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。     

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。     

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。认为东方人皮肤松弛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很不明显，其皮肤的舒展度与肌肉骨膜系统的舒展度相差亦甚大。传统的额部除皱术，由于分离平面在帽状腱膜下，其额肌抵抗力影响了额部皱纹的舒展，就必须切除一块或三块额肌条和作部分皱眉肌及降眉肌切除，作者的手术实践也体会到，切除松弛皮肤３ｃｍ，ＳＭＡＳ仅能提紧２ｃｍ左右。如在骨膜下分离，由于受其舒展度限制，面部的肌肉系统又不能象额肌那样切除，切除的皮肤量就必然受到限制而影响除皱效果。作者仍主张分离平面在额部应选择在帽状腱膜下，颞区在颞浅筋膜上，面颊部在浅筋膜层。本文并对ＳＭＡＳ悬吊及术中有关注意事项也进行了讨论。     

面部除皱术要点分析

对自１９９１年１９９４年收治的３４例（女性２９、男性５）面部除皱术患者，作回顾性分析，认为制定正确的手术适应证，掌握局部解剖，注意分层解剖额、颞、ＳＭＡＳ－颈阔肌层，加强术后处理，可提高手术效果（避免术后并发症）》     

面部除皱术与相关解剖学

本文报告我院115例除皱手术的经验。重点讨论了除皱术式选择,皮肤支持韧带和SMAS和SMAP瓣在下面除皱术中的重要意义,解剖分离平面及与面神经的解剖关系和相关并发症的预防等问题。     

面部除皱术进展

面部除皱术于本世纪初始于西方[1] 。纵观 10 0年手术方法的发展可以看出 :手术部位从局部到整体 ,剥离范围从无到有 ,剥离层次由浅到深 ,由单层次剥离到多层次剥离 ,手术切口由大到小。现在医生可根据老化的情况和手术需要 ,以及对不同手术方法的掌握程度而选择相应的方法。1　单纯皮下剥离切除法1 1　局部皮肤切除缝合190 6年Ｍｉｌｌｅｒ[2 ] 首先设计于皱纹区局部切除一块皮肤组织 ,直接缝合切口 ,Ｋｏｌｌｅ[3 ] 描述了去除不同部位皱纹的切口设计 :在皱纹局部 (如额部、颞部、鼻唇沟部、颈部舌骨上或下 )设计呈新月形或椭圆形的切口 ,…     

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线拉紧松驰的头皮达到悬吊除皱目的。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，无严重并发症性。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。     

不同术式在中下面部除皱术中的应用及美学效果对比

目的：对比SMAS筋膜瓣折叠重构与单纯SMAS筋膜下悬吊切口在中下面部除皱术中的应用效果。方法：回顾性分析2018年5月-2019年12月92例行中下面部除皱术的就医者临床资料,根据手术切口,将采用改良切口SMAS筋膜瓣折叠重构的就医者纳入A组（n=51）,将采用传统切口单纯SMAS筋膜下悬吊的就医者纳入B组（n=41）,比较两组临床疗效、围术期指标、客观测量指标（下颌部高度、下颌缘角度、颈部角度）、主观评估指标（鼻唇沟、木偶纹、下颌部形态）以及术后并发症发生率。结果：A组治疗优良率92.16%与B组90.24%比较,差异无统计学意义（P>0.05）;A组手术时间（113.92±18.66）min和术后恢复时间（13.26±1.93）d均短于B组（168.06±26.73）min和（16.39±2.06）d,手术切口长度（9.27±1.41）cm短于B组（13.91±1.62）cm,差异均有统计学意义（P<0.05）;两组手术前后下颌部高度、下颌缘角度、颈部角度组内及组间比较差异均无统计学意义（P>0.05）;两组术后鼻唇沟、木偶纹、下颌部形态较术前均有改善,但术后组...     

