传统前徙步骤的附加技术矫正重度上睑下垂PPT演示课件.ppt

ShiHengBRAVOUAestheticPlasticHospital,AdjunctiveTechniquestoTraditionalAdvancementProceduresfortreatingSevereBlepharoptosis,2,PlasticandReconstructiveSurgeryApril2014Volume133,Number4,3,Tocreateamorephysiologic（生理性的）eyelidopeninginpatientswithsevereblepharoptosis(睑下垂),theauthorsusedlaminapropriamucosaofconjunctiva（结膜的睑板固有粘膜）,whichcontinuestothecheckligamentofthesuperiorfornix(上穹窿的check韧带),inadditiontolevatoraponeurosisandMllersmuscleasacompositeflap.Inpatientswithepicanthalfolds（内眦赘皮）withassociatedtelecanthus（内眦间距过大）,theauthorsalsoperformedepicanthoplastywithmedialcanthaltendonshortening.,Background,4,5,1.Superiorrectusmuscle.2.Levatormuscle.3.ConjoiningofSRMwithlevatormusclesheath.4.Tenonscapsule.5.Suspensoryligamentofsuperiorfornix.6.Whitnallsligament.7.Frontalismuscle.8.Browfatpad.9.Orbitalorbicularis.10.Arcusmarginalis.11.Orbitalseptum.12.Preaponeuroticfatpad.13.Preseptalorbicularis.14.Postorbicularisfascia.15.Levatoraponeurosis.16.Superiorconjunctivalfornix.17.Mllersmuscle.18.Conjunctiva.19.Superiortarsus.20.Pretarsalorbicularis.,腱膜前脂肪Pre-aponeuroticfat眶隔前脂肪Pre-septalfat睑板前脂肪Pretarsalfat眼轮匝肌下脂肪retro-orbicularisoculifat(ROOF)sub-orbicularisoculifat(SOOF),6,7,8,Methods,Fiftyblepharoptosispatients(85eyelids)withadegreeofptosisofgreaterthan4mmunderwenttheadvancementtechniqueusingthelevatoraponeurosisMllersmusclelaminapropriamucosaofconjunctivaasacompositeflap.Twenty-one(42percent)ofthosepatientsalsounderwentsplitV-Wepicanthoplastyandplicationofthemedialcanthaltendonforepicanthalfoldswithassociatedtelecanthus.Degreeofptosisandlevatorfunctionweremeasuredpreoperativelyandpostoperatively.,9,Results,Completeornear-completecorrectionofptosis(degreeofptosis,4mm)forthisstudy.The50patients(85eyelids)underwenttheadvancementtechniqueusingthelevatoraponeurosisMllersmusclelaminapropriamucosaofconjunctivacompositeflap.Twenty-oneof50patients(42percent,42eyelids)hadepicanthalfoldswithassociatedtelecanthusandthereforeunderwentepicanthoplastyandshorteningofthemedialcanthaltendon.,18,OperativeTechnique,Thedoubleeyelidincisionlineismarkedontheuppereyelid6to9mmabovethelidmargin,dependingonthepersonalpreferenceofpatientswithoutdoubleeyelids.ModifiedV-Wplastyisdesignedontheskinmedialtotheepicanthalfoldsofpatientswithblepharoptosisandepicanthalfoldswithassociatedtelecanthus.Epicanthalfoldswithassociatedtelecanthusarecorrectedbeforeptosiscorrectionisperformed.Theoperationisusuallyperformedwiththepatientunderlocalanesthesiawithintravenousororalsedation.,19,20,CorrectionofSevereBlepharoptosis,Anincisionismadealongthedoubleeyelidmarkaftersubcutaneousinfiltrationwith1%lidocainewith1:100,000epinephrine.EpinephrineisomittedduringdeeperinjectiontopreventstimulationoftheMllersmuscle.Theupperanteriorsurfaceofthetarsalplateandtheorbitalseptumareexposedafterexcisionofpretarsalsofttissue.Theorbitalseptumiscutatitslowestpartandtheprotrudingorbitalfatispartlyexcisedtoexposethelevatoraponeurosis.Tetracaine（丁卡因）eyedropsareappliedtothecornea（角膜）,andcornealeyeprotectorsareappliedtotheglobe.,Thelevatoraponeurosis,Mllersmuscle,andlaminapropriamucosaofconjunctivaarethendetachedcarefullyfromthesuperiortarsalborderandunderlyingconjunctivalepitheliumwithsharpirisscissorswiththehelpofthesethreetractionsutures.InjectionofpurelidocaineintothesuperiorportionofthetarsusfacilitatesthedetachmentoftheMllersmuscleandthelaminafromthesuperiortarsalborderandtheconjunctivalepitheliumbycausingthetissuestoballoonupslightly.Insomecases,darkcorneaisvisiblethroughtheconjunctivalepithelium.ThedetachedlevatoraponeurosisMllersmusclelaminapropriamucosacompositeflapisadvancedontotheanteriorsurfaceofthetarsus.,21,22,23,24,RESULTS,Fiftypatients(85eyelids)withptosisgreaterthan4mmwereoperatedon(Table1).Ofthesepatients,38(76percent)hadcongenitalptosisand35(70percent)hadbilateralptosis.Ofthe35patientswhohadbilateralptosis,eightexhibitedeyelidasymmetryofmorethan1mm.Patientagesrangedfrom12to89years(meanage,35.7years).,Thedegreeofptosisamongthe85eyelidsrangedfrom4to8mm.Seventy-seveneyelids(90.6percent)had4to5mmofptosis,andeight(9.4percent)hadmorethan6mm.Levatorfunctionamongthe85eyelidsrangedfrom7to2mm.Fifty-fiveeyelids(64.7percent)hadfairlevatorfunction(7to5mm).Inprimarycases,theadvancedcompositeflapwasresectedatlessthan5mm(mean,3mm).Inrevisioncasescausedbyincompletecorrectionofptosis,thecompositeflapwasfurtheradvancedandresectedbyabout3mm.,25,Allpatientswerefollowedpostoperativelyfor6monthsto9years(Table2).Completecorrectionofptosis(degreeofptosis,1mm)wasobtainedin54eyelids(63.5percent),andmildresidualptosis(degreeofptosis,2mm)wasseenin22eyelids(25.9percent).Inthenineeyelidswithmoderateresidualptosis(degreeofptosis,3mm),twopatients(foureyelids)underwentautogenousfascialata（自体阔筋膜）suspensiontothefrontalismusclebecauseofpoorlevatorfunction.Theremainingpatientsrefusedtheprocedure.,26,Themostcommoncomplicationwasincompletecorrectionofptosis.Reoperationwasperformedin15eyelids,withfurtheradvancementofthecompositeflap.In41eyelids(48percent),lagophthalmosof1to2mmandmildlidlagwerepresentforthefirstfewmonthspostoperativelybutwereseentoresolveafter6months,exceptinthreepatientswhowerelosttofollow-up.Minorcomplications,suchaschemosis(结膜水肿),ecchymosis（瘀斑）andcornealirritation（角膜刺激）,werewellrecoveredbyconservativetreatmentssuchaseyelubricants（润滑剂）.,27,28,Fig.4.A49-year-oldmanpresentedwithbilateralcongenitalblepharoptosis.(Above,left)Preoperativestraight-aheadgaze.(Above,right)One-yearpostoperativeresultsafteradvancementofthecompositeflap.(Below)Closureofeyes.,29,30,Fig.6.A26-year-oldmanpresentedwithbilateralcongenitalblepharoptosisandepicanthalfoldsassociatedwithmoderatetelecanthus.(Above,left)Preoperativestraight-aheadgaze.(Above,right)Two-yearpostoperative(Below,left)Upwardgaze.(Below,right)Downwardgaze.,31,DISCUSSION,WehavebeeninterestedintheadvancementtechniqueofusingthelevatoraponeurosisMllersmusclecompositeasaflapinthecorrectionofblepharoptosis,andhavereportedtheresults.Wefoundthateyelidelevationwasstilldeficientforusingthistechniqueinpatientswithsevereptosis.Aftergainingafurtherunderstandingofthedeeperconnectionbetweenthelaminapropriamucosaofconjunctivaandthecheckligamentofthesuperiorfornix,weincorporatedthelaminaintothecompositeflap。WepostulatedthatsimultaneousadvancementofthelevatoraponeurosisMllersmusclelaminapropriamucosaofconjunctivacompositeasaflapproducesstrongerpowertocorrectsevereptosis.,32,Thelevatoraponeurosisisconnectedsuperiorlytothelevatorpalpebraesuperiorismuscle（提上睑肌）andtheWhitnallsligament,andhasfirmosseousinsertionatthemedialandlateralhorns.AdvancementofthedistallevatoraponeuroticmargindownwardonthetarsalplateraisesthetarsusdynamicallybyincreasinglevatorfunctionandstaticallybypullingontheelasticWhitnallsligamentandshortenedlevatoraponeurosisitself.,33,Mllersmusclehasnormalfunctioneveninsevereptosisandhas2to3mmofeyelidliftingpower.Mllersmuscleisanimportantterminalattachmentofthelevatormuscletothesuperiortarsalborder,andshorteningtheMllersmusclemayaugmentitsphysiologicrolebyincreasingthetensilestrengthofthemuscle.,34,Thelaminapropriamucosaoftheconjunctivaiscontinuouswiththeelasticcheckligamentofthesuperiorfornix,andshorteningthelaminapropriamucosapullsonthecheckligament.Therefore,advancementofthesethreedistinctanatomicstructuressimultaneouslytothetarsalplateproducesintegratedpowertoraisetheuppereyelidinanaturalsuperior-posteriorvector.,35,Patientswithsevereeyelidptosisattempttousethreemusclestomaximizeeyelidopening.Theinitialattemptisbytheprimarycomponentofeyelidelevationthelevatormuscle（提上睑肌）.Thenextphaseofeyelidopeningthatpatientsattemptinvolvesuseofthesuperiorrectusmuscle（上直肌）tolookupward.Thethirdphaseistheuseofthefrontalismuscle（额肌）.,36,thecheckligamentisconnectedanteriorlytothelevatorpalpebraesuperiorismuscleandposteriorlytothesuperiorrectusmuscle.pullingthecheckligamentpullsthelevatorpalpebraesuperiorismuscleandthesuperiorrectusmuscle.,37,Onecanpostulate假定thatthecheckligamentpullsthesuperiorrectusmusclemoredirectlysincetheconnectionbetweenthecheckligamentandthelevatorpalpebraesuperiorismuscleallowssomeglidingmotion,whiletheconnectionbetweenthecheckligamentandthesuperiorrectusmuscleisrelativelyfirm.,38,Anotheradvantageofusingthelevatorpalpebraesuperiorismuscle,Mllersmuscle,andsuperiorrectusmuscle,comparedwithusingjustonemuscle,isthereducedshorteningofoneparticularmuscle.Distributingtheshorteningtoothereyeelevatingmusclesandaugmentingthephysiologiccomponentofeyelidelevationallowsdecreasedeyelidshorteningtogainthesameliftingeffect.Intheory,thisshouldinducelesslagophthalmosandlidlag,asnoticedinourresults.,39,Insevereptosiscorrection,thereisanincreasedchanceofpostoperativedoubleeyelidasymmetry,sincea