[摘要]目的:探討應(yīng)用眶隔脂肪游離移植改善淚槽的臨床效果,分析該方法的優(yōu)點(diǎn)與局限性。方法:對(duì)2019年1月-2021年12月在哈爾濱醫(yī)科大學(xué)附屬二院應(yīng)用眶隔脂肪游離移植治療淚槽畸形的臨床資料進(jìn)行回顧性分析,共納入41例就醫(yī)者,年齡18~35歲,平均31.2歲。術(shù)前對(duì)就醫(yī)者眶下區(qū)狀態(tài)、淚槽畸形程度及就醫(yī)者期望值進(jìn)行評(píng)價(jià),對(duì)于適合采取眶隔脂肪游離移植的就醫(yī)者,通過醫(yī)患共同決策的方法確定手術(shù)方式及手術(shù)細(xì)節(jié)。結(jié)膜入路微創(chuàng)下切取眶隔脂肪并形成脂肪微粒繼而注射至標(biāo)記好的淚槽區(qū)域眼輪匝肌下層,觀察即刻手術(shù)效果。術(shù)后定期隨訪治療效果及患者滿意度。結(jié)果:術(shù)后隨訪半年以上。所有就醫(yī)者無(wú)并發(fā)癥發(fā)生,術(shù)后腫脹輕,局部消腫速度快,淚槽畸形改善明顯。結(jié)論:眶隔脂肪游離移植是改善年輕淚槽畸形就醫(yī)者的有效方法。該方法的局限性在于眶隔脂肪量體積不足,因此對(duì)于年齡較大或局部衰老明顯就醫(yī)者不適合此種方法。
[關(guān)鍵詞]眶隔脂肪;游離移植;淚槽畸形;年輕化;瞼袋;瞼頰溝
[中圖分類號(hào)]R779.6" " [文獻(xiàn)標(biāo)志碼]A" " [文章編號(hào)]1008-6455(2023)12-0027-02
Application of Orbital Septum Fat Free Transplantation in Correction of Lacrimal Groove Deformity
ZHANG Miaobo,TENG Wen,WANG Min,ZHANG Yingbo
(Department of Plastic Surgery,the Second Affiliated Hospital of Harbin Medical University,Harbin 150001,Heilongjiang,China)
Abstract: Objective" To explore the advantages and shortcoming of free orbital fat transplantation for improving tear trough. Methods" The clinical data of patients who received free orbital fat transplantation in transconjunctival approach low blepharoplasty from" January 2019 to October 2021 were analyzed retrospectively.41 patients whose age were from 18 to 35 and average age was 31.2. The condition of low blepharo area,tear trough and requirement of patients were analyzed and filtered out the patients who were fitted for free orbital fat transplantation. Then,according to principles of shared decision making,plastic surgeron and patients discussed and exchanged views about the details and style of operation.The orbital fat was cut through transconjectival approach and then injected them into the area of tear trough.Surgeron and patients observed the form until the patient were satisfied with the morphology of tear trough area. Results" "Surgerons completed the operation for every patient.All the patients were followed beyond half a year and they were satisfied with the surgical results.No complication happened among all the patients. Conclusion" Free orbital fat transplantation for improving tear trough was the suitable choice in many surgical treatments.However,due to no enough of orbital fat volume,it wasn’t fit for patients whose age was old or whose tear trough was severe.
