传统前徙步骤的附加技术矫正重度上睑下垂.ppt

Shi HengBRAVOU Aesthetic Plastic Hospital,Adjunctive Techniques to Traditional Advancement Procedures for treating Severe Blepharoptosis,2,Plastic and Reconstructive Surgery April 2014Volume 133,Number 4,3,To create a more physiologic（生理性的）eyelid opening in patients with severe blepharoptosis(睑下垂),the authors used lamina propria mucosa of conjunctiva（结膜的睑板固有粘膜）,which continues to the check ligament of the superior fornix(上穹窿的check韧带),in addition to levator aponeurosis and Mllers muscle as a composite flap.In patients with epicanthal folds（内眦赘皮）with associated telecanthus（内眦间距过大）,the authors also performed epicanthoplasty with medial canthal tendon shortening.,Background,4,5,1.Superior rectus muscle.2.Levator muscle.3.Conjoining of SRMwith levator muscle sheath.4.Tenons capsule.5.Suspensory ligament of superior fornix.6.Whitnalls ligament.7.Frontalismuscle.8.Brow fat pad.9.Orbital orbicularis.10.Arcus marginalis.11.Orbital septum.12.Preaponeurotic fat pad.13.Preseptal orbicularis.14.Postorbicularis fascia.15.Levator aponeurosis.16.Superior conjunctival fornix.17.Mllers muscle.18.Conjunctiva.19.Superior tarsus.20.Pretarsal orbicularis.,6,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 oculi fat(ROOF)sub-orbicularis oculi fat(SOOF),7,8,Methods,Fifty blepharoptosis patients(85 eyelids)with a degree of ptosis of greater than 4 mm underwent the advancement technique using the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva as a composite flap.Twenty-one(42 percent)of those patients also underwent split V-W epicanthoplasty and plication of the medial canthal tendon for epicanthal folds with associated telecanthus.Degree of ptosis and levator function were measured preoperatively and postoperatively.,9,Results,Complete or near-complete correction of ptosis(degree of ptosis,1 mm)was achieved in 54 eyelids(63.5 percent)and mild residual ptosis轻度残余下垂(degree of ptosis,1 to 2 mm)was observed in 22 eyelids(25.9 percent)in postoperative follow-up after 6 months.The most common complication was reoperation,which was done in 15 eyelids(17.6 percent)because of incomplete correction.,10,Conclusions,The advancement technique using the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva composite was effective in the treatment of severe blepharoptosis with levator function of 2 to 7 mm.The technique produced elevating motion of the physiologic eyelid in a superior-posterior direction.There were no serious complications,such as long-term lagophthalmos（睑闭合不全）or lid lag（眼球迟滞）.,11,Severe ptosis presents a difficult condition because a significant amount of eyelid excursion is required to correct it.In addition,in congenital ptosis,levator muscle function is often poor.We define severe ptosis as the degree of ptosis greater than 4 mm,as described by Isaksson.,12,Frontalis suspension is commonly performed to bypass the issue of poor levator muscle function.However,there are many drawbacks associated with frontalis suspension,such as lagophthalmos,lid lag,lid distortion,and unnatural eyelid movement in a superior direction following overaction of the frontalis muscle.Holmstrm and Santanelli reported on suspension of the eyelid to the check ligament of the superior fornix in congenital blepharoptosis.,13,The check ligament of the superior fornix（上穹窿）,which emanates from the sheaths of the levator and superior rectus muscles and from Tenons capsule,contains collagen fibers,elastin fibers,and smooth muscle fibers.Superficial and deep extensions of the check ligament continue to the superior conjunctival fornix and conjunctiva.This check ligament was confirmed by Lukas and colleagues and Hwang and colleagues as the intermuscular transverse ligament（肌间横韧带）and conjoint fascial sheath（CFS，联合筋膜鞘）,respectively.,14,15,Kakizaki and colleagues classified the conjunctiva into lamina propria mucosa of conjunctiva and conjunctival epithelium.The lamina propria mucosa of conjunctiva is located just posterior to the Mllers muscle and has a rich vascular plexus.The lamina is as thick as Mllers muscle and inserts onto the posterior half of the superior tarsal border.The lamina continues proximally to the check ligament and is thought to have a suspensory effect on the upper eyelid.,16,We used the levator aponeurosis,Mllers muscle,and lamina propria mucosa of conjunctiva in the treatment of severe blepharoptosis.In cases of epicanthal folds with associated telecanthus,epicanthoplasty and medial canthal tendon shortening（内眦韧带缩短）were performed simultaneously to enlarge the palpebral opening and to release the tension of the upper medial eyelid