四层次重置联合眶周定点悬吊重建下睑亚单位美学结构

四层次重置联合眶周定点悬吊重建下睑亚单位美学结构

张中峰俞美萍曹丽莉宿建勇

本文来源：《中华整形外科杂志》2023年8月第39卷第8期

DOI:10. 3760 / cma.j.cn114453-20221021-00331

作者单位：浙江省荣军医院美容整形外科，嘉兴314000

通信作者：张中峰，Email：zzf67017060@163.com

引用本文

张中峰,俞美萍,曹丽莉,等. 四层次重置联合眶周定点悬吊重建下睑亚单位美学结构[J]. 中华整形外科杂志,2023,39(08)：879-887.DOI:10.3760/cma.j.cn114453-20221021-00331

【摘要】

目的探讨下睑缘入路行皮瓣、肌皮瓣、眶隔膜瓣、眶隔脂肪瓣四层次重置联合眶周定点悬吊面中部复合软组织，重建下睑亚单位美学结构的临床效果。

方法回顾性分析2019年6月至2021年8月浙江省荣军医院美容整形外科收治的经下睑缘切口行中面部年轻化手术患者的临床资料。手术采用下睑缘入路，行眶隔前间隙、上颌前间隙、颧前间隙松解形成肌皮瓣，释放固定眶隔脂肪瓣，解剖眶隔膜瓣行眶周横纵排列的渔网状交叉缝合固定；坐位上推面部软组织确定中、外侧悬吊点及悬吊组织，进行悬吊点标记、固定，提升并修剪肌皮瓣与下睑缘皮肤重叠部分形成皮瓣等手术操作。术后进行随访，通过患者自评(十分满意、满意、不满意、十分不满意)，以及1位未参与手术的整形外科主治医师采用观察者总体美容改善评分法(IGAIS)(－1~3分，分数越高表明改善效果越显著)，对下睑亚单位美学结构(笑丘、下睑皱襞、下睑板下沟、睑颊交界区)的重建效果进行评价。

结果共纳入96例患者，其中男7例，女89例，年龄38~83岁，平均53岁。所有患者术后1周眼部肿胀基本消退，无血肿、下睑退缩、睑球分离、下睑外翻等并发症出现，无颧骨外侧软组织堆积及悬吊点凹陷畸形；术后随访6~12个月，所有患者笑丘、下睑皱襞、下睑板下沟重建效果好，其中2例睑颊交界区稍明显，呈现轻度脂肪膨出眼袋，3例睑颊沟轻微显现，其余患者睑颊交界区的弧面连续性好。患者自评情况：非常满意76例，满意16例，不满意4例；医生IGAIS评分结果：96例患者评分为(2.43±0.35)分，其中76例3分，16例2分，4例1分。

结论经下睑缘入路行皮瓣、肌皮瓣、眶隔膜瓣、眶隔脂肪瓣四层次重置联合眶周定点悬吊面中部复合软组织，能够有效地重建笑丘、下睑皱襞、下睑板下沟、睑颊交界区亚单位美学结构，可获得较好的美学效果。

【关键词】眼睑；下睑亚单位；眶隔膜瓣；眶隔脂肪瓣；肌皮瓣；皮瓣；定点悬吊

基金项目：嘉兴市科技计划项目（2020AD30005）

Four-layer reposition combined with periorbital fixed-point suspension to reconstruct the aesthetic structure of lower eyelid subunits

Zhang Zhongfeng, Yu Meiping, Cao Lili, Su Jianyong

Department of Beauty and Plastic Surgery, Rongjun Hospital of Zhejiang Province, Jiaxing 314000, China

Corresponding author: Zhang Zhongfeng, Email: zzf67017060@163.com

【Abstract】

Objective To investigate the clinical effect of four-layer reposition of skin flap, musculocutaneous flap, orbital septum flap, and orbitum septum fat flap via lower eyelid margin approach, combined with periorbital fixed-point suspension of the midfacial soft tissue, to reconstruct the aesthetic structure of lower eyelid subunits.

Methods The clinical data of patients admitted to the Department of Beauty and Plastic Surgery of Zhejiang Rongjun Hospital for midface rejuvenation via lower eyelid margin approach surgery from June 2019 to August 2021 were retrospectively analyzed. The layer above the orbital septal, maxillary space, and zygomatic space were dissected to form a musculocutaneous flap. The septal fat flap was released and fixed, then the orbital septum flap was dissected and to make a net-like fixation in horizontal and vertical arrangement around the orbit. The mid and lateral suspension points and suspension tissues were determined and marked by pushing up the facial soft tissues in the sitting position, followed by fixation. Then, the abondant part of the musculocutaneous flap and the lower eyelid margin skin were trimmed to form a flap. Post-operative follow-up was performed by patient self-assessment (very satisfied, satisfied, dissatisfied, very dissatisfied). One attending plastic surgeon who was not involved in the surgery evaluated the results of the reconstruction of the aesthetic structures of the lower lid subunits, including laughing hill, lower eyelid fold, inferior sulcus of the lower tarsal plate, and eyelid-cheek junction based on global aesthetic improvement scale (IGAIS) (-1 to 3, the higher the score the more significant the improvement).

