【作者】 侯文明；

【导师】 徐达传；

【作者基本信息】 中国人民解放军第一军医大学 ， 临床解剖学， 2003， 博士

【摘要】 一、目的 1．对眶周脂肪垫进行系统全面的解剖学基础及临床应用研究，填补国内外在此方面的空白，对眶周各脂肪垫的解剖概念进行区别定位，避免目前对眶周脂肪垫中的部分脂肪垫仍存在的概念和定位上的混淆。 2．研究眶周皮下脂肪分布特点及与眶周老化性皱纹形成的关系，探索眶周皮下脂肪在眶周老化性皱纹形成中的作用，探索眶周老化皱纹的针对性的除皱方法，为眶周老化皱纹的去除提供一套完整的思路。 3．研究眉皮下脂肪及眉脂肪垫瓣设计的解剖学基础及操作要点，探索眉皮下脂肪及眉脂肪垫新的临床应用价值，为上睑凹陷畸形、上睑粘连多层皱折畸形及重睑过宽畸形等寻求一种具有血供的脂肪组织移植修复方法，解决游离脂肪移植修复上睑凹陷等畸形吸收率高的难题。 4．研究眶周美容畸形(aesthetic deformity)的解剖学基础及其美容整形修复方法，主要是上睑肥厚、臃肿、下垂及上睑凹陷畸形；下睑袋状畸形及下睑凹陷畸形的解剖学基础及其美容整形修复方法。 5．在下睑成形中，对眶隔脂肪的处理存在不同的观点，结合临床实践，在此加以讨论，提出自己的观点。 二、材料与方法 (一)基础解剖部分 1．选用15例(30侧)10％福尔马林防腐固定，经动脉灌注的成人头部标本，所选标本中年龄20～70岁，男10例，女5例。 2．由表及里逐层解剖眶周皮下、眉周、上睑、下睑及颧部，采用肉眼观察眶周各区皮下脂肪分布特点及与眶周老化改变的关系，观察眉皮下脂研究生:侯文明导师:徐达传肪、眉脂肪垫、上睑眼轮匝肌下脂肪垫、下睑眼轮匝肌下脂肪垫的位置、界限、毗邻关系及血管构筑;观察上睑眼轮匝肌下脂肪垫范围及与眉脂肪垫和眶隔脂肪的关系并做个体间的比较。采用直尺测量各脂肪垫面积大小，厚度。对重要血管及相关神经进行标记并摄影记录。 3.模拟设计并形成眉脂肪垫瓣，测量瓣的大小、蒂部的位置、卞要毗邻关系、瓣翻转后所能覆盖眼部的范围。探索眉脂肪垫瓣设计要点及形成操作要点及注意事项。 (二)临床部分 1.临床观察老年病例的眶周老化改变的形态学特征并照相。采用不同方法行眶周除皱使眶周年轻化，例如:肉毒素注射除皱、自体颗粒脂肪注射除皱、聚丙烯酞胺水凝胶注射除皱、膨体聚四氟乙烯薄片衬垫除皱、眶额部拉皮除皱术、上、下睑去皮成形除皱术。 2.临床行切眉术及额眉提升术病例各ro例，术中观察眉脂肪垫的存在、形态、大小及层次。 3.临床上纹坏眉及洗眉后疤痕病例10例，在行坏眉切除术中，对眉皮下脂肪长度、宽度及厚度进行测量。并对眉皮下脂肪瓣进行模拟设计，观察眉皮下脂肪瓣面积大小，蒂部位置，翻转后可覆盖上睑范围，以确定临床上行眉皮下脂肪瓣翻转修复上睑凹陷、上睑粘连及多层皱折等畸形的可行性。 4.上睑外侧臃肿肥厚下垂病例要求行重睑术病例10例，另有两例行重睑术后仍觉上睑臃肿「垂要求再次手术的病例。术中判断上睑眼轮匝肌肥厚情况并决定是否行其剪除术。 5.临床要求行下睑眼袋去除病例31例，采用三种方法行下睑眼袋去除术:经结膜入路眼袋去除术、经下睑缘切口入路眼袋去除术和经下睑缘切口入路，保留眶隔脂肪的眼袋去除术。第一军医大学2000级博士学位论文 三、结果 (一)基础解剖部分 1.眶周老化性皱纹与眶周皮下脂肪分布特点:老年尸体头部标本中，上睑下睑区域共同表现为皮肤薄，无皮下脂肪。静态皱纹浅细者，额区，鼻区，颖区有一层皮下脂肪，静态皱纹粗深者，在额区、鼻区和颖区皮下脂肪缺乏。 2.眉皮下脂肪:眉皮下脂肪大小相当于眉毛所在位置范围大小，向上可分离至眉上0.3一0.scm，向下至眶缘部在眉部皮肤与上睑皮肤转薄处开始变薄。眉皮下脂肪厚度(2.5士0.4)~，长度(4.8士0.4) cm，宽度(l .5士0.2)cm。眉皮下脂肪可设计成瓣的大小约为4.8 cmx 1.scm。向下翻转至眶缘部与眼轮匝肌相连，并以此部位为瓣的蒂部，可由与眼轮匝肌的连接部提供血供，翻转后瓣的大小可覆盖上睑。 3.眉脂肪垫:眉脂肪垫位于眶上神经血管束，眉外侧2/3范围相当于眉所在位置上下及外侧端一定范围内，其层次在额肌与眶部眼轮匝肌层下骨膜层上，呈向双侧颖部及向上逐渐变薄的扁平的长椭圆形状。平均长度为(3.9士0.1) cm，在眉中心垂直线上平均宽度为(l .90士0.2) cm，平均厚度为(0 .18士0.06)~。眉脂肪垫内有来自眶上动静脉的“肩脂肪热动静脉’，。眉脂肪垫瓣的大小可设计成约4.ocmX2.ocm，瓣的蒂部‘!‘〔设公十在经瞳孔垂直线与眉毛相交处，宽度约Icm，瓣翻转后可覆盖1几睑。 4.上睑眼轮匝肌下脂肪垫:在上睑部眼轮匝肌卜，睑板筋膜及眶隔筋膜前有一层纤维脂肪层，是眉脂肪垫层向卜的延续，形态相当于整个上睑的形态，大小相当于整个上睑的大小。该脂肪层与眉脂肪垫有位置及个体差异上的区别。 5.下睑眼轮匝肌卜脂肪垫:位于下睑眼轮匝肌层下眶骨缘与颧大肌之间，颧部骨膜层表面，眼轮匝肌下脂肪垫的大部分位于眶缘下外侧1/2。更多还原

