RU2302222C1 - Contour plasty method for treating the cases of retraction of superior orbitopalpebral sulcus of anophthalmic orbit - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves introducing transplant into upper eyelid. Umbilical cord bioplant shaped as spindle is used as the transplant. The transplant is introduced into tunnel arranged in correspondence with superior orbit bone boundary. The tunnel is spindle-shaped and has its middle portion widened.

EFFECT: reduced risk of cicatricial deformity and transplant migration.

2 cl, 5 dwg

Description

The invention relates to medicine, in particular to ophthalmology, and can be used in the surgical treatment of retraction of the superior orbit-palpebral groove (OPB) of the anophthalmic orbit.

There are methods for the prevention of retraction of the upper OPB of the anophthalmic orbit, which consist in the formation of a sufficient volume of the musculoskeletal stump during enucleation, however, in the long-term postoperative period, more than 6 months, a different degree of visible retraction of the orbit-palpebral groove is detected, from 2 mm or more in 10-34.3% of the cases operated (Davydov D.V. Biomedical aspects of the integrated use of biomaterials in patients with anophthalmus // Author. Doctoral dissertation ... - M., - 2000, p. 23; Filatova I. .A. Comp lex system for surgical rehabilitation of patients with anophthalmus. Author's abstract, Doctor of dissertation M. - 2001; Harlampidi MP Development of optimal methods of enucleation to improve the cosmetic parameters of eye prosthetics. // Abstract of Candidate of Diss. - M., - 2002 g., - p. 16.

There are methods of surgical correction of the lowering of the upper OPB by introducing into the lower orbital wall an anthophthalmic orbit, subperiosteal, hydrogel injection implant, in which the contents of the orbit and the musculoskeletal stump are displaced upward, making up for the insufficient volume in the upper part of the orbit (Davydov D.V. Mediko biological aspects of the integrated use of biomaterials in patients with anophthalmus // Author. Doctoral diss. ... - M., - 2000 - p. 26).

The disadvantage of this method are

- the possibility of hidden unpredictable redistribution of liquid hydrogel through the natural gap of the lower wall of the orbit (sulcus infraorbitalis) or through unconsolidated, undiagnosed fractures of the lower wall of the orbit into the maxillary sinus;

- the possibility of trauma to the lower orbit nerve (nervus infraorbitalis) with blind injection of the subperiosteal administration of a liquid hydrogel;

- the possibility of intra-arterial penetration of the embolus of a liquid hydrogel through arteria infraorbitalis with a blind injection subperiosteal administration of a liquid hydrogel;

- lack of certified serial production of injectors with liquid hydrogel.

Another analog that eliminates the lowering of the upper OPB is the method of delayed plastics of the musculoskeletal stump with an carbon felt implant (RF Patent No. 2054910 dated 02.27.96 and RF Patent No. 2143869 dated 10.01.00), the essence of which is supplementing the volume of the previously formed musculoskeletal stump or partially resolved implant of the musculoskeletal stump with carbon felt “Karbotekstim”.

The disadvantage of the prototype method is

- the possibility of scarring of unpredictable deformations of the previously operated musculoskeletal stump, often already containing a synthetic implant;

- the possibility of intraoperative bleeding and hematomas of the operated area from non-decaying newly formed vessels of scar tissue;

- the possibility of immobilization of the musculoskeletal stump due to the progression of fibrosis of the tendons and bodies of the oculomotor muscles;

- the possibility of progressive cicatricial contraction of the conjunctival sac of the prosthetic cavity due to repeated cicatricial process in the underlying area;

- blackening of the conjunctival sac due to leaching of particles of carbon felt;

- the possibility of developing non-specific granular inflammation of the musculoskeletal stump due to autoimmune sensitization of the body with an increase in the titer of antibodies to synthetic implants.

The closest analogue-prototype of surgical correction of lowering of the upper OPB is homo- and heteroplasty of the upper eyelid, in which the dura mater is introduced into the thickness of the upper eyelid between the skin and the circular muscle or between the circular muscle and the tarsoorbital fascia (Alexandrova A.A., Pastukhova A. N. Medical and social rehabilitation of patients with anophthalmus in the Omsk region // Eye prosthetics and plastic surgery in the orbit. Sat scientific nos. Tr - M., - 1987, p. 115-116), or hetero-cartilage from calves (Zaykova M.V. ., Shevtsova N.A. Is moves of eyelid, conjunctival cavity and orbit plasty in children and adolescents // Bulletin of Ophthalmology. - 1974. - No. 5, p. 56-59), or donor cartilage (homochromatic). Starkov G.L. Correction of post-traumatic eyelid insufficiency with plastics of preserved canned cartilage and a free skin flap // Bulletin of Ophthalmology. - 1977 - No. 1. - p.23-24).

