关于东方人的内窥镜除皱术

近年来在欧美取代传统的除皱术,以最小限度的皮肤切口,利用关节镜进行表情肌的悬吊,即内窥镜除皱术正在广泛兴起。但是,有人强调东方人的皮肤特征及审美观与欧美人有差别。在此我们对东方人面部老化状态进行分类设计手术方案。前额部以上提肌与下制肌的形态分为三类。①上提肌紧张为伸展皮肤行帽状腱膜下剥离;②上提肌弛缓时为提升眉行骨膜下剥离;③下制肌紧张时行下制肌切除。颊部以皮肤、筋膜与皮下脂肪的状态进行分类。有皮肤松弛者行广泛皮下剥离,多余皮肤切除。无皮肤松弛的筋膜松弛者,在内窥镜下行耳前的ＳＭＡＳ筋膜分离提升。皮下脂肪堆积者行颊部及颧部的脂肪吸引。麻醉采用局部麻醉并用镇静剂。使用器械为直径４ｍｍ的硬性内窥镜辅以电视显示系统。在内窥镜直视下分离至眶缘、颧弓上、腮腺前缘浅层,要注意勿损伤皮神经及面神经,对分离后的筋膜以及骨膜以尼龙线进行悬吊。然后,用罗丝钉固定于前额部颅骨。由于使用了内窥镜,我们的除皱病人猛增。１９９４年７月至１９９８年８月共进行了前额除皱１６５例,颞部除皱２９例,颊部除皱９７例,全面部除皱７０例,总计为３６１例。同时也减少了包括面神经损伤等并发症     

小切口额颞部除皱术

为了减轻损伤程度，在按传统方法做了大量额颞部除皱手术的基础上，参考了内窥镜除皱手术的一些原理和方法，于１９９４年开展了盲视下小切口额颞部除皱术。为此，设计了专用的手术分离器和齿状切割刀。整个手术只需在额部正中及颞部发际内作３处不足１ｃｍ长的纵行切口，额部及顶部在帽状腱膜下进行分离，至两侧颞线改在颞部皮下颞浅筋膜浅面分离。用齿状切割刀切断部分额肌和帽状腱膜及皱眉肌、降眉肌，沿冠状缝切断部分帽状腱膜。舒平额颞部皮肤皱纹，将多余的头皮向上后推向头顶部，切实加压包扎。用此方法做额颞部除皱１０６例，取得了满意的效果。突出的优点是损伤少、瘢痕小、快速。作者详细总结了该方法的手术操作、体会和注意事项。     

面部除皱术18例

总结面部除皱术１８例，对骨膜下除皱是否适用于东方人进行了讨论，认为东方人皮肤松驰的特点主要是因为年老，皮下脂肪减少，皮肤老化松弛而缺乏弹性，但皮下的肌肉系统与骨膜虽有松弛但往往是不明显，其皮肤的舒展度与肌肉骨膜系统的舒展度相差亦甚大。     

颞深部眶颧骨膜下除皱及SMAS剪力除皱术

笔者报告１９９３￣１９９６年４６例面部除皱的经验，其中１２例颞深部眶颧骨膜下除皱（内含６例颧弓缩小整形），有或没有合并ＳＭＡＳ剪力除皱的，３４例进行两个层次的除皱及剪力ＳＭＡＳ除皱。颞深部眶骨膜上除皱术采用颅面外科手术进路，在颞窝前方，眶周，外眦韧带区，部分眶内，颧弓周围及上颌骨前、外侧方分离骨膜、将其与帽状腱膜，颞浅筋膜及上半面部的皮肤，头皮同时提紧，有的病例同时进行颧弓缩小整形，术后使上半面部     

射频手术机器辅助内窥镜骨膜下额颞部除皱术

目的探讨射频手术机器在内窥镜骨膜下额颞部除皱术中的应用。方法常规内窥镜骨膜下额颞部除皱术中,应用射频手术机器切割及凝固电极行骨膜下剥离,尤其是眶周和额颞移行区充分分离,仔细分离切割皱眉肌、降眉肌及部分额肌,松弛皮肤钛钉固定于颅骨外板。结果本组10例均获得满意效果。结论射频手术机器辅助内窥镜骨膜下额颞部除皱术,能准确分离切割额颞部肌肉,除皱效果确切、持久。     