【Abstract】 1. Objective(1) To give a systemic and comprehensive anatomic study to the periorbital fat pad, to differentiate the anatomic concept of each fat pad of the periorbital, to fill in the gaps in this systemic study and application and to avoid any anatomic concept confusion that exists in some part fat pad of the periorbital fat pad.(2) To study the relationship between the periorbital aging wrinkles and the distribution characteristic of the periorbital subcutaneous fat, to investigate the function of the periorbital subcutaneous fat in the development of the periorbital aging wrinkles. In the light of the anatomic mechanisms of the periorbital aging wrinkles, to investigate cosmetic and plastic methods that were aimed at the periorbital aging wrinkles, and to provide complete train of thought to cosmetic and plastic repairing of the periorbital aging wrinkles.(3) To investigate anatomic base and operation main point of the design of the brow subcutaneous fat flap and brow fat pad flap, to investigate the new clinic application value of the brow subcutaneous fat and brow fat pad, to provide an operation method of fat tissue transferring with blood supply to repair the sunken and/or multiply folded upper eyelid, too wide double eyelid deformity and to dissolve the difficult problem of the high absorption rate in free fat grafts for repairing the upper eyelid deformity.(4) To investigate anatomic base of the periorbital aesthetic deformity and the cosmetic and plastic methods for repairing the deformity. The major periorbital aesthetic deformity is the lateral upper eyelid fullness and heaviness, the sunken upper eyelid deformity, the bags of the lower eyelids and the sunken lower eyelid.(5) There still exist different views in dealing with the orbital fat pad during the lower eyelid blepharoplasty, we presented our views combine with our clinic practice.2. Materials and methods(1) Basic anatomic part(1)30 sides of 15 antiseptic adult specimens were studied, among the selected specimens, the age range was 20-60years.There were ten males and 5 females.(2)To dissect the subcutaneous per orbital area, peribrow area, the upper eyelid area, the lower eyelid area and the malar area layer by layer from surface to deep, To observe the distribution characteristic of the subcutaneous fat of each area of the periorbital by naked eye, to observe the relationship between the distribution characteristic of the subcutaneous fat of each area of the per orbital and the change of the periorbital aging, to observe the location, bound, neighborhood and blood vessel construction of the subcutaneous brow fat, the brow fat pad, The retro-orbicularis oculi fat pad and the suborbicularis oculi fat pad; to observe the scope of the retro-orbicularis oculi fat pad and the relationship between the brow fat fad and between the orbital fat pad; to observe the relationship between the suborbicularis oculi fat pad and the orbital fat pad; to measure the dimension and thickness of each fat pad; to mark theimportant blood vessel and nerve and to record the results by taking a photograph.(3)To design and develop the brow fat pad flap, to measure the dimension of the flap, the location of the pedicle, the main neighborhood, and the covering scope of the eye after the flap be transferred.(2) Clinic part(1)To observe the morphological appearance of periorbital aging wrinkles in clinic and to record the results by taking a photograph, and to use different methods of rhytidectomy for periorbital rejuvenation, for example: Treatment of wrinkles with Botox. treatment of wrinkles with autologous fat injection, treatment of wrinkles with hydrophilic polyacylamide gel injection, orbital and forehead facelift and blepharoplasty.(2) There were ten cases that accepted browplasty and ten cases that accepted foread-brow lift operation. During browpalsty operation we divided the orbicular oculi muscle and observed the exist of the brow fat pad.; and during the foread- brow lift operation through coronal incision w更多还原