上睑软组织结构的应用解剖学研究

发布时间：2018-06-01 14:55

本文选题：P45塑化技术 + 上睑　；参考：《大连医科大学》2015年博士论文

【摘要】：一、目的:1、对上睑软组织进行系统全面的解剖学研究,为上睑部整形美容外科提供解剖学资料。研究睑周脂肪垫的分布和位置对其进行区分和归类。2、研究睑周脂肪分布特点及与上睑凹陷、上睑臃肿肥厚形成的关系,探索睑周脂肪在眼部整形美容手术中的作用,探索重睑成形术时对睑周脂肪的处理方法。3、研究眶上缘区域筋膜脂肪瓣设计的解剖学基础,辅以临床术中解剖,探索眼轮匝肌下层和眶缘脂肪组织的临床应用价值,为上睑凹陷畸形寻求一种简单易行的手术方法,解决眉脂肪垫修复上睑凹陷畸形操作复杂的难题。4、研究睑周动脉血管的解剖学基础及临床应用,明确眼动脉分支的走行和分布范围,明确上睑的动脉弓分布特点和来源,选择有效血管蒂,指导临床对上睑损伤的治疗。探索睑周动脉吻合的潜在区域,结合临床,避免填充物注射引起的并发症。二、材料与方法第一部分:对16具(32例)头颈部标本进行P45断层塑化切片的制作,观察上睑软组织的结构和层次,观察上睑脂肪垫的位置和分布第二部分:选用12具(24例)头颈部标本进行上眼睑区域的解剖,所选标本年龄在40-70岁之间,男性头颈部标本20例,女性头颈部标本4例。由表及里逐层解剖上眼睑,观察眼轮匝肌下区域的软组织分布,观察各个脂肪垫的位置、界限、毗邻关系,比较和断层塑化切片的结果是否具有相关性。采用游标卡尺、直尺测量,拍照记录。选取大连医科大学附属第一医院整形美容科2010年到2015年,行切眉术和额眉提升术病例共56例进行临床术中解剖观察,均为女性,33岁-65岁,平均年龄54岁,以眼眉低垂和老年性上睑凹陷患者为主,同时伴有上睑皮肤松弛、眉外侧下垂为主要表现。在术中,可逐层观察眉部区域以及上睑区域,对额肌、眼轮匝肌、眼轮匝肌下脂肪、眉脂肪垫进行肉眼观察和测量。同时在术中观察眶区脂肪层的分布范围,额肌和眼轮匝肌交错区域的肌肉走形、测量额肌和眼轮匝肌以及此区域软组织的厚度和长度,探索其在临床上治疗老年性上睑凹陷可行性。经患者同意后拍照记录。临床行重睑成形术病例69例,全部伴有上睑臃肿,所有病例中全部为女性,年龄在18岁-48岁,平均年龄28岁。术中采用显微解剖,由表及里逐层观察上睑区域,观察上睑眼轮匝肌后脂肪的分布和界限,和眶隔脂肪的关系,同时比较个体之间的差异。采用直尺测量,经患者同意后拍照记录。第三部分:新鲜成人头颈部标本22例,所有标本头颈部均无畸形、骨折、肿瘤以及破损,分成三组。第一组大体解剖10例,第二组动脉造影后计算机三维重建10例,第三组血管铸型2例。分别观察,眼动脉的终末分支的走行,上睑动脉弓的构成,眶周动脉的吻合区域。为睑周整形手术提供解剖学基础,整体而系统而为睑周的整形美容手术及医学解剖学教学提供直观全面的形态学资料,建立睑周动脉血管的三维解剖模型。三、结果第一部分采用p45断层塑化技术对上睑软组织的解剖学研究在32例上睑p45塑化切片中我们观察到上眼睑的层次结构:由浅入深依次为皮肤、皮下浅筋膜、眼轮匝肌、眼轮匝肌后脂肪、肌下间隙、眶隔、眶隔脂肪,筋膜纤维层和睑结膜。提上睑肌、muller肌、提上睑肌腱膜的结构有以下的两种变异:类型i:提上睑肌的下层特别薄,参与muller肌的形成,比例为75%。类型ii:提上睑肌的末端不分层,向前仅延伸为muller肌,而提上睑肌腱膜在提上睑肌的上表面发出,厚度极薄,比例为25%。根据眶隔前脂肪(眼轮匝肌下眶隔前脂肪)和眶隔后脂肪(眶隔脂肪)在上睑区域分布比例的不同,上睑脂肪组织的分布分为三种类型,分别为眶隔前优势型(n=10,31.3%)、眶隔后优势型(n=4,12.5%)以及眶隔均衡型(n=18,56.3%)。在三种类型中,眶隔前脂肪和眶隔后脂肪所占的比例不同。第二部分上睑软组织的解剖学基础与临床应用研究肉眼观察比较全部病例,眼轮匝肌后脂肪层有显著的个体差异,厚度不一,以外侧增厚较明显。眼轮匝肌后脂肪下为眶隔,眶隔后为眶隔脂肪,集中在眶缘下方。眼轮匝肌后脂肪与眶隔相比含有更多的纤维,在大体解剖中发现,眶隔前脂肪与眶隔后脂肪的分布关系与在p45断层塑化切片的观察结果一致。在24例标本中,根据眶隔前脂肪和眶隔后脂肪在上睑区域分布比例的不同,把眶隔前脂肪和眶隔后脂肪的关系分为三种类型,其中眶隔前优势型上睑出现的比例为29.2%(7/24)、眶隔后优势型上睑的比例为16.7%(4/24)、而眶隔均衡型上睑的比例为54.2%(13/24)。56例中轻度老年性上睑凹陷患者采用眼轮匝肌筋膜脂肪瓣法,手术全部成功,上睑凹陷修复效果明显,无血肿和其他并发症发生,上睑和眶区的皮肤无感觉异常,额肌和眼轮匝肌的功能正常。无继发性凹陷产生。术后随访12个月,患者满意。术中临床解剖观察测量可见:眼轮匝肌筋膜瓣的平均厚度为(2.24±0.15)mm,筋膜瓣可向下剥离的长度(7.56±0.12)mm。第三部分睑眶部动脉系统的解剖学基础与计算机三维重建研究上睑眼动脉的终末支包括眶上动脉、滑车上动脉、鼻背动脉、睑内侧动脉、泪腺动脉、内眦动脉。眼动脉的走行分为眶隔外型、眶隔内型、鼻背动脉缺如型、眶上动脉缺如型,在眶隔外型中,在我们的观察可见眶隔外型的两种亚型,即眼动脉在出眶隔后先向下形成鼻背动脉,然后上行成为滑车上动脉,为第一种亚型;眼动脉在出眶隔后同时形成两个分支,下行分支的鼻背动脉和上行分支的滑车上动脉,为第二种亚型。上睑的动脉血供来源为五条横向动脉弓和一条纵向动脉弓,分别为上睑缘动脉弓、睑板动脉弓、眶周深动脉弓、眶周浅动脉弓、睑周动脉弓;一条纵向动脉弓为眼轮匝肌动脉弓。眶周深动脉弓的来源主要为滑车上动脉的分支,部分来自眶上动脉。睑周的动脉吻合区域主要有三个:眉间和鼻背区域,主要是两侧滑车上动脉的吻合(吻合点4-6);鼻翼区域,主要是鼻翼动脉、鼻背动脉和鼻唇沟动脉的吻合;眶外侧区域,主要是眶周深动脉弓、眶周浅动脉弓和颞浅动脉额支的吻合;三个区域是填充物注射逆行入血的危险区域。四、结论1、P45塑化技术对于眼周的软组织研究提供了新的技术方法。2、本文阐明了上睑脂肪的分布类型,即以眶隔前脂肪为主填充上睑的眶隔前优势型,以眶隔前脂肪和眶隔后脂肪比例均匀的填充上睑的眶隔均衡型,和以眶隔后脂肪为主充盈上睑的眶隔后优势型。3、含有纤维结构的眶隔前脂肪在上睑形成屏障作用,与眶隔后脂肪在眶上缘的前端形成上睑脂肪的优势区域。4、在上睑手术中应避免造成对上睑脂肪优势区域的损伤,同时上睑脂肪的优势区域可指导一些上睑手术的治疗。5、上睑眼轮匝肌筋膜脂肪瓣方法操作简单有效,并发症少,是有效治疗轻中度老年性上睑凹陷的手术方法。6、上睑眼动脉终末支的走行分为眶隔外类型、眶隔内类型、鼻背动脉缺如型、眶上动脉缺如型,眶隔外型分为三种亚型,主要区分点是滑车上动脉和鼻背动脉从眼动脉发出分支的顺行,明确滑车上动脉和鼻背动脉的关系,有助于在行以滑车上动脉为血管蒂皮瓣进行鼻背修复时避免对鼻背动脉的损伤。7、上睑的动脉血管来源包括五条横向走行的动脉弓和一条纵向的动脉弓,纵向动脉弓走行于眼轮匝肌内。明确上睑动脉弓的走行和分布,为上睑修复手术皮瓣的选取提供更多可靠的血管蒂来源,为上睑皮瓣修复提供可靠的解剖学依据。8、睑周动脉血管的吻合区域主要包括三个区域,眉间和鼻根区域、鼻翼区域、眶外侧区域,这些区域的血管吻合和眼动脉想连,逆行阻力小。9、在注射填充物治疗面部缺陷时,应避免损伤眉间区域、鼻翼区域和眶外侧区域的动脉血管,防止填充物在这些区域入血,减少注射填充美容手术并发症的产生。
