下睑缘和口内联合切口面中部提升术

目的:探讨经下睑缘和口内联合切口骨膜下面中部提升手术方法的临床疗效和解剖基础。方法:采用下睑袋切除术的手术切口,在眼轮匝肌下层次常规完成下睑松弛皮肤切除术后,于眶缘下2￣3mm切开骨膜,通过口内切口在梨状孔下缘水平切开骨膜,共同完成颧骨和上颌骨的骨膜下分离,外侧的分离止于颧大肌起点的内侧,内侧为鼻骨与上颌骨转折处。切开剥离范围内、外侧骨膜,将颊部脂肪垫的前叶及其下的骨膜,颧部的皮下脂肪垫向上外固定,然后将骨膜与眶缘的骨膜向上外方重叠缝合,缝合下睑切口。结果:采用本方法临床治疗下睑皮肤松弛和面中部老化患者13例,并发症轻,可同时达到下睑和面中部满意的美容效果。结论:本方法切口隐蔽,并发症少,可作为面中部年轻化手术的推荐使用方法。     

眶脂肪保留和眼轮匝肌瓣悬吊法整复睑袋畸形

目的预防睑袋整复术后出现下睑凹陷和巩膜过多显露等并发症。方法术中沿眶下缘松解眶隔,释放出眶脂肪,将其充填眶下缘凹陷,并设计下睑眼轮匝肌瓣,用以缩紧悬吊松弛下垂的下睑肌肉与皮肤。结果从１９９６年９月至１９９７年５月,共以此法整复睑袋畸形３０例。２６例得到３～８个月随访,除１例因一侧眼轮匝肌瓣固定不牢致下睑轻度外翻外,其余均获满意效果。结论此法既可有效地矫正睑袋畸形,又可避免术后出现下睑凹陷和巩膜过多显露状况,同时具有颊提升效果,可使全中面部变得年轻化。     

眶脂肪保留和眼轮匝肌瓣悬吊法整复睑袋畸形

目的 预防睑袋整复术后出现下睑凹陷和巩膜过多显露等并发症。方法 术中沿眶下缘松解眶隔,释放出眶脂肪,将其充填眶下缘凹陷,并设计下睑眼轮匝肌瓣,用以缩紧悬吊松驰下垂的下睑肌肉与皮肤。结果 从1996年9月至1997年5月,共以此法整复睑袋畸形30例。26例得到3－8个月随访,除1例因一侧眼轮匝肌瓣固定不牢致下睑轻度外翻外,其余均获满意效果。结论 此法既可有效地矫正睑袋畸形,又可避免术后出现下睑凹陷和巩膜过多显露状况,同时具有颊提升效果,可使全中面部变得年轻化。     

Benefits from Lifting of the Lower Eyelid

Lifting the lower eyelid includes removing skin excess of the lid and, most of the time, improves the fat herniation without any removal of the fat because of the tension of the orbicularis muscle obtained with this maneuver. The ``lifting' also corrects the arcus marginalis as well as malar bags when they exist. Most of the crow's-feet lines are eliminated by this procedure, and the superior aspect of the nasolabial fold is often considerably smoothed.     

