经结膜入路下睑袋矫正术联合脂肪来源干细胞基质胶移植在眶下区年轻化中的效果分析

经结膜入路下睑袋矫正术联合脂肪来源干细胞基质胶移植在眶下区年轻化中的效果分析

吴闯严志杨名何宸

本文来源：《中华整形外科杂志》2023年2月第39卷第2期

DOI:10. 3760 / cma.j.cn114453-20220709-00214

作者单位：武汉市第一医院整形外科，武汉430022

通信作者：严志，Email：59599744@qq.com

引用本文

吴闯，严志，杨名，等. 经结膜入路下睑袋矫正术联合脂肪来源干细胞基质胶移植在眶下区年轻化中的效果分析 [J] . 中华整形外科杂志, 2023, 39(2) : 134-140. DOI: 10.3760/cma.j.cn114453-20220709-00214.

【摘要】

目的探讨经结膜入路下睑袋矫正术联合脂肪来源干细胞基质胶（SVF-gel）移植在眶下区年轻化中的应用效果。

方法回顾性分析2019年4月至2021年4月武汉市第一医院整形外科门诊收治的眶下区年轻化患者的临床资料。根据术前照片对泪沟畸形进行Hirmand分型。术中采用经结膜入路去除膨出的眶隔脂肪，同时抽取腹部或大腿脂肪制备SVF-gel，进行泪沟或眶下区凹陷注射填充治疗。术后对患者进行随访观察，记录手术相关并发症。术前、术后根据泪沟畸形等级量表（TTRS），分别对泪沟凹陷深度、色素沉着程度、颧脂肪垫下垂程度及下睑皮肤皱褶程度进行评分，总分越高提示泪沟畸形越严重；根据Barton美学评级标准，对眶-颊结合部的形态进行评级（0~3 级）；结合患者手术效果满意度调查表（非常满意、满意、不满意3个等级），综合分析患者下睑袋及泪沟矫治的美学效果。采用SPSS 22.0软件进行统计学分析，呈正态分布的计量资料用±s表示，术前、术后TTRS评分比较采用配对样本t检验，P＜0.05为差异有统计学意义。

结果共纳入92例双侧下睑袋伴泪沟或中面部凹陷患者。其中男15例，女77例，年龄（38.8±9.6）岁（21~55岁）。术前Hirmand泪沟分型：Ⅱ型37例、Ⅲ型55例。所有患者术后3 d均有不同程度结膜水肿及下睑肿胀，其中35例出现不同程度的皮肤淤斑，术后1~2周均自行恢复，均未出现血肿、复视、脂肪液化、脂肪结节及脂肪栓塞等并发症。术后随访6~12个月。术前、术后TTRS评分比较：与术前比较，Hirmand泪沟Ⅱ型患者［（2.37±0.78）分 vs. （4.83±0.98）分，t=36.54，P<0.001］和Ⅲ型患者［（2.61±0.60）分 vs. （5.38±0.93）分，t=55.20，P<0.001］的TTRS评分在术后均有明显降低，差异均有统计学意义。术前、术后Barton美学评级比较：对于HirmandⅡ型患者，术前评级为1级7例、2级19例、 3级11例，术后改善为0级36例、1级1例；对于Hirmand Ⅲ型患者，术前评级为2级20例、 3级35例，术后改善为0级50例、1级5例。术后患者满意度调查：非常满意85例（92.4%）、满意5例（5.4%）、不满意2例（2.2%）。2例不满意患者中1例因泪沟畸形改善效果不明显，3个月后行第2次 SVF-gel填充，达到满意效果；1例患者因术后下睑外侧仍有睑袋，3个月后再次手术矫正，达到满意效果。

结论对于无明显皮肤松弛的下睑袋伴泪沟或眶下区凹陷患者，采用经结膜入路下睑袋矫正术联合SVF-gel移植术治疗，可以达到眶下区年轻化的效果。

【关键词】干细胞；下睑袋；泪沟；下睑袋矫正术；脂肪来源干细胞基质胶

Effect analysis of transconjunctival lower blepharoplasty combined with stromal vascular fraction-geltransplantation in suborbital rejuvenation

Wu Chuang, Yan Zhi, Yang Ming, He Chen

Department of Plastic Surgery, Wuhan No.1 Hospital, Wuhan 430022, China

Corresponding author: Yan Zhi, Email: 59599744@qq.com

【Abstract】

Objective To investigate the effect of transconjunctival lower blepharoplasty combined with stromal vascular fraction-gel (SVF-gel) transplantation in suborbital rejuvenation.