Results A total of 96 patients were included, including 7 males and 89 females, aged 38-83 years, with an average age of 53 years. In all patients, the swelling subsided 1 week after surgery, with no complication such as hematoma, lower eyelid retraction, blepharon separation, lower eyelid ectropion, etc. There was no malar lateral soft tissue accumulation and suspension point sunken deformity. 6-12 months postoperative follow-up showed that all patients had expected benefit outcomes in the reconstruction of laughing hill, lower eyelid fold, and inferior sulcus of lower tarsal plate. Yet, fat bulgings at the eyelid-cheek junction were moderately visible in 2 cases, and it is slightly visible in 3 cases. The rest of the patients had good curvilinear continuity in the eyelid-cheek junction area. Patient self-assessment showed that 76 were very satisfied, 16 were satisfied, and 4 were dissatisfied. IGAIS score showed 96 patients scored 2.43±0.35, with 76 scored 3, 16 scored 2 and 4 scored 1.

Conclusion Four-layer reposition of skin flap, musculocutaneous flap, orbital septum flap, and orbital septum fat flap via lower eyelid margin approach, combined with periorbital fixed-point suspension of the midfacial soft tissue can effectively reconstruct the aesthetic structure of the lower eyelid subunits, including the laughing hill, lower eyelid fold, inferior sulcus of inferior tarsal plate and eyelid-cheek junction.

【Key words】Eyelids; Lower eyelid subunit; Orbital septum flap; Orbital septum fat flap; Musculocutaneous flap; Skin flap; Fixed-point suspension

Fund program: Science and Technology Bureau Project of Jiaxing (2020AD30005)

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

Ethical Approval: Ethical approval was given by the Medical Ethics Committee of Rongjun Hospital of Zhejiang Province (2020-9).

随着面部解剖学和衰老机制的进一步阐明及应用，眶周区域的年轻化[ 1 ]日益受到患者和专科医生的重视，经下睑缘入路行眼袋手术及面中部提升年轻化手术大量应用于临床，并取得了较满意的效果。然而，对下睑美学亚单位(包括笑丘[ 2 ]、下睑皱襞[ 3 ]、下睑板下沟[ 2 ]及平滑的睑颊交界区)的重建，缺乏足够的认识，使得术后下睑区域美学亚单位丧失，从而影响手术效果。为了使眶周年轻化手术后下睑区能获得更好的美学效果，我们在对患者行面中部年轻化手术的同时，采用皮瓣、肌皮瓣、眶隔膜瓣、眶隔脂肪瓣四层次重置联合眶周定点悬吊面中部下垂复合软组织的方法，重建下睑亚单位美学结构，取得良好的临床效果。

资料与方法

一、资料选择

回顾性分析2019年6月至2021年8月浙江省荣军医院美容整形外科收治的经下睑缘切口行中面部年轻化手术患者的临床资料。纳入标准：(1)下睑美学亚单位结构缺失或不明显，重建诉求强烈；(2)面中部软组织松弛及下垂、眶颊沟明显；(3)术区无感染及皮肤肿瘤；(4)无严重基础疾病，如心脏病、肝病、肾病、控制不良的高血压、糖尿病等；(5)采用皮瓣、肌皮瓣、眶隔膜瓣、眶隔脂肪瓣四层次重置联合眶周定点悬吊面中部下垂复合软组织的方法进行中面部年轻化。排除标准：(1)不遵从医嘱；(2)研究期间因居住地的变迁等原因不愿意继续本研究；(3)资料不完整。本研究经浙江省荣军医院伦理委员会批准[2020伦审研第(9)号]，所有患者手术前均签署知情同意书，并同意将其资料用于本研究。

二、方法

(一)手术设计

患者取坐位，标记睑颊交界区凹陷范围，经口角垂线与鼻唇沟连线相交点，垂直上推面部软组织及鼻唇部位浅层脂肪，标记经瞳孔垂线面中部软组织最高点及经外眶缘垂线颧部软组织最高点，以5号针头分别于该2点经皮肤垂直穿刺至骨膜，注入美蓝标记( 图1A~1C )。患者取平卧位，术者端坐于患者头部正前方，嘱患者睁眼斜向上观看术者胸部位置，以距内眦点5 mm、下睑睫毛缘1~2 mm处为起点做下睑缘弧形平行线至近外眦角处，转而距外眦隐裂1~2 mm处做其平行线，定为第1条画线；以无齿镊的一齿落于第1条画线，反复多点夹捏下睑松弛皮肤至下睑睫毛微动为止，连接另一齿的多个落点，并与第1条画线首尾相连，作为第2条画线，2条画线之间的区域定为基础去皮区( 图1D )。

