本文選題：P45塑化技術 + 上瞼��； 參考：《大連醫(yī)科大學》2015年博士論文

【摘要】：一、目的:1、對上瞼軟組織進行系統(tǒng)全面的解剖學研究,為上瞼部整形美容外科提供解剖學資料。研究瞼周脂肪墊的分布和位置對其進行區(qū)分和歸類。2、研究瞼周脂肪分布特點及與上瞼凹陷、上瞼臃腫肥厚形成的關系,探索瞼周脂肪在眼部整形美容手術中的作用,探索重瞼成形術時對瞼周脂肪的處理方法。3、研究眶上緣區(qū)域筋膜脂肪瓣設計的解剖學基礎,輔以臨床術中解剖,探索眼輪匝肌下層和眶緣脂肪組織的臨床應用價值,為上瞼凹陷畸形尋求一種簡單易行的手術方法,解決眉脂肪墊修復上瞼凹陷畸形操作復雜的難題。4、研究瞼周動脈血管的解剖學基礎及臨床應用,明確眼動脈分支的走行和分布范圍,明確上瞼的動脈弓分布特點和來源,選擇有效血管蒂,指導臨床對上瞼損傷的治療。探索瞼周動脈吻合的潛在區(qū)域,結合臨床,避免填充物注射引起的并發(fā)癥。二、材料與方法第一部分:對16具(32例)頭頸部標本進行P45斷層塑化切片的制作,觀察上瞼軟組織的結構和層次,觀察上瞼脂肪墊的位置和分布第二部分:選用12具(24例)頭頸部標本進行上眼瞼區(qū)域的解剖,所選標本年齡在40-70歲之間,男性頭頸部標本20例,女性頭頸部標本4例。由表及里逐層解剖上眼瞼,觀察眼輪匝肌下區(qū)域的軟組織分布,觀察各個脂肪墊的位置、界限、毗鄰關系,比較和斷層塑化切片的結果是否具有相關性。采用游標卡尺、直尺測量,拍照記錄。選取大連醫(yī)科大學附屬第一醫(yī)院整形美容科2010年到2015年,行切眉術和額眉提升術病例共56例進行臨床術中解剖觀察,均為女性,33歲-65歲,平均年齡54歲,以眼眉低垂和老年性上瞼凹陷患者為主,同時伴有上瞼皮膚松弛、眉外側下垂為主要表現(xiàn)。在術中,可逐層觀察眉部區(qū)域以及上瞼區(qū)域,對額肌、眼輪匝肌、眼輪匝肌下脂肪、眉脂肪墊進行肉眼觀察和測量。同時在術中觀察眶區(qū)脂肪層的分布范圍,額肌和眼輪匝肌交錯區(qū)域的肌肉走形、測量額肌和眼輪匝肌以及此區(qū)域軟組織的厚度和長度,探索其在臨床上治療老年性上瞼凹陷可行性。經(jīng)患者同意后拍照記錄。臨床行重瞼成形術病例69例,全部伴有上瞼臃腫,所有病例中全部為女性,年齡在18歲-48歲,平均年齡28歲。術中采用顯微解剖,由表及里逐層觀察上瞼區(qū)域,觀察上瞼眼輪匝肌后脂肪的分布和界限,和眶隔脂肪的關系,同時比較個體之間的差異。采用直尺測量,經(jīng)患者同意后拍照記錄。第三部分:新鮮成人頭頸部標本22例,所有標本頭頸部均無畸形、骨折、腫瘤以及破損,分成三組。第一組大體解剖10例,第二組動脈造影后計算機三維重建10例,第三組血管鑄型2例。分別觀察,眼動脈的終末分支的走行,上瞼動脈弓的構成,眶周動脈的吻合區(qū)域。為瞼周整形手術提供解剖學基礎,整體而系統(tǒng)而為瞼周的整形美容手術及醫(yī)學解剖學教學提供直觀全面的形態(tài)學資料,建立瞼周動脈血管的三維解剖模型。三、結果第一部分采用p45斷層塑化技術對上瞼軟組織的解剖學研究在32例上瞼p45塑化切片中我們觀察到上眼瞼的層次結構:由淺入深依次為皮膚、皮下淺筋膜、眼輪匝肌、眼輪匝肌后脂肪、肌下間隙、眶隔、眶隔脂肪,筋膜纖維層和瞼結膜。提上瞼肌、muller肌、提上瞼肌腱膜的結構有以下的兩種變異:類型i:提上瞼肌的下層特別薄,參與muller肌的形成,比例為75%。類型ii:提上瞼肌的末端不分層,向前僅延伸為muller肌,而提上瞼肌腱膜在提上瞼肌的上表面發(fā)出,厚度極薄,比例為25%。根據(jù)眶隔前脂肪(眼輪匝肌下眶隔前脂肪)和眶隔后脂肪(眶隔脂肪)在上瞼區(qū)域分布比例的不同,上瞼脂肪組織的分布分為三種類型,分別為眶隔前優(yōu)勢型(n=10,31.3%)、眶隔后優(yōu)勢型(n=4,12.5%)以及眶隔均衡型(n=18,56.3%)。在三種類型中,眶隔前脂肪和眶隔后脂肪所占的比例不同。第二部分上瞼軟組織的解剖學基礎與臨床應用研究肉眼觀察比較全部病例,眼輪匝肌后脂肪層有顯著的個體差異,厚度不一,以外側增厚較明顯。眼輪匝肌后脂肪下為眶隔,眶隔后為眶隔脂肪,集中在眶緣下方。眼輪匝肌后脂肪與眶隔相比含有更多的纖維,在大體解剖中發(fā)現(xiàn),眶隔前脂肪與眶隔后脂肪的分布關系與在p45斷層塑化切片的觀察結果一致。在24例標本中,根據(jù)眶隔前脂肪和眶隔后脂肪在上瞼區(qū)域分布比例的不同,把眶隔前脂肪和眶隔后脂肪的關系分為三種類型,其中眶隔前優(yōu)勢型上瞼出現(xiàn)的比例為29.2%(7/24)、眶隔后優(yōu)勢型上瞼的比例為16.7%(4/24)、而眶隔均衡型上瞼的比例為54.2%(13/24)。56例中輕度老年性上瞼凹陷患者采用眼輪匝肌筋膜脂肪瓣法,手術全部成功,上瞼凹陷修復效果明顯,無血腫和其他并發(fā)癥發(fā)生,上瞼和眶區(qū)的皮膚無感覺異常,額肌和眼輪匝肌的功能正常。無繼發(fā)性凹陷產(chǎn)生。術后隨訪12個月,患者滿意。術中臨床解剖觀察測量可見:眼輪匝肌筋膜瓣的平均厚度為(2.24±0.15)mm,筋膜瓣可向下剝離的長度(7.56±0.12)mm。第三部分瞼眶部動脈系統(tǒng)的解剖學基礎與計算機三維重建研究上瞼眼動脈的終末支包括眶上動脈、滑車上動脈、鼻背動脈、瞼內(nèi)側動脈、淚腺動脈、內(nèi)眥動脈。眼動脈的走行分為眶隔外型、眶隔內(nèi)型、鼻背動脈缺如型、眶上動脈缺如型,在眶隔外型中,在我們的觀察可見眶隔外型的兩種亞型,即眼動脈在出眶隔后先向下形成鼻背動脈,然后上行成為滑車上動脈,為第一種亞型;眼動脈在出眶隔后同時形成兩個分支,下行分支的鼻背動脈和上行分支的滑車上動脈,為第二種亞型。上瞼的動脈血供來源為五條橫向動脈弓和一條縱向動脈弓,分別為上瞼緣動脈弓、瞼板動脈弓、眶周深動脈弓、眶周淺動脈弓、瞼周動脈弓;一條縱向動脈弓為眼輪匝肌動脈弓�？糁苌顒用}弓的來源主要為滑車上動脈的分支,部分來自眶上動脈。瞼周的動脈吻合區(qū)域主要有三個:眉間和鼻背區(qū)域,主要是兩側滑車上動脈的吻合(吻合點4-6);鼻翼區(qū)域,主要是鼻翼動脈、鼻背動脈和鼻唇溝動脈的吻合;眶外側區(qū)域,主要是眶周深動脈弓、眶周淺動脈弓和顳淺動脈額支的吻合;三個區(qū)域是填充物注射逆行入血的危險區(qū)域。四、結論1、P45塑化技術對于眼周的軟組織研究提供了新的技術方法。2、本文闡明了上瞼脂肪的分布類型,即以眶隔前脂肪為主填充上瞼的眶隔前優(yōu)勢型,以眶隔前脂肪和眶隔后脂肪比例均勻的填充上瞼的眶隔均衡型,和以眶隔后脂肪為主充盈上瞼的眶隔后優(yōu)勢型。3、含有纖維結構的眶隔前脂肪在上瞼形成屏障作用,與眶隔后脂肪在眶上緣的前端形成上瞼脂肪的優(yōu)勢區(qū)域。4、在上瞼手術中應避免造成對上瞼脂肪優(yōu)勢區(qū)域的損傷,同時上瞼脂肪的優(yōu)勢區(qū)域可指導一些上瞼手術的治療。5、上瞼眼輪匝肌筋膜脂肪瓣方法操作簡單有效,并發(fā)癥少,是有效治療輕中度老年性上瞼凹陷的手術方法。6、上瞼眼動脈終末支的走行分為眶隔外類型、眶隔內(nèi)類型、鼻背動脈缺如型、眶上動脈缺如型,眶隔外型分為三種亞型,主要區(qū)分點是滑車上動脈和鼻背動脈從眼動脈發(fā)出分支的順行,明確滑車上動脈和鼻背動脈的關系,有助于在行以滑車上動脈為血管蒂皮瓣進行鼻背修復時避免對鼻背動脈的損傷。7、上瞼的動脈血管來源包括五條橫向走行的動脈弓和一條縱向的動脈弓,縱向動脈弓走行于眼輪匝肌內(nèi)。明確上瞼動脈弓的走行和分布,為上瞼修復手術皮瓣的選取提供更多可靠的血管蒂來源,為上瞼皮瓣修復提供可靠的解剖學依據(jù)。8、瞼周動脈血管的吻合區(qū)域主要包括三個區(qū)域,眉間和鼻根區(qū)域、鼻翼區(qū)域、眶外側區(qū)域,這些區(qū)域的血管吻合和眼動脈想連,逆行阻力小。9、在注射填充物治療面部缺陷時,應避免損傷眉間區(qū)域、鼻翼區(qū)域和眶外側區(qū)域的動脈血管,防止填充物在這些區(qū)域入血,減少注射填充美容手術并發(fā)癥的產(chǎn)生。
