提上睑肌腱膜瓣与额肌腱膜瓣悬吊在重度上睑下垂中的应用

目的：为了保持了提上睑肌的原位附着，使矫治后的上眼睑弧度自然、更接近生理要求.方法：在患侧上睑分离制作提上睑肌腱膜瓣和额肌腱膜瓣，将二瓣重叠缝合.结果：对34例（48只）重度上睑下垂进行矫治.其中，对26例患者，30只眼随访，除4例矫治不足，其余均可达到睁眼时双眼基本对称，睑缘弧度正常.结论：本方法保持了提上睑肌在睑板上的原有附着结构和生理功能，悬吊牢固，睑缘和重睑弧度满意.省去眉上切口，简化步骤，美容效果明显。     

提上睑肌腱膜瓣联合额肌瓣悬吊治疗先天性上睑下垂畸形

目的：研究改良的提上睑肌腱膜瓣联合额肌悬吊治疗重度先天性上睑下垂的，临床治疗效果。方法：自2005年8月～2008年3月，笔者采用该方法矫治重度先天性上睑下垂患者20例，年龄6～27岁，单侧8例，双侧12例。手术形成蒂在睑板上缘的的提上睑肌腱膜瓣，并与额肌建立连接，模拟提上睑肌上提眼睑的功能。结果：本组患者20名，术后随访6个月，15例矫正效果良好，4例好转，1例无效，部分患者出现不同程度的眼睑闭合不全，术后2-3月恢复。无明显并发症发生，效果良好。结论：与单纯的额肌悬吊不同，该术式形成的上提眼睑系统更符合生理结构，并且具备动态矫正效果，手术后外形满意、功能良好。     

A guide for determining center of levator aponeurosis and palpebral fissure width in blepharoptosis surgery

Formation of a natural upper eyelid curvature and elevation of the upper eyelid have to be accomplished in blepharoptosis surgery. We describe an easy and reproducible method to obtain a natural eyelid curvature. First, the mechanical center of the levator aponeurosis, representing the point where the surgeon can feel equal resistances from the medial and lateral sides of the aponeurosis, was determined. Then, the supra-pupillary point on eye opening, namely the center of the palpebral fissure, was secured by pulling the eyelid margin. When correctly pulled, the eyelid margin formed an isosceles triangle. The center of the levator aponeurosis was then fixed on the tarsus corresponding to the supra-pupillary point on eye opening. After determining the apex of the upper eyelid, additional sutures were made to obtain a quadratic curve of the upper eyelid, resulting in a natural eyelid curvature.     

额肌筋膜瓣矫正上睑下垂并发症的统计

目的探讨额肌筋膜瓣悬吊术在矫正上睑下垂术后并发症发生的原因及防治措施,提高手术效果。方法对５１３例在住院期间及门诊复查中发现的术后并发症进行病因和防治研究。结果发现术后并发症共１４种并以相应措施防治。结论绝大部分并发症可以防治,额肌筋膜瓣悬吊术矫治完全性上睑下垂的效果可靠。     

上睑提肌腱膜瓣与额肌瓣悬吊缝合矫正重度上睑下垂

目的：为克服单纯额肌瓣悬吊治疗重度上睑下垂存在的缺点，更好地保持眼睑的原有结构，使矫治后的眼睑符合其生理和生物力学特点。方法：在患侧分别形成额肌瓣和上睑提肌腱膜瓣，将两瓣相互重叠缝合固定，起到悬吊上睑、矫正下垂畸形的作用。结果：利用该方法对46例52侧重度上睑下垂的眼睑进行了治疗，随访患者24例，28侧眼睑，其中23侧眼睑取得了较满意的治疗效果，患睑睁大时额肌收缩两侧眼裂大小基本对称，可达到正常睑缘的位置。睑缘弧度及重睑线外形满意。5侧眼睑矫正不完全，仍有一定程度的下垂。结论：术者认为利用无功能的上睑提肌形成腱膜瓣与传统的额肌瓣重叠悬吊缝合，保持了眼睑的原有结构，具有上睑悬吊牢固、不易复发、睑缘和重睑线弧度及外观满意的优点，对畸形矫正效果良好，优于传统的单纯额肌悬吊术。     

