提上睑肌-Müller's肌复合体的相关解剖及其临床应用研究
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摘要
目的：先天性单纯性上睑下垂是整形外科常见的一类疾病，迄今报道的上睑下垂矫正术近百种，但尚没有一种手术方法可以矫正所有类型的上睑下垂，而且每种术式都不同程度的存在治疗的局限性和自身的缺点。为了解决这些传统术式的局限性,降低术后的并发症，本研究通过对提上睑肌-Müller’s肌复合体进行尸体解剖学研究，为临床选择提上睑肌-Müller’s肌复合体重叠短缩的方法矫正先天性上睑下垂提供解剖学基础，并通过对一系列病人的临床研究和随访，评价该术式的治疗效果，为上睑下垂的治疗提供新的选择。
方法：本研究第一部分采用去除眶上壁骨质的开放式入路对5具经10%福尔马林固定的成人尸头10只眼睑的上睑进行解剖学研究，在去除眶上壁骨质后，逐层分离并显露提上睑肌-Müller’s肌复合体，通过对提上睑肌-Müller’s肌复合体、Müller’s肌、Whintall韧带等相关解剖学研究和测量，为进一步的临床研究提供数据支持。第二部分我们回顾了在2007-2011年间，我科采用将提上睑肌-Müller’s肌复合体重叠短缩的方法对49例（75眼）先天性上睑下垂患者进行了手术矫正以及术后长期的随访，我们将术前病人眼睑下垂程度与术后矫正的程度通过Cochran-Mantel-Haenszel方法进行对比。而术前提上睑肌肌力与术后矫正程度及术后提上睑肌肌力则通过Fisher’s exact法进行配对对比，评价该术式的治疗效果。第三部分回顾了在2007-2013年间，我科选择利用提上睑肌-Müller’s肌复合体重叠短缩术及额肌瓣转移术分别矫正患有先天性小睑裂综合征病人，通过联合传统的Mustardé五瓣法进行内眦开大术及Fox法外眦成形术，一期矫正该类患者13例，经过系统的随访后，我们将病人术前垂直睑裂高度、水平睑裂宽度、内眦间距宽度、内眦间距宽度与水平睑裂宽度比值与术后情况进行独立t检验，并对两种方法术前术后矫正情况进行配对t检验，进一步评价两种术式的效果。
结果：
本研究第一部分，我们在对5具尸头10只眼睑的提上睑肌-Müller’s复合体进行了解剖和测量，我们测量的结果是：提上睑肌-Müller’s复合体的总长度是52.09±1.43mm，以Whitnall韧带为界限，肌肉部分长度为36.09±0.72mm；腱膜部分长度为16.04±1.50mm；Müller’s肌长度为10.41±0.73mm。
在第二部分中，在所有选择提上睑肌-Müller’s肌复合体重叠短缩法进行的先天性上睑下垂病人中（75眼），有59眼（78.7%）得到了完全矫正，16眼（21.3%）得到了不完全矫正；术前提上睑肌肌力>4mm的眼睑比术前提上睑肌肌力<4mm的眼睑获得了较高的完全矫正率（91.5%vs.57.1%; p <0.05）。而术后提上睑肌肌力>4mm的眼的数量从术前的47眼增加到62眼（p <0.05）术后有超过82.7%的病人提上睑肌肌力最终大于4mm。
在第三部分的研究中，通过将接受提上睑肌-Müller’s肌复合体重叠短缩法的小睑裂综合征病人（5例）与接受额肌瓣法矫正的病人（8例）进行长期随访和对比，在所有13例病人中，术前和术后HLFL，VLFW，IICD，IICD/HLFL均存在有显著差异p<0.01。所有患者术后IICD减少，而HLFL增加，IICD/HLFL值，在额肌瓣组：小于1.3者，占62.5%。大于1.5者占25%。而在复合体重叠短缩组，小于1.3者，占80%。无大于1.5者。二种矫正方法术前术后对比并无明显的统计学差异。复合体重叠短缩组术后IICD/HLFL值为：1.26±0.04；而额肌瓣组为：1.33±0.19。两组结果对比未见明显统计学差异。
结论：
1、提上睑肌-Müller’s肌复合体起源于眶尖肌肉总腱环，全长52.09±1.43mm；其中，肌肉部分长度为36.09±0.72mm；腱膜部分长度为16.04±1.50mm。上横韧带位于提上睑肌腱膜远端与睑板上缘上方二者相毗连处上16.04±1.50mm。
2、Müller’s肌的肌纤维起源于提上睑肌后方的肌纤维，其长度为10.41±0.73mm。提上睑肌-Müller’s肌复合体的深面及结膜之间存在一间隙，即复合体后间隙，该间隙在解剖过程中较易分离。
3、提上睑肌-Müller’s肌重叠短缩法适用于各种程度的先天性单纯性上睑下垂，能够增强患者术后的提上睑肌的肌力，术后并发症少。在长期随访病例中，临床效果确切，不易复发。
4、在一期法矫正先天性小睑裂畸形中，无论选择传统额肌瓣法还是提上睑肌-Müller’s肌复合体重叠短缩法，在与Mustardé五瓣法及Fox法外眦成形术联合使用时，对于小睑裂畸形的矫正效果显著。
Objective：
Blepharoptosis is a common condition characterized by an abnormallylow-lying upper eyelid margin that is less than2.0mm above the midpoint of thepupil or greater than2.0mm lower than the contralateral eyelid margin.Numerous method have been reported in the literatures to correct blepharoptosisin the past years. Although different method has its own indications andadvantages. It also carries a risk of complications that need to be carefullyconsidered when choosing a technique for surgical treatment. To reduce the riskof these complications, we have used a modified levator aponeurosis-müllermuscle complex reinsertion technique to correct blepharoptosis. The purpose ofthis study was to evaluate the outcomes of ptosis correction surgery using thistechnique after a anatomic and clinical research of the aponeurosis–müller’smuscle complex.