PR49LOWER LID BLEPHAROPLASTY

Introduction Lower lid blepharoplasty traditionally is considered a more complex procedure than upper lid blepharoplasty. More factors effect the success of the procedure and complications are more frequent. In lower lid blepharoplasty the following anatomic features are observed pre‐operatively and are often modified surgically: Lateral canthus position, interpalpebral slant, lower lid position, size and shape of the lateral scleral triangle, lower lid fat pad buldes, lower lid tone, lid‐cheek junction, and tear trough deformity. The following findings significantly effect surgical execution but are not modified surgically: presense of dry eyes/tear quality and the presence of relative enophthalmos or exopthalmos. Methods/Techniques Lower lid blepharoplasty is performed with the patient in a supine position and with conscious sedation or general anesthesia. Corneal protection lenses are placed. Local anesthesia is injected for hemostasis in the lower lid, along the infraorbial rim, and at the lateral orbital rim. A scalpel is used to make an incision from the lateral canthus in a lateral direction one cm long. The angel in changed infero‐obliquely to travel in a subcilliary location for one cm. The bovie is used to incise to that lateral orbial rim taking care to preserve the periosteum. Scissors are used to create a plane in the subcilliary location between the muscle and the skin. A subcilliary skin incision is made with the scissors. An incision is then made in the orbicularis oculi muscle inferior to the skin incision in order to preserve at least 4 mm of pre‐tarsal muscle. A skin muscle flap is then raised in the pre‐septal plane. The orbito‐malar ligament released and small portion of the lateral superior cheek is raised in a pre‐periosteal plane. Scissors are used to perform a septectomy. If the preoperative inspection demonstrated fat bulges and an absent tear trough, a conservative amount of fat is resected at the level of the orbital rim. If a prominent lid cheek junction is present and if a medial tear trough is present the fat is reposition over the infra‐orbital rim. In the case of medial tear trough correction, the medial origin of the levator labii superioris alaque nasae is elevated. Fat pads are repositioned beneath the tear trough and sutured in place to the periosteum of the superior maxilla using 6‐O vicryl. Attention is then turned to the lateral canthus. A canthopexy or lateral canthoplasty is performed in almost every lower lid blepharoplasty in order to shape the lower lid margin and the lateral scleral triangle. If the lower lid has minimal laxity defined by less than 6 mm of lid distraction from the globe with forcep retraction, a canthopexy is attempted in order to avoid a lateral canthotomy and the potential associated morbidity. If there is significant lower lid laxity, a lateral canthotomy and lateral canthoplasty is performed. 4‐O mersiline suture is used to the suture the lateral canthus to the lateral orbital rim. If lid tightening does not occur sufficiently, the lower lid is too long. In this case a lower cantholysis in performed and the lid is shortened laterally using scissors. 4‐O mersiline is used to re‐construct the lateral canthus by suturing the lower lid lateral cut margin to the lateral orbital rim in a posterior position. The vertical position and the depth of the canthoplasty or canthopexy suture placement is determined by the preoperative assessment of globe prominence using a Hertel exophthalmeter. Subsequent to management of the lateral canthus, skin‐muscle flap is redraped, trimmed and fixed in place at and lateral to the lateral orbital rim. Conservative resection of skin in important for the avoidance of complications. Results 485 patients underwent lower blepharoplasty with the technique described. The average age of the patient was 52 years. 90% patients were women and 10% were men. 73%% underwent canthopexy and 27% underwent canthoplasty. 185 were secondary lower bleaphroplasties. Satisfaction rates were high. Minor complications included chemosis, lateral canthal webbing, and excess skin requiring revision. Major complications included hematoma, lid malposition or ectropion. 3% required re‐operation for lower lid retraction. Conclusions Lower lid belpharoplasty is an important procedure in order to achieve a balanced natural appearance. Complications, while more common than those in upper lid belpahroplasty, occur at relatively low rates. Satisfaction rates are generally high. The keys to success are proper canthal positioning for lid shape and support bolstered by an orbicularis flap properly placed and firmly fixed to the lateral orbital periosteum in order to correct lower lid laxity.     

眼轮匝肌悬吊法睑袋成形术的改进

目的探讨在眼轮匝肌悬吊法睑袋成形术中,通过眼轮匝肌支持韧带完全松解,使附着在眶缘骨膜上松弛的皮肤、皮下组织得以充分释放,以达到下睑组织和眶颧组织整体提紧效果的改良手术方法。方法对409例具有较明显沟槽畸形的患者,在行眼轮匝肌悬吊法睑袋成形术过程中,增加了眼轮匝肌支持韧带离断、韧带断端上提与眶隔筋膜固定的操作,对眼轮匝肌悬吊法进行改进。结果经术后随访1～3年,全部受术者沟槽畸形改观明显,无1例出现并发症,得到比较满意的疗效。结论改良的眼轮匝肌悬吊法睑袋成形术。松解了眶颧部皮肤,有利于恢复睑颊复合体的平整自然,对改善沟槽畸形尤为有效。此法简单易行,安全性高,可作为下睑袋成形术的优选术式。     

中老年人切开法重睑术后重睑线末端分叉的原因及预防

目的:探索中老年人切开法重睑术后出现重睑线末端分叉的原因及其预防措施。方法:根据中老年上睑的解剖学特点,在中老年切开法重睑手术中,酌情去除外眦部位下垂松弛的眼轮匝肌组织,使重睑线尾端自然上翘,避免产生末端分叉的外观。结果:本组共64例患者,术后随访6～12个月,均未出现重睑线末端分叉外观,重睑形成线条流畅,眼部的整体效果得到明显改善。结论:去除外眦部位的眼轮匝肌,重新形成重睑线,使原有物质基础彻底消除,是解决中老年人重睑术后外眦鱼尾外观的关键。     

