【作者】 陈晖；

【导师】 王先成；

【作者基本信息】 中南大学 ， 临床医学（专业学位）， 2024， 博士

【摘要】 背景:面部脂肪室的发现使面部解剖学研究翻开了新篇章,也使面部整形外科技术得到了新发展。中面部是面部美容整形手术的重点操作部位之一,对中面部脂肪室的解剖学及其临床意义进行研究具有重要意义。据我们了解,这一研究领域目前缺少中面部脂肪室的系统性回顾研究。在文献中,大部分中面部浅层脂肪室的解剖范围、边界较为一致、确定,但是,中面部深层脂肪室的解剖范围、边界仍存在争议。此外,国内尚没有涉及利用染料探究中面部脂肪室的解剖学研究。面部填充是面部年轻化的重要手段之一,基于中面部脂肪室的精准化填充具有良好应用前景,实现中面部脂肪室的3D可视化具有重要临床意义。目的:1.确定各个中面部脂肪室的解剖范围并统一名称,探究中面部脂肪室的解剖学和组织学特点;概述中面部随衰老发生的改变及相关机制。2.探究中面部脂肪室的应用解剖学特点;探究中面部颊内侧深层脂肪(DMCF)室的的解剖结构。3.探究中面部脂肪室的3D可视化方法,探究中面部脂肪室与毗邻结构关系的3D可视化方法。方法:1.中面部脂肪室的系统性回顾:通过关键词系统性检索文献,确定纳排标准,浏览摘要和全文,评估文献质量并纳入符合要求的研究,针对中面部脂肪室的解剖学和临床应用进行系统性回顾,客观评价、描述中面部脂肪室的解剖学特点及中面部随衰老发生的改变。2.中面部脂肪室的应用解剖:将亚甲基蓝染料注入大体标本的中面部单侧骨膜上平面,按以下顺序逐层解剖染色侧和非染色侧:皮肤、浅层脂肪、深层脂肪、骨膜上平面。解剖内容包括:筋膜、韧带、血管、神经等重要结构与深层脂肪室的关系,DMCF的解剖学特点和边界,DMCF与毗邻结构的关系,中面部其它重要结构的解剖学特点。3.头部CT扫描和中面部脂肪室的3D可视化:根据中面部脂肪室的边界与面部标志点的关系,对中面部浅、深层的各个脂肪室进行定位。通过三维建模软件,参考获得的脂肪室的位置和面部解剖结构的数据,在头颅模型上构建中面部的3D模型实现中面部脂肪室的3D可视化。结果:1.共纳入46篇文献。从4个方面对中面部脂肪室进行客观评价与描述:脂肪室的解剖学特点、脂肪室与血管神经的关系、脂肪室与限制韧带及筋膜的关系、中面部随衰老的改变。除颊外侧脂肪室、DMCF的解剖边界有待进一步明确外,大部分中面部脂肪室的边界、位置在文献中较为一致。肌肉、真性韧带、假性韧带等构成中面部脂肪室的边界。中面部的血管、神经与中面部SMAS下的深层脂肪室和深层间隙有解剖联系。中面部脂肪室之间的隔与中面部假性韧带的位置相对应。随着衰老,中面部的结缔组织、中面部脂肪室的脂肪分布量发生改变,中面部的脂肪分布由于组织移动(下垂)发生改变,中面部的骨骼发生退缩、吸收,骨轴向发生转动。此外,性别、BMI等因素对中面部脂肪室的脂肪分布量也有影响。2.14侧半侧面部标本被用于解剖。所有染色后的半侧面部标本的中面部深层存在一个边界清楚的脂肪室,该脂肪室为DMCF的内侧部。DMCF在表情肌下,眶骨、上颌骨和梨状孔之上,可以分为内外两个部分,亚甲基蓝染色液只在DMCF的内侧部内扩散。DMCF的内侧部位于梨状孔、外鼻旁,对前颊的内侧部分起到支持作用,并协调口周处的脂肪。DMCF的上界为LLSAN的骨插入,与“V形畸形”内界的位置相对应。提口角肌(LAO)未被亚甲基蓝染色,LAO的骨插入在DMCF内侧部的外侧。中面部内侧的深层存在Ristow间隙,该间隙未被亚甲基蓝染色。在分层解剖中,所有面部标本的睑部和眶部眼轮匝肌之间存在眼轮匝肌支持韧带(ORL)。染色后的半侧面部标本提示ORL分隔开睑部和颊部的脂肪。角动脉在DMCF的内侧部走行,角静脉在DMCF的外侧部走行。3.基于中面部脂肪室具有固定的边界、范围,通过参考内眦点、外眦点、颧点、鼻翼边缘点、眶下孔、瞳孔距离中线的距离以及鼻根点和鼻下点之间的距离,本研究分析中面部各个浅、深层脂肪室的边界与上述标志点的关系并确定中面部脂肪室在面部的详细位置。基于中面部脂肪室的详细位置,本研究归纳得到中面部脂肪室的厚度,提出基于脂肪室的精准填充策略,并成功构建出中面部脂肪室的3D模型。中面部脂肪室的可视化模型包括中面部的表情肌,中面部的浅层脂肪室(眶下脂肪室、眶外侧脂肪室、颊内侧脂肪室、颊中部脂肪室、颊外侧脂肪室和鼻唇脂肪室),下颌脂肪室,中面部的深层脂肪室(SOOF内侧部和外侧部、DMCF内侧部和外侧部),颊脂垫,以及中面部SMAS下的间隙(上颌前间隙、颊间隙和Ristow间隙)。结论:1.中面部的大部分脂肪室具有明确的边界和范围,它们的边界由韧带、表情肌、筋膜等构成。了解中面部浅、深脂肪室的位置、边界有助于实施安全有效的中面部微创操作。在中面部年轻化中,整形美容手术操作主要需要解决软组织下垂和容积丢失。中面部脂肪室的脂肪分布量与年龄、性别、BMI等因素有关。2.中面部的脂肪分层排列,其深层脂肪DMCF以脂肪室的形式存在,具有固定的解剖边界。在中面部的深层体积填充中,LAO可作为进入DMCF内侧部的指示地标。DMCF内侧部的边界有面血管走行,术者在填充注射操作中避开DMCF的边界更安全。3.基于中面部的脂肪室具有固定边界,中面部的各个浅、深层脂肪室和深层间隙可以通过中面中点线和面部标志点被精确分析定位。可以通过数字虚拟人体来构建以中面部脂肪室为中心的中面部3D可视化模型。该3D可视化模型可有效呈现中面部的解剖结构,为临床实施个性化、精准化的中面部容积填充提供理论指导。图50幅,表11个,参考文献117篇。更多还原

【Abstract】 Background:The discovery of the facial fat compartment has opened a new chapter in the study of facial anatomy and has led to new developments in facial plastic surgery techniques.The midface is one of the key operative sites in facial aesthetic plastic surgery and further research into the applied anatomical features and clinical significance of the midfacial fat compartment is of great importance.To our knowledge,there are currently no domestic studies using dyes for midfacial fat compartment anatomy.The anatomical extent and boundaries of most superficial midfacial fat compartments are more established in the literature,but the anatomical extent and boundaries of deep midfacial fat compartments are still controversial.Facial plastic surgery procedures based on the anatomy of the mid-facial fat compartment are a hot topic of research,and precision fillers based on the mid-facial fat compartment have good prospects for application.Objective:1.To investigate the anatomical,histological,and imaging features of the midface fat compartments,to objectively describe the fat compartments of the midface,determine their anatomical extent and standardize their names;to outline the changes that occur in the midface