The disadvantage of the method according to the prototype is

- the lack of elastic properties of the biological homo-and heterograft, which in the conditions of continuous mobility of the upper eyelid prevents the formation of a fibrous capsule;

- a significant amount of cartilage resorption in a relatively short time due to the lack of germination of the cartilage by its own connective tissue and vessels;

- the possibility of inhibiting the function of the upper eyelid lifter (m. levator palpebri) due to the rough structure of the graft;

- high probability of migration for homo - and hetero-cartilage graft;

- high probability of cicatricial deformity for the dura mater;

- the possibility of autoimmune inflammation with lysing of grafts and secondary cicatricial deformity of the zone of its introduction.

The task is to propose a method for contour plasty of the upper orbit-palpebral groove of the anophthalmic orbit.

The technical result is to eliminate the retraction of the upper eyelid on an outpatient basis by using a umbilical bioplant - the umbilical cord.

The technical result is achieved by the fact that OPB retraction plastic surgery is performed with umbilical cord bioplant tissue — the umbilical cord (manufactured by Bioplast, Izhevsk) only in the presence of a movable volumetric centrally located musculoskeletal stump of at least 70% (about 7 cm ³ , on average) the volume of the contralateral healthy eye, and in the presence of a cosmetic thin-walled individual prosthesis, as well as in the absence of lagophthalmos or ptosis of the upper eyelid, which is a necessary condition for eliminating the discredit of the method bah.

Upper OPB retraction plastic surgery is performed under local anesthesia, distributing the anesthetic subcutaneously from the temporal bone edge of the anophthalmic orbit above and along the palpebral fold of the upper eyelid to the nasal bone edge of the anophthalmic orbit. Then, skin incisions are performed 4-5 mm higher than the external and internal ligament of the eyelids by 1-1.5 cm. A spatula is inserted subcutaneously through the temporal notch using a blunt dissection technique to form a tunnel, the course of which must correspond to the upper bone border of the orbit, and the tunnel does not should merge with the fold of the upper eyelid, while it should have a uniform expansion in the middle third of the length and narrowing in the temporal and nasal thirds. When using the umbilical bioplant - the umbilical cord, proposed by the manufacturer, the length is brought into correspondence according to the linear dimensions of the upper eyelid from the temporal to the nasal incision, however, the width of the bioplant - umbilical cord does not change, but model the volumetric shape. To do this, the end sections of the bioplant — the umbilical cord — are cut with two longitudinal incisions, the formed flaps are laid one on top of the other and stitched in this position with one 5/0 vicryl stitch. The umbilical bioplant modeled in this way - the umbilical cord acquires volume and should resemble a “spindle”. Using a conductor, for example, a spatula laid along the channel, a umbilical umbilical cord is inserted into the fibers of the circular orbital muscle with curved tweezers, sliding along the conductor, the umbilical cord is fixed to the periosteum of the orbit edge in the area of the nasal skin incision with 4/0 4/0 Vicryl suture. Holding the bioplant - the umbilical cord by pressing through the skin, the conductor is removed from the tunnel. Fixation of the temporal end of the umbilical bioplant - the umbilical cord is carried out similarly to the nasal. On the edges of the skin incisions impose one U-shaped silk seam 6/0. The immobilizing monocular dressing is held for 4-5 days continuously, then with dressings 1 time in three days for 1 month. This period is minimally sufficient for the formation of the fibrous capsule of the bioplant - the umbilical cord and the exclusion of migration and deformation of the bioplant - the umbilical cord. The extraction of the prosthesis for processing in the specified period is prohibited. Antiseptic treatment of the prosthesis, for example, with a solution of 1% dioxidine or metragil in the conjunctival sac is carried out with each ligation.

