【作者】 于浩；

【导师】 归来； 张海明；

【作者基本信息】 中国协和医科大学 ， 整形外科， 2008， 博士

【摘要】 一.目的对下睑及其邻近区域进行系统、详细的解剖研究,明确国人眶隔弓状扩张部、眶隔脂肪、下睑缩肌等相关结构的部位、范围、形态、性状和毗邻关系,为临床寻找更加合理的下睑部整复手术提供解剖学理论基础。对2000年以来治疗的1990例下睑袋畸形患者进行回顾性总结,根据下睑袋畸形的不同特点提出完善的下睑袋畸形分型方法,并提出相关手术治疗对策。二.材料和方法（一）基础部分:材料:10具（20侧）成人尸体头部标本,男3具,女7具,年龄范围56—72岁。方法:1侧采用矢状断层切片;19侧采用由表及里逐层解剖,观察下睑部及邻近区域各解剖结构间的部位、范围、形态、性状和相互间联系,采用游标卡尺测量,并作文字和图象记录。（二）临床部分:临床资料:1990例下睑袋畸形患者:女性1923例,男性67例,年龄范围17—71岁。方法:记录不同患者下睑袋畸形的特点,分别应用不同手术方法进行治疗,并对其中391例患者进行了平均12.05个月的随访。三.结果（一）基础部分:1、眶隔弓状缘在眶下缘的止点从内眦到外眦并不沿眶骨缘顶点走行,而是由眶内壁走行到眶外壁;眶隔各部分厚度不一,由内眦侧向外眦侧逐渐增厚。2、弓状扩张部为眶隔的附属结构,起于眶隔,斜行向内眦方向深部走行,走行过程中与眶隔有纤维联系,在下斜肌中1/3段与包绕下斜肌的下睑缩肌浅层汇合,最终汇入Lockwood韧带。3、切开弓状缘向上掀起眶隔,眶隔脂肪分为两叶,两叶脂肪团通过下斜枷喾指簟Ｏ蛏畈孔纷?眶隔脂肪与深部球后脂肪之间亦存在分隔,眶隔脂肪与深部球后脂肪性状不同。另外,在2具3侧标本的外眦下方,有一倒三角形的赘生脂肪,该脂肪来源于上睑眶隔内,由眶隔深面外眦韧带浅面的潜在腔隙坠入下睑眶隔内。4、下睑缩肌与眶隔在下睑板下2.5-3.4mm处融合,共同形成一膜样结构前行附着在下睑板下缘。（二）临床部分:1、下睑眶脂肪的突出可以归纳为下列组合:①内侧眶隔脂肪和外侧眶隔脂肪内侧叶突出;②内侧眶隔脂肪和外侧眶隔脂肪突出;③内侧眶隔脂肪、外侧眶隔脂肪内侧叶和外侧赘生脂肪突出;④内侧眶隔脂肪、外侧眶隔脂肪和外侧赘生脂肪突出;⑤内侧眶隔脂肪、外侧眶隔脂肪、外侧赘生脂肪或/和球后脂肪突出。2、根据下睑袋畸形的特点将其分为四个类型五个亚型:Ⅰ型:单纯皮肤松弛,可伴有眼轮匝肌肥厚。Ⅱ型:单纯眶隔脂肪突出,可以有轻微皮肤松弛。根据眶隔脂肪突出特点又分为两型:Ⅱ₁型:内侧眶隔脂肪和外侧眶隔脂肪内侧叶突出,Ⅱ₂型:内侧眶隔脂肪和外侧眶隔脂肪均外突;Ⅲ型为松弛型眶隔脂肪疝出,眶隔脂肪疝出伴有下睑皮肤、眼轮匝肌、眶隔的松驰;Ⅳ型为Ⅲ型伴下睑支持结构松弛。3、根据1990例患者不同的下睑袋畸形特点,对应每种手术方法的适应证和禁忌症,分别用①单纯睑缘皮肤切除下睑袋整复术;②皮瓣法下睑袋整复术;③微创结膜入路下睑袋整复术;④微创结膜入路结合单纯睑缘皮肤切除下睑袋整复术;⑤肌皮瓣法下睑袋整复术;⑥肌皮瓣法结合眼轮匝肌悬吊下睑袋整复术;⑦肌皮瓣法结合下睑缘楔形切除下睑袋整复术。对其中391例患者进行了平均为12.05个月的随访,随访中部分患者（共58例）有不同程度外形不良,但没有下睑外翻等严重并发症出现。四.结论1、根据眶脂肪的来源和包膜特点,下睑眶隔内脂肪应分为内侧眶隔脂肪、外侧眶隔脂肪和外侧赘生脂肪,其中外侧眶隔脂肪又根据弓状扩张部分为内侧叶和外侧叶。2、从解剖学角度,最佳的结膜入路切口应该位于下睑睑板下缘2.5mm以内,行眶隔前入路。3、下睑袋的畸形可分为四个类型五个亚型:Ⅰ型为单纯皮肤松弛,可伴有眼轮匝肌肥厚;Ⅱ型为单纯眶隔脂肪突出,可伴有轻微皮肤松弛:Ⅱ₁型:内侧眶隔脂肪和外侧眶隔脂肪内侧叶突出,Ⅱ₂型:内侧眶隔脂肪和外侧眶隔脂肪均外突;Ⅲ型为松弛型眶隔脂肪疝出,眶隔脂肪疝出伴有下睑皮肤、眼轮匝肌、眶隔的松驰;Ⅳ型为Ⅲ型伴下睑支持结构松弛。4、我们针对下睑袋畸形的具体特点,应用①单纯睑缘皮肤切除下睑袋整复术;②皮瓣法下睑袋整复术;③微创结膜入路下睑袋整复术;④微创结膜入路结合单纯睑缘皮肤切除下睑袋整复术;⑤肌皮瓣法下睑袋整复术;⑥肌皮瓣法结合眼轮匝肌悬吊下睑袋整复术;⑦肌皮瓣法结合下睑缘楔形切除下睑袋整复术。共7种不同的手术方法进行治疗,证明这些手术方法能解决相应下睑袋畸形特点,但从另一个方面讲,这些方法亦存在着固有的缺点。因此,在临床上要根据患者的要求、详细的术前检查其下睑袋畸形的特征来选择合适的手术方法,从而取得良好的手术效果。更多还原

【Abstract】 1.ObjectiveThis paper is to give a systemic and comprehensive anatomic study on the lower eyelid and its surrounding area,investigate the position, extent,appearance,character,and adjacent relationships of the postseptal eyelid fat,arcuate expansion,lower lid retractor and other structures,and present the anatomical basis for the execution of the more rational lower eyelid blepharoplasty.Also,this paper aims to summarize the 1990 consecutive cases which we cured since 2000,presents a better classification for the lower palpebral bags,and provides relative different operative techniques.2.Materials and methods（1）Basic anatomic part:Materials:10 antiseptic adult specimens（20 sides） were studied, ages ranged from 56 to 72.There were three males and seven females.Methods:1 side of the specimens was sagittal sliced;the other 19 sides were dissected layer by layer from surface to deep which aimed to observe the position,extent,appearance,character,and adjacent relationships of each anatomical structure in the lower eyelid and its surrounding area.These specimens were measured with the sliding caliper, and the result was recorded by words and photos.