硬腭黏膜移植联合眶周表浅肌肉腱膜系统皮瓣重建全层眼睑缺损

目的:探讨利用自体游离硬腭黏膜植片替代后睑组织联合眶周表浅肌肉腱膜系统(SMAS)皮瓣转移修复缺损的前层眼睑皮肤,重建因肿瘤术后或外伤所致的全层眼睑缺损的临床疗效。方法:对16例≥眼睑全长1/2中重度全层眼睑缺损患者,全部用口腔硬腭黏膜植片替代睑板和结膜,再造后层眼睑;用眶周血供丰富的表浅肌肉腱膜系统(SMAS)皮瓣转移覆盖于硬腭黏膜上,替代缺损的眼睑皮肤肌肉层再造前层眼睑,其中10例采用眼轮匝肌单蒂皮瓣,3例为颞浅动脉皮瓣,2例为上睑皮肤轮匝肌双蒂皮瓣,1例为眉上皮瓣。手术操作中首先行硬腭黏膜移植,然后根据眼睑前层缺损的部位和范围设计眶周的SMAS转移皮瓣,手术完毕行睑缘缝合3～6mo后切开。结果:全部患者随访>12mo,硬腭黏膜植片及其转移皮瓣全部成活,无移位、感染和坏死等不良反应,无收缩,眼睑外观及功能改善满意。结论:硬腭黏膜联合SMAS皮瓣转移修复重建眼睑全层缺损,可以一次性修复眼睑缺损的皮肤、睑板、结膜,疗效肯定,具有较高的临床应用价值。     

硬腭黏膜移植联合眼周皮瓣修复下睑全层缺损

目的:探讨用硬腭黏膜植片修复眼睑缺损后层,眼周皮瓣修复眼睑前层缺损,这一联合手术的临床效果。方法:对8例因下睑肿瘤切除所致的下睑全层缺损,采用自体硬腭黏膜移植联合眼周皮瓣重建下睑。结果:随访8mo以上,全部病例硬腭黏膜植片及转移皮瓣全部成活,除1例下睑轻度退缩外,眼睑外观和功能满意,获得良好效果。结论:硬腭黏膜移植联合眼周皮瓣修复下睑全层缺损,可以一次性修复缺损的皮肤、睑板、结膜,效果肯定,具有较高的临床价值。     

自体硬腭黏膜移植联合眶周皮瓣修复全层眼睑缺损

目的：评价眼睑恶性肿瘤切除术后采用自体硬腭黏膜移植联合眶周皮瓣进行眼睑再造的临床效果。 方法：患者10例10眼行眼睑恶性肿瘤切除术后重度眼睑缺损,采用硬腭黏膜移植替代眼睑后层,即睑板和睑结膜层,利用眶周皮瓣修复眼睑前层。 结果：术后随访6~12mo,眼睑外观及功能基本恢复正常。硬腭黏膜移植片及转移皮瓣全部成活,无感染、移位、挛缩。 结论：自体硬腭黏膜移植联合眶周皮瓣转移修复全层眼睑缺损,效果肯定。     

眼睑恶性肿瘤切除术后中重度眼睑缺损的Ⅰ期修复

目的:探讨眼睑恶性肿瘤切除术后中重度眼睑缺损I期修复的手术方法和疗效。方法:2010-01/2011-10对11例11眼患者行眼睑恶性肿瘤切除术后,利用硬腭黏膜移植联合眼周皮瓣或游离皮瓣修复眼睑全层缺损行眼睑再造术。其中男3例,女8例,年龄38～77岁,眼睑全部缺损4例,1/2～2/3眼睑缺损7例。眼睑基底细胞癌6例,睑板腺癌4例,眼睑鳞状细胞癌1例。结果:术后眼睑外观及功能恢复满意,随诊6～24mo无1例肿瘤复发。结论:硬腭黏膜移植联合眼周皮瓣或游离皮瓣修复眼睑恶性肿瘤切除术后中重度眼睑全层缺损,在眼睑外形和功能上可获得满意的效果,疗效肯定,具有较高的临床价值。     

