现代面中除皱术的面神经解剖学研究

目的 明确ＳＭＡＳ与面神经的关系。方法 对１２具（２４例）成人尸头行大体解剖观察。结果 ＳＭＡＳ分布于面中部,向前逐渐变薄,于口角水平外侧水小范围的“洞区”。面神经出腮腺后,并非在ＳＭＡＳ深面。而是在咬肌筋膜深面走行。面神经额支在颧弓以下０．５ｃｍ区域穿出深筋膜,跨过颧弓。在颊脂肪垫区,大部分神经分支走行在垫内,小部分分支形成面神经丛,分布于其表面。在颧大肌表面上１／３恒定有一颧支跨过,支配眼轮匝     

面神经额支的分布与面部上提术的关系

目的明确面神经额支在颧弓及颞部的软组织走行层次和分布。方法对９具尸头（１８侧）颜面行大体解剖观察。结果面神经额支的分支数目为３～７支,平均５支,无恒定的行径及体表投影。将颧弓均分成三段,统计跨过各段表面的额支分支数,发现额支并非仅限于颧弓的中后段,而是近全颧弓均有额支分支跨过,其分布密度以中１／３段最高,占总数的４４４４％（４０／９０）;前１／３段次之,占３８８９％（３５／９０）;后１／３段又次之,占１６６７％（１５／９０）。额支分布于颧弓和颞部的浅筋膜层（即ＳＭＡＳ）的深面,其前段表面分支支配下外侧的眼轮匝肌,中段表面分支支配外侧的眼轮匝肌及少部分额肌,后段表面分支支配额肌和耳前肌。结论行骨膜下剥离面部上提术时,为减少面神经额支的损伤,应注意辨认颞部和颧弓部位的软组织层次,并非靠限制颧弓部位的解剖范围。     

现代面部除皱术的面神经解剖学研究

目的明确 SMAS 与面神经的关系。方法对12具(24侧)成人尸头行大体解剖观察。结果 SMAS 分布于面中部,向前逐渐变薄,于口角水平外侧有小范围的“洞区”。面神经出腮腺后,并非在 SMAS 深面,而是在咬肌筋膜深面走行。面神经额支在颧弓以下0.5cm 区域穿出深筋膜,跨过颧弓。在颊脂肪垫区,大部分面神经分支走行在垫内,小部分分支形成面神经丛,分布于其表面。在颧大肌表面上1/3恒定有一颧支跨过,支配眼轮匝肌下外侧9例(占37.5%);颧大、小肌及眼轮匝肌8例(占33.3%);颧大、小肌7例(占29.2%)。结论面部多层次剥离除皱术应在颧弓以下0.5cm 区域行 SMAS 下剥离,至面中部时,应注意保护颧大肌表面上1/3段的面神经颧支,只在颧大肌中下2/3段区域进行剥离,向内掀起颧脂肪垫;或通过下睑缘皮肤切口,向下掀起眼轮匝肌(注意保护位于颧大肌上1/3段的面神经颧支),与经耳前 SMAS 下剥离腔隙连通,如上操作可避免面神经损伤。     

颧弓骨膜上入路面中部模拟手术损伤情况的解剖学观察

目的 寻找在盲视下,颞部入路、骨膜上剥离进入面中部的安全手术路径.方法 对4具(8侧)成人尸头标本,在盲视下以颞部入路行骨膜上剥离进入面中部上颌骨前面,进行解剖、测量及组织学观察.结果 颞支跨颧弓时主要集中在颧弓中段,它到颧弓骨膜的垂直距离最大为5.12mm,最小为2.82mm,平均3.87mm.在颞深筋膜浅层剥离至眶外侧时,若以外眦点外(33±5)mm,外眦点下(28±5)mm,在测量得出的眼轮匝肌轮廓覆盖所形成的弧形范围内,以眼轮匝肌下脂肪垫深层为剥离平面进入面中部,可有效避免面神经损伤.此手术路径避开了颧大肌的骨膜上起点,但颧小肌的大部分骨膜上起点因在此范围内而遭严重破坏.结论 盲视下经眶外侧、眼轮匝肌深面,以眼轮匝肌下脂肪垫深层为剥离平面进入面中部的剥离路径,是一种简便、安全、有效的手术路径.     