衰老所致泪槽畸形和睑颊沟畸形发生机制的解剖学研究

目的 研究衰老所致泪槽畸形及脸颊沟畸形解剖学方面的形成机制.方法 对6具60岁以上泪槽畸形及睑颊沟畸形较明显的尸体标本(男性3具,女性3具,平均年龄67.2岁)的下睑及眶周区域做逐层解剖(12侧),观察眶部各层组织间的相互关系.结果 泪槽畸形及睑颊沟畸形处于眼睑较薄皮肤与颧颊部较厚皮肤的交界处,皮肤与眼轮匝肌附着较紧密;颧部脂肪上缘覆盖于眼轮匝肌睑部与眶部的结合部,并与泪槽及睑颊沟的位置相对应,颧部脂肪七缘不随颧脂肪垫下移;内侧眼轮匝肌眶部与提上唇鼻翼肌之间隙与泪槽位置不对应;眼轮匝肌限制韧带起于眶下缘并止于眼轮匝肌睑部与眶部的结合部,外宽内窄,在内侧1/3延续为内眦部深层眼轮匝肌,直接贴附于眶下缘骨面;眼轮匝肌下脂肪位于眶部外下方,薄且松弛;眶隔附着于眶下缘.眶脂肪向前下方膨出.结论 泪槽畸形和睑颊沟畸形形成是衰老所致各层组织松弛、萎缩和下移等综合因素共同作用的结果,其中眶隔及眼轮匝肌限制韧带限制组织下移的作用町能是眶下缘凹陷更加凸显的关键.     

眶颊沟老化特征的解剖学研究

目的通过对眶颊联合区域进行解剖学研究,探讨眶颊联合老化后形成眶颊沟的发生机制。方法选取13具（26侧）10％甲醛固定的成人尸头标本,其中男9具（18侧）,女4具（8侧）,年龄22～78岁。应用显微下术器械在10倍的解剖显微镜下逐层解剖眼周,重点解削下睑眶部和眶外侧,了解并描述各区的解削学层次,解剖显露眶外侧增厚区,认真记录眶外侧增厚区解剖学位置并照相保存。结果（1）眶外侧区层次：皮肤层、皮下脂肪层、眼轮匝肌层、眶外侧增厚区、颞中筋膜层、骨膜层。（2）眶外侧增厚区：起于眶外侧缘向外侧走行在颢中筋膜表面,成三角形,三角形的顶角距外眦角25．24～37．20mm。眶外侧增厚区与颞中筋膜紧密粘连区也成三角形,顶点距外眦角（9．28±0．45）mm。向内侧走行在眼轮匝肌下眶隔表面,分为上、下睑部,下睑部成横V形,V上臂与睑板前筋膜粘连,距外眦角21．69～37．2lmm。下臂与眶下缘粘连,距外眦角垂线（13．55±0．52）mm。V顶点距外眦角垂线（11．35±0．27）mm。结论眶颊联合老化后形成眶颊沟的主要原因是皮下脂肪层和颞中筋膜层的脂肪萎缩所致。     

Existe-t-il un traitement approprié aux poches prémalaires ?

The treatment of malar bags is known to be particularly difficult; although it is not the most frequent palpebral anomaly justifying a surgical recourse, this problem cannot be ignored. It is important to distinguish their minor forms and to be able to analyze them in order to propose the best to our patients. We review the literature concerning this subject. The various surgical techniques are discussed and we present five of our cases. Even taking into account its various evolutions, the standard lower eyelid blepharoplasty can correct neither the ptosis nor the excess of orbicularis oculi muscle, which appear to be the main components of the malar bag. Publications, precisely mentioning malar bags or festoons, analyzing their physiopathology or their treatments, are few. We discuss the current data of the literature and on the results obtained in our experiment, and the surgical techniques suggested for their treatment. All the techniques suggested for the malar bags remain local or regional approaches. Results obtained with those techniques do not seem effective to us: although it has not been specifically proposed for the treatment of malar bags, the midface sub-periosteal lift, combining a skin flap lower eyelid dissection and a subperiosteal malar dissection, seems to be able to correct the lowest part of the orbicularis oculi muscle due to its concentric action and its major vertical vector of traction. This study underlines the importance of clinical analysis of the malar bags to appreciate the contribution of each element. So the surgeon will be able to choose the most adapted treatment, which is most often a midface sub-periosteal lift associated with a blepharoplasty.     

