颞部脂肪室的解剖学研究及在颞部大容量脂肪移植中的意义

颞部脂肪室的解剖学研究及在颞部大容量脂肪移植中的意义

葛皓杰1 林彪斌2 方柏荣1

本文来源：《中华整形外科杂志》2023年6月第39卷第6期

DOI:10. 3760 / cma.j.cn114453-20220727-00235

作者单位：1中南大学湘雅二医院整形美容（烧伤）外科，长沙410011；2长沙美莱医疗美容医院，长沙410011

通信作者：方柏荣，Email：fbrfbr2004@csu.edu.cn；林彪斌，Email：373258236@qq.com

引用本文

葛皓杰, 林彪斌, 方柏荣. 颞部脂肪室的解剖学研究及在颞部大容量脂肪移植中的意义 [J] . 中华整形外科杂志, 2023, 39(6) : 646-654. DOI: 10.3760/cma.j.cn114453-20220727-00235.

【摘要】

目的通过尸头解剖探索颞部主要脂肪室的解剖层次和自体脂肪的填充入路，以及临床回顾性分析大容量脂肪填充颞部的效果。

方法通过对5具新鲜尸头(10侧，年龄25~50岁，男性2具，女性3具)的颞部脂肪室解剖，明确颞部脂肪室大容量填充的安全、稳定的层次。回顾性分析2020年1月至2021年1月中南大学湘雅二医院整形美容(烧伤)外科及长沙美莱医疗美容医院收治的颞部脂肪移植患者资料。按照脂肪填充注射层次和量，将纳入患者分为大容量组和常规组。大容量组需要满足填充层次至少包括3层脂肪室，填充量一般大于15 ml；常规组仅填充1~2个层次，为皮下脂肪和颞中筋膜，填充量一般小于15 ml。术中从额部发际线内进针，针对主要的脂肪室进行脂肪注射。对比研究2组的单侧注射剂量及术后3个月的手术医师Likert量表评分、患者满意度等指标。术后3个月随访评估时，以首次手术中利用剩余脂肪制作的脂肪来源干细胞基质胶(SVF-gel)进行局部微调。

结果解剖研究发现颞部存在浅、中、深3层主要脂肪室，即皮下脂肪层、颞浅脂肪垫及颞深脂肪垫；年老患者颞部的皮下脂肪菲薄，颞浅脂肪垫及颞深脂肪垫萎缩明显，对颞部浅层软组织支撑作用明显减弱，颞深脂肪垫可见明显萎缩伴一定程度的下移。临床研究共纳入50例接受双侧颞部脂肪移植的女性患者，常规组和大容量组各25例。常规组年龄为(32.7±7.1)岁，身体质量指数(BMI)为(20.2±1.9)kg/m2；大容量组年龄为(32.5±8.3)岁，BMI为(19.8±2.0)kg/m2；两组的年龄和BMI的差异均无统计学意义(P>0.05)。大容量组填充剂量为(19.66±4.61)ml/侧，手术医师Likert量表评分为(4.32±0.63)分，患者满意率为92.0%(23/25)；常规组填充剂量为(11.06±2.62)ml/侧，手术医师Likert量表评分为(3.32±0.80)分，患者满意率为68.0%(17/25)；这3个指标在2组间的差异均有统计学意义(P<0.05)。大容量组手术效果更好，患者对手术效果更加满意。随访期间所有患者无感染、脂肪液化、栓塞及神经损伤等严重并发症出现。

结论解剖研究证明了颞部主要的3层脂肪室填充层次明确，尤其是颞深脂肪垫的穿刺入路安全而可行，为颞部大容量脂肪填充提供了依据，相较于传统的浅层填充，多层次大容量填充可明显提高填充效果和患者满意度。

【关键词】解剖学；脂肪室；脂肪移植；颞部年轻化

The anatomical approach of temporal fat compartments and its significance in temporal large-volume fat transplantation

Ge Haojie1, Lin Biaobin2, Fang Bairong1

1Department of Plastic and Aesthetic (Burn) Surgery, the Second Xiangya Hospital, Central South University, Changsha 410011, China; 2Changsha Mylike Medical Cosmetic Hospital, Changsha 410011, China

Corresponding author: Fang Bairong, Email: fbrfbr2004@csu.edu.cn; Lin Biaobin, Email: 373258236@qq.com

【Abstract】

Objective To explore the anatomical levels and injection approaches of the major temporal fat compartments through cadaveric head dissection and to analyze the efficacy of high-volume fat transplantation of the temporal region in a clinical retrospective research.