[Abstract]:Objective: 1, a systematic and comprehensive anatomical study of the soft tissue of the upper eyelid was carried out to provide anatomical data for the upper eyelid plastic surgery. The distribution and location of the peri palpebral fat pad were distinguished and classified for.2. The characteristics of the peri palpebral fat distribution and the relationship with the upper eyelid depression and the formation of upper eyelid hypertrophy were studied, and the peri palpebral fat was explored in the eye. The role of plastic and cosmetic surgery to explore the treatment of peri palpebral fat during double eyelid plasty.3, to study the anatomical basis of the fascia fat flap in the upper rim of the orbital rim, and to explore the clinical application value of the inferior orbicularis oculi muscle and the orbital margin by clinical anatomy, and to seek a simple and easy operation for the deformity of the upper eyelid. To solve the complicated problem of the operation of the eyebrow fat pad to repair the deformity of the upper eyelid.4, the anatomical basis and clinical application of the peripalpebral artery were studied, the walking and distribution of the branches of the ophthalmic artery were clearly defined, the characteristics and sources of the arterial arch distribution of the upper eyelid were clearly defined, and the effective vascular pedicle was selected to guide the treatment of the upper eyelid injury. The potential areas of anastomosis, combined with clinical, avoid complications caused by injections. Two, materials and methods: Part 1: making P45 slices of 16 (32 cases) head and neck specimens, observing the structure and level of the soft tissue of the upper eyelid, observing the position and distribution of the upper lid fat pad in second parts: 12 (24 cases) head and neck specimens were selected. The upper eyelid area was dissected. The age of the selected specimens was between 40-70 years old, 20 male and female head and neck specimens and 4 female head and neck specimens. The soft tissue distribution in the region of the orbicularis oculi muscle was observed from the surface and the soft tissue distribution in the region of the orbicularis oculi muscle. The location, boundary, adjacent relationship, comparison and the results of the slice of the fault plasticization were observed. A total of 56 cases of eyebrow resection and forehead eyebrow lifting were selected from 2010 to 2015 of the First Affiliated Hospital of Dalian Medical University. All the cases were observed in 56 cases, all were female, 33 years old -65 years old, the average age was 54 years old, with eyebrow drooping and senile depression in the upper eyelid. In the operation, the eyebrow area and the upper eyelid area can be observed by layer by layer, the eyebrow muscle, orbicularis oculi muscle, the orbicularis oculi muscle, the