硬腭黏膜移植联合眶周皮瓣转移重建眼睑的眼表功能

目的 评价硬腭黏膜移植联合眶周皮瓣转移治疗因机械伤、眼睑恶性肿瘤切除术后眼睑全层缺损的疗效.设计回顾性病例系列.研究对象 13例(13眼)因机械伤或眼睑恶性肿瘤切除术后眼睑全层缺损患者.方法 对13例患者行自体硬腭黏膜移植联合眶周皮瓣转移术.记录手术前、后患者的睑裂长度、睑裂高度、睑闭合不全的程度,泪膜破裂时间,Schirmer Ⅰ试验和角膜荧光素染色积分,术后半年睑缘切开时取移植的硬腭黏膜进行组织学检查.随访8个月以上.主要指标手术效果、泪膜破裂时间、Schirmer Ⅰ试验和角膜荧光素染色积分、移植后硬腭黏膜的组织学结构.结果 11眼达到眼表功能优秀的治疗效果,2眼良好,手术前后患者的眼表功能无明显变化.自体硬腭黏膜移植眼睑后可与残留睑板结膜良好愈合,未见有植人物感染现象.手术半年后硬腭黏膜上皮与结膜上皮结构类似,黏膜上皮内出现杯状样细胞.结论 硬腭黏膜片移植联合眶周皮瓣转移是眼睑重建的良好方法,手术不影响患者的眼表功能.受眼局部微环境的影响,硬腭黏膜可能逐渐向结膜形态发生转变.     

眼睑恶性肿瘤切除中度眼睑缺损的即期整复

目的 探讨眼睑恶性肿瘤切除后所致大面积眼睑缺损的手术整复方法和技巧.方法 在局部麻醉或全身麻醉下,手术切除上下睑病变组织,后层缺损采取结膜睑板瓣修补或硬腭、异体巩膜移植替代睑板;前层采用全厚皮片游离移植或带蒂皮瓣滑行转位修补睑皮肤缺损,进行眼睑缺损的一期修复.结果 临床治疗患者9例,术后均获得一期愈合;效果满意.结论 恶性眼睑肿瘤所致的大面积眼睑缺损,在切除肿瘤的同时立即行眼睑缺损的一期整复,效果确实、疗效满意.     

眼睑瘢痕畸形的手术治疗

目的探讨不同类型瘢痕性眼睑畸形的手术方式及治疗效果。方法瘢痕性眼睑畸形10例（15眼）,分别行瘢痕松解及游离皮瓣移植术4例（7眼）,瘢痕松解游离皮瓣移植同时行羊膜移植1例（1眼）,瘢痕松解联合“Z”字皮瓣转位2例（3眼）,瘢痕松解联合带蒂皮瓣转位1例（1眼）;瘢痕松解联合眼轮匝肌蒂皮瓣修复1例（1眼）,瘢痕松解联合睑板楔形切除联合双下眼睑成形术1例（2眼）。结果10例（15眼）手术后获得不同程度满意的外观和功能恢复。结论在眼睑瘢痕修复时,只要能使皮肤缺损和结膜囊完整性得到修复,瘢痕性眼睑畸形恢复眼睑功能及外观,效果良好。     

眼睑肿瘤手术切除与Ⅰ期修复的疗效观察

目的：探讨采用眼睑肿瘤局部切除术+病理检查或术中冰冻切片检查,同时Ⅰ期行眼睑修复手术的临床效果。

方法：对眼睑肿瘤患者92例92眼均行局部切除+Ⅰ期行眼睑修复手术+常规病理检查(37例疑似恶性肿瘤术中行快速冰冻切片检查,如为恶性行按Mohs法切除),并同时Ⅰ期采用自体游离硬腭黏膜移植或Hughes法修复联合眼周皮瓣重建眼睑。

结果：术后病理诊断为良性肿瘤52例,恶性肿瘤40例。全部病例皮瓣及硬腭黏膜植片等全部成活。随访均6mo以上,无1例肿瘤复发。眼睑外观和活动闭合功能满意,获得良好效果。