The advantages of the proposed method are:

- work in the area of a directly pathological condition;

- the absence of trauma to the musculoskeletal stump;

- no impact on the conjunctival vagina of the ocular prosthesis;

- the elastic structure of the umbilical bioplant - the umbilical cord, a sufficient volume, with a minimum mass, subcutaneously fills significant defects;

- high hydrophilicity of umbilical bioplant - umbilical cord and the presence of one layer of cubic epithelium and the main membrane on its surface prevents the adhesion of the walls of the cavity, the decline of its internal volume and adhesions;

- the absence of excessive aseptic inflammation on the umbilical bioplant - the umbilical cord and cases of its rejection due to the immunocompetence of the avascular stromal matrix and its ability to express HLA-A, D, C and other antigens;

- umbilical bioplant - umbilical cord as a fetal tissue suppresses cicatricial transformations of the area of plastic subcutaneous intervention due to the presence of tumor necrosis factor alpha (TNF-alpha), regulates myofibroplastic differentiation of normal fibroblasts;

- eliminates the risk of ptosis or retraction of the upper eyelid due to the lack of direct and indirect effects of the operated zone and umbilical bioplant - the umbilical cord on the muscle that raises the upper eyelid due to the subcutaneous location of the volumetric plastic zone.

Analysis of the clinical effectiveness of the contour plasty of the orbit-palpebral groove contour was performed in the postoperative period of 8 months - 1.5 years in a group of patients after enucleation with plastic surgery of the musculoskeletal stump (12 patients - 12 eyes) and in patients who had sufficient volume, centrally located musculoskeletal stump (14 eyes), formed by other ophthalmic surgeons at least 6 months earlier. The results of the cosmetic effect of the treatment as the most difficult for quantitative assessment were photo-documented on face and side photographs and were supplemented by questionnaires for a subjective assessment of the operational effect according to the proposed point estimate: good, satisfactory, unsatisfactory. In all cases of operations (26 eyes), in the long term, patients reported a stable state of the operated area from 8 to 1.5 years, the absence of periods of inflammation or decreased motor activity of the upper eyelid. According to the questionnaire, the result was rated in all cases (26 eyes) as good.

Example 1

Patient N. - 65 years old, was admitted with complaints of gross asymmetry of the face due to the absence of the right eye. Figure 1.1. The results of individual prosthetics do not eliminate this defect.

During the examination, B-ultrasound diagnostics of the anteroposterior axis (PZO) of the healthy left eye equal to 24.4 mm and PZO of the ophthalmic musculoskeletal stump on the right equal to 20 mm was performed. The normal ratio for successful cosmetic prosthetics with a thin-walled individual prosthesis, 4-5 m high, was established, however, the results of the prosthetics did not compensate for the lowering of the upper orbit-palpebral groove (OPB). The patient was treated by analogy, injecting into the lower orbital wall of the anophthalmic orbit, subperiosteal, hydrogel injection implant, Fig.2.1, to compensate for insufficient tissue volume in the upper part of the anophthalmic orbit by displacing the musculoskeletal stump upward. The cosmetic result of the treatment of lowering of the upper orbit-palpebral groove is not obtained, Fig.1.2. The patient was referred to an MRI study of the orbits to monitor the redistribution of the liquid hydrogel after subperiosteal administration. According to the results of an MRI study, a subperiosteal redistribution of the liquid injection hydrogel was predominantly to the apex of the orbit, indicated by the arrow, Fig.2.2 and the absence of displacement of the musculoskeletal stump (UEC) of the eye to the upper part of the orbit due to the common fibrosis of the orbital tissue and the muscular cone of the OEC of the eye.

After 4-6 months, the patient is scheduled to undergo a reoperation by the proposed method of contour plasty of the upper orbit-palpebral sulcus with a umbilical bioplant.

Example 2

Patient K., 51 years old, was admitted with complaints of facial asymmetry due to a lack of a right eye. The results of individual prosthetics do not eliminate this defect of Fig. 3.1.

