近十余年来,求美者对眼部的审美需求发生了一些改变,使得眼睑美容整形外科的关注方向和眼整形外科医师的知识结构也发生了一些变化.相关领域的研究不断深入,新观念、新见解、新技术、新问题不断出现,一些争议也随之而来.现就眼睑美容整形领域大家关注的热点问题谈一点粗浅看法.

Objective:To investigate the application and effect of frontal flap combined with tarsalconjunctiva flap in the repair of widely full-thickness defects of the lower eyelid.Methods:From January 2016 to March 2018, 9 patients with extensive full-thickness lower eyelid defect were admitted to the Plastic Surgery Department of Changhai Hospital Affiliated to the Naval Military Medical University. All the lengths of lower eyelid defects were greater than a half of the full length. Then we designed forehead flaps combined with tarsalconjunctival flaps to cover the wounds. The second stage operation was done after 4-6 weeks to cut the pedicle and dress the eyelid.Results:All the frontal flaps of 9 patients survived. One patient had lower eyelid retraction and the lid position returned to normal half a year later. One underwent thinning surgery because of lower eyelid flap hypertrophy and one were because of pedicle hypertrophy. The appearance and function of other patients were greatly improved after surgery, and they were satisfied with the operation effect. No repair operation was performed in the future.Conclusions:The frontal flap with good quality of blood supply has a high survival rate and can be used to repair the wide defect of the lower eyelid with tarsalconjunctival flaps.

睡醒时上睑下垂是一种少见的眼睑疾病,表现为患者从睡眠中醒来时短暂的不能自主睁开眼睛,借助外力撑开眼睑后便可恢复自主睁眼能力.由于报道病例较少,临床医师对其认识不足,易与先天性上睑下垂、睁眼失用症等眼睑疾病混淆,造成误诊.现回顾睡醒时上睑下垂相关文献,对该疾病的病因机制、鉴别诊断及治疗等作一综述.

Background and Objectives The keystone design perforator island flap (KDPIF) is often used to cover defects in reliable blood supply and similar skin patterns, but its mobility is limited, especially when the wound is large or occurs around joints. Here, we describe a modified KDPIF, boat-shaped flap. We added a V shape along the lateral arc, forming a V-Y flap on KDPIF's outer arc shapes like a sail. This paper also describes a clinical study to evaluate this method. Method From September 2014 to March 2017, 31 patients were operated on using the boat-shaped flap in our department and were followed up annually with clinical evaluation. The wound locations included joints (n = 11), trunk (n = 18), and face (n = 2). Fifteen defects were >= 5 x 5 cm(2). Results After 6 to 24 months of follow-up, 29 patients had first-intention healing and were satisfied with the morphology and function. Secondary healing was observed in two patients, and the wounds were closed after dressing treatment for 2 weeks. Conclusion The boat-shaped flap enhances the mobility and achieves strong resistance to tension. The modified curvilinear shape prevents the joint activity from being restricted, with visually concealed scars. It is particularly applicable for repairing large wounds and defects around joints.

自近年来,联合筋膜鞘(conjoint fascial sheath,CFS)悬吊法上睑下垂矫正术迅速成为国内眼整形美容领域的研究热点.现回顾CFS研究的历史,从CFS解剖学研究存在的问题展开讲述研究的方法与成果,对当前临床研究的现状进行回顾与分析,并对CFS悬吊法上睑下垂矫正术未来研究的可能方向作一展望.

