Archives of Aesthetic Plastic Surgery Vol. 19, No. 1, 29-33, 2013 정제된구조적미세지방이식을이용한함몰안검및다중겹눈꺼풀의교정 김성민 1 정보람 2 홍종원 2 노태석 2 유대현 2 김영석 2 1 아이미성형외과, 페이스리모델링연구소, 2 연세대학교의과대학성형외과학교실 - 인체조직복원연구소 Correction of Sunken and/or Multiple Folded Upper Eyelid by Refined Structural Micro-Fat Graft: Technical Pearls Sung Min Kim, M.D. 1, Boh Rham Jeong, M.D. 2, Jong Won Hong, M.D. 2, Tai Suk Roh, M.D. 2, Dae Hyun Lew, M.D. 2, Young Seok Kim, M.D. 2 1 Imi Plastic and Aesthetic Surgery Clinic, Institute for Face Remodeling, Seoul, Korea, 2 Institute for Human Tissue Restoration, Department of Plastic & Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea Structural micro-fat graft is one of the surgical techniques for facial rejuvenation, and it is reliable for correction of sunken upper eyelids especially. However, several factors may influence surgical outcomes substancially. The author introduces the modified micro-fat graft to correct sunken eyelids and multiple eyelid folds to make better results. A series of 162 patients who underwent the refined structural micro-fat graft were included in this study. The purified fat was injected into the subcutaneous and sub-orbicularis oculi muscle layer of the upper eyelids through the 19-gauge cannula with 1 ml syringe. After the operation, all patients were followed up on 2 weeks, 1 month, 3 months, 6months, and 1 year. Clinical photographs were taken every visit and the author evaluated the volume and symmetry of the eyelids and checked the satisfaction of each patient and any complications. Among the 162 patients, 156 patients were satisfied with the upper eyelid volume after primary fat graft and other 6 patients were performed secondary fat graft. Even though the volume of the fat was sufficient, 4 patients showed palpable fat nodule during the follow-up period. Modified micro-fat graft is a simple, safe, and alternative method to correct sunken eyelids and multiple eyelid folds. (Archives of Aesthetic Plastic Surgery 19: 29, 2013) Key Word: Structural fat graft, Sunken eyelid, Blepharoplasty Original Article 29 I. 서론 노화로인한상안검의피하지방및안와지방의위축으로눈이꺼져보이거나, 여러겹의상안검주름이있을때실제 Received January 15, 2013 Revised February 16, 2013 Accepted February 20, 2013 Address Correspondence: Young Seok Kim, M.D., Ph.D., Dept. of Plastic & Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University, College of Medicine, 211 Eonju-ro, Gangnam-gu, SEOUL, 135-720, KOREA. Tel: +82-2-2019-3422, FAX: +82-2-577-4914, E-mail: PSYSKIM@yuhs.ac 보다나이가더들어보이거나피곤해보이게된다. 1 이러한상안검의함몰과다중주름의교정을위해절개식상안검수술, 진피지방이식, 근막지방이식, 필러주입등이사용되어왔다. 2-5 1991년 Coleman이구조적지방이식을발표한이후안면부의피부주름과피하지방의위축을교정하기위한목적으로지방이식은매우효과적이고안전한방법으로널리사용되고있으며상안검의함몰을위해서도구조적지방이식이적용되었다. 6 하지만상안검에구조적지방이식을사용할경우사람마다일정한지방의생존율을예상하기힘들고일정시간이지난후지방의생존율의저하로교정효과가감소되는현상이발생한다. 4,7 물론이의예방을위해과교정을시행하기도하지만, 자칫과교정시과대생존된지방이얇