Arcus Marginalis Release II Via Endoscopic Midface-Lift

Tear troughs in combination with midfacial ptosis may be early and synergistic signs of aging. Premaxillary and suborbicularis oculi fat (SOOF) descent decreases soft tissue volume covering the orbital rim, while prolapsing retroseptal fat actually underscores the resulting tear trough shadow. This volume change precedes skin redundancy. Thus, volume redistribution avoiding external skin incisions is the adequate treatment. De la Plaza’s transconjunctival lower lid blepharoplasty is a reliable tool for arcus marginalis release. For patients also requiring an endoscopic midface-lift, even the transconjunctival incision for intraorbital fat compartment realignment can be avoided by performing the release of the lower orbita septum via the buccal mucosa incision. Presented in part at the XXth anniversary meeting of the Mediterranean Society of Plastic Aesthetic Surgery, Nice France, 13–15 April 2007     

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.     

Lower blepharoplasty: transconjunctival fat repositioning

Traditionally, lower eyelid herniated fat is removed, which may cause a sunken or hollow lid appearance, especially in patients with a tear-trough deformity (nasojugal groove). Lower eyelid transconjunctival fat repositioning, defined as the subperiosteal repositioning of the medial and central lower eyelid herniated orbital fat into the nasojugal fold, may prevent the surgical hollow lower eyelid appearance while treating the herniated fat. Fat repositioning may be combined with an endoscopic subperiosteal midface-lift, transcutaneous skin pinch, and transconjunctival orbicularis oculi excision. This technique offers a powerful tool in the surgical armamentarium of the facial plastic surgeon.     

Z 成形术联合内眦部眼轮匝肌切除矫正内眦赘皮的临床效果

目的 比较Z成形术联合内眦部眼轮匝肌切除矫正法与切开法重睑成形术在内眦赘皮中的应用效 果。方法 选取2023年1月-6月桦甸菲阳医疗美容诊所收治的80例内眦赘皮患者作为研究对象,根据治疗 方法不同分为对照组和观察组,各40例。对照组行切开法重睑成形术,观察组行Z成形术联合内眦部眼轮 匝肌切除矫正法,比较两组睑裂长度（HLFL）、内眦间距（ICD）、睑裂长度和内眦间距比值（HLFL/ ICD）、并发症发生率、手术满意度。结果 观察组手术后HLFL、HLFL/ICD大于对照组,ICD小于对照组 （P ＜0.05）;观察组并发症发生率为2.50%,低于对照组的17.50%（P ＜0.05）;观察组满意度为97.50%, 高于对照组的77.50%（P ＜0.05）。结论 采用Z成形术联合内眦部眼轮匝肌切除矫正法治疗内眦赘皮,可 以增大睑裂长度、内眦间距,使睑裂长度和内眦间距比值更符合面部美学比例,且能减少并发症发生几 率,提高满意度,值得应用。     

经重睑切口行眉上提术治疗上睑松弛伴眉下垂

目的：介绍一种经重睑切口治疗上睑松弛伴眉下垂的手术方法。方法：经重睑切口,在眼轮匝肌和眶隔之间向上分离达眉下缘,再于额肌和眉脂肪垫之间分离至眉上方,将眉下缘处的眼轮匝肌固定在眶骨骨膜上,将眉毛提升在理想位置。结果：本组20例患者,15例术后随访1周～1年,均获满意效果。眉毛位于理想位置,上睑明显年轻化,无并发症。结论：经重睑切口行眉上提固定术治疗上睑皮肤松弛伴眉下垂能获得满意效果。     

眶外缘眼轮匝肌舒平悬吊法在除皱术中的应用

目的：探讨除皱术中应用眶外侧眼轮匝肌舒平悬吊法矫正鱼尾纹和外眼角下垂的效果。方法：除皱术中采用眼轮匝肌浅面分离至外眦,彻底松解鱼尾纹;再将眶外侧眼轮匝肌外缘向外、上方舒平并悬吊至颞浅筋膜,矫正鱼尾纹和外眼角下垂。结果：此法2003-2010年临床应用591例。就医者随访2～51个月,鱼尾纹和外眼角下垂改善效果明显,无并发症。结论：此手术方法操作简单,有效矫正了鱼尾纹和外眼角下垂,是一种行之有效的除皱方法。     

The vertical midface lift. An improved procedure.