eyebrow fat pad are observed and measured by the naked eye. Meanwhile, the distribution of the fatty layer in the orbital region, the muscles in the frontal and the orbicularis orbicularis muscles are observed during the operation. The thickness and length of the frontal muscle and orbicularis oculi muscle and the soft tissue of the region were measured to explore the feasibility of clinical treatment for the senile depression of the upper eyelid. After the patient's consent, 69 cases of double eyelid plasty, all with the upper eyelid bloated, all were female in all cases, the age of 18 years old -48 years, and the average age of 28 years. During the operation, microdissection was used to observe the area of the upper eyelid by layer by layer, observe the distribution and boundary of the fat in the posterior orbicularis orbicularis muscle, and the relationship between the orbital fat and the difference between individuals. The third part: 22 cases of fresh adult head and neck specimens, all the head and neck parts of all the specimens were no malformation. Shape, fracture, tumor and breakage were divided into three groups. The first group was divided into 10 cases, second groups of arteriography, 10 cases of computer three-dimensional reconstruction, and 2 cases of the third group of vascular cast type. The system provides visual and comprehensive morphological data for the plastic surgery of the eyelid and the teaching of medical anatomy and establish a three-dimensional anatomical model of the blood vessels of the palpebral artery. Three. Results the first part, the anatomical study of the soft tissue of the upper eyelid by P45 tomography technique was used to observe the upper eyelid hierarchy in the 32 cases of the upper eyelid plastic section. Structure: skin, subcutaneous fascia, orbicularis oculi, orbicularis oculi muscle, orbicularis oculi muscle, posterior muscle space, orbital septum, orbital septum fat, fascial fiber layer and eyelid conjunctiva. The structure of upper eyelid muscle, Muller muscle, and levator aponeurosis have two kinds of variation: type i:, the lower lid of upper eyelid muscle is especially thin, and participates in the formation of Muller muscle, the proportion is 75%. class. The end of the upper eyelid muscle is not stratified and extends only to the Muller muscle, and the upper eyelid aponeurosis emits on the upper surface of the upper eyelid muscle, and the thickness is very thin. The proportion of the 25%. is based on the distribution of the upper eyelid region in the distribution of the upper eyelid adipose tissue according to the distribution of the anterior fat in the orbital septum (the oculi orbicularis orbital septum) and the orbital septum fat (the orbital septum) in the upper eyelid region. Three types, preorbital predominance (n=10,31.3%), posterior orbital septum dominance (n=4,12.5%) and orbital septum equilibrium (n=18,56.3%). In three types, the proportion of the preorbital fat and the posterior orbital septum is different. Second parts of the soft tissue of the upper eyelid There are significant individual differences in the posterior fatty layer of the