（2）Clinical part:Clinical documents:There were 1990 consecutive cases,and ages ranged from 17 to 71.There were 1923 females and 67 males.Methods:we recorded the different characters of each patient’s lower palpebral bags,and cured them with relative different operative technique.We followed up 391 cases for a median time of 12.05 months.3.Results:（1）Basic anatomic part:①The arcus marginalis of the orbital septum is found to insert the infraorbital rim not along the superior most point but to insert from the inner wall to the outer wall of the infraorbital rim.The thickness of the orbital septum is not uniform but getting thickening from medial to lateral.②The arcuate expansion is an accessory structure of the orbital septum.It originates from the orbital septum,and extends in a medial and deep way with the orbital septum sending strands to it all along the course.It joins the lower lid retractor in the 1/3 section of the inferior oblique muscle,and converges to the Lockwood’s ligament in the end.③we incised the orbital septum along the arcus marginalia,and turned it over toward the eyelid margin.The postseptal eyelid fat is divided into two pads by the inferior oblique muscle.There is a membrane between the postseptal eyelid fat and the deeper retrobulbar fat,and their characters are different.We also found an inverse triangle fat below the lateral canthal tendon in 3 sides of the specimens.The fat came from the upper eyelid and fell into the lower eyelid through the pocket which bounded by the orbital septum anteriorly and the lateral canthal tendon posteriorly.④The distinct junction of the lower eyelid retractor and the orbital septum was confirmed in all specimens,with the distance from the inferior tarsal border to the junction ranged from 2.5mm to 3.4mm.（2）Clinical part:①The herniation of the orbital fat in the lower eyelid can be classified into 5 types:Herniation of the medial postseptal fat compartment and the medial part of the lateral postseptal fat compartment; Herniation of the medial and lateral postseptal fat compartment; Herniation of the medial postseptal fat compartment,the medial part of the lateral postseptal fat compartment and the lateral excrescent fat; Herniation of the medial and lateral postseptal fat compartment and the lateral excrescent fat;Herniation of the medial and lateral postseptal fat compartment,the lateral excrescent fat with/without the retrobulbar fat.②According to clinical pathological characters,the lower palpebral bags were divided into 4 types and 5 subtypes:ⅠSimple skin chalasis with /without orbicularis oculi pachynsis;ⅡSimple herniation of the postseptal eyelid fat with/without skin chalasis.It can be divided into two subtypes:Ⅱ₁ Herniation of the medial postseptal fat compartment and the medial part of the lateral postseptal fat compartment;Ⅱ₂ Herniation of the medial and lateral postseptal fat compartment;ⅢHerniation of the postseptal fat compartment with chalasis of the skin,the orbicularis oculi and the orbital septum;ⅣTheⅢtype combined with the chalasis of the support structures of the lower eyelid.