Methods：
In the first section, five adult cadaveric head preserved with10%formalinwere dissected at the upper eyelid region with a open removal of the superiororbital wall. The mark and location of important structures were furtherdetermined. The aponeurosis–müller’s muscle complex, the leavtor aponeurosis, the Müller’s muscle and Whitnall ligament were exposed, illustrated and therelevant distance was measured.
In the second section,75eyelids of49patients with congenitalblepharoptosis were treated with the modified levator aponeurosis-müller’smuscle complex reinsertion technique between2007and2011. The follow-upperiod ranged from6months to4years, with a mean follow-up of23months.Preoperative ptosis severity was compared with the degree of ptosis correctionby using the Cochran-Mantel-Haenszel statistic. Preoperative levator functionwas compared with the degree of ptosis correction and the postoperative levatorfunction by using Fisher exact test for paired data.
In the third section, a total of13patients were diagnosed with BPES andunderwent single-stage correction by either the modified levatoraponeurosis-müller's muscle complex reinsertion technique or frontalis muscletransfer technique, combined with Mustardé medial canthoplasty and Fox lateralcanthoplasty from2007to2013. The follow-up period ranged from1to6years,Statistical analysis was performed by paired t-test and independent t-test, toevaluate the pre-and postoperative HLFL, VLFW, IICD, and IICD/HLFL data.A p-value of <0.05was considered to be statistically significant.
Result:
In the first section, the total length of the levator aponeurosis-müller'smuscle complex is52.09±1.43mm; Separated by Whitnall ligament, the lengthof the muscle is36.09±0.72mm；The length of the aponeurosis is16.04±1.50mm; The length of müller's muscle is10.41±0.73mm.
In the second section, Sufficient correction was obtained in59(78.7%) of75eyelids, and insufficient correction was obtained in16eyelids (21.3%).Eyelids with preoperative levator function of greater than4mm had a higherrate of sufficient correction than those with preoperative levator function lessthan4mm (91.5%vs57.1%; P G0.05). The number of eyelids with levatorfunction greater than4mm increased from47preoperatively to62postoperatively (P<0.05).
In the third section, Significant differences were observed between themean pre and postoperative values for VLFW, HLFL, IICD and the IICD/HLFLratio (all p <0.0001). The value of IICD decreased with surgery and HLFLincreased with surgery, which led to an overall decrease in the IICD/HLFL ratiopostoperatively compared to the preoperative value. In the frontalis muscletransfer group, the IICD/HLFL ratio was less than1.3for62.5%of patients andgreater than1.5for25%of patients. In the levator aponeurosis-müller's musclecomplex group, the IICD/HLFL ratio was less than1.3for80%. There was nosignificant differences observed between the two groups.
Conclusion：
1. The levator aponeurosis-müller's muscle complex originated from themusclar tendinous ring of the orbital apex. The total length of the levatoraponeurosis-müller's muscle complex is52.09±1.43mm; Separated by Whitnallligament is located16.04±1.50mm away from the supratarsal border.
2. Müller's muscle originated from the deep part of levator aponeurosismuscle. The length of müller's muscle is10.41±0.73mm. The interspacebetween the levator aponeurosis-müller's muscle complex and conjunctiva isquite easy to be dissected dring operation.