Tarsal resection operation in correction of severe unilateral blepharoptosis with poor levator function

There are many options for surgical repair of congenital unilateral ptosis with poor levator function. We performed resection of tarsus, Müller muscle, and conjunctiva in conjunction with an intraoperative adjustable levator resection. Resection of tarsus, Müller muscle, and conjunctiva in conjunction with levator resection was performed in a prospective series of 17 consecutive patients with unilateral ptosis with poor levator function over a 2-year period. Pre- and postoperative upper eyelid margin to reflex distance, degree of levator function, amount of operative tarsus and Müller muscle resection, postoperative eyelid symmetry, and postoperative complications were evaluated. Mean preoperative upper eyelid margin to reflex distance was 0.11 mm. Mean postoperative upper eyelid margin to reflex distance was 3.20 mm. Improved postoperative eyelid symmetry within 1.0 and 1.5 mm was demonstrated in most of our cases (58% and 76%, respectively). The major complication has been exposure keratitis. Resection of tarsus, Müller muscle, and conjunctiva combined with adjustable levator resection can correct severe unilateral ptosis with poor levator function.     

额肌筋膜瓣矫正上睑下垂并发症的统计

目的 探讨 额肌筋膜瓣悬吊术在矫正上睑下垂术后并发症发生的原因及预防措施，提高手术效果。方法 对５１３例在住院期间及门诊复查中发现的术后并发症进行病因和防治研究。结果 发现术后并发症共１４种并以相应的措施防治。结论 绝大部分并发症可以防治，额肌筋膜瓣悬吊术矫治疗完全性上睑下垂的效果可靠。     

上睑提肌腱膜在重睑术中的应用

目的 探讨将皮肤与睑板粘连形成重睑,以达到术后闭眼时留下较明显人工皱褶的目的,使临床效果更加完善.方法 沿设计线切开皮肤,在眶隔与上睑提肌腱膜融合部剪开并显露上睑提肌,充分松解上睑提肌腱膜与眶隔筋膜的粘连,使上睑提肌腱膜运动自由,切口下缘眼轮匝肌适当去除,形成重睑时将切口下缘皮瓣与上睑提肌腱膜缝合3针,使得受术者睁闭眼时与上睑提肌一起运动.结果 术后随访58例(116只眼睛),睁眼时重睑弧度自然流畅,睫毛微微上翘,闭眼时重睑切口瘢痕不明显、较平整,无明显皱褶,重睑无“香肠样”外观.结论 此方法手术时间短,创伤小,恢复快重睑术后无“香肠样”外观及闭眼时无明显皱褶,美观逼真,术后外形和功能均令人满意.     

提上睑肌缩短前徙术治疗重度先天性上睑下垂疗效观察

目的：评价经皮肤入路提上睑肌缩短前徙术治疗重度先天性上睑下垂的手术效果。方法：重度先天性上睑下垂64例（82只眼），提上睑肌活动度在4m以下，行经皮肤入路提上睑肌缩短前徙术。手术采用经典术式，术后严密观察上睑位置，随诊6～24个月。结果：术后3例在观察期间出现回退或欠矫，2例经再次手术矫正．术后一周内7例出现轻度暴露性角膜炎，经治疗好转。结论：大部分重度先天性上睑下垂可通过提上睑肌缩短前徙手术恢复容貌，精细手术操作能有效避免手术并发症。     

提上睑肌腱膜缩短术治疗老年性上睑下垂

目的 探讨提上睑肌腱膜缩短术治疗老年性上睑下垂的临床疗效.方法 对7例(111眼)老年性上睑下垂患者,应用新斯的明试验排除重症肌无力后,行提上睑肌腱膜缩短术矫治上睑下垂.结果 本组所有患者术后上睑缘达角膜上缘以下1～2 mm水平,上睑凹陷得到矫正.结论 提上睑肌腱膜缩短术,是矫治老年性上睑下垂的有效方法.     