Methods The clinical data of patients with suborbital rejuvenation who were admitted to the Department of Plastic Surgery, Wuhan No.1 Hospital from April 2019 to April 2021 were retrospectively analyzed. Hirmand classification of tear trough deformity was performed based on preoperative photographs. The expanded orbital septum fat was removed through the conjunctival approach, and the SVF-gel was extracted from the fat which was harvested from abdomen or thigh. The tear trough or suborbital depression was corrected by SVF|gel injection. The patients were followed up and the complications related to the operation were recorded. According to tear trough rating scale (TTRS), the depth of tear trough depression, the degree of pigmentation, the sagging degree of zygomatic fat pad and the degree of lower eyelid skin fold were scored before and after operation. The higher the total score indicates the greater severity of the lacrimal groove deformity. The morphology of the orbitalbuccal junction was rated (0 to 3) according to the Barton aesthetic rating criteria. The aesthetic effects of lower eyelid bag and tear trough correction were comprehensively analyzed based on the satisfaction questionnaire (very satisfied, satisfied, dissatisfied 3 grades). SPSS 22.0 software was used for statistical analysis, and the normally distributed measurement data were represented by Mean±SD. Paired sample t-test was used to compare preoperative and postoperative TTRS scores, and P<0.05 was considered statistically significant.

Results A total of 92 patients with bilateral lower eyelid bag accompanied by tear trough or middle facial depression were included. There were 15 males and 77 females, aged (38.8±9.6) years (21-55 years). Preoperative Hirmand tear trough classification was performed as type Ⅱ in 37 cases, as type Ⅲ in 55 cases. All patients had conjunctival edema and lower eyelid swelling of different degrees 3 days after surgery, among which 35 patients had skin ecchymosis of different degrees, which recovered spontaneously 1 to 2 weeks after surgery, and no complications such as hematoma, diplopia, fat liquefaction, fat nodule and fat embolism occurred. Postoperative followup was conducted for 6 to 12 months. Comparison of preoperative and postoperative TTRS scores: compared with preoperative results, the TTRS scores of Hirmand type Ⅱ patients ［(2.37±0.78) points vs. (4.83±0.98) points, t=36.54, P<0.001］ and type Ⅲ patients ［(2.61±0.60) points vs. (5.38±0.93) points, t=55.20, P<0.001］ were significantly decreased after surgery, and the differences were statistically significant. Comparison of Barton aesthetic rating before and after surgery: for Hirmand type Ⅱ patients, preoperative rating was grade 1 in 7 cases, grade 2 in 19 cases, grade 3 in 11 cases, and postoperative improvement was grade 0 in 36 cases and grade 1 in 1 case; for Hirmand type Ⅲ patients, preoperative ratings were grade 2 in 20 cases, grade 3 in 35 cases, and postoperative improvement was grade 0 in 50 cases, grade 1 in 5 cases. Postoperative patient satisfaction survey: 85 cases (92.4%) were very satisfied, 5 cases (5.4%) were satisfied, 2 cases (2.2%) were dissatisfied. For the 2 patients who were not satisfied, one patient had no obvious improvement due to tear trough deformity, and was filled with SVF-gel for the second time 3 months later, achieving satisfactory results. One patient still had baggy eye on the outer side of the lower eyelid after surgery, which was corrected again 3 months later and achieved satisfactory results.

Conclusion For patients with lower eyelid bag with tear trough or suborbital depression without obvious skin relaxation, lower eyelid bag correction through conjunctival approach combined with SVF-gel transplantation can achieve the effect of rejuvenation of the suborbital region.