3. The modified levator aponeurosis-müller’s muscle complex reinsertiontechnique is effective for any congenital ptosis with levator function and it canimprove levator function after the operation.
4. Either levator aponeurosis-müller's muscle complex reinsertiontechnique or frontalis muscle transfer technique are effective for single-stagecorrection of blepharophimosis-ptosis-epicanthus inversus syndrome combinedwith Mustardé medial canthoplasty and Fox lateral canthoplasty.
方法：本研究第一部分采用去除眶上壁骨质的开放式入路对5具经10%福尔马林固定的成人尸头10只眼睑的上睑进行解剖学研究，在去除眶上壁骨质后，逐层分离并显露提上睑肌-Müller’s肌复合体，通过对提上睑肌-Müller’s肌复合体、Müller’s肌、Whintall韧带等相关解剖学研究和测量，为进一步的临床研究提供数据支持。第二部分我们回顾了在2007-2011年间，我科采用将提上睑肌-Müller’s肌复合体重叠短缩的方法对49例（75眼）先天性上睑下垂患者进行了手术矫正以及术后长期的随访，我们将术前病人眼睑下垂程度与术后矫正的程度通过Cochran-Mantel-Haenszel方法进行对比。而术前提上睑肌肌力与术后矫正程度及术后提上睑肌肌力则通过Fisher’s exact法进行配对对比，评价该术式的治疗效果。第三部分回顾了在2007-2013年间，我科选择利用提上睑肌-Müller’s肌复合体重叠短缩术及额肌瓣转移术分别矫正患有先天性小睑裂综合征病人，通过联合传统的Mustardé五瓣法进行内眦开大术及Fox法外眦成形术，一期矫正该类患者13例，经过系统的随访后，我们将病人术前垂直睑裂高度、水平睑裂宽度、内眦间距宽度、内眦间距宽度与水平睑裂宽度比值与术后情况进行独立t检验，并对两种方法术前术后矫正情况进行配对t检验，进一步评价两种术式的效果。
结果：
本研究第一部分，我们在对5具尸头10只眼睑的提上睑肌-Müller’s复合体进行了解剖和测量，我们测量的结果是：提上睑肌-Müller’s复合体的总长度是52.09±1.43mm，以Whitnall韧带为界限，肌肉部分长度为36.09±0.72mm；腱膜部分长度为16.04±1.50mm；Müller’s肌长度为10.41±0.73mm。
在第二部分中，在所有选择提上睑肌-Müller’s肌复合体重叠短缩法进行的先天性上睑下垂病人中（75眼），有59眼（78.7%）得到了完全矫正，16眼（21.3%）得到了不完全矫正；术前提上睑肌肌力>4mm的眼睑比术前提上睑肌肌力<4mm的眼睑获得了较高的完全矫正率（91.5%vs.57.1%; p <0.05）。而术后提上睑肌肌力>4mm的眼的数量从术前的47眼增加到62眼（p <0.05）术后有超过82.7%的病人提上睑肌肌力最终大于4mm。
在第三部分的研究中，通过将接受提上睑肌-Müller’s肌复合体重叠短缩法的小睑裂综合征病人（5例）与接受额肌瓣法矫正的病人（8例）进行长期随访和对比，在所有13例病人中，术前和术后HLFL，VLFW，IICD，IICD/HLFL均存在有显著差异p<0.01。所有患者术后IICD减少，而HLFL增加，IICD/HLFL值，在额肌瓣组：小于1.3者，占62.5%。大于1.5者占25%。而在复合体重叠短缩组，小于1.3者，占80%。无大于1.5者。二种矫正方法术前术后对比并无明显的统计学差异。复合体重叠短缩组术后IICD/HLFL值为：1.26±0.04；而额肌瓣组为：1.33±0.19。两组结果对比未见明显统计学差异。
结论：
1、提上睑肌-Müller’s肌复合体起源于眶尖肌肉总腱环，全长52.09±1.43mm；其中，肌肉部分长度为36.09±0.72mm；腱膜部分长度为16.04±1.50mm。上横韧带位于提上睑肌腱膜远端与睑板上缘上方二者相毗连处上16.04±1.50mm。
2、Müller’s肌的肌纤维起源于提上睑肌后方的肌纤维，其长度为10.41±0.73mm。提上睑肌-Müller’s肌复合体的深面及结膜之间存在一间隙，即复合体后间隙，该间隙在解剖过程中较易分离。
3、提上睑肌-Müller’s肌重叠短缩法适用于各种程度的先天性单纯性上睑下垂，能够增强患者术后的提上睑肌的肌力，术后并发症少。在长期随访病例中，临床效果确切，不易复发。
4、在一期法矫正先天性小睑裂畸形中，无论选择传统额肌瓣法还是提上睑肌-Müller’s肌复合体重叠短缩法，在与Mustardé五瓣法及Fox法外眦成形术联合使用时，对于小睑裂畸形的矫正效果显著。
Objective：
Blepharoptosis is a common condition characterized by an abnormallylow-lying upper eyelid margin that is less than2.0mm above the midpoint of thepupil or greater than2.0mm lower than the contralateral eyelid margin.Numerous method have been reported in the literatures to correct blepharoptosisin the past years. Although different method has its own indications andadvantages. It also carries a risk of complications that need to be carefullyconsidered when choosing a technique for surgical treatment. To reduce the riskof these complications, we have used a modified levator aponeurosis-müllermuscle complex reinsertion technique to correct blepharoptosis. The purpose ofthis study was to evaluate the outcomes of ptosis correction surgery using thistechnique after a anatomic and clinical research of the aponeurosis–müller’smuscle complex.