skin and tethering fold,which impedes（阻止）the action of eyelid elevation.,17,PATIENTS AND METHODS,Between January of 2004 and September of 2012,we recruited 50 Korean patients with severe blepharoptosis(degree of ptosis,4 mm)for this study.The 50 patients(85 eyelids)underwent the advancement technique using the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva composite flap.Twenty-one of 50 patients(42 percent,42 eyelids)had epicanthal folds with associated telecanthus and therefore underwent epicanthoplasty and shortening of the medial canthal tendon.,18,Operative Technique,The double eyelid incision line is marked on the upper eyelid 6 to 9 mm above the lid margin,depending on the personal preference of patients without double eyelids.Modified V-W plasty is designed on the skin medial to the epicanthal folds of patients with blepharoptosis and epicanthal folds with associated telecanthus.Epicanthal folds with associated telecanthus are corrected before ptosis correction is performed.The operation is usually performed with the patient under local anesthesia with intravenous or oral sedation.,19,20,Correction of Severe Blepharoptosis,An incision is made along the double eyelid mark after subcutaneous infiltration with 1%lidocaine with 1:100,000 epinephrine.Epinephrine is omitted during deeper injection to prevent stimulation of the Mllers muscle.The upper anterior surface of the tarsal plate and the orbital septum are exposed after excision of pretarsal soft tissue.The orbital septum is cut at its lowest part and the protruding orbital fat is partly excised to expose the levator aponeurosis.Tetracaine（丁卡因）eye drops are applied to the cornea（角膜）,and corneal eye protectors are applied to the globe.,21,The levator aponeurosis,Mllers muscle,and lamina propria mucosa of conjunctiva are then detached carefully from the superior tarsal border and underlying conjunctival epithelium with sharp iris scissors with the help of these three traction sutures.Injection of pure lidocaine into the superior portion of the tarsus facilitates the detachment of the Mllers muscle and the lamina from the superior tarsal border and the conjunctival epithelium by causing the tissues to balloon up slightly.In some cases,dark cornea is visible through the conjunctival epithelium.The detached levator aponeurosisMllers musclelamina propria mucosa composite flap is advanced onto the anterior surface of the tarsus.,22,23,24,RESULTS,Fifty patients(85 eyelids)with ptosis greater than 4 mm were operated on(Table 1).Of these patients,38(76 percent)had congenital ptosis and 35(70 percent)had bilateral ptosis.Of the 35 patients who had bilateral ptosis,eight exhibited eyelid asymmetry of more than 1 mm.Patient ages ranged from 12 to 89 years(mean age,35.7 years).,25,The degree of ptosis among the 85 eyelids ranged from 4 to 8 mm.Seventy-seven eyelids(90.6 percent)had 4 to 5 mm of ptosis,and eight(9.4 percent)had more than 6 mm.Levator function among the 85 eyelids ranged from 7 to 2 mm.Fifty-five eyelids(64.7 percent)had fair levator function(7 to 5 mm).In primary cases,the advanced composite flap was resected at less than 5 mm(mean,3 mm).In revision cases caused by incomplete correction of ptosis,the composite flap was further advanced and resected by about 3 mm.,26,All patients were followed postoperatively for 6 months to 9 years(Table 2).Complete correction of ptosis(degree of ptosis,1 mm)was obtained in 54 eyelids(63.5 percent),and mild residual ptosis(degree of ptosis,2 mm)was seen in 22 eyelids(25.9 percent).In the nine eyelids with moderate residual ptosis(degree of ptosis,3 mm),two patients(four eyelids)underwent autogenous fascia lata（自体阔筋膜）suspension to the frontalis muscle because of poor levator function.The remaining patients refused the procedure.,27,The most common complication was incomplete correction of ptosis.Reoperation was performed in 15 eyelids,with further advancement of the composite flap.In 41 eyelids(48 percent),lagophthalmos of 1 to 2 mm and mild lid lag were present for the first few months postoperatively but were seen to resolve after 6 months,except in three patients who were lost to follow-up.Minor complications,such as chemosis(结膜水肿),ecchymosis（瘀斑）and corneal irritation（角膜刺激）,were well recovered by conservative treatments such as eye lubricants（润滑剂）.,28,Fig.4.A 49-year-old man presented with bilateral congenital blepharoptosis.(Above,left)Preoperative straight-ahead gaze.(Above,right)One-year postoperative results after advancement of the composite flap.(Below)Closure of eyes.,29,30,Fig.6.A 26-year-old man presented with bilateral congenital blepharoptosis and epicanthal folds associated with moderate telecanthus.