In 2003, Behan 1 Behan F.C. The Keystone Design Perforator Island Flap in reconstructive surgery. ANZ J Surg. 2003; 73: 112-120 Crossref PubMed Scopus (226) Google Scholar was the first to report the Keystone Design Perforator Island Flap (KDPIF). The KDPIF has the advantages of simple design, convenient operation, certain perforator blood supply, adjacent tissue, good appearance and nearby texture. Therefore, it has been widely applied to repairing skin soft tissue defects caused by trauma, tumor resection, and scars. 2 Shayan R. Behan F.C. Re: the "keystone concept': time for some science. ANZ J Surg. 2013; 83: 499-500 Google Scholar , 3 Behan F.C. Paddle A. Rozen W.M. et al. Quadriceps keystone island flap for radical inguinal lymphadenectomy: a reliable locoregional island flap for large groin defects. ANZ J Surg. 2013; 83: 942-947 Google Scholar However, the KDPIF has certain issues such as excessive tension, constraint on the closure of the donor area, 4 Rao A.L. Janna R.K. Keystone flap: versatile flap for reconstruction of limb defects. J Clin Diagn Res. 2015; 9: PC05-PC07 PubMed Google Scholar , 5 Hessam S. Sand M. Bechara F.G. The keystone flap: expanding the dermatologic surgeon's armamentarium. J Dtsch Dermatol Ges. 2015; 13: 70-72 Google Scholar and skin contractures due to straight line scars across the joints in repairing large-size defects of the trunk, the joints or other moving areas. To address these problems, on the base of KDFIP, we designed an extra V shape on the lateral curve of the flap. Because the whole appearance of the flap like a boat, we also called this modified KDPIF as a Boat-Shaped Flap. The added “V” like a sail is the key point to reduce the tension of the flap and the surrounding soft tissues.

Aim: To clarify the gross anatomy structure of the check ligament of the palpebra superior in relation to congenital blepharoptosis operation. Method: Seven fixed and three fresh cadavers of Chinese adults (between 53 and 76 years old; 5 males and 5 females) were used. Gross dissection was performed on fourteen eyes in seven cadavers. In three fixed cadavers, six bulbus oculi received histological sections for immunohistochemical tests. Result: Below the levator upon the superior rectus, the check ligament described by Lockwood is found. It extends bilaterally and attaches to the orbital wall behind the inner and lateral canthus tendon. Between the inferior obliquus and the inferior rectus, we also found a sheath structure similar to the check ligament extending bilaterally to the orbital wall. These two structures form an annular fascial system surrounding the eyeball. The medial half of the fascial sheath is tenacious, and the immunohistochemical test proves that smooth muscle cells are found in this part. Conclusion: We call this whole fascial sheath surrounding the circumocular muscle the Extraocular Check Ligament System (ECLS), and it plays a restricting and checking role in the movement of the eyeball. Surgeons should be aware of the ECLS when performing ptosis or other blepharal surgery. (C) 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

目的 探究与内眦松弛相关的内眦腱及其周围组织的精细解剖结构.方法 对7具(共14侧)中国成年人头部截取眉以下、眶下孔以上的眼眶标本,其中10侧行内眦部逐层精细解剖,4侧行水平位组织学切片研究,观察内眦腱及其毗邻组织解剖特点及相互关系.结果 ⑴上、下睑板内侧,睑板延续为纤维组织,走行于泪小管周围,在内眦角处与内眦腱的纤维相融合后纤维束呈锥形向鼻侧走行并附着于眶内侧壁分为浅、深两部分.⑵内眦腱浅部纤维横跨泪囊中部前方,止于泪前嵴和上颌骨额突.⑶内眦腱深部纤维质韧且厚,紧密附着于泪后嵴的上2/3及泪囊窝顶部.⑷内直肌Check韧带融合后止于泪阜后方的结膜穹窿.结论 内眦角位置的稳定与内眦腱锥形附着密切相关;内眦腱深部及内直肌Check韧带是使眼睑紧贴眼球的主要力量;内眦松弛、泪点外移主要与睑板-内眦腱延伸部的松弛有关.

目的 探讨Z成形术在美容性外眦开大术后外眦蹼状瘢痕畸形修复中的应用效果.方法 回顾分析近2年来就诊的11例外眦开大术后外眦蹼状瘢痕畸形患者的临床资料.根据外眦的解剖和外观特点,按照Z成形术的原则设计皮瓣修复畸形外观.结果 所有患者术后皮瓣全部成活,无延迟愈合.其中,10例外眦角圆钝患者术后外眦形状明显改善,患者较满意;1例溢泪患者症状有改善;2例改善不明显;1例结膜炎患者术后症状有改善.结论 与内眦开大术不同,外眦开大术因破坏了局部解剖结构易导致外眦蹼状瘢痕形成.采用Z成形术修复外眦蹼状瘢痕畸形的方法简单有效,并能尽量维持外眦开大幅度,可减少相关并发症的发生.