面神经额支的分布与面部上提术的关系

目的明确面神额支在颧弓及颢部的软组织走行层次和分布。方法对9具尸头(18侧)颜面行大体解剖观察。结果面神经额支的分支数目为3～7支,平均5支,无恒定的行径及体表投影。将颧弓均分成三段,统计跨过各段表面的额支分支数,发现额支并非仅限于颧弓的中后段,而是近全颧弓均有额支分支跨过,其分布密度以中1/3段最高,占总数的44.44%(40/90);前1/3段次之,占38.89%(35/90);后1/3段又次之,占16.67%(15/90)。额支分布于颧弓和颞部的浅筋膜层(即 SMAS)的深面,其前段表面分支支配下外侧的眼轮匝肌,中段表面分支支配外侧的眼轮匝肌及少部分额肌,后段表面分支支配额肌和耳前肌。结论行骨膜下剥离面部上提术时,为减少面神经额支的损伤,应注意辨认颞部和颧弓部位的软组织层次,并非靠限制颧弓部位的解剖范围。     

面神经分支在颞区的显微解剖学研究

目的 明确面神经在颞区的分布层次和范围，指导面部年轻化手术的操作入路。方法 12具(24侧)成人尸头标本，于5倍光学显微镜下行颞区的解剖观察。结果 颞区包含面神经的颞支和颧支：由面神经的上支分出，出腮腺上缘，颞支发出3～8个分支、颧支2～4个分支，行于颞浅筋膜深面。颞支越过颧弓至颞区，分布于额肌、眼轮匝肌、皱眉肌和耳周围肌等组织，主导其运动；颧支由腮腺上缘向前上方越过颧弓至外眦，支配眼轮匝肌和颧肌的运动；两支之间以及与眼神经的眶上神经和泪腺神经之间．都有交通支。结论 面神经的颞支和颧支分布在颞浅筋膜的深面和颞深筋膜的浅层之间的组织内，支配额部、眼周和耳部的表情肌运动；面部年轻化手术在分离颞区时．应避免在此层进行。     

高位SMAS联合颧脂肪垫及眼轮匝肌悬吊在面中部除皱术中的应用

目的探讨一种相对微创的面中部除皱技术,并分析高位SMAS联合颧脂肪垫及眼轮匝肌提升对面中部老化的改善情况。方法对121例患者实施高位SMAS联合颧脂肪垫及眼轮匝肌悬吊,于颞部发际缘设计切口,在颧弓以上范围沿SMAS浅层剥离,将下垂的颧脂肪垫、SMAS和眼轮匝肌悬吊于颞深筋膜,去除多余的皮肤组织,使下垂的面部组织维持长期的提升效果。结果本组121例患者术后随访6周至1年,均取得了面中部年轻化的效果;术后恢复时间较短,未发生面神经损伤、面部皮下血肿、切口感染等并发症;手术切口瘢痕较隐蔽。结论高位SMAS及颧脂肪垫和眼轮匝肌的复位,是面中部年轻化的关键。皮下层的安全剥离避免了面神经分支的损伤。该方法对面中部除皱效果较显著,皮下分离安全,且具有简便、效果持久等优点。     

面神经额支的分布与面部上提术的关系

目的 明确面神经额支在颧部的软组织走行层次的分布。方法 对９人尸头（１８例）颜面行大体解剖观察。结果 面神经额支的分支数目为３￣７支，平均５支，无恒定的行径及体表投影。将颧弓均分成三段，统计跨过各段表面的额支分支数，发现额支交非仅限于颧弓的中后段，而是近全颧弓均有额支分支跨过，其分布密度以中１／３段最高，占总数的４４．４％（４０／９０）；前１／３段次之，中３８．８９％（３５／９０）；后１／３段又次     

内窥镜辅助中面部提升术的颞区解剖学研究

目的:明确颞区的血管神经分布,为内窥镜辅助颞部切口中面部提升术提供详细的颞区解剖层次。方法:收集10具24h内死亡的新鲜尸体头标本,将标本随机分为2组,分别进行血管造影和神经解剖染色等处理。结果:颞区位于颅顶的两侧,为颞肌和颞筋膜在头部的分布区域。此部位的组织层次由浅入深有血管的层次可分为:颞浅筋膜、颞浅脂肪垫、颞肌、颅骨,共4层。无血管的层次为:皮肤、皮下组织、颞深筋膜深浅层、颞深脂肪垫、颅骨骨膜,共6层。颞浅筋膜层有颞浅动静脉、面神经的颞支、颧支和颞浅神经分布。颞深筋膜分为浅、深两层,两层之间有颞浅脂肪垫和颞中静脉。结论:颞部切口常被应用于颞部除皱术和面部提升术,较安全且有效的解剖层面需要分区描述。切口的分离层次在颞深筋膜深层;眶外缘注意哨兵静脉彻底止血;向下在融合线处走在颞脂肪垫的浅层,注意保护颞中动静脉;触及颧弓则进入骨膜下;穿过颧弓后面中部的分离层次在SMAS层深面,SMAS层深面剥离后,在颧弓处向浅层纵向分离保护面神经分支。为了确保手术的安全性,术中避免损伤面神经及血管,需要注意切口,融合线,颧弓位置的不同层次。     