Archives of Aesthetic Plastic Surgery Vol. 19, No. 1, 2013 30 은상안검아래로투영되어보여지고만져지게되는부작용이발생할수있다. 7 이에저자들은생착률을향상시키면서부작용을최소화하고일정한결과를예측할수있는함몰상안검및다중주름상안검의교정을위한저자들의정제된구조적지방이식방법을소개하고자한다. Ⅱ. 재료및방법가. 대상 2006년 4월부터 2012년 4월까지총 162명의함몰상안검환자를대상으로하였다. 환자군은여자 154명, 남자 8명이였고평균나이는 38.8세였으며평균경과관찰기간은 3년이었다. 모든환자는함몰상안검를갖는환자였으며 52명은함몰상안검과다중상안검주름을동시에지닌환자였다. 118명은상안검성형수술과거력이없었으며 44명은과거상안검성형수술의과거력이있었다. 단안검하수인환자는본술식의적응증에적합하지않기때문에환자의 Margin reflex distance(mrd) 1을측정하여한국인의평균 MRD 1(+4.5) 보다 2 mm 이상낮은환자는대상에서제외하였다. 8 나. 수술방법디자인을위해앉은상태에서상안검의함몰된부위와다중주름의고랑부분을펜으로미리정확히표시하였다. 상안와융기 (supra-orbital ridge) 등볼륨감이있는부분은지방이이식되지말아야하므로이곳은 x 표시를하였다 (Fig. 1). 지방채취의공여부는내측허벅지에서만시행하였다. 지방의채취와주입은 Coleman의방식을따랐다. 9 팽창마취액은 1,000 ml의 0.9 % 생리식염수와에피네프린 1 mg, 2 % 리도케인 20 ml를혼합하여사용했으며직경 3 mm, 길이 15~20 cm 캐뉼라를이용하여지방을채취한후 3,000 rpm으로 3분동안원심분리를하였다. 10 채취된지방중고밀도지방만을사용하였다. 11 고밀도지방은원심분리후하단의수용성성분과적혈구층을제거한후남은최하단의 1.0 ml의지방이다. 고밀도지방만을 1 ml 루어-락주사기에 0.8 ml씩나누어담아주입할준비를하였다. 주입부의마취는 1 % 리도케인과에피네프린을 1:100,000 로혼합하여 0.3 ml 이하의양만을사용하였다. 부분마취이후 18G 주사바늘을이용해상안검의피부를관통한후, 끝이뭉뚝한 type-i 19G Coleman 케뉼라로가장깊이함몰된안검부위를중심으로지방이주입될부분에전반적인충분한터널링을시행하였다. 지방의주입은주로 type-i 19G Coleman 캐뉼라를사용하였으며, 이전의상안검성형술로인한조직유착이있는경우에는 type-iii 19G Coleman 캐뉼라를통해유착을해리하며주입하였다. 6,9 지방의주입은소량을여러번으로나누어천천히주입하였다 (Fig. 2). 상안검의피하지방층과눈둘레근아래층에만지방을이식하였으며, 안와격막및그아래층에는터널링이나이식을하지않았다. 지방의주입은미용적으로함몰상안검이교정되었다고관찰될때까지시행하였고절대과교정을하지않았으며, 한쪽상안검당지방이식량이 2 ml가넘지않도록하였다. 수술중어느정도이식이되었다고판단되면환자를앉히고상안검의볼륨의정도를평가하며눈은감았다뜨게하여불편함이없는지확인한후추가이식또는수술종료여부를결정하였다. 수술직후, 2주후, 1달후, 3달후, 6개월후, 1년후에환자의정면사진을찍어서이식된지방의생존을평가하고환자의만족도및부작용유무를확인하였다. III. 결과총 162명의상안검함몰환자 (324례) 를대상으로정제된 Fig. 1. A design before the operation in a 55-year-old female patient. (Left) Preoperative view. Severely sunken multiple folds and highfolds present at both upper eyelids. Retraction of upper eyelid was also present due to a decreasing volume. Sunken area and sulcus of multiple folds were accurately marked with a surgical marking pen. (Right) Voluminous area was marked with not to be with fat, such as the supra-orbital ridge. Fig. 2. The procedure of the micro-fat graft using 19-gauge cannula. (Left) Injection must be performed precisely and meticulously. It is important inject minimal amount of fat in a constant rate. (Right) A 19-gauge cannula was used, which is the thinnest cannula that can inject fat without resistance.