目的 探讨眶隔重置法重睑成形术在临床上的应用效果.方法 将50例单睑女性求美者随机分为实验组(25例)和对照组(25例).实验组采用眶隔重置法行重睑成形术:切开眼轮匝肌显露眶隔后,在眶隔与提肌腱膜融合点上方约4 mm横行切开眶隔,将其下置与切口下唇皮肤、眼轮匝肌缝合固定,修剪多余眶隔,间断缝合闭合皮肤切口.对照组采用传统方法手术.结果 经6个月随访,实验组求美者的重睑瘢痕较轻、凹陷不明显,"肉条感"比例少,术中术后双眼不对称比例较传统术式少,术后水肿程度较轻,恢复后的重睑更加自然.结论 与传统重睑成形术式相比,眶隔重置法重睑成形术具有较为灵活的粘连方式,加之组织去除量较少,使上睑组织结构破坏也较少,故形成的重睑更加自然,恢复时间较短,并发症较少,可作为一种新的重睑成形术式.

To investigate the effectiveness of adipose tissue-derived stem cells sheet combined with atelocollagen matrix on a mouse model of radiation-induced skin injury, adipose tissue-derived stem cells were harvested from the bilateral groin of mice and were screened out by fluorescence-activated cell sorting. Cell sheets were created on a temperature-responsive cell culture surface. The wound recovery rate was detected by measuring the injury area and the recovery shapes of wound were monitored by hematoxylin–eosin, Masson’s trichrome, and immunohistochemical staining. Quantitative reverse transcription polymerase chain reaction and Western blot analysis were conducted to detect relative mRNA expression level of interleukin-1β and protein expression level of vascular endothelial growth factor, respectively. As results, the three-layer adipose tissue-derived stem cells sheet combined with atelocollagen matrix treatment promoted wound healing significantly compared to other treatments. More collagen, higher vessel density, and milder inflammation were observed in the group of three-layer adipose tissue-derived stem cells sheet combined with atelocollagen matrix compared with other treatments. Moreover, both mRNA expression level of interleukin-1β and protein expression level of vascular endothelial growth factor were drastically decreased in that group. In conclusion, three-layer adipose tissue-derived stem cells sheet combined with atelocollagen matrix could promote wound healing synergistically, providing a substantial advance in cell-based tissue engineering and wound healing.

"Cosmetic lateral canthoplasty" and "vertical enlargement of the palpebral aperture"have been in heated discussion in the field of cosmetic surgery in recent years. The author attempted to summarize and analyze both surgeries, including the history of technical evolution, anatomical basis, clinical research and complications, in order to provide a clear and correct understanding.

Objective To investigate the lateral canthoplasty and canthopexy with bone drilling to correct lower eyelid malposition and its benefit. Methods From January 2014 to January 2019, lateral canthopexy with bone drilling technique was used to repair 56 patients with lower eyelid malposition in Department of Plastic and Reconstructive Surgery of Changhai Hospital. Forty-four patients with lower eyelid ectopic had multiple previous surgeries, and 12 patients had congenital lower eyelid retraction. For patients without lower palpebral margin extension, lateral canthopexy with bone drilling technique was applied. For patients with lower palpebral margin extension, the lateral canthus angle was exposed to shorten the lower eyelid margin. For congenital lower eyelid retraction, the lateral canthus tendon was completely cut off, and then fixed with double armed sutures. Results Operations were successfully performed on all 56 patients, and the patients were followed up for 1-38 months. Forty-nine patients achieved good eyelid shape and satisfied with the operative effects (87.5％). Malposition was ameliorated in 6 patients (10.7％). One remained uncorrected (1.8％). Conclusions Lateral canthopexy with bone drilling technique could obtain firm suspension force. For lower eyelid malposition, especially for patients with recurrent malposition or congenital lower eyelid retraction, satisfied function and appearance could be achieved.