结论：本组病例中近一半的眼睑肿瘤病例为恶性,故更应及早手术治疗。对疑似恶性的应在术中行冰冻切片明确性质,以利于Ⅰ期切除干净,减少复发、转移。切除后根据眼睑缺损情况行Ⅰ期行修复手术,缺损较大的内层采用硬腭黏膜移植或Hughes法修复,外层皮瓣采用眼周皮瓣滑行、游离皮瓣 、风筝皮瓣、单纯对位缝合等修复。硬腭黏膜移植在上睑修复时应慎重。     

风筝皮瓣修复眼睑黄色瘤切除后的眼睑前层缺损

目的 探讨风筝皮瓣在修复眼睑黄色瘤切除后所致的眼睑前层缺损中的应用.方法 黄色瘤切除后,于缺损颞侧皮肤松弛部位沿皮纹方向设计风筝皮瓣,按设计线切开皮肤,在眼轮匝肌下剥离形成以眼轮匝肌为皮下蒂的风筝皮瓣,推进至皮肤缺损区,用5-0尼龙线缝合切口.自2005年以来共应用16例,20只眼,年龄34～68岁,缺损面积为5mm×10mm～10mm×22mm.结果 皮瓣全部成活,切口Ⅰ期愈合,随访时间3个月至3年,眼睑外形双侧对称,切口瘢痕不明显.结论 对于眼睑较大黄色瘤切除后直接缝合会导致眼睑畸形的眼睑前层缺损,用风筝皮瓣进行修复简单易行,效果可靠.皮瓣转移后局部平整,无须去除多余皮肤组织,手术后恢复时间短,具有取材方便、便于推广等优点.     

眼部烧伤眼睑全层缺损修复术成功的影响因素

目的探讨影响游离皮瓣联合异体巩膜、羊膜移植修复眼睑缺损成功的因素。方法选择2000年2月-2007年10月西安市眼科医院收治的41例（41眼）的眼烧伤眼睑全层缺损者。其中热烧伤15例,碱烧伤20例,酸烧伤6例。烧伤后3～24个月,行大腿内侧游离皮瓣联合同种异体巩膜及羊膜移植术。其中5例联合行睑球粘连分离及板层角膜移植术。术后随访6—36个月。结果眼睑再造术41例中有35例眼睑重建成功,移植片成活,其中5例在6～12个月出现瘢痕收缩,使眼睑部分闭合不全。6例术后2周出现皮瓣愈合不良、脱落、溶解。结论自体游离皮瓣联合同种异体巩膜、羊膜移植修复眼烧伤所致的眼睑全层缺损,是临床治疗烧伤眼睑缺损的有效方法。手术时机的选择、烧伤程度的评估、手术方法的改善是决定手术成功的重要因素。     

风筝皮瓣修复眼睑前层及中面部皮肤缺损

目的 评价风筝皮瓣修复合并或不合并中面部皮肤缺损的眼睑前层缺损的疗效.方法 自2008年1月至2010年3月,以面部皮下组织为蒂,设计"风筝"皮瓣,联合或不联合硬腭黏膜移植,修复合并或不合并中面部皮肤缺损的眼睑缺损共10例.眼睑前层或和中面部皮肤缺损面积为(1.2～6.5)cm2、(0.7～4.0)cm2.其中下眼睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,下睑内侧水平方向1/2、垂直方向完全全层缺损、下泪小点下泪小管缺损合并中面部皮肤缺损1例,下睑水平及垂直方向均完全全层缺损合并下泪小点及下泪小管缺损1例,上下睑水平方向完全、垂直方向1/3全层缺损合并上下泪小点泪小管缺损1例,下睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,全上眼睑前层及颞部皮肤缺损1例,下睑内侧水平方向1/3、垂直方向1/5前层缺损1例,上下睑中央水平方向2/3、上睑垂直方向1/3,下睑垂直方向2/3全层缺损1例,上下睑内侧1/3前层及内呲内侧皮肤缺损合并上下泪小点缺损1例,外眦外侧前层及颞部皮肤缺损1例.结果 皮瓣均无张力修复缺损,皮瓣及硬腭黏膜均全部成活,眼睑外形、功能完全恢复.结论 风筝皮瓣是修复眼睑缺损及面部皮肤缺损的良好方法.