We describe a novel procedure for an anatomically-based face lift to correct vertical vectors in the ageing face. It has the advantage of surgical simplicity, minimal tissue removal and minimal risk. It provides an effective readjustment of cheek volume and correction of periorbital hollowness. Natural facial expression is preserved largely because there is no change in the position of the lateral canthus. The cheek is mobilised subperiosteally through a blepharoplasty incision. A second dissection is made via a short temporal incision, to join the infraorbital dissection. A Hagedorn needle is then inserted through a point inferior to the lateral canthus and in line horizontally with the nasal ala. It is passed to the orbital incision, charged with a loop of suture material, and pulled down again to the cheek incision, from where it is pushed back to the orbit to suspend the cheek. The upper border of orbicularis oculi is fixed firmly to the temporalis aponeurosis at the level of the temporal incision. We now frequently use an Endotine Midface device for fixation. Of the first 150 patients, results were excellent or good in 145. This represents a revival of the subperiosteal mask lift, and abandons the use of endoscopic techniques. In spite of its simplicity, the operation involves subperiosteal dissection as well as delicate eyelid surgery that necessitate plastic surgical skill.     

三点微切口重睑术184例临床观察

目的:改进三点微切口重睑术效果更持久的方法。方法:在重睑线距内、外眦各5mm和黄金点处切开三个3mm长切口,剪除切口下及切口间眼轮匝肌,7-0单丝尼龙线行睑板前筋膜与切口上下缘真皮内翻缝合。结果:本组病例184例,随访3~12月,重睑弧度流畅,形态自然,切口痕迹不显。结论:经过改良的三点微切口重睑术,术后肿胀轻,恢复快,效果持久、可靠。     

小切口重睑成形术同期内眦赘皮矫正

目的：观察小切口重睑成形术同期内眦赘皮矫正的美容效果。方法：采用一段式或三点式小切口法,即于重睑线中部设计长5～10mm切口,或于重睑线内、中、外各设计长3～5mm切口,切开皮肤及皮下组织,经切口剪除少许眼轮匝肌及部分多余眶隔脂肪,以5-0丝线间断缝合,重睑形成。继而行＂△＂形去皮鼻根部深层固定矫正内眦赘皮。结果：26例获得较长期随访,随访时间6个月～3年,受访者均对手术效果表示满意。结论：小切口重睑成形术同期内眦赘皮矫正美容效果肯定、方法简单。     

Evolution in techniques for endoscopic brow lift with deep temporal fixation only and lower blepharoplasty-transconjunctival fat repositioning

As we become more confident with our surgical skills following our fellowship training, some of our approaches and techniques will be modified or changed. My primary evolutionary change involves procedures of the upper third of the face, primarily the brow lift and treatment of lower eyelid fat techniques. Traditional methods of forehead and brow rejuvenation, such as coronal, pretrichal, and direct brow lifts, have provided facial plastic surgeons with effective brow elevation for many years. In the past decade, the endoscopic brow lift has rapidly become accepted as part of the surgical armamentarium and is frequently the technique of choice. In general, the temporal dissection, temporal fixation, forehead subperiosteal or subgaleal dissection with release, and treatment to the brow depressor musculature have been standardized. Methods of bony fixation remain a controversial topic as there are numerous methods. We advocate deep temporal fixation only without bone fixation to achieve effective, long-term brow elevation. Traditionally, lower eyelid herniated fat is removed, which may cause a sunken or hollow lid appearance, especially in patients with a tear trough deformity (nasojugal groove). Lower eyelid transconjunctival fat repositioning, defined as the subperiosteal repositioning of the medial and central lower eyelid herniated orbital fat into the nasojugal fold, may prevent the surgical, hollow lower eyelid appearance while treating the herniated fat. Fat repositioning may be combined with an endoscopic subperiosteal midface-lift, transcutaneous skin pinch, and transconjunctival orbicularis oculi excision. This technique offers a powerful tool in the surgical armamentarium of the facial plastic surgeon.