muscle. The lateral thickening is more obvious. The posterior fat of the orbicularis orbicularis is the orbital septum, the orbital septum is the orbital septum, and the orbital septum is concentrated below the orbital margin. The posterior fat of the orbicularis orbicularis muscle has more fibers than the orbital septum. In the general anatomy, the relationship between the preorbital fat and the post orbital fat distribution is found in P45 In 24 specimens, the relationship between the preorbital fat and the posterior orbital fat in the upper eyelid region was divided into three types, including 29.2% (7/24) of preorbital prepredominant upper eyelid and 16.7% of the superior superior eyelid in the posterior orbital septum. (4/24), the proportion of the equalizing upper eyelid of the orbital septum was 54.2% (13/24).56, with the orbicularis oculi muscle fascia fat flap in the mild senile depression patients, the operation was all successful. The repair effect of the upper eyelid depression was obvious, no hematoma and other complications occurred, the skin of the upper eyelid and the orbital area had no sensation abnormality, and the function of the frontal muscles and orbicularis oculi muscles was normal. Secondary depression was produced. The patients were followed up for 12 months, and the patients were satisfied. Intraoperative anatomical observation and observation showed that the average thickness of the orbicularis oculi fascial flap was (2.24 + 0.15) mm, the length of the fascial flap can be dissected (7.56 + 0.12) mm. third part of the eyelid orbital artery system and the computer 3D reconstruction to study the end of the upper eyelid artery. The end branch includes the superior orbital artery, the upper trochlear artery, the dorsal nasal artery, the medial palpebral artery, the medial palpebral artery, the lacrimal gland artery, the medial canthus artery. The ocular artery is divided into the orbital septum, the orbital septum, the dorsal nasal artery and the orbital artery, and in the orbital septum, we can see the two subtypes of the orbital septum, that is, the ophthalmic artery is down first after the orbital septum. The formation of the dorsal artery of the nose, then ascending into the upper artery of the trochlear, is the first subtype; the ocular artery forms two branches at the same time after the orbital septum, the dorsal artery of the descending branch of the nose and the upper branch of the superior trochlear artery, which are the second subtypes. The arterial blood supply of the upper eyelid is derived from five transverse arteries and a longitudinal artery arch, respectively. The upper eyelid movement is the upper eyelid movement, respectively. The pulse arch, the palpebral arch arch, the deep orbital arch, the periorbital shallow artery arch, the peripalpebral arch; a longitudinal artery arch is the orbicularis oculi artery arch. The source of the deep orbital arch is mainly the branch of the superior trochlear artery, partly from the superior orbital artery. The main anastomosis area of the palpebral artery is three: the eyebrow and the dorsal region of the nose, mainly on both sides of