Frontalis-Orbicularis Oculi Muscle Flap for Correction of Blepharoptosis Caused by Traumatic Oculomotor Nerve Palsy

應用額肌眼輪匝肌皮瓣改善創傷性動眼神經麻痺引起之眼瞼下垂－病例報告

余宗宸(Benny Tsung Yu) ； 陳信甫(Hsing-Fu Chen) ； 陳建安(Jian-An Chen) ； 馮冠明(Guan Ming Feng)

《臺灣整形外科醫學會雜誌》 26卷2期 (2017/06) Pp. 184-190

摘要

Background: Oculomotor nerve palsy with neurogenic blepharoptosis is often the result of closed head injury. Although various techniques have been described to correct blepharoptosis, none of these techniques fully fulfill the patients' esthetic needs. Frontalis suspension surgery is still considered the procedure of choice for the treatment of patients with neurogenic blepharoptosis. However, this method is still hindered by stationary lifting of the sling. In contrast, frontalis-orbicularis oculi muscle (FOOM) flap can provide a more dynamic eye movement after blepharoptosis correction. Aim and Objective: We present a case with traumatic cranial nerve III palsy that resulted in neurogenic blepharoptosis, which was corrected using the FOOM flap method. Case Description: A 15-year-old girl suffered a traffic accident that resulted in intracerebral hemorrhage and subdural hemorrhage with mild midline shift to the left. Initial physical examination revealed dilatation of the left pupil of size 8.0 mm with absence of light reflex. Craniectomy was performed immediately. However, the accident further complicated resulting in cranial nerve III palsy with severe left upper eyelid ptosis. Since the patient was transferred from the ophthalmology outpatient department and esthetic concern was her priority, the FOOM flap-shortening technique was performed with resection of a total of 24 mm of flap. Result: Cranial nerve VII innervated FOOM flap was pulled down to replace the dysfunctional levator muscle, which resulted in a more dynamic eye movement. Artificial tears and ointment were prescribed after the immediate postoperative period to prevent keratopathy. The patient underwent two revisional surgeries due to undercorrection. A total of 34 mm of muscle flap was resected. After 1 year of follow-up, the patient was satisfied with the result. Conclusion: The FOOM flap, which is innervated by cranial nerve VII, replaced the dysfunctional levator muscle that is innervated by the injured cranial nerve III to achieve more genuine upper eyelid pulling motion and meet the patient's esthetic needs.

關鍵字

blepharoptosis ； frontalis-orbicularis oculi muscle flap ； cranial nerve III palsy

並列摘要

背景：動眼神經麻痺引起的眼瞼下垂常是腦部創傷後結果。雖然有許多方式陸續被提出但並沒有一個能真正達到病人美觀的需求。目前額肌懸吊術還是治療神經性眼瞼下垂病人的首選。但是這方式只能達到靜態提拉的效果。反之，額肌眼輪匝肌皮瓣可提供動態的眼皮運動。目的及目標：文中敘述一位15歲女生以額肌眼輪匝肌皮瓣改善創傷性動眼神經麻痺引起的眼瞼下垂。材料及方法：15歲女孩因車禍致腦內及硬腦膜下出血併中線位移偏左。最初身體檢查顯示左眼無光反應併瞳孔放大8.0 mm。病人接受緊急顱骨切開術，最終還是留下動眼神經麻痺併左眼瞼下垂的後遺症。病患至眼科門診轉至整形外科門診治療，但病患始終只在意外觀的問題。我們運用額肌眼輪匝肌皮瓣為病人改善創傷性第三對腦神經麻痺所引起的眼瞼下垂，術中共切除24 mm的肌皮瓣。結果：我們運用由第七對腦神經支配的額肌眼輪匝肌皮瓣來取代無作用的提眼瞼肌以達到較動態的提眼皮動作。術後我們給予人工淚液與藥膏以防止角膜病變。病患最終另接受兩次修正手術，最後共切除34 mm的肌皮瓣。病患對於術後一年的結果還是感到滿意。結論：以第七對腦神經支配的額肌眼輪匝肌皮瓣來取代已麻痺的動眼神經支配的提眼瞼肌可達到相對自然的提眼動作更能滿足病人對於美觀的需求。