鼻筛眶骨骨折后继发畸形的二期重建

目的 探讨鼻筛眶骨骨折继发畸形的修复方法。方法 手术采用头皮冠状切口入路或邻近瘢痕切口入路，充分显露额鼻眶区骨折部位，用小裂钻行眶内缘弧形截骨，将突起的骨折块截除并打磨平整，缩窄两眶内缘之间的宽度。根据需要用2～3条自体颅骨外板叠加塑成鼻支架，在鼻根部用微型钛板将支架固定于额骨鼻突。充分松解内眦韧带与邻近组织的瘢痕粘连，避免复位时存在张力，必要时于眶底处充分剥离松解眶骨骨膜并纵行切开减张，使内眦韧带尽量在无张力的情况下牵拉复位至泪囊窝后上方，用钢丝穿经鼻骨固定。采用自体颅骨外板或高密度多孔聚乙烯(Medpor)修复眶内壁及其它眶壁缺损，矫正眼球内陷畸形。结果 1996年12月～2001年12月，共治疗严重鼻筛眶骨骨折晚期继发畸形患者34例，其中同时合并眶颧骨折12例、额骨骨折4例、Le Fort Ⅲ型骨折l例及Le Fort Ⅱ型骨折l例。所有患者术后畸形均获明显改善。结论 鼻筛眶骨骨折后期继发畸形手术的重点在于应用自体骨重建鼻背骨性支架，重塑鼻背轮廓；双侧眶内缘骨折突起截骨缩窄，内眦韧带复位固定和内眦整形矫正创伤性内眦距增宽，恢复鼻根部高度与内眦间距的协调比例关系；同时眶壁植骨矫正眼球内陷畸形。     

外伤性眶颧部骨折治疗50例临床分析

目的探讨根据不同的损伤类型及程度，选择性运用眶周截骨术及眶内充填术，对50例眶颧部骨折患者的整复治疗效果。方法根据眶颧部骨折的不同损伤程度，采用眶壁眶缘截骨术，恢复眼眶的解剖结构，并根据骨块复位程度．选用自体或医用材料进行眶周和眶内骨膜下充填，修复眼眶。结果50例患者术后双侧眼球突出度、面中部对称性，宽度等均较手术前有明显改善。本组有2例长期复视，5例术后有轻度眼球凹陷。结论眶周截骨复位术，辅助选用眶内材料充填可以有效矫正陈旧性眶颧部骨折畸形。     

微型钛板固定整复陈旧性眶底、眶骨骨折伴邻近颅面骨骨折

目的 探讨陈旧性爆裂眶底、眶骨骨折伴邻近颅面骨骨折所致面部畸形，整复后应用微型钛板（microplate）固定的临床疗效。方法 对20例陈旧性眶底、眶骨骨折患者，根据CT扫描和三维成像诊断，重新截骨复位，用微型钛板根据骨折部位和形态，采用跨2～3个骨折线固定，或将钛板越过粉碎骨折部位，呈桥状两端固定。结果 无论眶底眶缘单纯骨折或粉碎性骨折错位愈合，在整复后微型钛板固定，完全修复了颜面畸形，并恢复了眼球运动和咀嚼功能。随访6个月至1年，无1例发生钛板排斥反应或断裂脱落等并发症。结论 微型钛板可以达到眶骨骨折复位后坚强内固定，是目前整复眶骨和颜面部骨折最有效的固定方法之一，并且使用方法简便，容易掌握。     

眶骨骨折继发眼球内陷的外科治疗

目的　对眶骨骨折进行分类 ,明确导致眼球内陷的原因并采取相应的手术治疗 ,提高眼球内陷畸形的手术矫治效果。方法　所有患者术前常规X线片、眶部轴面及冠面CT检查。根据检查结果 ,将眶骨骨折主要分为两型 :Ⅰ .单纯眶壁骨折 ,眶缘完整。此类骨折的部位主要发生在骨壁薄弱的眶底及眶内壁。Ⅱ .构成眶骨的骨骼骨折移位造成的眶骨的破裂。多见于眶颧骨折和鼻筛眶骨折。对Ⅰ型骨折所导致的眼球内陷畸形经下睑睫毛缘下切口入路 ,采用自体骨或人工骨材料置入修复 ;Ⅱ型骨折所造成的眼球内陷首先将移位的骨折块截骨复位、小夹板坚强内固定 ,重建正常的眶缘并采用自体或人工材料置入同时修复眶壁。结果　自 1996年 7月 - 2 0 0 0年 10月 ,共治疗眼球内陷畸形患者 5 2例 ,其中Ⅰ型 10例 ,Ⅱ型4 2例。眼球内陷畸形均明显矫正。结论　眶骨骨折所造成的后期眼球内陷畸形主要是因为眶骨骨性容积增大所造成的眶内容物与眶骨骨性容积失衡的结果 ,可通过植骨的手段修复眶骨各壁的缺损、缩小扩大的眶腔、重建眶骨正常的解剖形态和眶容积而得以有效的矫正。     