除皱术中外耳的处理

目的　在除皱术中通过合适的手术设计和方法，既取得满意的除皱效果，又能防止术后外耳畸形。方法　术前合理设计耳前、耳后切口，术中皮下有限剥离，SMAS下广泛剥离，将颊部松垂组织上提缝合固定的张力放在SMAS层，既有效矫正颊部软组织松垂，又能使耳前耳后切口无张力缝合。结果　1995年至1999年共施行除皱术40例无并发症发生，术后效果满意。结论　除皱术中同时对外耳处理，能取得更加完美的手术效果。     

除皱术中外耳的处理

目的　在除皱术中通过合适的手术设计和方法 ,既取得满意的除皱效果 ,又能防止术后外耳畸形。方法　术前合理设计耳前、耳后切口 ,术中皮下有限剥离 ,SMAS下广泛剥离 ,将颊部松垂组织上提缝合固定的张力放在SMAS层 ,既有效矫正颊部软组织松垂 ,又能使耳前耳后切口无张力缝合。结果　 1995年至 1999年共施行除皱术 40例无并发症发生 ,术后效果满意。结论　除皱术中同时对外耳处理 ,能取得更加完美的手术效果。     

The oriental aging face: An evaluation of a decade of experience with the triangular SMAS flap technique in facelifting

The triangular SMAS flap technique was developed through a thorough understanding of the morphological and anatomical problems of the aging Oriental face. A unique manipulation of two triangular SMAS flaps—TSF-1 and TSF-2—permits three-directional lifting of the SMAS, which provides supportive and distributive lifting while reducing unwanted tension in the skin. TSF-1 is the excess portion of the main SMAS flap which results from cephalic lifting in the zygomatic area. TSF-2 is created from the excess portion produced by posterior advancement in the preauricular area, and is rotated to the postauricular area. Use of the TSF-1 flap involves complete excision, folding under, or free grafting. The retroauricular TSF-2 flap indirectly achieves platysmal plication. The author evaluates ten years of experience with the triangular SMAS flap technique and describes the entire aspect of the aging face in Orientals.The triangular SMAS flap technique was first presented at the 6th Congress of the International Society of Aesthetic Plastic Surgery, Tokyo, Japan, September 28–October 2, 1981     

The trifurcated SMAS flap: Three-part segmentation of the conventional flap for improved results in the midface,cheek, and neck

While SMAS surgery revolutionized facelift procedures, the single flap created by conventional dissections suffers the drawback that it can only be advanced in one direction and sutured in place under uniform tension. Division of the flap into three segments overcomes this problem and allows independent pull to be applied in different directions to the upper midface, cheek, and neck.Presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, Boston, Massachusetts, USA, April 1993     

Histologic and Ultrastructural Evaluation of Sutures Used for Surgical Fixation of the SMAS

In extensive SMAS face-lift surgery, retaining ligaments are released, and the SMAS is resutured to the deep fascia to maintain the advanced position. The suture used to reattach the SMAS should replicate the quality of support provided by the original ligaments. Nonabsorbable sutures (monofilament and braided) retrieved intraoperatively from 22 patients undergoing secondary face-lift procedures were examined by light microscopy and transmission electronmicroscopy. A distinctive enclosure of dense collagen and elastin formed around both types of suture. Based on the presence of inflammatory cells, fibroblasts, collagen, and elastin, the tissue reaction to monofilament suture was less than with the braided suture. The collagen and elastin were thicker around the braided suture, and, additionally the collagen matrix infiltrated between the individual filaments. Ultrastructural analysis of the braided suture showed significant collagen binding around each individual filament. The greater quantity of connective tissue around the thread which continued into the interstices of the braided suture has the characteristics of a ligament. This suggests a stronger and more lasting tissue fixation.     

Anatomical basis for the intrahepatic glissonian approach during hepatectomies

Background

Anatomical liver resections are based on some basic technical principles such as vascular control, ischemic area delineation to be resected and maximum parenchymal preservation. These aspects are achieved by the intrahepatic glissonian approach, which consists in accessing the pedicles of hepatic segments within the hepatic parenchyma. Small incisions on well-defined anatomical landmarks are performed to approach the pedicles, making dissection of the hilar plate unnecessary.

Aim

Analyze parameters in liver anatomy related to intrahepatic surgical technique to glissonians pedicles, to set the normal anatomy related to the procedure and thereby facilitate the attainment of this technique.

Methods

Anatomical parameters related to the intrahepatic glissonian approach were studied in 37 cadavers. Measurements were performed with precision instruments. Data were expressed as mean±standard deviation. The subjects were divided into groups according to gender and liver weight and groups were compared statistically.

Results

Twenty-five cadavers were male and 12 female. No statistically significant difference was observed in virtually all parameters when groups were compared. This demonstrates the consistency of the anatomical parameters related to the intrahepatic glissonian approach.

Conclusion

The results obtained in this study made possible major technical advances in the realization of open and laparoscopic hepatectomies with intrahepatic glissonian approach, and can help surgeons to perform liver resections by this method.     

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