层、深筋膜层、骨膜层。2、颞区神经包括耳颞神经、面神经颞支,乳突区神经包括耳大神经和枕小神经。3、颞浅筋膜和耳后筋膜存在丰富的血运,分别由颞浅动脉和耳后动脉供血。耳后动脉于耳后区域向后方发出1-2条较粗的横行分支,走行于耳后筋膜表面,其分布范围约为8.8cm×5.95cm。4、耳后肌由耳后动脉向后方发出的单支细小分支供血。5、耳后筋膜瓣上、中、下部的厚度分别为1.24±0.11mm、2.86±0.25mm和3.80±0.23mm。
结论：
耳廓再造手术中应严格按解剖层次进行操作,在形成筋膜瓣时,应保持解剖层次的连续性。术中使用耳后筋膜瓣包裹耳支架,具有形成方便、切口隐蔽、颅耳沟清晰等优势,同时保留了颞浅筋膜的完整。在形成耳后筋膜瓣的过程中,可适当保留一层较薄的皮下浅筋膜脂肪层,以保证筋膜瓣的血供,筋膜瓣下部可自其背侧的胸锁乳突肌表面进行分离,并且可以将表面耳后肌去除,以减小筋膜瓣厚度。
Objective:
Auricular reconstruction is one of the most challenging procedures in plastic surgery. The regions involved in the surgery include temporal region and mastoid region. The objective of this research is to clarify the layers of temporal and mastoid regions and distribution characteristics of the nerves and vessels. And also discuss the application of the anatomical results in auricular reconstruction.
Methods:
Four embalmed cadaver heads (eight sides) of adults were dissected with general method.
1. Dissect the anatomical layers of temporal and mastoid regions.
2. Dissect and observe the distribution of the nerves of temporal and the mastoid regions.
3. Dissect the muscles around the auricle and observe the blood supply of the auricularis posterior muscle.
4. Dissect the superficial temporal artery and the posterior auricular artery, as well as their branches. Observe the amount and distribution characteristics of the transverse branches within the retroauricular fascial flap.
5. Measure the thickness and range of the retroauricular fascial flap.
Result:
1. The order of anatomical layers of the temporal region is skin, subcutaneous tissue, superficial temporal fascia, subgaleatic connective tissue, deep temporal fascia, temporal muscle and pericranium. For the mastoid region, the order is skin, subcutaneous tissue, superficial mastoid fascia, subgaleatic connective tissue, deep fascia and pericranium.
2. The nerves of temporal region include auriculotemporal nerve and temporal branch of facial nerve. The innervation of mastoid region includes great auricular nerve and lesser occipital nerve.
3. Superficial temporal fascia and retroauricular fascia are richly vascular and supplied by the superficial temporal artery and the posterior auricular artery respectively. One or two thick transverse branches of posterior auricular artery are distributed on the surface of the retroauricular fascia, the range of which is around8.8cm×5.95cm.
4. The auricularis posterior muscle is supplied by a single branch of the posterior auricular artery.
5. The thickness of top, middle and bottom part of the retroauricular fascial flap is1.24±0.11mm、2.86±0.25mm and3.80±0.23mm respectively.
Conclusion:
The operation of auricular reconstruction should strictly follow the anatomical layers and keep continuity of the layers when dissecting the fascial flap. The retroauricular fascial flap is used for draping the posterior surface of the cartilage framework, which possess advantages of easily harvested, invisible incision, clear auriculocephalic sulcus and keep the integrity of the superficial temporal fascia at the same time. During the process of dissecting the retroauricular fascial flap, it is possible to remain a thin layer of subcutaneous tissue, which ensures the blood supply of the fascial flap. In addition, at the bottom part of the fascial flap, it can be separated between the surface of sternocleidomastoid muscle and the back side of the fascial flap. The auricularis posterior muscle can also be removed during the process in order to minimize the thickness of the fascial flap.