复合性眶周骨折的综合修复探讨

目的 探讨复合性眶周骨折的综合修复方法.方法 根据患者骨折的解剖结构、症状、外形及创口特点,应用表面微小切口或冠状切口,松解复位后,以钛板坚固内固定颅颌眶骨,辅以预成型钛网、羟基磷灰石修复骨缺损;对于继发鼻畸形者,可Ⅱ期鼻整形修复;对于伴眼内容物创伤者,联合眼科行肌肉松解、眶内衬垫填充法眶壁修补术;对于严重的眼球损伤,则由眼科医师行眼内容物剜除+义眼台植入术;对于伴发内眦韧带断裂致眼角变形者,手术探查内眦韧带并将之固定于鼻嵴相应处或Ⅱ期行眼角开大术,同期请眼科医师探查泪道损伤;对于伴发眶尖综合征或眶上裂综合征者,联合神经外科进行手术或通过Ⅱ期手术矫正上睑下垂.结果 本组共28例患者(32只眼),术后随访3～12个月.1例伴发眶尖综合征患儿术后仍存在轻度上睑下垂,2例眼球内陷患者术后仍存在眼球突度不对称,1例伴发低鼻歪鼻患者术后仍存在轻度的歪鼻畸形;其余24例患者外形较满意,眼睑及眼球运动自如,眼球突度对称,复视消失,鼻部及面形良好.结论 对于复合性眶周骨折的修复,既应对局部进行针对性骨折片复位,又需考虑整体进行综合修复,以达到最佳的治疗效果.     

颅内外联合入路矫治严重额眶骨折后遗畸形

目的：探讨颅内外联合入路治疗额眶骨折后遗畸形的有效方法。方法：根据有无大块骨质缺损额眶骨折主要分为两类：①额眶部大块骨组织缺损。②额眶部骨折塌陷，无大块骨组织缺陷。二者均经颅内外联合入路充分显露骨折部位，前者主要采用自体颅骨外板及人工骨行额眶部骨缺损的修复重建，后者则运用截骨复位、小钛板坚强内固定、植骨等颅颌面外科技术修复。结果：1998年6月－2000年10月，共治疗额眶骨折后遗畸形18例，其中同时合并大块骨组织缺损者12例，额眶部骨折塌陷，无大块骨组织缺损者6例，所有患者畸形明显改善，外形及功能恢复良好。结论：颅内外联合入路较单纯颅外入路更能清晰显露额眶骨折的部位，便于手术操作，与颅颌面外科各项技术灵活结合，可收到良好的手术效果。     

外伤后眶骨畸形伴眦角移位后期整复的近期疗效

目的 探讨外伤后眶骨畸形伴眦角移位的二期修复方法. 方法 1998年6月-2007年7月,收治外伤后陈旧性眶骨骨折畸形伴内、外眦韧带断裂移位37例.男22例,女15例;年龄13～46岁,平均21岁.车祸伤29例,拳击伤6例,木棍击伤2例.伤后至该次手术时间3个月～8年.眶颧骨折11例,鼻眶筛骨折15例,合并眶颧、鼻眶筛骨折8例,额骨骨折3例.第1次接受整复手术3l例,第2次手术6例.手术采用头皮冠状切口、下睑睫毛缘切口及口内龈颊沟切口入路,根据骨折畸形错位程度分别将骨折截断复位或对凸起处凿除磨平、凹陷处充填固定,重建正常眶缘结构:自体骨或Medpor眶内容充填薄片修复眶下壁,矫正眼球内陷畸形:充分松解内眦韧带与邻近组织的瘢痕粘连,根据眶内侧壁骨折有无移位情况,选择钢丝直接固定或骨折片复位后行内眦韧带固定术. 结果 36例术后切口I期愈合,1例因合并上颌窦炎引起重建眶下缘的肋骨感染致手术失败.其中24例获随访,随访时间3～6个月,未见植入物移位、排斥脱出及感染等并发症.12例眼球内陷患者有2例矫正不足.18例内眦韧带断离眦角移位的患者有3例矫正不足.其余患者外观明显改善,术后6个月对3例自体骨和Medpor移植患者行CI检查,显示固定良好. 结论 外伤后眶骨骨折伴眦角移位的畸形后期修复应重视骨折复位与填充,同时兼顾眦角移位修复和眼球内陷矫正,全面考虑,综合治疗才能取得理想效果.     