[Abstract]:Objective: 1, a systematic and comprehensive anatomical study of the soft tissue of the upper eyelid was carried out to provide anatomical data for the upper eyelid plastic surgery. The distribution and location of the peri palpebral fat pad were distinguished and classified for.2. The characteristics of the peri palpebral fat distribution and the relationship with the upper eyelid depression and the formation of upper eyelid hypertrophy were studied, and the peri palpebral fat was explored in the eye. The role of plastic and cosmetic surgery to explore the treatment of peri palpebral fat during double eyelid plasty.3, to study the anatomical basis of the fascia fat flap in the upper rim of the orbital rim, and to explore the clinical application value of the inferior orbicularis oculi muscle and the orbital margin by clinical anatomy, and to seek a simple and easy operation for the deformity of the upper eyelid. To solve the complicated problem of the operation of the eyebrow fat pad to repair the deformity of the upper eyelid.4, the anatomical basis and clinical application of the peripalpebral artery were studied, the walking and distribution of the branches of the ophthalmic artery were clearly defined, the characteristics and sources of the arterial arch distribution of the upper eyelid were clearly defined, and the effective vascular pedicle was selected to guide the treatment of the upper eyelid injury. The potential areas of anastomosis, combined with clinical, avoid complications caused by injections. Two, materials and methods: Part 1: making P45 slices of 16 (32 cases) head and neck specimens, observing the structure and level of the soft tissue of the upper eyelid, observing the position and distribution of the upper lid fat pad in second parts: 12 (24 cases) head and neck specimens were selected. The upper eyelid area was dissected. The age of the selected specimens was between 40-70 years old, 20 male and female head and neck specimens and 4 female head and neck specimens. The soft tissue distribution in the region of the orbicularis oculi muscle was observed from the surface and the soft tissue distribution in the region of the orbicularis oculi muscle. The location, boundary, adjacent relationship, comparison and the results of the slice of the fault plasticization were observed. A total of 56 cases of eyebrow resection and forehead eyebrow lifting were selected from 2010 to 2015 of the First Affiliated Hospital of Dalian Medical University. All the cases were observed in 56 cases, all were female, 33 years old -65 years old, the average age was 54 years old, with eyebrow drooping and senile depression in the upper eyelid. In the operation, the eyebrow area and the upper eyelid area can be observed by layer by layer, the eyebrow muscle, orbicularis oculi muscle, the orbicularis oculi muscle, the eyebrow fat pad are observed and measured by the naked eye. Meanwhile, the distribution of the fatty layer in the orbital region, the muscles in the frontal and the orbicularis