김성민등 : 지방이식을이용한함몰상안검의교정 구조적미세지방이식을시행하였다. 수술받은대부분의환 자는이식한지방의부피가 80 % 이상유지되어결과에만족 하였고특히다중쌍꺼풀선과높은쌍꺼풀선을보이면서함 몰안검을가진환자들에서만족도가더높았다. 6 명의환자 에서불완전교정으로 2 차이식을하였다. 감염, 혈종, 미세 석회화, 낭종형성등지방이식에서발생하는합병증은없었 으나지방의과다생착으로상안검에서육안적으로보이거 나만져지는지방덩어리를호소한환자는 4 명이었다. 안검 하수량은 2 mm 미만이지만상안검거근의기능이약한환자 에서지방이식후이전에비해서안검하수가심해진환자가 1 명있었다. 3 명의환자에서지방이식후함몰안검은교정되 었지만수술전보다눈이더작아보인다고호소하였다. 사 진판독상수술후 3 개월까지약간의이식된지방의감소가 보이지만그이후에는이식된지방이안정적으로생착되어 1 년이상의시간이지난후에도만족스러운상안검의부피 감을유지하였다. 증례 1 26 세여자로상안검수술과거력은없었으며함몰상안검 Fig. 3. A 26-year-old woman with no history of blepharoplasty was visited with both sunken eyelids and multiple folds on the left upper eyelid. (Left) Preoperative view. (Right) Two years after the operation. 과좌측에다중겹상안검주름을호소하였다. 우측에 0.9 ml 좌측에 1.3 ml씩한차례의지방이식후 2년후에도상안검부피감이유지되고다중주름도교정되었다 (Fig. 3). 증례 2 47세여자로안성형과거력없었으나돌출안과함께심한상안검의함몰로눈이피곤해보이고높은쌍꺼풀선을호소하였다. 우측 1.6 ml 좌측에 1.5 ml의지방을이식하였으며수술후 1년째모습으로상안검의부피감이회복되고높은쌍거풀선이교정되었다 (Fig. 4). 증례 3 36세여자로 2년전상안검수술후발생한함몰안검과부자연스러운쌍꺼풀선소견을보였다. 절개를통한상안검재수술을시행하지않고저자의정제된구조적미세지방이식만으로상안검의부피를회복하고쌍꺼풀의높이를조정하였다 (Fig. 5). 증례 4 27세여자로 5년전에상안검성형술받은이후함몰상안검이발생하였다. 저자들이본술식으로안검지방이식을시작할무렵에약 15~20 % 정도과교정하여수술을시행했던환자였다. 수술후눈을감았을때좌측상안검에육안으로보여지고만져지는덩어리를호소하였다. 눈을뜬상태에서는환자가현재의상안검부피감에만족하여스테로이드주입을통해만져지는지방을연화시켜주었다 (Fig. 6). 31 Fig. 4. A 47-year-old woman with no history of blepharoplasty was visited with exophthalmos. She was tired looking and showed severely sunken eyelids, and high-fold of upper eyelids. (Left) Preoperative view. (Right) One year after the operation. Fig. 5. A 36-year-old woman who had blepharoplasty two years ago was visited with sunken eyelids and an unnatural upper eyelid folds. (Left) Preoperative view. (Right) Six months after the fat graft without incisional blepharoplasty. Fig. 6. A 27-year-old woman who had blepharoplasty visited with sunken eyelids. (Left) Preoperative view. (Left, middle) Two months after the operation, about 15~20 % overcorrection was done. (Center) Five years after the operation. (Right, middle) Preoperative view with closed eyes. (Right) Five years after the operation with closed eyes. Arrow indicates a fat lump which is visible and palpable.