睑袋成形术并发泪囊功能不全

目的 探讨睑袋成形术导致泪囊功能不全的原因和治疗方法。方法 对睑袋成形术后无睑外翻出现溢泪的患者，进行泪道功能检查，功能不全者行下睑睑部眼轮匝肌缩短或断端吻合，下睑眶部眼轮匝肌上移手术。结果 28例患者因睑袋成形术后并发泪囊功能不全，再次手术时均发现有过量切除或未能缩紧（或缩紧不足）睑部眼轮匝肌。经手术加强睑部眼轮匝肌张力后，泪囊“泵”功能恢复，溢泪消失。结论睑袋成形术中，对多余及松弛组织去除量的控制不当，或术中未能有效地恢复下睑各层结构张力的平衡，尤其是下睑睑部眼轮匝肌张力明显减弱时，其泪囊的“泵”作用消失，出现功能性溢泪。通过手术恢复下睑轮匝肌张力的“泪泵”功能，有效地治疗了因睑袋成形术所并发的泪囊功能不全。     

复杂眶骨骨折的手术治疗

影响外形和眼球运动功能的复杂眶骨骨折,在头面部外伤中常见。本院近3年来,手术治疗了28例复杂眶骨骨折,疗效满意。报告如下。1临床资料1.1一般资料:28例中,男20例,女8例。眶内侧壁骨折或眶下壁骨折(包括击出性和击入性骨折)分别为8例、4例;两者均同时骨折为8例;颧骨及眶外侧壁击入性骨折为5例;上述3种骨折类型均具有,且存在Lefort-Ⅲ型骨折3例。28例均有复视、外观畸形、眼球运动障碍等症状。其中,眶内容物塌陷入上颌窦内的有4例。1.2治疗方法:28例患者均由耳鼻咽喉-头颈外科独立操作完成。8例眶内侧壁骨折者,采用经鼻内窥镜手术治疗:切除…     

眶颧复合骨折的综合手术整复

目的：评价眶颧复合骨折综合手术整复治疗的效果。方法：对眶颧复合骨折的患者施行早期骨折复位、钛钉钛板坚强内固定手术,部分眶容积增大的患者手术同期或术后2期行Medpor垫片眶内充填术矫正眼球凹陷。结果：25例眶颧复合骨折的患者接受了综合手术整复,均取得良好效果。结论：眶颧复合骨折伤后早期手术可以使眶颧骨折解剖学复位,眼球内陷患者通过Medpor垫片充填骨折区可减小眶容积,有效地矫正眼球凹陷。     

麻风麻痹性下睑外翻矫治的远期疗效

目的分析麻风所致麻痹性下睑外翻手术矫治的远期疗效。方法对术后已随访2～4年的74例(115只眼)麻风麻痹性下睑外翻手术病例进行了手术前后的分析。手术方法包括内眦成形、内眦韧带悬吊、内眦切除、外侧睑板悬吊、外眦成形和睑缩短术等。结果结膜充血从93只眼减少到40只眼(减少57%);溢泪从107只眼(轻度24只眼、中度36只眼、重度47只眼)减少到90只眼(轻度40只眼、中度32只眼、重度18只眼);睑闭合不全(轻闭时)从平均68mm下降到53mm(减少221%);角膜病变从51只眼减少到36只眼(减少294%)。手术前后平均视力无改变。总体手术疗效优18只眼(157%),良45只眼(391%),一般41只眼(357%),差11只眼(96%)。结论麻风麻痹性下睑外翻手术矫治对患者的角膜有一定的保护作用,并可改善结膜充血和溢泪等症状。     