Methods To clarify the safe and stable levels of high-volume filling of the temporal fat compartment by dissecting the temporal fat compartment of 5 fresh cadaveric heads (10 sides, 25-50 years old, 2 males, 3 females). We retrospectively analyzed the data of patients with temporal fat transplantation admitted to the Second Xiangya Hospital of Central South University and Changsha Mylike Medical Cosmetic Hospital from January 2020 to January 2021. According to the levels and volume of fat filling injection, the patients were divided into large-volume group and conventional group. In the large-volume group the patients were filled with at least three fat compartments with a filling volume of more than 15 ml, while in the conventional group only with 1 to 2 layers, which were the subcutaneous fat and the middle temporal fascia, and the filling volume was generally less than 15 ml. Fat injections were performed with a needle entry within the frontal hairline, targeting the main fat compartments. We compared and studied the mean injection volume per side, postoperative surgeon’s Likert scale score, patient satisfaction and other indicators in the two groups of cases. Stromal vascular fraction-gel(SVF-gel), which was made from surplus fat during the initial operation, was used to locally fine-tune the effect at the 3-month follow-up evaluation.

Results The anatomical study revealed the existence of three main fat compartments in the temporal region: subcutaneous fat layer, superficial and deep temporal fat pad. In the elderly cadavers, the subcutaneous fat was thin, the superficial temporal fat pad and deep temporal fat pad atrophied obviously, and the supporting effect on temporal superficial soft tissue was significantly weakened. The deep temporal fat pad showed obvious atrophy with a certain degree of downward movement. A total of 50 women who underwent bilateral temporal fat transplantation were enrolled in the clinical study, with 25 in the conventional group and 25 in the large-volume group. The age of the patients in the conventional group was (32.7±7.1) years, and the body mass index (BMI) was (20.2±1.9) kg/m2. In the large-volume group, the age was (32.5±8.3) years, and the BMI was (19.8±2.0) kg/m2. There were no significant differences in age and BMI between the two groups (all P>0.05). The filling volume was (19.66±4.61) ml/side in the large-volume group, with a Likert scale score of (4.32±0.63) and the patient satisfaction was 92.0%(23/25); the filling volume was (11.06±2.62) ml/side in the conventional group, with a Likert scale score of (3.32±0.80) and the patient satisfaction was 68.0%(17/25). There were statistical differences between the two groups (all P<0.05), suggesting that the large-volume group had better efficacy and patients were more satisfied. No severe complications such as infection, liquefaction, embolism, and nerve injury occurred in all patients during the follow-up period.

Conclusion Anatomical studies have proved that the main three-layer fat compartments filling in the temporal region have a clear approach, especially the feasibility of the puncture approach of the deep temporal fat pad, which provides the basis and feasibility for temporal fat filling with large volume. Compared with the conventional fat filling, multi-level and large-volume filling can significantly improve the surgical effect and patient satisfaction.

【Key words】Anatomy; Fat compartment; Fat grafting; Temporal rejuvenation

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: This study was conducted in accordance with the Helsinki Declaration.

自体脂肪是首选的面部年轻化填充材料[1]。然而面部自体脂肪填充，尤其是颞部，存在填充量少、吸收率高、纠正效果差等问题，据统计填充后颞部脂肪平均留存率不足50%[2]。所以相比于面部的其他部位，颞部凹陷的改善往往需要更大容量的脂肪进行填充，根据既往文献统计及我们的经验，往往要过量30%~50%[3]。想要安全可靠地对颞部脂肪室进行大容量填充，需要明确颞部主要脂肪室的分布，尤其是中层、深层脂肪室，寻找安全可行的穿刺入路以靶向大容量填充萎缩的自然脂肪室，以便为患者一次手术解决颞部凹陷的问题。而既往文献报道多仅侧重于颞部的血管及神经解剖[4,5,6]，或者仅侧重浅层脂肪室的组织注射填充[7,8]，鲜有针对颞部的多层脂肪室并为注射填充提供指导的解剖研究。本研究拟结合解剖入路探索颞部的主要脂肪室及填充层次，并通过临床回顾性分析探讨大容量颞部脂肪填充相较于传统浅层脂肪室填充在效果上的优势。

资料与方法

一、颞部脂肪室解剖研究

共对5具(10侧)新鲜尸头进行解剖，年龄25~50岁，尸头均来自于中南大学湘雅医学院解剖教研室，其中成年男性2具，成年女性3具。采用乳胶灌注显示动、静脉，红色乳胶显示动脉，蓝色乳胶显示静脉。颞部自耳前行问号形切口，从切口上缘向下逐层剥离组织至颧弓水平，寻找并记录颞部主要的脂肪室组织及主要血管、神经等组织，探索与填充层次和注射入路相关的可行性。