orbicularis muscles are observed during the operation. The thickness and length of the frontal muscle and orbicularis oculi muscle and the soft tissue of the region were measured to explore the feasibility of clinical treatment for the senile depression of the upper eyelid. After the patient's consent, 69 cases of double eyelid plasty, all with the upper eyelid bloated, all were female in all cases, the age of 18 years old -48 years, and the average age of 28 years. During the operation, microdissection was used to observe the area of the upper eyelid by layer by layer, observe the distribution and boundary of the fat in the posterior orbicularis orbicularis muscle, and the relationship between the orbital fat and the difference between individuals. The third part: 22 cases of fresh adult head and neck specimens, all the head and neck parts of all the specimens were no malformation. Shape, fracture, tumor and breakage were divided into three groups. The first group was divided into 10 cases, second groups of arteriography, 10 cases of computer three-dimensional reconstruction, and 2 cases of the third group of vascular cast type. The system provides visual and comprehensive morphological data for the plastic surgery of the eyelid and the teaching of medical anatomy and establish a three-dimensional anatomical model of the blood vessels of the palpebral artery. Three. Results the first part, the anatomical study of the soft tissue of the upper eyelid by P45 tomography technique was used to observe the upper eyelid hierarchy in the 32 cases of the upper eyelid plastic section. Structure: skin, subcutaneous fascia, orbicularis oculi, orbicularis oculi muscle, orbicularis oculi muscle, posterior muscle space, orbital septum, orbital septum fat, fascial fiber layer and eyelid conjunctiva. The structure of upper eyelid muscle, Muller muscle, and levator aponeurosis have two kinds of variation: type i:, the lower lid of upper eyelid muscle is especially thin, and participates in the formation of Muller muscle, the proportion is 75%. class. The end of the upper eyelid muscle is not stratified and extends only to the Muller muscle, and the upper eyelid aponeurosis emits on the upper surface of the upper eyelid muscle, and the thickness is very thin. The proportion of the 25%. is based on the distribution of the upper eyelid region in the distribution of the upper eyelid adipose tissue according to the distribution of the anterior fat in the orbital septum (the oculi orbicularis orbital septum) and the orbital septum fat (the orbital septum) in the upper eyelid region. Three types, preorbital predominance (n=10,31.3%), posterior orbital septum dominance (n=4,12.5%) and orbital septum equilibrium (n=18,56.3%). In three types, the proportion of the preorbital fat and the posterior orbital septum is different. Second parts of the soft tissue of the upper eyelid There are significant individual differences in the posterior fatty layer of the muscle. The lateral thickening is more obvious. The posterior fat of the orbicularis orbicularis is the orbital septum, the