面神经颧支支配颧肌的显微解剖学研究

目的 明确面神经颧支的终末分支进入颧肌的位置和体表标志.方法 将10具(20侧)10%甲醛固定的成人尸头标本,解剖观察面神经颧支的走行及分支情况,以经口角的水平线为X轴,经同侧外眦角的垂线为Y轴,测量并记录颧支入肌支在坐标轴上的位置并进行体表定位.结果 面神经颧支自腮腺前上缘出腮腺,分为1～3支型,以2支型为主(占65%,13侧).浅支经颧大肌头侧浅面支配眼轮匝肌,深支有2～6支为主干支,平均(3.40±1.06)支,从颧大肌上1/2深面呈节段"爪"形支配该肌,入肌神经数为3～8支,平均(6.00±1.49)支.结论 在行中面部手术时,在颧大肌下2/3表面进行分离是安全的,尽量避免在颧肌的深面进行分离,尤其是上1/2深面,极易损伤面神经颧支;在其下1/2深面分离时,应紧贴颧大肌,以免损伤从其深面经过的面神经颊支.     

The extended SMAS facelift: identifying the lateral zygomaticus major muscle border using bony anatomic landmarks

Extended superficial musculoaponeurotic system (SMAS) rhytidectomy has been advocated for improving nasolabial fold prominence. Extended subSMAS dissection requires release of the SMAS typically from the upper lateral border of the zygomaticus major muscle and continued dissection medial to this muscle. This maneuver releases the zygomatic retaining ligaments and achieves more effective mobilization and elevation of the ptotic malar soft tissues, resulting in more dramatic effacement of the nasolabial crease. Despite its presumed advantages, few reports have suggested greater risk of nerve injury with this technique compared with other limited sub-SMAS dissection techniques. Although the caudal extent of the zygomaticus muscle insertion to the modiolus of the mouth has been well delineated, the more cephalad origin has been vaguely defined. We attempted to define anatomic landmarks which could serve to more reliably identify the upper extent of the lateral zygomaticus major muscle border and more safely guide extended sub-SMAS dissections. Bilateral zygomaticus major muscles were identified in 13 cadaver heads with 4.0-power loupe magnification. Bony anatomic landmarks were identified that would predict the location of the lateral border of the zygomaticus major muscle. The upper extent of the lateral border of the zygomaticus major muscle was defined in relation to an oblique line extending from the mental protuberance to the notch defined at the most anterior-inferior aspect of the temporal fossa at the junction of the frontal process and temporal process of the zygomatic bone. The lateral border of the zygomaticus major muscle was observed 4.4 +/- 2.2 mm lateral and parallel to this line. More accurate prediction of the location of the upper extent of the lateral border of the zygomaticus major muscle using the above bony anatomic landmarks may limit nerve injury during SMAS dissections in extended SMAS rhytidectomy.     

广泛多层次剥离复合除皱术

目的　矫正鼻唇沟过深、颌下线中断等面中下部老化表现。方法　行面中下部超过鼻唇沟的广泛皮下及SMAS下剥离 ,将掀起的SMAS瓣 ,依耳轮脚及耳垂下极水平分成三份 ,分别向上、后、乳突方向悬吊 ,对松弛的眼轮匝肌进行紧缩和悬吊 ,将颧脂肪垫向外上方向牵拉固定于颧骨体表面筋膜 ,去除部分过度增厚的颧脂肪垫。结果　12例面中部老化明显者 ,手术后随访 5个月至 3年 ,效果良好 ,无面瘫、血肿等并发症。结论　该术式对鼻唇沟面中下部老化表现矫正十分安全有效     