Two cases of primary malignant melanoma of the lacrimal sac

BACKGROUND: Malignancy of the lacrimal sac is rare, and primary malignant melanoma in this region is extremely rare. METHODS: We report two cases of malignant melanoma of the lacrimal sac presented with epiphora and a palpable mass in the medial canthal area. We performed radical surgery and radiation therapy. RESULTS: The light microscopic, immunohistochemical, and electron microscopic studies confirmed the diagnosis. One of the patients, a 65-year-old-woman, has no evidence of recurrence or distant metastasis 3 years after surgery and radiotherapy, whereas another patient, a 56-year-old man, died of distant metastasis 6 months after surgery and radiotherapy. CONCLUSIONS: We present two cases of malignant melanoma of the lacrimal sac that masqueraded as chronic dacryocystitis. Head and neck surgeons should be aware of this disease entity when encountered with patients with epiphora and mass in the medial canthal area.     

Surgical treatment of the nasolabial angle in balanced rhinoplasty

Aesthetic rhinoplasty is a complex surgical procedure that contains numerous components; when performed harmoniously, it should yield a successful, balanced result. The process begins with a comprehensive nasal analysis and surgical planning. Many surgeons concentrate on altering the nasal dorsum and nasal tip but may ignore potential contributions to overall appearance from the caudal nasal septum and nasal spine. One of the key parameters for evaluation and aesthetic treatment of the nose is the nasolabial angle. The nasal spine, caudal septum, and the medial crura of the lower lateral cartilages provide the framework for this area. Alteration of these structures, as well as nasal tip rotation and projection, may affect the resultant nasolabial angle, length of the upper lip, and overall harmony of the nose. Fullness at the nasolabial junction by a pushing philtrum may also result in an unbalanced appearance. The literature is replete with methods for categorizing the nasal tip and recommended surgical treatments. Treatment of the caudal septum and the nasal spine is often an afterthought that is left to the aesthetic judgment of the surgeon. A chart-with recommended treatment for the caudal septum and nasal spine following appropriate profile analysis-is included in the interest of a more systematic process. The chart takes account of the length of the nose, nasolabial angle, and possible presence of a pushing philtrum with suggested treatments to allow for proper tip placement and aesthetic balance to the nose. Adherence to this process provides a valuable tool for assuring a harmonious result in rhinoplasty.     

改良鼻侧缝合点缩短内眦韧带矫正重度内眦赘皮

目的：探讨重度内眦赘皮矫正术的手术要点,旨在尽量减少术后赘皮复发,缩短瘢痕恢复时间。方法：将内眦部横行切口延长至下睑缘内侧,通过此切口,彻底松解局部错构的眼轮匝肌,充分暴露内眦韧带前支鼻侧骨膜隆突止点,将其与内眦韧带起点缝合,折叠缩短内眦韧带,矫正重度内眦赘皮,同时完成重睑成形术。结果：2004年9月～2009年6月临床应用28例,其中25例得到半年以上随访,内眦赘皮矫正效果良好,切口瘢痕恢复快,重睑形态自然。结论：采用改良鼻侧缝合点折叠缩短内眦韧带,结合松解错构的眼轮匝肌矫正重度内眦赘皮,同期行重睑成形术,手术效果明显、稳定,患者满意度高。     

A case of epiphora and recurrent basal cell carcinoma of the nasal tip and review of acquired nasolacrimal system obstruction

A case of a 67-year-old man with recurrent basal cell carcinoma of the nasal tip and an incidental symptom of epiphora (volunteered by the patient) is presented. Epiphora is an abnormal overflow of tears that fail to drain into the inferior nasal meatus via the nasolacrimal system. Within the differential diagnosis of epiphora and nasolacrimal obstruction is neoplasm – primary, secondary or metastatic. On further investigation, including computed tomography imaging, he was subsequently found to have invasive disease extending along the left embryological cleavage plane superiorly to the medial canthal tendon. An excision attempt using Mohs technique by the dermatological surgeon was unsuccessful in adequately clearing the margins, and revealed a diagnosis of morphea-like basal cell cancer. This failure, taken together with the extent of disease identified by computed tomography scan, resulted in significant alteration of the operative approach. The patient underwent extensive tumour extirpation and nasal reconstruction using a forehead flap.The present case alerts surgeons involved in the management of skin cancers to the importance of the anatomical relationship of the nasolacrimal apparatus to embryological soft tissue cleavage planes when dealing with recurrent and aggressive lesions. In addition, it serves as a reminder to inquire about the signs and symptoms associated with nasolacrimal obstruction. Moreover, when preparing for surgical excision of recurrent aggressive basal cell carcinoma, high-quality imaging is essential to tailor the operative plan.     