Key words: orbital fat; free transplatation; abnormal tear trough; rejuvenation; eye bag; sulcus palpebrae buccalis
隨著對(duì)眶下區(qū)和中面部解剖認(rèn)識(shí)的不斷深入,眶下區(qū)年輕化的理念亦不斷更新[1-2]。目前主流觀點(diǎn)認(rèn)為瞼袋及眶下區(qū)衰老過程中眶隔脂肪不增加甚至減少,同時(shí)年齡增大,眶前壁逐步薄弱退化使眶隔脂肪疝出,眶隔脂肪位置發(fā)生改變導(dǎo)致瞼袋及淚槽的出現(xiàn)或加重。因此,傳統(tǒng)瞼袋整形術(shù)被逐漸棄用或少用,隨之而來(lái)的是眶隔脂肪釋放重置術(shù)??舾糁踞尫胖刂眯g(shù)將眶隔脂肪重置于淚槽或瞼頰溝使之平整[3]。但是眶隔脂肪釋放重置術(shù)需要松解或切斷淚槽韌帶和部分眼輪匝肌限制韌帶,手術(shù)創(chuàng)傷大,術(shù)后恢復(fù)期長(zhǎng),可能發(fā)生血腫、下瞼外翻等并發(fā)[4-5]。因此,探索更加微創(chuàng),簡(jiǎn)單有效的眶隔脂肪釋放重置技術(shù)成為醫(yī)患雙方的共同需求。本研究應(yīng)用眶隔脂肪游離移植治療淚槽畸形獲得較好效果,現(xiàn)對(duì)相關(guān)方法和經(jīng)驗(yàn)進(jìn)行總結(jié),報(bào)道如下,以供臨床參考。
1" 資料和方法
1.1 一般資料:收集2019年1月-2021年12月在哈爾濱醫(yī)科大學(xué)附屬二院行眶隔脂肪游離移植治療淚槽畸形的就醫(yī)者資料進(jìn)行回顧性分析。共41例,均為女性,年齡18~35歲,平均31.2歲,所有就醫(yī)者均主動(dòng)要求消除瞼袋,改善淚溝。上述所有就醫(yī)者均在行結(jié)膜入路瞼袋整形術(shù)時(shí)進(jìn)行眶隔脂肪游離移植回填淚槽及部分瞼頰溝。本研究通過哈爾濱大學(xué)附屬第二醫(yī)院倫理委員會(huì)批準(zhǔn)。
1.2 手術(shù)方法
1.2.1 術(shù)前評(píng)估:常規(guī)術(shù)前檢查及實(shí)驗(yàn)室檢查,詳細(xì)告知就醫(yī)者及其家屬手術(shù)相關(guān)注意事項(xiàng)及潛在風(fēng)險(xiǎn),并簽署手術(shù)同意書和拍照。囑就醫(yī)者自然坐位或直立位平視前方,觀察和評(píng)估瞼袋情況,包括眶隔脂肪量的多少,皮膚、眼輪匝肌及眶隔松弛程度、淚槽及瞼頰溝嚴(yán)重程度等,并用記號(hào)筆標(biāo)記清楚。
1.2.2 術(shù)中操作:就醫(yī)者取平臥位,眶下神經(jīng)阻滯加局部麻醉,在瞼板下緣做橫行結(jié)膜切口,充分顯露眶隔脂肪,依次部分切除眶隔脂肪內(nèi)側(cè)、中間及外側(cè)團(tuán),切除時(shí)注意保護(hù)下斜肌。切除脂肪后檢查創(chuàng)腔出血,結(jié)膜切口無(wú)組織嵌頓,還納下瞼緣至正常位置。將切取的眶隔脂肪制備成顆粒脂肪,將顆粒脂肪置于注射器中備用。通過結(jié)膜切口將上述顆粒脂肪注射于淚槽處,注射平面位于眼輪匝肌下層,邊注射邊觀察,局部適當(dāng)按摩。脂肪注射完畢后檢查雙側(cè)對(duì)稱性及注射區(qū)域是否平整并囑患者上下轉(zhuǎn)動(dòng)眼球觀察局部形態(tài),直至醫(yī)患雙方均滿意,膠貼適當(dāng)固定加壓手術(shù)區(qū)域。
1.3 觀察指標(biāo)
1.3.1 單側(cè)眶隔脂肪注射體積:統(tǒng)計(jì)就醫(yī)者單側(cè)眶隔脂肪注射體積。
1.3.2 瞼袋及眶下區(qū)改善效果:術(shù)后3個(gè)月醫(yī)患雙方分別評(píng)價(jià)瞼袋、淚槽及瞼頰溝改善情況并進(jìn)行量表分析,分級(jí)標(biāo)準(zhǔn):①0分,不滿意;②1分,基本滿意;③2分,滿意;④3分,非常滿意。根據(jù)所得分值統(tǒng)計(jì)醫(yī)患雙方滿意度。
1.3.3 創(chuàng)傷反應(yīng):包括術(shù)后腫脹程度及腫脹消退時(shí)間、術(shù)后血腫及局部瘀血情況、下瞼緣形態(tài)等。
1.3.4 并發(fā)癥:記錄術(shù)后瘀血、血腫、感染、結(jié)膜水腫等并發(fā)癥的發(fā)生情況。