Abstract：

Objective To evaluate the effect of rehabilitating the anterior 1amella of eyelids and midfacial skin defects with kite flap.Methods From January 2008 to March 2010,with or without combination of a hard palate mucosal grafts,the kite flap on a subcutaneous pedicle have been used to repair defect in the anterior lamella of eyelids and midfacial skin in 10 patients.The area of the defect in the anterior lamella of eyelids and midfacial skin ranged from(1.2～6.5)×(0.8～4)cm.Among them,defects span central 4/5 in horizontal direction and complete in vertical direction in full-thickness lower eyelid and partes zygomatica skin in 2 patient,medial 1/2 in horizontal direction and complete in vertical direction and puncta and canaliculus in full-thickness lower eyelid and midface skin in 1 patient,complete lower eyelid and inferior puncta and canaliculus in 1 patient,complete in horizontal direction and 1/3 in vertical direction and puncta and canaliculus both in full-thickness upper and lower eyelids in 1 patient,complete anterior layer of upper eyelid and temples skin in 1 patient,medial 1/3 in horizontal direction and 1/5 in vertical direction in the anterior lamella of lower eyelid in 1 patient,central 2/3 in horizontal direction and 1/3 in vertical direction in full-thickness upper eyelid,and central 2/3 in horizontal direction and 2/3 in vertical direction in full-thickness lower eyelid in 1 patient,medial 1/3 of anterior lamella and puncta and canaliculus both in upper and lower eyelid and inside skin of medial canthus in 1 patient,outside skin of outer canthus and temples skin in 1 patient.Results All flaps and hard palate mucosal grafts were survived.All defects were repaired without tention.The cosmetic appearance and function of eyelids rehabilitated.Conclusions The kite flap provides a competitive method for repairing the anterior lamella of eyelids and facial skin defects.     

Reconstruction of the irradiated contracted socket with an expanded superficial temporalis fascial flap.

PURPOSE: To describe the reconstruction of an irradiated contracted socket with an expanded superficial temporalis fascial flap and oral mucosa. METHODS: A superficial temporalis fascial flap was first expanded with tissue expansion techniques and then rotated into the orbit to revascularize the socket. The mucosal surface of the socket was secondarily grafted with buccal and hard palate mucosa. RESULTS: The expanded superficial temporalis fascial flap was used to revascularize the socket for grafting with hard palate and buccal mucosa. This resulted in the successful retention of an ocular prosthesis. CONCLUSION: The expanded superficial temporalis fascial flap is a useful technique in reconstruction of the contracted socket.     

Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients

PURPOSE: To review one surgeon's experience with posterior lamellar grafting for lower eyelid elevation over a 15-year period, comparing the success of different posterior lamellar grafts used in 4 etiology groups. METHODS: A retrospective chart review of 400 patients (659 eyelids) was conducted. Patients were grouped into thyroid ophthalmopathy, previous surgery, trauma, and idiopathic causes. Three graft types were used: hard palate mucosa, free tarsoconjunctival, and free scleral. Objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy, and subjective patient symptoms, preoperatively and postoperatively were compared between graft types and etiologic groups. Complications were tabulated and compared between groups, as was any need for further surgery. The mean follow-up interval was 16.5 months. The main outcome measures were objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy. RESULTS: A mean reduction in lagophthalmos ( approximately 0.5 mm), superficial punctate keratopathy (mean score reduction = 0.2, on a scale of 1-3), and scleral show ( approximately 1.3 mm) was demonstrated for all etiology groups and graft types. Furthermore, 90% of patients subjectively reported a reduction of 1 to 3 symptoms. Hard palate mucosa grafts were more likely to be used than tarsoconjunctival grafts in cases with one or more previous surgeries (p < 0.001). Complications were more common with tarsoconjunctival grafts (except for bleeding), but the difference was statistically significant only for wound dehiscence (p = 0.004). CONCLUSIONS: Lower eyelid retraction repair with posterior lamellar grafting and lateral eyelid tightening can be recommended with confidence for eyelid retraction patients because most improved subjectively and by objective examination.     