the trochlear. Arterial anastomosis (anastomosis point 4-6); nasal alar area, mainly the nasal alar artery, the anastomosis of the nasal dorsum artery and the nasolabial artery; the lateral orbit area, mainly the orbital deep artery arch, the superficial orbital arch and the superficial temporal artery, and the three region is a dangerous area for injecting the retrograde into the blood. Four, 1, P45 plasticization technique for the peritaric The soft tissue study provides a new technical method.2. This article clarifies the distribution of upper eyelid fat, that is, preorbital septum prepredominant type with preorbital fat mainly filled with the upper eyelid, with a uniform filling of the orbital septum with the preorbital fat and the posterior orbital septum, and the preorbital septum predominant.3 with the post orbital fat filling the upper eyelid. Fibrous structure of the preorbital fat in the upper eyelid formation barrier, and the posterior orbital fat in the upper edge of the orbital margin to form the upper eyelid fat in the superior area.4, in the upper eyelid operation should avoid causing the upper eyelid fat area of the damage, while the upper eyelid fat area can guide the treatment of some eyelid surgery for the treatment of.5, upper eyelid orbicularis muscle tendons The membrane fat flap is a simple and effective operation with few complications. It is an effective method for the treatment of light and moderate senile upper eyelid depression,.6. The end branch of the upper eyelid artery is divided into the orbital septum type, the orbital septum type, the nasal dorsum artery, the superior orbital artery and the orbital septum are divided into three subtypes, the main point is the upper artery and nose of the trochlear artery and the nose. The relationship between the upper artery and the dorsal artery of the trochlear artery and the dorsal trunk of the trochlear artery helps to avoid the damage to the dorsal artery of the nasal dorsum by the upper artery of the superior trochlear artery for the repair of the dorsal artery of the nose.7. The arterial blood vessels of the upper eyelid include five transverse arteries and a longitudinal artery, longitudinal artery, and the longitudinal artery. The operation and distribution of the upper eyelid artery arch can provide more reliable source of vascular pedicle for the selection of the flap for the upper eyelid repair operation, and provide a reliable anatomical basis for the repair of the upper eyelid flap. The anastomosis area of the peripalpebral artery is mainly composed of three regions, the eyebrow and the nasal root area, the Alar area, the lateral orbit. Areas where vascular anastomosis and eye artery connect, retrograde resistance is small.9, and in the treatment of facial defects by injecting filling, the arterial vessels in the eyebrow area, the Alar area and the lateral orbit should be avoided, preventing the filling from the blood in these areas and reducing the complications of the injection filled cosmetic surgery.
【學位授予單位】：大連醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R322.91

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