with ageing and the mechanisms involved.2.To explore the applied anatomy of the deep medial cheek fat(DMCF)compartment;to explore the applied anatomy of the midface.3.To visualize the detailed anatomical location of the midfacial fat compartment and the relationship between the midfacial fat compartment and adjoining structures to provide reference and guidance for clinical practice.Methods:1.Systematic review of the midfacial fat compartment:A systematic review of the anatomy and clinical applications of the midfacial fat compartment was conducted by systematically searching the literature by index term,browsing abstracts and full text,assessing the quality of the literature,and including studies that met the requirements,critically evaluating and describing the anatomical features of the midfacial fat compartment and the changes that occur in the midface with ageing.2.Applied anatomy of the midfacial fat compartment:Methylene blue is injected into the supraperiosteal plane of the midface of specimen and dissected layer by layer in the following order:skin,superficial fat,deep fat to the supraperiosteal plane,noting the association of important structures such as fascia,ligaments,blood vessels and nerves with the deep fat compartment.Explore the anatomical features of the DMCF,the boundaries of the DMCF,the relationship of the DMCF to adjacent structures and study the important anatomical structures of the midface.3.CT scan of the head and 3D visualization of the midface:Using the relationship between the boundaries of the fat compartments of the midface and the facial landmark points,the various fat compartments in the superficial and deep layers of the midface were localized;using the locations of the fat compartments obtained and the data of the associated expression muscles as a reference,a 3D model of the midface was drawn on the cranial model by 3D modelling software to realize 3D visualization of the midface to provide guidance for clinical operations.Results:1.Forty-six articles were included in the literature.The fat compartments of the midface were critically evaluated and described from four aspects,including their anatomical characteristics,their relationship with vascular nerves,their relationship with the restrictive ligaments and fascia,and their changes with ageing.The boundaries and location of most mid-facial fat compartments are more consistent in the literature,except for the anatomical boundaries of the lateral cheek fat compartment and DMCF,which need further clarification.The muscles,true ligaments and pseudo ligaments form the boundaries of the midface fat compartments.The vasculature and nerves of the midface are closely associated with the deep fat compartments and deep space beneath the midface SMAS.The septa between the midfacial fat compartments correspond to the position of the midfacial pseudo ligaments.The connective tissue of the midface changes with ageing.The amount of fat distribution in the midface fat compartments changes with ageing,with atrophy of the deep fat compartments and a reduction in fat distribution contributing to the ageing of the midface.With ageing,the fat distribution in the midface changes due to tissue movement,the bones of the midface undergo regression and resorption,and the bones rotate axially.In addition,gender and BMI influence the amount of fat distribution in the fat compartment of the midface.2.Fourteen hemifacial specimens were used for dissection.A well-defined fat compartment,the medial part of the DMCF,was observed on the