(Above,left)Preoperative straight-ahead gaze.(Above,right)Two-year postoperative(Below,left)Upward gaze.(Below,right)Downward gaze.,31,DISCUSSION,32,We have been interested in the advancement technique of using the levator aponeurosisMllers muscle composite as a flap in the correctionof blepharoptosis,and have reported the results.We found that eyelid elevation was still deficient for using this technique in patients with severe ptosis.After gaining a further understanding of the deeper connection between the lamina propria mucosa of conjunctiva and the check ligament of the superior fornix,we incorporated the lamina into the composite flap。We postulated that simultaneous advancement of the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva composite as a flap produces stronger power to correct severe ptosis.,33,The levator aponeurosis is connected superiorly to the levator palpebrae superioris muscle（提上睑肌）and the Whitnalls ligament,and has firm osseous insertion at the medial and lateral horns.Advancement of the distal levator aponeurotic margin downward on the tarsal plate raises the tarsus dynamically by increasing levator function and statically by pulling on the elastic Whitnalls ligament and shortened levator aponeurosis itself.,34,Mllers muscle has normal function even in severe ptosis and has 2 to 3 mm of eyelid lifting power.Mllers muscle is an important terminal attachment of the levator muscle to the superior tarsal border,and shortening the Mllers muscle may augment its physiologic role by increasing the tensile strength of the muscle.,35,The lamina propria mucosa of the conjunctiva is continuous with the elastic check ligament of the superior fornix,and shortening the lamina propria mucosa pulls on the check ligament.Therefore,advancement of these three distinct anatomic structures simultaneously to the tarsal plate produces integrated power to raise the upper eyelid in a natural superior-posterior vector.,36,Patients with severe eyelid ptosis attempt to use three muscles to maximize eyelid opening.The initial attempt is by the primary component of eyelid elevationthe levator muscle（提上睑肌）.The next phase of eyelid opening that patients attempt involves use of the superior rectus muscle（上直肌）to look upward.The third phase is the use of the frontalis muscle（额肌）.,37,the check ligament is connected anteriorly to the levator palpebrae superioris muscle and posteriorly to the superior rectus muscle.pulling the check ligament pulls the levator palpebrae superioris muscle and the superior rectus muscle.,38,One can postulate假定 that the check ligament pulls the superior rectus muscle more directly since the connection between the check ligament and the levator palpebrae superioris muscle allows some gliding motion,while the connection between the check ligament and the superior rectus muscle is relatively firm.,39,Another advantage of using the levator palpebraesuperioris muscle,Mllers muscle,and superior rectus muscle,compared with using just one muscle,is the reduced shortening of one particular muscle.Distributing the shortening to other eye elevating muscles and augmenting the physiologic component of eyelid elevation allows decreased eyelid shortening to gain the same lifting effect.In theory,this should induce less lagophthalmos and lid lag,as noticed in our results.,40,In severe ptosis correction,there is an increased chance of postoperative double eyelid asymmetry,since a significant change in the positioning of the levator aponeurosis is made during ptosis correction.These patients often need revisional surgery for fold asymmetry.In extreme cases of severe ptosis with very poor levator function,we recommend the frontalis sling method.For our technique to be effective,we believe that some levator function should exist.,41,CONCLUSIONS,42,The technique of advancement of the levator aponeurosisMllers musclelamina propria mucosa of conjunctiva composite as a flap was effective in the treatment of severe ptosis with preexisting levator function of greater than 2 mm.In patients with epicanthal folds with associated telecanthus,epicanthoplasty and medial canthal tendon shortening enlarged the palpebral fissure opening and eliminated the constricting factors that hinder upper eyelid elevation.Our technique produced physiological eyelid excursion in a superior-posterior direction.The amount of resected advanced composite tissue stump was less than 5 mm,and there were no serious complications,such as long-term lagophthalmos or lid lag.,43,44,Thank you!,