Spatial orientation of motor innervation to the lower orbicularis oculi muscle

Background: Blepharoplasty and midface access incisions that are currently used were designed on the premise that innervation to the lower eyelid orbicularis oculi muscle approaches the muscle from its lateral aspect and that its segmental fascicles run parallel to the muscle's fibers. These incisions yield a high rate of complications that include ectropion and other eyelid malpositions. Objective: The goal of this study was to investigate the innervation of the lower orbicularis oculi muscle and determine how it is affected by lower eyelid surgery. Methods: Macroscopic anatomic dissections were performed on 10 frozen cadavers, and the origin and distribution of innervation was mapped. An additional 12 fresh cadaver specimens were dissected through use of 3.5× loupe magnification. Six ultrafresh cadaver specimens were used for histologic examination. Fixation was done in 10% formaldehyde. Axial incisions perpendicular to the facial plane were made at 5-mm intervals from the lower forehead level to the oral commissure. Hematoxylin and eosin specimens and Masson's trichrome specimens were made from alternating slices taken at 5-mm intervals. Results: The results of this anatomic study suggest that the upper eyelid orbicularis oculi muscle is innervated by fascicles of the temporal branch of the facial (VII) nerve. These nerves travel along the undersurface of the muscle and branch out parallel to the muscle fibers. The lower eyelid orbicularis oculi muscle seems to be innervated by 3 to 5 branches of the zygomatic nerve, which splits into 2 large groups of fascicles as it crosses the zygomaticus major muscle. These nerves continue toward the orbicularis oculi muscle, splitting into a plexus of nerves that approaches the orbicularis oculi muscle fibers at an angle of approximately 90°. No significant branches from the lateral aspect of the lower orbicularis oculi were observed in this study. Conclusions: The results of this anatomic study indicate that techniques that (1) approach the midface through the lower eyelid and (2) change the plane of dissection from deep to the orbicularis oculi muscle to superficial to the zygomaticus major muscle may place the innervation of the orbicularis oculi muscle at much higher risk.     

Anatomical basis for a safe and easier approach to composite rhytidectomy

The authors present the anatomical findings that have made an easier approach to composite rhytidectomy possible. The lower lateral border of the orbicularis oculi muscle (OOM) overlies the zygomaticus major muscle (ZMM), the upper third of which tightly adheres to the malar bone. The OOM is innervated throughout over its circumference by a plexus of small facial nerve branches. From its deeper surface, the ZMM is innervated by two to four branches in its upper third and middle third. These branches are jeopardized in an extended sub-SMAS dissection as this tends to go deep into the ZMM. The malar fat pad is superficial to the SMAS layer that invests the zygomaticus and levator labii muscles and, with age, tends to slide downward, medially deepening the nasolabial folds. An extended dissection beyond the OOM tends to remain superficial to the upper part of the ZMM, zygomaticus minor, and levator muscle complex. We have found that extending the suborbicularis dissection inferiorly and laterally offers three major advantages: (1) The correct deep subcutaneous plane just above the ZMM, zygomaticus minor muscle, and levator complex can be found easily, leaving all of the fat attached to the skin. The only structures at risk are some minor motor branches to the OOM that can be divided without any morbidity because of the extensive plexiform innervation. (2) A. change in the plane from a sub-SMAS to a deep subcutaneous dissection over the ZMM can be made easily and safely by means of separate dissections for the lateral and the medial parts of the cheek with the ZMM acting as a watershed area; the two dissections can then be united under direct vision avoiding any trauma to the muscle or motor nerve branches. (3) The correct repositioning and deep fixation of the malar fat pad is easily performed. This approach has been applied successfully in 19 patients without any complications. We believe that the correct performance of this technical modification, which provides the same composite flaps as those described by Hamra, is easier and may be safer than the standard lateral approach.Presented at the XIIth International Congress of the International Society of Aesthetic Plastic Surgery, Paris, France, September 1993     

多层综合除皱术

目的应用多层综合的除皱方法使老化的面部年轻化。方法进行多层次解剖分离，使老化移位的组织复位。包括皮肤及骨膜层的提紧，ＳＭＡＳ的悬吊，颧弓韧带的重建，颧骨的修薄。结果自１９９３年以来，完成手术２８例，效果满意。结论面部老化是不同组织，不同解剖结构变化的综合体现。单一层次的除皱方法不能取得全面的年轻化效果，多层综合的除皱方法恢复了年轻的解剖生理关系，使因老化导致的面部软组织的松弛移位得到充分的矫正，具有全面的年轻化效果