【Key words】Stem cells; Lower eyelid bag; Tear trough; Lower eyelid bag removal; Stromal vascular fraction-gel

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: Ethical approval was given by the Medical Ethics Committee of Wuhan No.1 Hospital(W202207-3).

眶下区的衰老外观常表现为下睑袋膨出、泪沟或眶下区凹陷、颧颊部脂肪下垂、下睑皮肤松弛、皱纹以及皮肤暗沉（“黑眼圈”）等问题，呈现出疲惫面容，影响生活和社交［1］。眶下区年轻化的手术治疗主要围绕解决这些问题展开，治疗方法有经皮肤入路或者结膜入路眶隔脂肪祛除术［2］、眶隔脂肪释放重置术［3］或眶隔脂肪游离回填术［4］等，临床报道较多。近年来，对脂肪来源干细胞基质胶（stromal vascular fraction-gel，SVF-gel）的研究不断深入，为眶下区年轻化的治疗提供了新思路［5-7］。笔者在临床实践中针对下睑袋伴泪沟或眶下区凹陷患者，采用经结膜入路下睑袋矫正术联合SVF-gel移植术治疗，积累了一定的经验，报道如下。

资料与方法

一、资料选择

回顾性分析2019年4月至2021年4月武汉市第一医院整形外科门诊收治的眶下区年轻化患者的临床资料。纳入标准：（1）初次行下睑手术者；（2）有下睑袋伴泪沟畸形或眶下区凹陷者；（3）无明显下睑皮肤松弛，皮肤弹性尚可者（无需行外切眼袋）；（4）手术方式采用经结膜入路下睑袋矫正术联合SVF-gel移植术。需满足以上全部条件时，才可纳入本研究。排除标准：（1）下睑有内翻、外翻或缺损畸形者；（2）下睑局部区域既往有外伤瘢痕者。

本研究已获得武汉市第一医院伦理委员会批准（W202207-3），所有患者均签署手术知情同意书，对手术治疗过程及风险知情同意，并同意将其资料用于本研究。

二、方法

（一）手术方法

1. 术前准备：所有患者术前均行血常规、凝血功能、胸部X线片、心电图、传染病相关检查。术前通过数码相机采集患者的正位及45°侧位照片。按照Hirmand法对其泪沟进行分型［8］：Ⅰ型，眶内侧凹陷，平缓地向颊部走行；Ⅱ型，眶内侧区至眶中部容量缺损，颊部中等程度容量不足；Ⅲ型，眶周自中央至两侧完全性凹陷，伴颧颊沟形成。患者取坐位，仰视下标记下睑袋明显膨出的位置、泪沟及中面部凹陷的范围。评估下睑皮肤、眼轮匝肌松弛情况及下睑凹陷所需的填充量。了解术前是否有下睑外翻、睑板退缩或睑球分离症状。标记吸脂部位。

2. 经结膜入路下睑袋矫正术：患者取平卧位，均采用静脉辅助麻醉，术区常规消毒铺巾。用盐酸丙美卡因滴眼液滴眼，单侧1~2滴。翻开下睑暴露穹隆结膜，在双侧下睑结膜深面进行局部浸润麻醉（2％利多卡因5 ml + 生理盐水5 ml + 1∶200 000肾上腺素），每侧约1 ml。在距离睑缘约0.5 cm的结膜面做一长约1.0 cm的切口，切开黏膜，用眼科剪钝性剥离至眼轮匝肌深面、眶隔前间隙平面，暴露眶隔，剪开部分眶隔膜，依次去除膨出的中央、内侧及外侧脂肪团, 继续向眶下缘钝性剥离，直至暴露弓状缘及眼轮匝肌骨性起始部，注射少量麻药，然后在弓状缘处松解泪沟韧带，彻底止血，对合结膜面黏膜切口，可不用缝合。