(二)手术方法

患者取仰卧位，以2%碘酊固定设计线，常规消毒铺巾。将2%利多卡因10 ml加入0.1~0.2 ml的0.1%肾上腺素混合液，行眶下孔神经、颧面神经阻滞麻醉，画线区域行皮下肿胀麻醉及眶缘骨膜上浸润麻醉。用11号尖刀片按照标记切开皮肤，切除下睑基础去皮区皮肤。嘱患者睁眼平视，保持眼轮匝肌无张力，距下睑缘8~10 mm处切开眶前眼轮匝肌( 图1E )，进入眶隔筋膜前疏松间隙，形成肌皮瓣。以双蚊式钳分别夹持切口下缘皮下内、外1/3两点，向斜下方牵引，用电刀笔在肌层与眶隔筋膜间持续分离达眶骨弓状缘，此时可见增厚的亮白色眼轮匝肌节制韧带与眶缘骨膜紧密相连。在骨膜前用电刀切开眼轮匝肌节制韧带，对眶下孔发出的较粗大眶隔分支血管通过电凝严密止血，于提上唇肌表面钝性分离，直至暴露上颌前间隙脂肪、筋膜复合组织术前标记。外侧在颧骨骨膜表面钝性分离，注意保护颧面神经血管束，直至暴露颧前间隙的脂肪、筋膜复合组织术前标记( 图1F，1G )。沿眶骨下缘上方1 mm处以电刀横行切开眶隔筋膜，松解近下睑板下缘的眶筋膜组织与下睑缘眼轮匝肌、睑板下缘的反折粘连，形成蒂在上方的眶隔膜瓣( 图1H )，从上、下、左、右4个方向牵引眶隔膜瓣，以无下睑外翻、下睑退缩及睑球分离为度，充分松解释放内、中、外侧的眶隔脂肪，用6-0尼龙线进行两两缝合，形成一个整体的舌状眶隔脂肪瓣，用5-0尼龙线将其无张力牵引平铺至睑颊交界凹陷区域并固定。将眶隔膜瓣展平铺于眶隔脂肪前，以6-0尼龙线于眶骨缘、眶隔膜瓣表面行连续纵横排列的渔网状交叉缝合( 图1I )。在垂直方向上推面中部软组织及鼻唇部位浅层脂肪，以3-0尼龙线缝绕颌前内侧面术前标记的复合组织一圈，缝合悬吊于眶骨膜缘对应点，以3-0缝线垂直悬吊颧前内侧面复合组织术前标记，缝合固定于眶骨膜外缘对应点( 图2A~2F )。嘱患者睁眼目视额部方向，向斜外上方提紧肌皮瓣，用3-0尼龙线将眼轮匝肌缝合固定于外眦角隐裂下方的外眦韧带处( 图1J ，图2G，2H )，切除与下睑缘及外眦角隐裂切口线重叠的皮肤、肌肉复合组织，修剪并切除肌皮瓣与下睑缘皮肤重叠部分的皮下组织及肌纤维组织，使肌皮瓣与下睑缘皮肤重叠的部分形成菲薄的皮瓣( 图1K )。至此，完成下睑区皮瓣、肌皮瓣、眶隔膜瓣、眶隔脂肪瓣4个层次的重置，此时可见下睑缘由内至外逐渐隆起的笑丘，皮瓣与肌皮瓣的厚薄转折相交处形成隐约可见的下睑皱襞线。用7-0尼龙线横褥式缝合下睑缘相叠合的眼轮匝肌，缝合下睑皮肤关闭切口。

(三)术后处理

术后切口涂抹红霉素眼药膏，并以敷料覆盖，切口下缘剥离面以3M肤色弹力胶带轻加压包扎。术后48 h换药，去除伤口外敷料暴露切口，更换3M肤色弹力胶带，术后7 d拆线并去除弹力胶带。

(四)术后随访与效果评价

术后6、12个月于门诊随访，末次随访时从以下2个方面评价笑丘、下睑皱襞、下睑板下沟、睑颊交界区的弧面连续重建效果。(1)患者对手术效果进行自评，分为十分满意、满意、不满意、十分不满意4个等级。(2)将患者术前及术后随访照片交于1位未参与治疗的整形外科主治医师，采用观察者总体美容改善评分法(global aesthetic improvement scale, IGAIS )[ 4 ]进行评价：3分，改善非常显著(治疗后达到了最佳美容效果)；2分，改善显著(相对原来的状态外观有显著改善，但是未达到最佳美容效果)；1分，改善(相对原来的状态外观有部分改善)；0分，无改善(术前、术后没有发生变化，相对原来状态差别不大)；－1分，较术前更差(外观比以前更糟)。

结果

......