1.4 統(tǒng)計(jì)學(xué)分析:SPSS 20.0軟件處理數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析,計(jì)量資料以(xˉ±s)表示。
2" 結(jié)果
2.1 所有就醫(yī)者均順利完成手術(shù),術(shù)中注射眶隔脂肪量0.6~1.3 ml,平均(0.8±0.02)ml(單側(cè))。醫(yī)生和就醫(yī)者對(duì)手術(shù)滿意度評(píng)分分別為(2.53±0.28)分和(2.97±0.34)分,說(shuō)明醫(yī)患雙方均對(duì)手術(shù)效果滿意。就醫(yī)者眶下區(qū)改善效果佳,術(shù)后淚槽基本消失,瞼頰溝改善,下瞼區(qū)域平整。術(shù)后未出現(xiàn)瘀血、血腫、感染、結(jié)膜水腫等,瞼緣形態(tài)正常。所有就醫(yī)者無(wú)嚴(yán)重并發(fā)癥發(fā)生。
2.2 典型病例:某女,29歲,先天性下眼區(qū)域臃腫,淚槽畸形。局麻下行結(jié)膜入路瞼袋整形術(shù),術(shù)中左側(cè)切除眶隔脂肪1.0 ml,右側(cè)切除眶隔脂肪1.1 ml。將眶隔脂肪體外制備成顆粒狀脂肪,采用Coleman技術(shù)注射至淚槽區(qū)域,注射層次在眼輪匝肌下,注射過程中和注射后囑就醫(yī)者坐位觀察注射區(qū)域的平整度,直至形態(tài)滿意。手術(shù)區(qū)域壓迫或冰敷40 min后患者離院,患者術(shù)后及時(shí)隨訪,效果良好,醫(yī)患雙方均滿意。典型病例手術(shù)前后圖片見圖1。
3" 討論
近年來(lái)對(duì)淚槽韌帶及眼輪匝肌限制韌帶等眶周結(jié)構(gòu)的精準(zhǔn)解剖研究取得了重要進(jìn)展,在此基礎(chǔ)上瞼袋整形術(shù)的理念發(fā)生了較大的轉(zhuǎn)變[6-8]。在瞼袋整形術(shù)時(shí)應(yīng)該把眶下區(qū)及面中部等綜合考量,重視淚槽、瞼頰溝等衰老因素的處理,其中具有代表性的是Harma眶隔脂肪釋放重置技術(shù),通過眶隔脂肪釋放達(dá)到消除淚槽的目的,并使局部平整并緊縮眶隔膜[9-11]。
相對(duì)于傳統(tǒng)的瞼袋整形術(shù)而言眶隔脂肪釋放重置術(shù)創(chuàng)傷較大[12]。對(duì)于眶周松弛嚴(yán)重和支持結(jié)構(gòu)薄弱的就醫(yī)者在行眶隔脂肪釋放重置時(shí)需要進(jìn)行眼輪匝肌懸吊或外眥韌帶成形術(shù)以避免遠(yuǎn)期的下瞼退縮;這進(jìn)一步增加了就醫(yī)者的創(chuàng)傷和手術(shù)風(fēng)險(xiǎn)。本研究采用眶隔脂肪游離移植取得了較好的效果。對(duì)于進(jìn)行結(jié)膜入路瞼袋整形術(shù)的就醫(yī)者,把切除的眶隔脂肪游離至淚槽區(qū)域是比較理想的辦法。與結(jié)膜入路眶隔脂肪釋放技術(shù)相比,有以下優(yōu)點(diǎn):①由于避免了眶下緣的剝離和解剖使手術(shù)創(chuàng)傷更小,不易發(fā)生血腫等并發(fā)癥,術(shù)后腫脹輕微,就醫(yī)者易于接受。②淚槽區(qū)域沒有進(jìn)行廣泛的手術(shù)分離、縫合等技術(shù)操作,局部解剖結(jié)構(gòu)和組織層次得以基本保留,深部粘連和瘢痕化程度輕,為年輕就醫(yī)者未來(lái)進(jìn)行再次填充或手術(shù)預(yù)留了更多可行性。③與其他部位脂肪相比,眶隔脂肪組織致密,細(xì)膩,易于制備成微小顆粒,同時(shí)眶隔脂肪移植于淚槽處屬于原位移植或鄰位移植,由于歸巢效應(yīng)的存在,加之局部血運(yùn)豐富,脂肪移植成活率高。
綜上,在合理選擇適應(yīng)證的基礎(chǔ)上,眶隔脂肪游離移植矯正淚槽畸形具有一定的優(yōu)點(diǎn),運(yùn)用得當(dāng),能夠獲得較好的術(shù)后效果。
[參考文獻(xiàn)]
[1]Sarhaddi D,Nahai F R,Nahai F.transconjunctival lower lid blepharoplasty with and without fat preservation and skin resurfacing[J].Facial Plast Surg Clin North Am,2021,29(2):229-241.