颞深部眶颧骨膜下除皱及SMAS剪力除皱术

笔者报告１９９３～１９９６年４６例面部除皱的经验，其中１２例颞深部眶颧骨膜下除皱（内含６例颧弓缩小整形），有或没有合并ＳＭＡＳ剪力除皱，３４例进行两个层次的除皱及剪力ＳＭＡＳ除皱。颞深部眶颧骨膜下除皱术采用颅面外科手术进路，在颞窝前方，眶周，外眦韧带区，部分眶内，颧弓周围及上颌骨前、外侧方分离骨膜，将其与帽状腱膜，颞浅筋膜及上半面部的皮肤、头皮同时提紧。有的病例同时进行颧弓缩小整形，术后使上半面部皮肤提紧，并使眼轮匝肌及其周围组织提紧，眉弓及眼角上悬，上、下眼睑松弛矫正，眼鼻沟，鼻唇沟变浅。特别对中年以上的上２／３面部除皱有效。ＳＭＡＳ剪力除皱是下半面部除皱。将皮肤及ＳＭＡＳ两平面进行提紧，耳前制成Ｓ状ＳＭＡＳ瓣，在其中央剪成两半，向上及向耳后方提紧，使颊、下颌、颈部松弛组织提紧，鼻唇沟变浅。颏下区松坠的脂肪作抽吸或切除。     

内窥镜下额颞部除皱术

目的：探讨内窥镜下额、颞部除皱术的临床应用效果。方法：从2003年到2004年，施行内窥镜下额、颞部除皱术28例。采用额部小切口，在帽状腱膜下和骨膜下平面剥离，用缝线和螺钉固定后推的头皮和额部皮肤。结果：28例患者术后效果满意，且脱发、感觉减退和出血等手术并发症少。结论：内窥镜下额、颞部除皱术同传统面部除皱手术相比具有很多优点，可以推广使用。     

46例改良除皱术体会

４６例改良除皱术体会郭志伟一、临床资料本组共４６例，其中男性１２例，女性３４例，年龄最大６１岁，最小３２岁。６例为全面部除皱，２８例为额颞部除皱，１２例颞部鱼尾纹小范围除皱。对全面部及额颞部除皱术均采用帽状腱膜及颞部皮下脂肪层分离。切除部分额肌，悬吊...     

面部三层剥离除皱术

随年龄增长 ,面部皮肤、皮下组织、肌层及骨骼逐渐蜕变、萎缩、松垂 ,表面形成皱纹 ,呈现出衰老的征象。面部除皱术在于改善以上老化形态 ,手术方法虽多 ,但各有特点。1991年 12月以来 ,我们应用骨膜下层、ＳＭＡＳ下层和皮下浅筋膜层同时分层剥离行除皱术 2 5例 ,获得满意效果。1　手术方法手术在全麻下进行　按设计切口于头部切开头皮 ,头顶部在帽状腱膜下疏松结缔组织层 ,颞部在颞浅筋膜深层 ,向下、前剥离达眉弓上和眉间鼻根部皱纹区 ,分离完毕后 ,分别纵、横切断额肌和皱眉肌。于颞面颊部 ,沿耳前和耳后设计切口切开皮肤达皮下脂肪层 ,…     

面部小切口悬吊除皱术

目的在小切口除皱基础上增加悬吊技术,探讨悬吊术的手术要点及并发症的发生原因和处理方法,以其达到最佳的除皱效果.方法行额部、头顶部帽状腱膜下及颞部、颊部皮下小切口分离术区,切断且松解部分额肌、皱眉肌,利用Gore-Tex线拉紧松弛的皮肤达到悬吊除皱目的.结果笔者为96例患者行上半面部小切口悬吊除皱术,门诊随访35例,大多数患者取得满意的除皱效果,无严重并发症发生.结论面部小切口悬吊除皱术在小切口分离的基础上增加了悬吊的力量,比传统手术方法操作相对简单、组织损伤轻、并发症少、除皱效果确切、值得推广.     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.