stained specimen deep in the midface,below the expression muscle and above the orbital bone,maxilla,and pyriform foramen.The DMCF is divided into two parts,the medial and lateral parts,and the methylene blue stain diffuses only within the medial part of the DMCF.The medial part of the DMCF is located next to the pear-shaped foramen,the external nasal area,which supports the medial part of the anterior cheek and coordinates the fat around the mouth.The upper border of the DMCF corresponds to the position of the medial border of the"V-shaped deformity".The levator anguli muscle(LAO)is not stained with methylene blue.Ristow’s space is present in the deep medial midface and is not stained.The orbicularis retaining ligament(ORL)was observed in all anatomical specimens in a layered dissection,which was located between the palpebral and orbital parts of the orbicularis oculi muscle separating the lid and cheek fat.The angular artery runs medial to the DMCF,and the angular vein runs lateral to the DMCF.3.Based on the fact that the fat compartments of the midface have fixed boundaries and ranges,a 3D model of the fat compartments of the midface was constructed based on the distance between the medial canthus point,the lateral canthus point,the zygomatic point,the nasal rim point,the infraorbital foramen,the pupil from the midline and the distance between the nasal root point and the inferior nasal point as a reference.The3D model of the midface fat compartment was constructed and visualised in 3D.The model includes the midface expression muscles,the jowl fat compartment and the superficial fat compartments of the midface(infraorbital,lateral orbital,medial cheek,middle cheek,lateral cheek and nasolabial fat compartments),the deep fat compartments of the midface(medial and lateral SOOF,medial and lateral DMCF),the buccal fat pad,and the sub-SMAS spaces of the midface(premaxillary space,buccal space and Ristow space).Conclusions:1.The boundaries of the superficial and deep midfacial fat compartments are composed of ligaments,expression muscles and fascia,and most of the midfacial fat compartments have well-defined boundaries and extent.Understanding the location and boundaries of the superficial and deep midfacial fat compartments facilitates the practice of safe and effective minimally invasive midfacial procedures.In midface rejuvenation,the main need is to address soft tissue sagging and volume loss.Factors such as BMI and gender,which affect the amount of facial fat,should be considered when studying changes in the facial fat compartment with age.2.The fat in the midface is arranged in layers,and its deep fat DMCF exists in the form of fat compartments with fixed anatomical boundaries.In deep volumetric filling of the midface,LAO can be used as a landmark for accessing the medial part of the DMCF,which is bounded by facial vessels,and it is safer for the operator to avoid the boundary of the DMCF during filler injections.3.Since the fat compartment of the midface has fixed boundaries,the individual superficial and deep fat compartments and deep interstitial spaces of the midface can be precisely analyzed and localized by the midface midpoint line and facial marker points.A 3D visualization model of the midface centered on the fat chambers of the midface can be constructed using a digital virtual human body.The 3D visualization model can clearly present the anatomical structure of the midface,which is of clinical significance for the implementation of personalized and precise midface volumetric filling.更多还原