Methods：
In the first section, five adult cadaveric head preserved with10%formalinwere dissected at the upper eyelid region with a open removal of the superiororbital wall. The mark and location of important structures were furtherdetermined. The aponeurosis–müller’s muscle complex, the leavtor aponeurosis, the Müller’s muscle and Whitnall ligament were exposed, illustrated and therelevant distance was measured.
In the second section,75eyelids of49patients with congenitalblepharoptosis were treated with the modified levator aponeurosis-müller’smuscle complex reinsertion technique between2007and2011. The follow-upperiod ranged from6months to4years, with a mean follow-up of23months.Preoperative ptosis severity was compared with the degree of ptosis correctionby using the Cochran-Mantel-Haenszel statistic. Preoperative levator functionwas compared with the degree of ptosis correction and the postoperative levatorfunction by using Fisher exact test for paired data.
In the third section, a total of13patients were diagnosed with BPES andunderwent single-stage correction by either the modified levatoraponeurosis-müller's muscle complex reinsertion technique or frontalis muscletransfer technique, combined with Mustardé medial canthoplasty and Fox lateralcanthoplasty from2007to2013. The follow-up period ranged from1to6years,Statistical analysis was performed by paired t-test and independent t-test, toevaluate the pre-and postoperative HLFL, VLFW, IICD, and IICD/HLFL data.A p-value of <0.05was considered to be statistically significant.
Result:
In the first section, the total length of the levator aponeurosis-müller'smuscle complex is52.09±1.43mm; Separated by Whitnall ligament, the lengthof the muscle is36.09±0.72mm；The length of the aponeurosis is16.04±1.50mm; The length of müller's muscle is10.41±0.73mm.
In the second section, Sufficient correction was obtained in59(78.7%) of75eyelids, and insufficient correction was obtained in16eyelids (21.3%).Eyelids with preoperative levator function of greater than4mm had a higherrate of sufficient correction than those with preoperative levator function lessthan4mm (91.5%vs57.1%; P G0.05). The number of eyelids with levatorfunction greater than4mm increased from47preoperatively to62postoperatively (P<0.05).
In the third section, Significant differences were observed between themean pre and postoperative values for VLFW, HLFL, IICD and the IICD/HLFLratio (all p <0.0001). The value of IICD decreased with surgery and HLFLincreased with surgery, which led to an overall decrease in the IICD/HLFL ratiopostoperatively compared to the preoperative value. In the frontalis muscletransfer group, the IICD/HLFL ratio was less than1.3for62.5%of patients andgreater than1.5for25%of patients. In the levator aponeurosis-müller's musclecomplex group, the IICD/HLFL ratio was less than1.3for80%. There was nosignificant differences observed between the two groups.
Conclusion：
1. The levator aponeurosis-müller's muscle complex originated from themusclar tendinous ring of the orbital apex. The total length of the levatoraponeurosis-müller's muscle complex is52.09±1.43mm; Separated by Whitnallligament is located16.04±1.50mm away from the supratarsal border.
2. Müller's muscle originated from the deep part of levator aponeurosismuscle. The length of müller's muscle is10.41±0.73mm. The interspacebetween the levator aponeurosis-müller's muscle complex and conjunctiva isquite easy to be dissected dring operation.
3. The modified levator aponeurosis-müller’s muscle complex reinsertiontechnique is effective for any congenital ptosis with levator function and it canimprove levator function after the operation.
4. Either levator aponeurosis-müller's muscle complex reinsertiontechnique or frontalis muscle transfer technique are effective for single-stagecorrection of blepharophimosis-ptosis-epicanthus inversus syndrome combinedwith Mustardé medial canthoplasty and Fox lateral canthoplasty.
引文
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