3. 自体脂肪获取及SVF-gel制备：在静脉麻醉辅助下，使用1.0 mm×350 mm注水针将肿胀液（2%利多卡因10 ml+罗哌卡因10 ml+生理盐水500 ml+1%肾上腺素0.5 ml）均匀注射于腹部或者大腿待吸脂区皮下脂肪层内，使用2.5 mm×350 mm多侧孔吸脂针获取脂肪，静置10~15 min后初步去除底层液体，将静置的脂肪以1 200×g离心3 min，再次去掉底层液体，保留中层脂肪及上层油脂，将其转移至 20 ml 注射器中，先通过1.2 mm孔径的转换接头连接1个空注射器进行反复推注，推注速度约为10 ml/s，推注10~15次，然后换成0.8 mm孔径的转换接头再进行1遍，将脂肪充分乳糜化，然后将装有乳糜化脂肪的注射器在一定负压下进行摇晃，直到脂肪呈“果粒橙样”为止，再将其以2 000×g离心3 min，留取中层胶冻样浓缩物，即得SVF-gel，置入 1 ml 注射器中备用。每获取10 ml脂肪大约产出 1.5 ml SVF-gel。

4. SVF-gel填充：将术前标记的凹陷区域进行眶下神经阻滞麻醉，进针点采用局部浸润麻醉。将1 ml注射器连接25 G钝针，于眶缘外侧隐蔽部位沿外眦垂线与沿鼻翼缘水平线交叉点作为进针点，采用多平面、多隧道及退针均匀注射方式进行填充。（1）于泪沟凹陷区皮下浅层注射SVF-gel，每侧1~2 ml；（2）于中面部凹陷区骨膜浅层及皮下浅层注射SVF-gel，每侧2~3 ml；（3）于下睑肤色暗沉部位的真皮层，用27 G锐针点状注射SVF-gel，每侧 0.3~0.5 ml。填充完后用纱布轻轻抚平，进针点涂红霉素软膏，下睑区无需包扎。

（二）术后处理及随访观察

术后口服抗生素3 d；术后1周内用玻璃酸钠滴眼液（海露，德国URSAPHARM Arzneimittel GmbH公司）滴眼，每天3~4次，2~3滴/次；术后3 d内避免头部剧烈活动，避免剧烈咳嗽或憋气等；术后2周内避免下睑部位受到强力挤压、尽量减少面部表情活动，避免冰敷或者热敷。吸脂口用6.0丝线单纯间断缝合1针，术后10 d拆线；吸脂部位穿戴合适束身衣2~3周。术后门诊随访6~12个月，拍摄正位及45°侧位照片，记录感染、血肿、脂肪液化、脂肪结节、脂肪栓塞等术后并发症情况。

（三）效果评价

1. 泪沟畸形等级量表（tear trough rating scale，TTRS）评分：针对患者术前和术后末次随访照片，应用Sadick等［9］制定的TTRS，对双侧泪沟情况进行评价。TTRS内容包括：（1）泪沟深度，即泪前嵴到泪沟最深处的距离，每1 mm记1分；（2）色素沉着程度，无沉着为1分，轻微为2分，中等为3分，严重为4分；（3）颧脂肪垫下垂程度，下垂轻微为1分，中等为2分，严重为3分；（4）皮肤皱褶程度，褶皱轻微为1分，中等为2分，重度为3分，严重为4分。

2. Barton美学评级：针对患者术前和术后最后1次随访照片，根据Barton美学评级标准［10］，由 2名整形外科主治医师（未参与本组病例诊治）通过术前、术后照片对睑-颊部美学情况进行评级（0~3级）：（1）0级，即外观上不能区分弧形边缘或眶缘的线条，睑颊交界区没有过渡区，表现为平滑、年轻的轮廓；（2）1级，内侧存在轻微线条或凹陷，睑颊连接处横向过渡区平滑；（3）2级，睑颊交界区有中度可见的凹陷，从眶缘内侧延伸到外侧；（4）3级，睑颊交界处分界明显，存在明显的落差。

3. 患者术后效果满意度调查：调查患者对术后效果满意度情况，分为非常满意、满意、不满意 3个等级。

三、统计学分析

采用SPSS 22.0软件进行统计学分析。呈正态分布的计量资料用±s表示，对术前、术后TTRS评分的比较采用配对样本t检验，P＜0.05为差异有统计学意义。

结果

一、一般资料

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