During the examination, B-ultrasound diagnostics of the anteroposterior axis (PZO) of the healthy left eye, equal to 25.2 mm, and the PZO of the ophthalmic musculoskeletal stump on the right, equal to 21 mm, was performed. The normal ratio for successful cosmetic prosthetics with a thin-walled individual prosthesis, 4-5 m high, was established, however, the results of the prosthetics did not compensate for the retraction of the upper orbit-palpebral groove (OPB), especially in conditions of individual physiological protrusion of the left eyeball. The patient was treated according to the prototype analogue, homoplasty of the upper eyelid, with the introduction of the thickness of the upper eyelid between the circular muscle and the tarsoorbital fascia of the donor cartilage - homochondilism. Figure 3.2. The cosmetic result of the treatment of lowering of the upper orbit-palpebral groove is partially obtained. However, after 3 weeks, incomplete ptosis of the upper eyelid developed, which significantly reduced the cosmetic result of the operation, harmonious perception of the face and the quality of life of the patient.

After 4-6 months, the patient is scheduled to undergo a surgery to correct incomplete ptosis of the upper eyelid using the technique of suspending the eyelid to the frontal muscle.

Example 3

Patient K., 67 years old, was admitted with complaints of facial asymmetry due to a lack of a right eye. The results of individual prosthetics do not eliminate this defect, Fig. 4.1.

During the examination, B-ultrasound diagnostics of the anteroposterior axis (PZO) of the healthy left eye, equal to 24.1 mm, and the PZO of the ophthalmic musculoskeletal stump on the right, equal to 19.5 mm, was performed. The normal ratio for successful cosmetic prosthetics with a thin-walled individual prosthesis, 4-5 m high, has been established, but the results of the prosthetics do not eliminate the retraction of the superior orbit-palpebral groove (OPB). The deficit of the volume of the upper eyelid on the left is especially pronounced in conditions of chrono-involutional excess of the skin of the upper eyelid of the left eye. The patient was treated according to the proposed method of contour plasty of the upper orbit-palpebral sulcus with a umbilical bioplant, the umbilical cord of the right anophthalmic orbit. The cosmetic result of the treatment of lowering of the upper orbit-palpebral groove was obtained, stable for 1.5 years while maintaining the motor activity of the upper eyelid lifter. Under the conditions of the natural process of chrono-involution, the excess fold of dermatochalasis in the left eye progressed. The patient underwent cosmetic blepharoplasty of the upper eyelid of the left eye after 1.5 years to improve cosmetic performance and quality of life. Fig 4.2.

Example 4

Patient Sh. - 68 years old, was admitted with complaints of facial asymmetry due to lack of a right eye. The results of individual prosthetics do not eliminate this defect, Fig. 5.1.

During the examination, B-ultrasound diagnostics of the anteroposterior axis (PZO) of the healthy left eye, equal to 24.5 mm, and the PZO of the ophthalmic musculoskeletal stump on the right, equal to 20.8 mm, was performed. The normal ratio for successful cosmetic prosthetics with a thin-walled individual prosthesis, 4-5 m high, has been established, but the results of the prosthetics do not eliminate the retraction of the upper orbit-palpebral groove (OPB) of the right anophthalmic orbit. The deficit of the volume of the upper eyelid on the left is especially pronounced in conditions of chrono-involutional excess of the skin of the upper eyelid of the left eye. The patient was treated according to the proposed method of contour plasty of the upper orbit-palpebral sulcus with a umbilical bioplant, the umbilical cord of the right anophthalmic orbit. The cosmetic result of the treatment of lowering of the upper orbit-palpebral groove was obtained, stable for 1 year while maintaining the motor activity of the upper eyelid lifter. Under the conditions of the natural process of chrono-involution, the excess fold of dermatochalasis in the left eye progressed. The patient underwent cosmetic blepharoplasty of the upper eyelid of the left eye after 8 months to improve cosmetic indicators and quality of life. Fig 5.2.

Claims (2)

1. The method of contour plasty of the upper orbit-palpebral groove of the anophthalmic orbit, including the introduction of a graft into the thickness of the upper eyelid, characterized in that in the presence of a movable volumetric centrally located musculoskeletal stump, comprising at least 70% of the volume of the contralateral healthy eye and in the absence lagophthalmos or ptosis of the upper eyelid as a graft use a bioplant tissue - the umbilical cord, which is given the volume form of the spindle and which is introduced into the tunnel, the course of which The appropriate bone upper border of the orbit, the tunnel also has a spindle shape with an extension in its middle third. 2. The method according to claim 1, characterized in that the bioplant tissue - the umbilical cord is modeled in the form of a spindle, cutting its end sections with two longitudinal incisions, applying formed patches to each other and flashing one with 5/0 vicryl seam.

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