目的 探讨改良拱顶石皮瓣在上唇缺损修复中的应用价值.方法 切除肿瘤后的外侧切缘为皮瓣内侧边,平行鼻唇沟方向设计拱顶石皮瓣外侧边,皮瓣外侧边至鼻唇沟的距离与缺损创面的最大直径一致,鼻翼沟向外上延伸与外侧边相交形成一上底角,唇缘向外下延伸与外侧边相交形成下底角,进而形成一岛状皮瓣,对皮瓣进行分离推进转移至创面,分层间断缝合.结果 本组13例患者随访8～24个月,未出现并发症,无再次手术病例.结论 上唇拱顶石皮瓣血供良好,手术安全,瘢痕隐蔽,美容效果良好,修复效果满意.

Objective To explore the practicability and reproducibility of judgment method and assessment indexes for the end point of double eyelid surgery using 4+1 photography in supine position. Methods From 2017 October to 2018 October, 158 patients were included and randomly divided into 2 groups. Photos were taken by 4+1 photography in supine position of 79 patients, while other 79 patients in control group were evaluated by traditional observation. By 4+1 photography in supine position, the surgeon stood at the head side of the patient, taking photos with eyes movement:looking straight forward, looking up, looking downward and eye-closed. It was to observe the upper eyelid creases, upper and lower tissues ofdouble eyelid creases, and upper and lower eyelid margo palpebrae. In addition, the surgeon looked from patient's feet to observe the indexes such as upper margo palpebrae, to make a decision whether the surgery could finish. In control group, the surgeon observed the upper eyelid creases, upper and lower tissues of double eyelid creases and upper and lower eyelid margo palpebrae. The patient has to sit if necessary. Results All 158 patients were performed double eyelid surgery successfully. Average times of valuating end point was 1. 20 by 4+1 Photography in supine position, and 1. 53 in control group. The operation time of 4+1 photography group is (151.65±21.58) s, and control group were (241.53±33.53) s. The satisfaction level was increased to 89. 87％ in 4+1 photography group, compared to 78. 48％ in control group. Conclusions The 4+1 Photography method is simple and easy to practice. The observation indexes are accurate and comprehensive. It is useful in determining the end point of double eyelid plasty in supine position.

目的 观察无内眦赘皮者与不同类型内眦赘皮者内眦区皮下组织的显微结构,探究其存在的组织学差异.方法 招募无内眦赘皮者及有内眦赘皮者,将有内眦赘皮者分为:睑板型、睑型和逆向型.获取内眦区皮下至内眦腱上方的组织约3 mm×3 mm.标本制片经Masson染色,观察比较肌肉组织和纤维组织在构成、分布排列上的差异.结果 无内眦赘皮者组织松散,胶原纤维较丰富,混杂肌纤维,但未见具有完整包膜的束状肌肉组织;睑板型内眦赘皮者皮下胶原纤维组织分布广泛,肌肉组织稀疏,排列方向一致;睑型亦可见丰富的胶原纤维组织,其间见肌纤维,与胶原纤维排列方向一致,此外,肌肉组织含量较睑板型丰富,排列方向相同;逆向型胶原纤维中亦见肌纤维,二者排列方向一致,成束的肌肉组织含量丰富,纵横交错,排列方向不同.结论 不同类型的内眦赘皮的形成与内眦区皮下眼轮匝肌及纤维组织的含量、分布及排列方式密切相关,明确其间组织学差异对精细化内眦赘皮矫正术具有指导意义.