Extensive full-thickness eyelid reconstruction with rotation flaps through “subcutaneous tunnel” and palatal mucosal grafts

AIM: To reconstruct the extensive full-thickness defects of eyelids is a challenge for the plastic surgeon because of their complex anatomy and special functions. This article presents and discusses an improved surgical technique in which the orbicularis oculi myocutaneous flap is rotated through a “subcutaneous tunnel” in conjunction with a palatal mucosal graft employed for lining.METHODS: Data from 22 eyes with extensive full-thickness eyelid defects from various causes between 2009 and 2013 were analyzed in this study. After the different layers of eyelid were separated completely, a temporally based orbicularis oculi myocutaneous flap was designed following fishtail lines and was mobilized, leaving the base of the pedicle intact with a submuscular tissue attachment. The flap was then rotated through a “subcutaneous tunnel” to the defect, and the donor site was closed primarily. Posterior lamellar reconstruction was performed with a mucosal graft harvested from the hard palate.RESULTS:All the flaps were survived without any healing problems. There was no corneal irritation, flap contraction, or significant donor-site morbidity in the follow-up period. The incision scars were almost invisible. The defects were repaired completely, and the evaluations showed satisfactory function and appearance.CONCLUSION: This technique is an improved single-stage operation and can be applied to repair large, full-thickness eyelid defects from various causes. With our method, the functional and aesthetic results can be obtained in either the upper or lower eyelids.     

Eyelid mucous membrane grafts: a histologic study of hard palate, nasal turbinate, and buccal mucosal grafts

PURPOSE: To histologically evaluate the outcome of mucous membrane grafts to the eyelid. METHODS: Case series of 31 eyes from 24 patients who underwent transplantation of hard palate (25 eyes), buccal (1 eye), or nasal turbinate (5 eyes) mucosa to the posterior eyelid surface. These grafts were biopsied at 0.5 months to 84 months (mean, 20 months) postoperatively. They were examined with light microscopy and compared with either the donor mucosa from the same patient (2 patients) or the typical donor site histology (22 patients). RESULTS: Graft biopsies revealed general epithelial morphology that was quite similar to the respective donor sites in virtually all cases. Six (25%) of 24 hard palate graft biopsies, which were obtained at 8 months to 49 months (mean, 22 months) postoperatively, displayed orthokeratosis alternating with parakeratosis, while 12 (50%) demonstrated parakeratosis alone, and another 6 (25%) showed adjacent regions of parakeratotic and nonkeratinized epithelium. No hard palate grafts showed complete absence of keratinization after transplantation. Other significant findings included loss of goblet cells in nasal turbinate grafts and few submucosal glands remaining in any specimen. CONCLUSIONS: Full-thickness mucosal grafts typically maintain their native epithelial morphology following transplantation to the ocular surface. Submucosal glands usually do not survive transplantation, which could be the result of intentional thinning of the graft at the time of transplantation. Contrary to the opinion that hard palate graft epithelium usually undergoes metaplasia from keratinized to nonkeratinized within 6 months following transplantation to the eye, all hard palate grafts in this study remained orthokeratotic and/or parakeratotic.     

Hard palate mucosal grafts in oculoplastic surgery: donor site lessons

PURPOSE: Hard palate mucosal grafts have been used successfully in posterior lamellar reconstruction. Atypical surgical findings, techniques, and complications related to the hard palate donor site are reported herein. DESIGN: Interventional case series. METHODS: The medical records of five patients who were cared for in an institutional practice between 1987 and 2002 were retrospectively reviewed. All patients had unusual donor site findings discovered during or after hard palate mucosal grafting for eyelid or socket reconstruction. RESULTS: Seven eyelid reconstructions with hard palate grafts were performed on the five patients (three male, two female), with an age range of 14 to 73 years at surgery. Patients were followed for an average of 6 years (range: 9 months to 11 years). Unusual hard palate findings during surgery or the postoperative period included hard palate and maxillary sinus malignancy, torus palatinus, and persistent donor site bleeding that provoked gastric variceal bleeding in a patient with preexisting liver disease. Atypical surgical techniques included both inadvertent and intentional harvesting of hard palate tissue over the midline palatine raphe. CONCLUSION: Hard palate grafting is a successful and commonly practiced approach to eyelid and socket reconstruction. An awareness of unusual anatomic findings or techniques associated with the hard palate donor site may improve surgical outcomes and decrease patient morbidity.