上睑提肌内限制韧带松解在治疗先天性上睑下垂中的意义

目的 在睑板上缘附近的上睑提肌内，有跨于内外眦角之间数条横向纤维束带即限制韧带，我们探讨其在治疗先天性上睑下垂中的意义。方法 将此韧带松解，可基本矫正大部分经度上睑下垂病例。若为轻，中度上睑下垂，且韧带松解后上睑仍有部分下垂，还需进行睑提肌腱膜折叠术。重度上睑下垂韧带松解后，还需进行眉区额肌筋膜瓣悬吊术。结果 本组27例随访3个月～1年，27例40只眼中38只眼轻、中、重度上睑下垂均矫正满意，2只眼良好，未见睑下垂复发。结论 松解上睑提肌内限制韧带，有助于恢复上睑提肌睑功能，易于矫正睑下垂且手术创伤小，形态自然，不易复发。     

Lid retraction and levator aponeurosis defects in Graves' eye disease

Vertical palpebral fissure determinants and lid crease height were measured in patients with Graves' eye disease (GED) and in normal subjects. The fissure and crease height are positively correlated with exophthalmometer readings in each group. Compensatory levator aponeurosis defects are shown to occur in patients with GED. These, along with the effect of exophthalmos on the lower lid position, the observation that the lower lid is closer to the inferior limbus than the upper lid is to the superior limbus in normal subjects, and the effect of contracture of the inferior rectus on the lower lid position, explain why inferior scleral show is found to be greater than superior scleral show in patients with GED. Thus, lid retractor surgery in GED patients should be performed only after the palpebral fissure, levator function, and lid crease height stabilize, and after any contemplated surgery that would alter the exophthalmos and extraocular muscles has been performed.     

Preventing conjunctival prolapse and tarsal eversion following large excisions of levator muscle and aponeurosis for correction of congenital ptosis

Mattress sutures placed from the superior fornix conjunctiva through levator muscle and aponeurosis can be used to reconstruct the superior fornix following extensive dissection and resection of levator muscle and aponeurosis for severe congenital ptosis. This placement of sutures differs from the full-thickness mattress sutures from conjunctiva through skin commonly recommended by many textbooks in oculoplastic surgery, and appears to be more successful in preventing some of the complications that follow this type of oculoplastic surgery.     

Pathogenesis and surgical correction of dynamic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus.

The purpose of this study was to confirm whether lower scleral show is caused by the disinsertion of the levator aponeurosis from the tarsus. Aponeurotic advancement by vascular clips or by surgery involving the orbital septum significantly lowered the global position in the orbit and significantly diminished the degree of retraction of the lower eyelid, resulting in satisfactory improvement of lower scleral show in 100 patients with various aponeurotic blepharoptosis. Therefore, we propose the pathogenesis of lower scleral show as follows: additional contraction of the levator muscle to compensate for the disinsertion of the levator aponeurosis from the tarsus for maintenance of an adequate visual field is accompanied by additional contraction of the superior rectus muscle through the strong intermuscular fascia, resulting in upward rotation of the globe. To maintain the horizontal visual axis and foveation without inclination of the head in the primary gaze position, additional contraction of the inferior rectus muscle is induced, which pulls upon the inferior suspensory ligament of Lockwood and the capsulopalpebral fascia. The former displaces the globe upwards and the latter retracts the lower eyelid, resulting in dynamic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus, which can be surgically corrected.     

Transposition of the levator in blepharoptosis using a single superior lid crease incision

In 1999 we introduced the technique of transposition of the levator using a suture to the frontalis muscle for the correction of severe blepharoptosis [16, 17]. This operation was carried out using two skin incisions, one on the superior lid crease and the other at the superior margin of the eyebrow. It was later demonstrated that the levator muscle becomes reinnervated by the facial nerve branches to the frontalis muscle [18]. The results of this procedure have been satisfactory without infections or lagophthalmos [9, 19, 20]. The only limit of this technique is the ability of the patient to contract the frontalis muscle. This limitation, however, applies to any surgical technique which consists of suspension of the eyelid to the frontalis area. After having performed 22 levator transpositions, utilizing two skin incisions, the procedure is now performed with a single skin incision on the superior lid crease. With this modification the technique might be well accepted by those surgeons who deal with the problems of upper eyelid ptosis.