Archives of Aesthetic Plastic Surgery Vol. 19, No. 1, 2013 32 Fig. 7. A 38-year-old woman with no history of blepharoplasty visited with sunken eyelids and appearance of protruding looking eyes. (Left) Preoperative view. (Right) Six months after the operation, these symptoms were corrected with the refined structural micro fat graft. However she complained that her eyes look smaller than before the surgery. 증례 5 38 세여자로상안검수술과거력은없었으며, 상안검의함 몰과돌출안소견을보였다. 지방이식을통해상안검함몰을 교정하고돌출되어보이는눈모양을교정하였으나환자는 수술전보다눈이작아보인다고불평을하였다 (Fig. 7). IV. 고찰 상안검의함몰과다중주름은환자의얼굴을더늙고피곤 해보이게하며특히여성에있어서생동감있고매력적인인 상을주기어렵다. 이를개선하기위해서함몰된상안검부 위에근막지방이식, 진피지방이식, 절개식상안검수술중안 와격막안으로지방이식등여러가지수술법이개발되었지 만이식된자가조직의생착률이나술자의기술에따라결과 가달라질수있으며기본적으로절개식수술이기때문에시 술이복잡하고흉터의가능성이있으며혹불완전교정시 재수술을시행할때어려운점이많다. 2-4 Coleman 이소개한구조적미세지방이식은지방을쉽게 얻을수있으며반복해서여러번시술할수있다. 또한시술 방법이단순하고안전하여안면부의회춘술에서가장보편 적으로시행되고있는수술이고함몰상안검의교정에도널 리적용되고있다. 6,7 하지만상안검에지방을이식할경우가 장큰문제는이식한지방의흡수율이다. 따라서부피감감 소를극복하고안정된결과를만들기위해서적용되는과교 정과이로인해서발생되는이식부위의뭉쳐진지방덩어리, 그리고대량으로이식된지방조직의무게효과로인한불편 감이다. 기존의방법과비교할때저자들의방법은생착률과안정 되고최소량의균일한지방이식을위한방법이다. 우선공여 부의지방세포입자가작고균일하고부드러우며섬유조직 이적은내측허벅지에서채취하였다. 복부지방을선택할경 우지방입자가클뿐만아니라 Coleman 방법으로채취하고 정제하여도섬유조직이어느정도포함되게되므로지방주 입시 19G 캐뉼라입구가막혀균일한최소량의지방이식이어려워지게된다. 내측허벅지에서채취한고밀도지방만을사용하여과교정없이지방 0.1 ml 당 10~20회정도로나누어서시간이걸리더라도정밀하고세심하게이식하는것이저자들의정제된구조적미세지방이식술의핵심이다. 아울러 1 ml 주사기를전부지방으로채우기않고 0.8 ml 이하로채우는것도지방주입을용이하게할수있는기술적인방법이며, 그이유는피스톤을누르는거리가멀면균등한힘으로피스톤을밀어내기가어렵기때문이다. 또한약간이라도많은양의지방이주입되었다고판단되면반드시바로면봉을이용하여지방의충분한재분배를해주어야추후발생할수있는뭉쳐진지방덩어리를예방할수있다. 부족한만큼의상안검부피을충분히채우기위해서는이식된지방이 80 % 이상생존해야과다교정을예방할수있다. 이를위해저자들은 3차원구조로다빈도최소량지방주입술과고밀도지방만을이용하여지방의생착율를최대로유지시킬수있었으므로과교정없이지방이식을시행하였다. 이식되는지방입자의크기가작고여러개의미세입자로나누어이식할수록혈류가공급되는 3차원적인수혜부의조직안에서지방입자가주위조직과접촉되는부분이많아지게된다. 그결과원활한혈류공급을받게되므로지방조직의생착률이향상될수있다. 또한고밀도지방에는좀더많은혈류형성 cytokine과전구세포가저밀도지방보다많아이식후신생혈관화가더잘일어나지방의생착율을높이기때문이다. 11,14 상안검은안면에서도혈류가풍부하고임상적경험으로볼때다른안면부위에비해지방의생착율이높기때문에고밀도지방을이용할경우과교정없이도성공적인생착률을보였다. 이러한방법으로기술적오류가발생할요인을줄이고이식된지방의생착율을높일수있다. 하지만모든함몰상안검과다중주름을갖는환자에서본저자들의방법이적용되는것은아니다. 안검하수량이 2 mm 이상되는환자에서는시술후함몰안검은교정될수있지만안검하수는더악화될수있음을반드시주지시켜야한다. 더불어상안검의부피가채워지면서눈두덩의부피감으로젊어보이는효과는있지만이식된지방의부피가눈꺼풀을미는효과가발생하여쌍꺼풀이작아지므로상대적으로눈이더작아보일수있다. 그렇기때문에상안검의부피를채우는효과와필연적으로쌍꺼풀이작아질수있는현상을주지시키고눈이작게보이기를싫어하는환자에게는반드시충분한수술전설명을하고수술여부를결정해야한다.
