传统前徙步骤的附加技术矫正重度上睑下垂（参考材料）

传统前徙步骤的附加技术矫正重度上睑下垂（参考材料） Boston?Wilmington?Shanghai Thefollowing materialwas usedby Adon LLC duringan oralpresentation anddiscussion.Without theaompanying oralments,the textis inpleteas arecord of the presentation.This documentcontains informationand methodologydescriptions intendedsolely forthe use of clientpersonnel.No partof itmay becirculated,quoted,or reproducedfor distributionoutside thisclient withoutthe priorwritten approvalof AdonLLC.NOTICE:Proprietary andConfidential Copyright?xxAdonLLC,All RightsReserved ShiHeng BRAVOUAesthetic PlasticHospital AdjunctiveTechniques toTraditional AdvancementProcedures fortreating Severe Blepharoptosis PP lasticand RR econstructiveS Surgery AprilxxVolume133,Number42?To createa morephysiologic（生理性的）eyelid openingin patientswith severe blepharoptosis(睑下垂),?the authorsused lamina propria mucosa of conjunctiva（结膜的睑板固有粘膜）,which continuesto the check ligament of the superior fornix(上穹窿的check韧带),?in additionto levator aponeurosis andMllers muscleas a posite flap.?In patientswith epicanthal folds（内眦赘皮）with associated telecanthus（内眦间距过大）,the authorsalso performedepicanthoplasty withmedial canthaltendon shortening.Background341.Superior rectus muscle.2.Levator muscle.3.Conjoining ofSRM with levator musclesheath.4.Tenons capsule.5.Suspensory ligament of superior fornix.6.Whitnalls ligament.7.Frontalismuscle.8.Brow fatpad.9.Orbital orbicularis.10.Arcus marginalis.11.Orbital septum.12.Preaponeurotic fatpad.13.Preseptal orbicularis.14.Postorbicularis fascia.15.Levator aponeurosis.16.Superior conjunctival fornix.17.Mllers muscle.18.Conjunctiva.19.Superior tarsus.20.Pretarsal orbicularis.5?腱膜前脂肪Pre-aponeurotic fat?眶隔前脂肪Pre-septal fat?睑板前脂肪Pretarsal fat?眼轮匝肌下脂肪retro-orbicularis oculifat(ROOF)?sub-orbicularis oculifat(SOOF)67Methods?Fifty blepharoptosispatients(85eyelids)with adegree of ptosis ofgreater than4mm underwent the advancement technique using the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva as aposite flap.?Twenty-one(42percent)of thosepatients alsounderwent splitV-W epicanthoplasty and plicationof the medial canthaltendon forepicanthal folds with associated telecanthus.?Degree of ptosis andlevator functionwere measuredpreoperatively andpostoperatively.8Results?Complete ornear-plete correction of ptosis(degree ofptosis,4mm)for thisstudy.The50patients(85eyelids)underwenttheadvancementtechniqueusingthe levator aponeurosisMllers musclelaminapropria mucosaofconjunctiva posite flap.?Twenty-one of50patients(42percent,42eyelids)had epicanthalfolds withassociated telecanthusand thereforeunderwent epicanthoplastyand shorteningof themedial canthaltendon.17Operative Technique?The double eyelid incisionline ismarked on theupper eyelid6to9mm abovethe lidmargin,depending on the personalpreference of patients withoutdouble eyelids.?Modified V-W plastyis designedon theskin medialto theepicanthalfoldsofpatientswith blepharoptosis and epicanthalfolds withassociatedtelecanthus.?Epicanthal foldswithassociatedtelecanthus arecorrected beforeptosis correctionis performed.?The operationis usuallyperformed withthe patientunder localanesthesia withintravenous ororal sedation.1819Correction ofSevereBlepharoptosis?An incisionis madealong thedoubleeyelidmark aftersubcutaneous infiltrationwith1%lidocaine with1:100,000epinephrine.?Epinephrine isomitted duringdeeper injectionto preventstimulation of the Mllers muscle.?The upperanterior surface of thetarsal plateand theorbital septumare exposedafter excisionof pretarsalsoft tissue.?The orbitalseptum iscut atits lowestpart and the protrudingorbital fatis partlyexcised toexpose the levatoraponeurosis.?Tetracaine（丁卡因）eye dropsare appliedto thecornea（角膜）,and cornealeye protectorsare appliedto theglobe.20?The levatoraponeurosis,Mllers muscle,and laminapropria mucosaofconjunctivaare thendetached carefullyfrom the superior tarsal border andunderlying conjunctival epithelium withsharp irisscissors withthe helpof these three tractionsutures.?Injection ofpure lidocaineinto the superior portionof the tarsus facilitatesthe detachmentoftheMllers muscleand the lamina fromthesuperiortarsalborderand theconjunctivalepitheliumby causingthe tissuesto balloonup slightly.?In somecases,dark corneais visiblethrough theconjunctivalepithelium.The detachedlevatoraponeurosisMllers musclelaminapropriamucosa positeflap isadvanced onto the anteriorsurfaceofthetarsus.212223RESULTS?Fifty patients(85eyelids)with ptosisgreater than4mm wereoperated on(Table1).Of thesepatients,38(76percent)had congenitalptosis and35(70percent)had bilateralptosis.Of the35patients whohad bilateralptosis,eight exhibitedeyelid asymmetryof morethan1mm.?Patient agesranged from12to89years(mean age,35.7years).24?The degree ofptosisamong the85eyelids