二、临床研究

(一)资料选择

回顾性分析2020年1月至2021年1月就诊于中南大学湘雅二医院整形美容(烧伤)外科及长沙美莱医疗美容医院进行颞部脂肪移植面部年轻化治疗的患者资料。纳入标准：行双侧颞部脂肪填充的患者，可同时填充全面部，随访期间未行其他面部整形美容项目如鼻整形或者面部激光美容等。排除标准：患有严重内科疾病、心理疾病；有颞部外伤史或既往手术史。按照脂肪填充注射层次和量，将纳入患者分为大容量组和常规组。大容量组需要满足填充层次至少包括3层脂肪室(皮下脂肪、颞浅脂肪垫和颞深脂肪垫)，填充量一般大于15 ml；常规组仅填充1~2个层次，主要为皮下脂肪和颞中筋膜，填充量一般小于15 ml。本研究已参考赫尔辛基宣言，患者在充分知晓手术方式及风险后签署手术知情同意书，并同意将其资料用于临床研究。

(二)方法

术前拍摄患者面部多角度照片，以便术后随访时进行对比评价。

抽脂过程中患者取仰卧位，采用静脉中、深度全身麻醉及镇静。局部肿胀液配置：肾上腺素1 mg+2%利多卡因300 mg +1 000 ml生理盐水。脂肪供区首选大腿前外侧或内侧，使用20 ml注射器连接带多排侧孔的刨针抽脂，将获得的脂肪于1 200×g离心3 min，纯化后的脂肪用于填充，剩余的脂肪按照脂肪来源干细胞基质胶(stromal vascular fraction-gel，SVF-gel)的标准制备流程，通过Luer-Lok转换头机械乳化30次，再行1 600×g离心3 min，得到的SVF-gel在－20 ℃下保存备用[9]。

脂肪通过三通接头转移到1 ml螺纹注射器中，采用20 ml注射器针头在隐蔽部位进针，首选额部发际线或者发际内侧1 cm处，使用17 G或18 G钝针根据解剖基础入路，对颞部主要脂肪室进行分层注射，注意避开重要血管等结构。注脂前不注射肿胀液或者局麻药物，避免影响对注射剂量和效果的判断。故建议患者于全麻下吸脂，镇静、镇痛及神经阻滞麻醉辅助下进行脂肪注射。大容量组注射层次为皮下脂肪(浅层脂肪室)、颞浅脂肪垫(中层脂肪室)、颞深脂肪垫(深层脂肪室)和骨膜上；常规组注射层次为皮下脂肪和颞中筋膜。从额部发际线内侧进针，注意进针点在颞上隔的上方，进针后紧贴皮下，向下在颞部区域进行扇形注射，即填充皮下脂肪层；进针后从颞肌起始部位向深层穿入，沿着骨膜表面向下，朝向颧弓中点方向下行，即骨膜上的注射层次；沿着颞肌表面向下至颧弓上1~2 cm及颧弓水平间的范围即为颞深脂肪垫的注射层次；向下进针直至颧弓上方2 cm左右处，向浅层出针，突破颞深筋膜深层，进入颞浅脂肪垫，也可进针至颧弓水平后向后回退1~2 cm，向浅层突破进入颞浅脂肪垫，2种方法均可感受到明确的突破感。注意在颞部四周区域做好过渡注射。记录每侧注射量。

术后3个月随访时拍摄面部多角度照片，对患者进行满意度调查，分为非常满意、满意、一般、不满意和非常不满意，满意率＝(非常满意例数+满意例数)/总调查例数×100%。手术医师根据术前、术后照片进行Likert量表评价(1~5分)，1分为非常差，5分为非常好。此外，根据需要使用上次手术制备的SVF-gel对局部轻微凹凸不平予以矫正。

三、统计学处理

使用SPSSPRO(Scientific Platform Serving for Statistics Professional)数据分析平台进行统计分析。正态分布计量资料以x±s表示，2组间比较采用独立样本t检验，Cohen’s d值0.20~<0.50、0.50~0.80和>0.80分别对应2组间差异幅度小、中、大。计数资料以例数(%)表示，采用卡方检验进行分析。P<0.05为差异有统计学意义。

结　果

一、颞部软组织的基本解剖层次与脂肪室结构

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