耳再造手术是整形外科中最具挑战性的手术之一,术中所涉及的解剖区域包括颞区和乳突区。本研究通过解剖尸头标本,明确颞区、乳突区层次及神经、血管分布和走行特点,并讨论其在手术中的应用。
方法：
采用一般解剖学方法,对4例(8侧)尸头标本的颞区和乳突区进行逐层解剖：1、由浅向深解剖颞区和乳突区的层次；2、解剖颞区和乳突区神经,观察其走行和分布；3、解剖耳周肌肉分布情况及耳后肌供血血管；4、解剖颞浅动脉、耳后动脉及其分支,观察耳后筋膜瓣中横行血管的走行、数量及其于耳后筋膜瓣上的分布特点；5、测量耳后筋膜瓣的厚度及范围。
结果：
1、颞区层次由浅至深为：皮肤、皮下浅筋膜脂肪层、颞浅筋膜层、筋膜下疏松结缔组织层、颞深筋膜、颞肌、骨膜层；乳突区层次为：皮肤、皮下浅筋膜脂肪层、乳突浅筋膜层、筋膜下疏松结缔组织层、深筋膜层、骨膜层。2、颞区神经包括耳颞神经、面神经颞支,乳突区神经包括耳大神经和枕小神经。3、颞浅筋膜和耳后筋膜存在丰富的血运,分别由颞浅动脉和耳后动脉供血。耳后动脉于耳后区域向后方发出1-2条较粗的横行分支,走行于耳后筋膜表面,其分布范围约为8.8cm×5.95cm。4、耳后肌由耳后动脉向后方发出的单支细小分支供血。5、耳后筋膜瓣上、中、下部的厚度分别为1.24±0.11mm、2.86±0.25mm和3.80±0.23mm。
结论：
耳廓再造手术中应严格按解剖层次进行操作,在形成筋膜瓣时,应保持解剖层次的连续性。术中使用耳后筋膜瓣包裹耳支架,具有形成方便、切口隐蔽、颅耳沟清晰等优势,同时保留了颞浅筋膜的完整。在形成耳后筋膜瓣的过程中,可适当保留一层较薄的皮下浅筋膜脂肪层,以保证筋膜瓣的血供,筋膜瓣下部可自其背侧的胸锁乳突肌表面进行分离,并且可以将表面耳后肌去除,以减小筋膜瓣厚度。
Objective:
Auricular reconstruction is one of the most challenging procedures in plastic surgery. The regions involved in the surgery include temporal region and mastoid region. The objective of this research is to clarify the layers of temporal and mastoid regions and distribution characteristics of the nerves and vessels. And also discuss the application of the anatomical results in auricular reconstruction.
Methods:
Four embalmed cadaver heads (eight sides) of adults were dissected with general method.
1. Dissect the anatomical layers of temporal and mastoid regions.
2. Dissect and observe the distribution of the nerves of temporal and the mastoid regions.
3. Dissect the muscles around the auricle and observe the blood supply of the auricularis posterior muscle.
4. Dissect the superficial temporal artery and the posterior auricular artery, as well as their branches. Observe the amount and distribution characteristics of the transverse branches within the retroauricular fascial flap.
5. Measure the thickness and range of the retroauricular fascial flap.
Result:
1. The order of anatomical layers of the temporal region is skin, subcutaneous tissue, superficial temporal fascia, subgaleatic connective tissue, deep temporal fascia, temporal muscle and pericranium. For the mastoid region, the order is skin, subcutaneous tissue, superficial mastoid fascia, subgaleatic connective tissue, deep fascia and pericranium.
2. The nerves of temporal region include auriculotemporal nerve and temporal branch of facial nerve. The innervation of mastoid region includes great auricular nerve and lesser occipital nerve.
3. Superficial temporal fascia and retroauricular fascia are richly vascular and supplied by the superficial temporal artery and the posterior auricular artery respectively. One or two thick transverse branches of posterior auricular artery are distributed on the surface of the retroauricular fascia, the range of which is around8.8cm×5.95cm.
4. The auricularis posterior muscle is supplied by a single branch of the posterior auricular artery.
5. The thickness of top, middle and bottom part of the retroauricular fascial flap is1.24±0.11mm、2.86±0.25mm and3.80±0.23mm respectively.
Conclusion:
The operation of auricular reconstruction should strictly follow the anatomical layers and keep continuity of the layers when dissecting the fascial flap. The retroauricular fascial flap is used for draping the posterior surface of the cartilage framework, which possess advantages of easily harvested, invisible incision, clear auriculocephalic sulcus and keep the integrity of the superficial temporal fascia at the same time. During the process of dissecting the retroauricular fascial flap, it is possible to remain a thin layer of subcutaneous tissue, which ensures the blood supply of the fascial flap. In addition, at the bottom part of the fascial flap, it can be separated between the surface of sternocleidomastoid muscle and the back side of the fascial flap. The auricularis posterior muscle can also be removed during the process in order to minimize the thickness of the fascial flap.
引文
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2.刘海军,熊猛.先天性小耳畸形病因学研究进展[J].中国美容医学,2009,18(4)：574-576.
3. Nagata S. A new method of total reconstruction of the auricle for microtia [J]. Plast Reconstr Surg.1993 Aug; 92(2):187-201.
4.庄洪兴,蒋海越等.先天性小耳畸形的皮肤软组织扩张器法外耳再造术[J].中华整形外科杂志,2006,22(4)：286-289.
5.刘萍.耳郭再造术的现状[J].中国美容医学,2008,17(5)：769-771.
6.王怀经,张绍祥.局部解剖学(第2版)[M].北京：人民卫生出版社,2010.
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