③According to different patient’s character,we used different operation technique among seven types:Simple excision the skin of palpebral margins lower eyelid blepharoplasty;Skin flap lower eyelid blepharoplasty;Minimally invasive transconjunctival lower eyelid blepharoplasty;Minimally invasive transconjunctival lower eyelid blepharoplasty combined with simple excision the skin of palpebral margins;Myocutaneous flap lower eyelid blepharoplasty;Myocutaneous flap lower eyelid blepharoplasty combined with suspending the orbicularis oculi to periosteum;Myocutaneous flap lower eyelid blepharoplasty combined with wedged excision of the palpebral margin.We followed up 391 cases of the 1990 cases for a median time of 12.05 months.we observed that the results were good in 333 cases till the last follow-up,others of them suffered different kinds of unpleasant appearance,but no severe complication is included.4.Conclusion①According to the resource and the membrane of the fat compartment, the postseptal eyelid fat is divided into medial postseptal fat compartment,lateral postseptal fat compartment and the lateral excrescent fat.The lateral postseptal fat compartment is divided into two parts by the arcuate expansion.②The observation of anatomy shows that the preseptal approach is better than postseptal approach of the transconjunctival lower eyelid blepharoplasty.The incision on the conjunctiva should be within 2.5mm below the inferior tarsal border.③According to clinical pathological characters,the lower palpebral bags were divided into 4 types and 5 subtypes:ⅠSimple skin chalasis with /without orbicularis oculi pachynsis;ⅡSimple herniation of the postseptal eyelid fat with/without skin chalasis.It can be divided into two subtypes:Ⅱ₁ Herniation of the medial postseptal fat compartment and the medial part of the lateral postseptal fat compartment;Ⅱ₂ Herniation of the medial and lateral postsepta]fat compartment;ⅢHerniation of the postseptal fat compartment with chalasis of the skin,the orbicularis oculi and the orbital septum;ⅣTheⅢtype combined with the chalasis of the support structures of the lower eyelid.④According to different patient’s character,we can use different operation technique among seven types:Simple excision the skin of palpebral margins lower eyelid blepharoplasty;Skin flap lower eyelid blepharoplasty;Minimally invasive transconjunctival lower eyelid blepharoplasty;Minimally invasive transconjunctival lower eyelid blepharoplasty combined with simple excision the skin of palpebral margins;Myocutaneous flap lower eyelid blepharoplasty;Myocutaneous flap lower eyelid blepharoplasty combined with suspending the orbicularis oculi to periosteum;Myocutaneous flap lower eyelid blepharoplasty combined with wedged excision of the palpebral margin.We must perform the corresponding lower eyelid blepharoplasty according to the different patient’s requirement and the character of his/her lower palpebral bags observed before the operation.It can increase the post-operative satisfaction and reduce the complications.更多还原