非连续性重睑术同期横切法内眦赘皮矫正

目的:寻找一种能减少内眦赘皮矫正术后内眦瘢痕的手术方法。方法:重睑线内侧端与内眦点处留有3~5mm未切开的皮嵴,内眦赘皮采用横切法同时将内眦韧带折叠缝合固定在鼻骨骨膜上。结果:本组42例随访6~18个月,其中1例因内眦点固定不牢,术后外形欠满意,4例在内眦点处有点状瘢痕,其余外形满意,内眦瘢痕不显。结论:该手术方法可以明显减少内眦瘢痕的发生率,是一种值得推广的手术方法。     

羟基磷灰石微粒人工骨注入隆鼻的效果

目的探讨利用羟基磷灰石微粒人工骨（partical hydroxylaptite artificial bone, HA）修复鞍鼻的可行性及规范的手术操作;以及隆鼻失误后如何适当取出。方法用眼科剪或骨膜剥离器紧贴鼻骨,由鼻小柱旁切口进入,于鼻背筋膜深层分离隧道,在隧道内置入羟基磷灰石微粒,手法按摩塑形,缝合切口。结果18年HA注入隆鼻15000例,获随访6482例,优良率占94％,差和失败率占6％。结论对于鞍鼻和鼻外形基本正常而苛求尽善尽美者,利用HA注入隆鼻法,可获得满意、长期、稳定的效果,不失为一种可供选用的隆鼻方法。     

先天性睑裂狭小综合征74例的手术矫治

目的总结过去20年中，使用不同的手术方法治疗74例先天性睑裂狭小综合征的远期效果。方法针对74例先天性睑裂狭小综合征的临床特点，采用Ⅰ期或Ⅱ期的内外眦开大术和／或上睑下垂矫正术，24例患者接受了最长达9年的术后随访。结果54例矫正内眦赘皮常规采用墨氏法(Mustarde法)，但对20例轻度者采用了其他的内眦成形术；行内眦开大术时，36例选择性的施行了内眦韧带缩短术；在无上睑横向张力增加的情况下，33例选择行Ⅰ期先天性睑裂狭小综合征矫正术，其余41例行Ⅱ期矫正；经随访，Ⅰ期和Ⅱ期均能获得满意的手术效果；对患者合并的其他畸形，应根据情况待成年后酌情处理。结论在正确选择手术适应证的情况下，采用Ⅰ期或Ⅱ期的内外眦开大术和／或上睑下垂矫正术治疗先天性睑裂狭小综合征，均能取得较好的效果。     

Surgical treatment of the nasolabial angle in balanced rhinoplasty

Nasal analysis and surgical planning are crucial for a successful, aesthetically pleasing rhinoplasty. One of the key parameters for evaluation is the nasolabial angle. The nasal spine, caudal septum, and medial crura of the lower lateral cartilages provide the framework for this area. Alteration of these structures, as well as nasal tip rotation and projection, may affect the resultant nasolabial angle, length of the upper lip, and overall harmony of the nose. Fullness at the nasolabial junction caused by a pushing philtrum may also result in an unbalanced appearance. The literature is replete with methods for categorizing the nasal tip and with recommendations for surgical treatment. Treatment of the caudal septum and nasal spine is often an afterthought that is left up to the aesthetic judgment of the surgeon. To make this a more systematic decision, in 1990 we devised a classification for analysis and treatment of this area. This study included the length of the nose, the nasolabial angle, and the presence of a pushing philtrum, with suggested treatment to allow proper tip placement and to provide aesthetic balance to the nose. The only modification was in the order of presentation of nasal types. Since that publication, the senior author has consistently followed these guidelines and has found them to be a reliable tool in creating a harmonious result in rhinoplasty.