김성민등 : 지방이식을이용한함몰상안검의교정 상안검수술후에과다한지방제거로인해발생한함몰상안검과다중주름은 type-iii Coleman 캐뉼라를이용하여광범위한터널링을통한유착을제거후그위치에지방이식을하면충분히교정이가능하였다. 하지만상안검수술시과다지방제거로인한함몰안검이나다중주름이아니라수술시발생한안검피부와그하부층에정상적인쌍꺼풀선의위치가아닌비정상적인해부학적위치에견고한조직유착으로생긴다중주름혹은외상후생긴안와주변부의함몰반흔은저자들의방법으로도쉽게교정되지않을수있다. 이런경우, 반흔주변으로지방이채워지면서상대적으로반흔이더욱함몰되어보이므로수술전반드시상안검의반흔에대한평가가필수적이다. 13 V. 결론상안검의함몰과다중주름의교정방법으로저자들의정제된구조적미세지방이식은안전하고안정적인결과를보였다. 하지만수술을적용시키기앞서환자의적응증에유의하여야한다. 이식되는지방은반드시 19G Coleman 캐뉼라를통해지방입자 0.1 ml를 10~20회로나누어균일하게주입하는다빈도최소량지방이식을효과적으로사용하여야하며시간이걸리더라도세밀하게시행해야만성공적인결과를얻을수있다. REFERENCE 1. Weng CJ, Noordhoff MS: Complications of oriental blepharoplasty. Plast Reconstr Surg 83: 622, 1989 2. Yoon DJ, Kang CU, Bae YC: Correction of sunken upper eyelids using incisional double eyelidplasty and autologous microfat grafting into orbital septum. J Korean Soc Aesthetic Plast Surg 14(2):139, 2008 3. Lee Y, Kwon S, Hwang K: Correction of sunken and/or multiply folded upper eyelid by fascia-fat graft. Plast Reconstr Surg 107:15, 2001 4. Kim YK, Lee HG: Correction of sunken upper eyelid using dermofat graft. J Korean Soc Aesthetic Plast Surg 6(1): 44, 2000 5. Liew S, Nguyen DQ: Nonsurgical volumetric upper periorbital rejuvenation: a plastic surgeon s perspective. Aesthetic Plast Surg 35(3):319, 2011 6. Coleman SR: Facial recontouring with lipostructure. Clin Plast Surg 24: 347, 1997 7. Kim DK, Hong SH: Experiences in excessive fat survival after fat graft in upper eyelid. J Korean Soc Aesthetic Plast Surg 15(1): 82, 2009 8. Park DM, Song JW: Anthropometry of normal Korean eyelids. J Korean Soc Plast Reconstr Surg 17(5): 822, 1990 9. Coleman SR: Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 110:1731, 2002 10. Kim SM, Kim YS, Hong JW, Roh TS, Rah DK: An analysis of the experiences of 62 patients with moderate complications after full-face fat injection for augmentation. Plast Reconstr Surg 129(6):1359, 2012 11. Butala P, Hazen A, Szpalski C, Sultan SM, Coleman SR, Warren SM: Endogenous stem cell therapy enhances fat graft survival. Plast Reconstr Surg 130(2):293, 2012 12. Lee DE, Park SJ, Kim YB, Yang SJ, Park JS: Fat injection: a clinical experience of 231 cases. J Korean Soc Plast Reconstr Surg 23(3): 768, 1996 13. Lew DH, Kang JH, Cho IC: Surgical correction of multiple upper eyelid folds in East Asians. Plast Reconstr Surg 127(3):1323, 2011 14. Allen RJ Jr, Canizares O Jr, Scharf C, Nguyen PD, Thanik V, Saadeh PB, Coleman SR, Hazen A: Grading lipoaspirate: is there an optimal density for fat grafting? Plast Reconstr Surg 131(1):38, 2013 33