orbital septum is the orbital septum, and the orbital septum is concentrated below the orbital margin. The posterior fat of the orbicularis orbicularis muscle has more fibers than the orbital septum. In the general anatomy, the relationship between the preorbital fat and the post orbital fat distribution is found in P45 In 24 specimens, the relationship between the preorbital fat and the posterior orbital fat in the upper eyelid region was divided into three types, including 29.2% (7/24) of preorbital prepredominant upper eyelid and 16.7% of the superior superior eyelid in the posterior orbital septum. (4/24), the proportion of the equalizing upper eyelid of the orbital septum was 54.2% (13/24).56, with the orbicularis oculi muscle fascia fat flap in the mild senile depression patients, the operation was all successful. The repair effect of the upper eyelid depression was obvious, no hematoma and other complications occurred, the skin of the upper eyelid and the orbital area had no sensation abnormality, and the function of the frontal muscles and orbicularis oculi muscles was normal. Secondary depression was produced. The patients were followed up for 12 months, and the patients were satisfied. Intraoperative anatomical observation and observation showed that the average thickness of the orbicularis oculi fascial flap was (2.24 + 0.15) mm, the length of the fascial flap can be dissected (7.56 + 0.12) mm. third part of the eyelid orbital artery system and the computer 3D reconstruction to study the end of the upper eyelid artery. The end branch includes the superior orbital artery, the upper trochlear artery, the dorsal nasal artery, the medial palpebral artery, the medial palpebral artery, the lacrimal gland artery, the medial canthus artery. The ocular artery is divided into the orbital septum, the orbital septum, the dorsal nasal artery and the orbital artery, and in the orbital septum, we can see the two subtypes of the orbital septum, that is, the ophthalmic artery is down first after the orbital septum. The formation of the dorsal artery of the nose, then ascending into the upper artery of the trochlear, is the first subtype; the ocular artery forms two branches at the same time after the orbital septum, the dorsal artery of the descending branch of the nose and the upper branch of the superior trochlear artery, which are the second subtypes. The arterial blood supply of the upper eyelid is derived from five transverse arteries and a longitudinal artery arch, respectively. The upper eyelid movement is the upper eyelid movement, respectively. The pulse arch, the palpebral arch arch, the deep orbital arch, the periorbital shallow artery arch, the peripalpebral arch; a longitudinal artery arch is the orbicularis oculi artery arch. The source of the deep orbital arch is mainly the branch of the superior trochlear artery, partly from the superior orbital artery. The main anastomosis area of the palpebral artery is three: the eyebrow and the dorsal region of the nose, mainly on both sides of the trochlear. Arterial anastomosis (anastomosis point 4-6); nasal