rangedfrom4to8mm.Seventy-seven eyelids(90.6percent)had4to5mm ofptosis,and eight(9.4percent)had morethan6mm.?Levator functionamong the85eyelids rangedfrom7to2mm.Fifty-five eyelids(64.7percent)had fairlevator function(7to5mm).?In primarycases,the advanced positeflap was resectedat lessthan5mm(mean,3mm).In revisioncases causedby inpletecorrection ofptosis,the positeflap wasfurther advancedand resectedby about3mm.25?All patientswere followedpostoperatively for6months to9years(Table2).?Complete correctionofptosis(degree ofptosis,1mm)was obtainedin54eyelids(63.5percent),and mildresidual ptosis(degree ofptosis,2mm)was seenin22eyelids(25.9percent).?In thenine eyelidswith moderateresidual ptosis(degreeofptosis,3mm),two patients(four eyelids)underwent autogenousfascia lata（自体阔筋膜）suspension to the frontalis muscle becauseofpoor levator function.The remainingpatients refusedthe procedure.26?The mostmon plicationwas inpletecorrectionofptosis.?Reoperation wasperformed in15eyelids,with furtheradvancement ofthe positeflap.?In41eyelids(48percent),lagophthalmos of1to2mm andmild lidlag werepresent forthe firstfew monthspostoperatively butwere seento resolveafter6months,except inthree patientswho werelost tofollow-up.?Minor plications,such aschemosis(结膜水肿),ehymosis（瘀斑）and cornealirritation（角膜刺激）,were wellrecovered byconservative treatmentssuch aseye lubricants（润滑剂）.27Fig.4.A49-year-old manpresented withbilateral congenitalblepharoptosis.(Above,left)Preoperative straight-ahead gaze.(Above,right)One-year postoperativeresults afteradvancement ofthe positeflap.(Below)Closure ofeyes.2829Fig.6.A26-year-old manpresented withbilateral congenitalblepharoptosis andepicanthalfoldsassociated withmoderate telecanthus.(Above,left)Preoperative straight-ahead gaze.(Above,right)Two-year postoperative(Below,left)Upward gaze.(Below,right)Downward gaze.3031?We havebeen interestedin theadvancementtechniqueof usingthe levatoraponeurosisMllers muscleposite asa flapin thecorrectionof blepharoptosis,and havereported theresults.?We foundthat eyelidelevation wasstill deficientfor usingthis techniquein patientswith severe ptosis.?After gaininga furtherunderstanding ofthe deeperconnection between the laminapropriamucosaofconjunctivaand thecheck ligamentofthesuperiorfornix,we incorporatedthe laminainto thepositeflap。 ?We postulatedthat simultaneousadvancement ofthe levatoraponeurosisMllers musclelaminapropriamucosaofconjunctiva positeasaflap producesstronger power tocorrectsevere ptosis.32?The levatoraponeurosis isconnected superiorlytothe levator palpebraesuperioris muscle（提上睑肌）and theWhitnalls ligament,and hasfirm osseousinsertion atthemedialand lateralhorns.?Advancement ofthe distallevator aponeuroticmargin downwardonthetarsal plateraises thetarsus dynamicallyby increasinglevator functionand staticallyby pullingonthe elastic Whitnalls ligamentand shortenedlevatoraponeurosisitself.33?Mllers musclehas normalfunction evenin severeptosis andhas2to3mm of eyelid liftingpower.?Mllers muscleisanimportant terminalattachment ofthe levatormuscle tothesuperiortarsalborder,and shorteningtheMllers musclemay augmentits physiologicrole byincreasing thetensile strengthofthemuscle.34?The laminapropriamucosaoftheconjunctivaiscontinuous withtheelastiheck ligamentofthesuperiorfornix,and shorteningthelaminapropriamucosapulls onthecheckligament.?Therefore,advancement ofthesethreedistinct anatomicstructures simultaneouslytothetarsal plateproduces integratedpowertoraise theupper eyelidin anatural superior-posterior vector.35?Patients withsevere eyelidptosis attemptto usethree musclesto maximizeeyelid opening.?The initialattempt isby theprimary ponent ofeyelidelevationthelevatormuscle（提上睑肌）.?The nextphase ofeyelid openingthat patientsattempt involvesuseofthesuperior rectus muscle（上直肌）to lookupward.?The thirdphase is the useofthefrontalis muscle（额肌）.36?thecheckligament isconnected anteriorlytothelevator palpebraesuperioris muscleand posteriorlytothesuperior rectus muscle.?pulling thecheckligamentpulls thelevator palpebraesuperioris muscleand thesuperiorrectus muscle.37?One canpostulate假定that thecheckligamentpulls thesuperiorrectusmuscle moredirectly sincethe connection betweenthecheckligamentandthelevator palpebraesuperioris muscleallows somegliding motion,while theconnectionbetweenthecheckligamentandthesuperiorrectusmuscleis relativelyfirm.38?Another advantageof usingthelevatorpalpebraesuperioris muscle,Mllersmuscle,and superiorrectusmuscle,pared withusing justone muscle,isthereduced shorteningof oneparticular muscle.?Distributing theshortening toother eyeelevating musclesand augmentingthe physiologiomponentofeyelidelevationallows decreasedeyelid shorteningto gain the samelifting effect.?In theory,this shouldinduce lesslagophthalmos andlidlag,as noticedin ourresults.39?In severep