目的 探讨臀股沟皮瓣在会阴肿瘤切除缺损修复中的应用价值.方法 以坐骨结节内侧1.0 cm为旋转点,根据会阴肿瘤切除后遗留创面大小,沿臀股沟向侧方设计轴形皮瓣修复缺损.结果 本组19例患者随访3～24个月,未出现严重并发症,仅3例出现轻微并发症,分别为切口浅层裂开、皮瓣供区脓肿及皮瓣远端淤血,均对症处理后痊愈,无再次手术病例.结论 臀股沟皮瓣血供良好,可根据需要修复直肠、阴道以及会阴皮肤恶性肿瘤遗留的巨大缺损,手术瘢痕较隐蔽,美容效果良好,修复效果较满意.

Objective To create a new method for the repair of anterior lobe defects with pretragal perforator flaps.Methods From March 2014 to November 2016,10 patients with anterior lobe defect were treated using pretragal perforator flaps.Bloodflow was detected preoperatively by ultrasound Doppler,and a pretragal flap pedicled with anterior tracts of the tragus was designed based on the condition of the anterior lobe defects,including size and distance from the distal border to the tragal.The flap was raised superficially to the SMAS fascia from the caudal border and incised primarily to the cephalic border until the pretragal flap was formed.After the flap was sutured to the defect,the donor site was closed primarily.Results All flaps survived primarily and incisions healed in stage one.All patients were followed up for 6～12 months postoperatively without any complications including bloated flaps,obvious scars or facial cat's ear deformities.The morphological and functional effects were satisfactory.Conclusion Application of the pretraga] perforator flaps mentioned above is a simple method for the repair of anterior lobe defects.This method can achieve a satisfactory result in aesthetics and function with a simple design,convenient procedure,reliable blood supply and concealed incision of donor site.This method deserves promotion.

目的 针对外眦部进行深入、系统地解剖学研究,以利于学者们更好地理解、评估或改进美容性外眦成形的术式.方法 对8具(共16侧)头部标本进行逐层精细解剖,同时结合组织学方法对外眦部相关解剖结构及相互之间的毗邻关系加以研究.结果 灰线与眼轮匝肌的关系密切,灰线在颞侧止于外眦角,而外眦腱浅部起于外眦角;睑板最外侧缘与外眦角位置大致对应;外眦角距眶外侧壁前缘5.5～8.1 mm,其位置的稳定与眼轮匝肌(睫部、睑板前部)、外眦腱浅部、提肌腱膜、外眦腱深部及周围结缔组织密切相关;Eisler's脂肪垫位于外眦腱浅部与深部之间,其上方与泪腺毗邻;颞侧结膜穹窿位于外眦腱深部的后方,紧贴眼球,深度4.2～7.1 mm,其位置的稳定与外直肌Check韧带关系密切.结论 美容性外眦成形术会对外眦部的相关正常组织结构造成不同程度的损害,而对其并发症与疗效的评估与权衡,取决于手术对正常组织结构及生理功能破坏的程度;此类手术的适应证应严格选择,手术应有限实施.

Background: Approximately 50% of Asians do not have upper eyelid creases. Full-incision methods may leave obvious scars and buried-suture methods cannot remove excess tissues to create a double eyelid. The new palpebral marginal incision technique masked the incision at the upper palpebral margin and removed the excess tissue, thereby achieving scarless and natural double eyelids. Methods: The modified technique involved the incision site and positioning processes. The incision line is 1.0-1.5 mm above the palpebral margin. A strip of orbicularis muscle beneath the positioned double eyelid must be removed. The orbital septum is then exposed, and a certain amount of orbital fat is removed. Next, the dermis and tarsal plate are sutured in an orderly manner. Finally, a strip of the redundant skin located approximately 1-3 mm above the incision is excised to correct blepharochalasis before the skin is closed. Results: This new technique was performed in 212 patients including 56 patients with blepharochalasis who had their skin excised during the surgery. The follow-up period ranged from 6 months to 3 years. Ninety-five percent of the patients rated excellent and good and that they were satisfied with their surgery, and no significant complications occurred. Conclusions: The following are the advantages of the authors' technique: (1) minimal or even no surgical scarring is discernible on the eyelids even when they are closed; (2) solves the problem of excessive tissue and correct blepharochalasis; and (3) the double eyelid fold is stable and natural for a long time. (C) 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.