alar area, mainly the nasal alar artery, the anastomosis of the nasal dorsum artery and the nasolabial artery; the lateral orbit area, mainly the orbital deep artery arch, the superficial orbital arch and the superficial temporal artery, and the three region is a dangerous area for injecting the retrograde into the blood. Four, 1, P45 plasticization technique for the peritaric The soft tissue study provides a new technical method.2. This article clarifies the distribution of upper eyelid fat, that is, preorbital septum prepredominant type with preorbital fat mainly filled with the upper eyelid, with a uniform filling of the orbital septum with the preorbital fat and the posterior orbital septum, and the preorbital septum predominant.3 with the post orbital fat filling the upper eyelid. Fibrous structure of the preorbital fat in the upper eyelid formation barrier, and the posterior orbital fat in the upper edge of the orbital margin to form the upper eyelid fat in the superior area.4, in the upper eyelid operation should avoid causing the upper eyelid fat area of the damage, while the upper eyelid fat area can guide the treatment of some eyelid surgery for the treatment of.5, upper eyelid orbicularis muscle tendons The membrane fat flap is a simple and effective operation with few complications. It is an effective method for the treatment of light and moderate senile upper eyelid depression,.6. The end branch of the upper eyelid artery is divided into the orbital septum type, the orbital septum type, the nasal dorsum artery, the superior orbital artery and the orbital septum are divided into three subtypes, the main point is the upper artery and nose of the trochlear artery and the nose. The relationship between the upper artery and the dorsal artery of the trochlear artery and the dorsal trunk of the trochlear artery helps to avoid the damage to the dorsal artery of the nasal dorsum by the upper artery of the superior trochlear artery for the repair of the dorsal artery of the nose.7. The arterial blood vessels of the upper eyelid include five transverse arteries and a longitudinal artery, longitudinal artery, and the longitudinal artery. The operation and distribution of the upper eyelid artery arch can provide more reliable source of vascular pedicle for the selection of the flap for the upper eyelid repair operation, and provide a reliable anatomical basis for the repair of the upper eyelid flap. The anastomosis area of the peripalpebral artery is mainly composed of three regions, the eyebrow and the nasal root area, the Alar area, the lateral orbit. Areas where vascular anastomosis and eye artery connect, retrograde resistance is small.9, and in the treatment of facial defects by injecting filling, the arterial vessels in the eyebrow area, the Alar area and the lateral orbit should be avoided, preventing the filling from the blood in these areas and reducing the complications of the injection filled cosmetic surgery.
【学位授予单位】：大连医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R322.91

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