[2]Charles W N,Lim H K,Charles R C,et al.Evidence-based blepharoplasty: an analysis of highly cited research papers[J].Ophthalmic Plast Reconstr Surg,2022,38(4):325-329.
[3]Jiang S,Quan Y,Wang J,et al.Fat grafting for facial rejuvenation using stromal vascular fraction gel injection[J].Clin Plast Surg,2020,47(1):73-79.
[4]IMcClure Corwin K,Tvedten E,Seiger E.Innovative minimally invasive technique for the lower blepharoplasty[J].J Cosmet
Dermatol,2022,21(8):3494-3495.
[5]Wong C H,Mendelson B.Extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution[J].Plast Reconstr Surg,2017,140(2):273-282.
[6]Mao S H,Chen C F,Yen CI,et al.A Combination of three-step lower blepharoplasty to correct four types of lower eyelid deformities in asian people[J].Aesthetic Plast Surg,2022,46(3):1224-1236.
[7]Blanch A,Zingarello V,Young K,et al.Single access upper blepharoplasty and lower lid lateral fat pad removal: A proven technique with low recurrence rate[J].J Plast Reconstr Aesthet Surg,2022,75(11):4297-4303.
[8]Chen A D,Lai Y W,Lai H T,et al.The impact of hering's law in blepharoptosis: literature review[J].Ann Plast Surg,2016,76 (1):96-100.
[9]Nikolis A,Chesnut C,Biesman B,et al.Expert recommendations on the use of hyaluronic acid filler for tear trough rejuvenation[J].Drugs Dermatol,2022,21(4):387-392.
[10]Ramesh S,Goldberg R A,Wulc A E,et al.Observations on the tear trough[J].Aesthet Surg J,2020,40(9):938-947.
[11]Bukhari S N A,Roswandi N L,Waqas M,et al.Hyaluronic acid,a promising skin rejuvenating biomedicine: A review of recent updates and pre-clinical and clinical investigations on cosmetic and nutricosmetic effects[J].Int J Biol Macromol,2018,120(5):1682-1695.
[12]Hwang K.Eponym of Naso-jugal fold and tear trough[J].J Craniofac Surg,2016,27(5):1350-1353.
[收稿日期]2022-10-26
本文引用格式:張淼波,滕雯,王敏,等.眶隔脂肪游離移植在矯正淚槽畸形中的應(yīng)用[J].中國(guó)美容醫(yī)學(xué),2023,32(12):27-29.