:::case previous inject filler lower eyelid for dolly eye , multile times for remove FB and correct rt eye ectropion , lt eye too much skin while smile , IMG_9618
📝 Case Summary
- History
- Multiple hyaluronic acid (or other) filler injections to the lower eyelid for “dolly eye.”
- Several procedures for foreign body (FB) removal (likely residual filler or nodules).
- Secondary changes:
- Right eye → cicatricial or involutional ectropion.
- Left eye → redundancy of lower lid skin, worsens on smiling (dynamic excess).
- Current concerns
- Cosmetic: persistent asymmetry, tired appearance, “too much skin” left eye.
- Functional: right ectropion → tearing, scleral show, possible exposure.
🔍 Clinical Issues
- Right lower eyelid
- Ectropion could be due to scarring from filler removal, skin shortage, or orbicularis laxity.
- Needs assessment of horizontal lid laxity (snap-back, distraction tests).
- Evaluate skin deficit vs. cicatrix.
- Left lower eyelid
- Excess skin when smiling suggests:
- Redundant orbicularis/skin fold.
- Possible “roll” due to prior filler removal scar.
- Important to assess in both static and dynamic states.
- Excess skin when smiling suggests:
- General
- History of multiple filler injections = higher risk of fibrosis, poor tissue glide, irregular planes.
- Revision surgery more complex than primary lower blepharoplasty.
🛠️ Management Options
Right Eye (Ectropion correction):
- Mild cases: lateral tarsal strip (LTS) + skin release.
- Cicatricial: scar release + midface support ± skin graft/skin flap if shortage.
- If orbicularis weakness: orbicularis suspension.
Left Eye (Excess skin):
- Conservative skin pinch excision (subciliary).
- Muscle tightening if orbicularis pseudoherniation.
- Avoid over-resection to prevent iatrogenic ectropion.
Both Eyes (General):
- Consider midface lift or canthopexy if support is poor.
- Use conservative, graded correction → avoid additional deformity.
- Patient counseling: results may be limited due to scarring.
⚠️ Key Points for Counseling
- Multiple prior procedures = higher risk of scarring and unpredictable healing.
- Goal is functional correction first (ectropion relief), cosmetic second.
- Revision lower eyelid surgery requires careful tissue handling and realistic expectations.
📝 病例摘要
病史
多次在下眼睑注射填充物（追求“洋娃娃眼”效果）。
多次 (duō cì) = multiple times, repeatedly
在 (zài) = at, in (location marker)
下 (xià) = lower, below
眼睑 (yǎn jiǎn) = eyelid
注射 (zhù shè) = inject, injection
填充物 (tián chōng wù) = filler, filling substance
追求 (zhuī qiú) = pursue, seek
洋娃娃 (yáng wá wa) = doll (Western-style doll)
眼 (yǎn) = eye
效果 (xiào guǒ) = effect, result
曾多次行异物取出手术（可能是残留填充物或结节）。
曾 (céng) = once, previously, formerly
多次 (duō cì) = multiple times, repeatedly
行 (xíng) = perform, carry out (formal/medical context)
异物 (yì wù) = foreign object/substance
取出 (qǔ chū) = remove, extract, take out
手术 (shǒu shù) = surgery, surgical procedure
可能 (kě néng) = possibly, may be
是 (shì) = is, are
残留 (cán liú) = remaining, residual
填充物 (tián chōng wù) = filler, filling substance
或 (huò) = or
结节 (jié jié) = nodule, lump
继发改变：
继发 (jì fā) = secondary, consequent, following from
改变 (gǎi biàn) = change, alteration, modification
右眼 → 下睑外翻（可能为瘢痕性或退行性）。
右眼 (yòu yǎn) = right eye
下 (xià) = lower, below
睑 (jiǎn) = eyelid
外翻 (wài fān) = eversion, turning outward
可能 (kě néng) = possibly, may be
为 (wéi) = is, being
瘢痕性 (bān hén xìng) = cicatricial, scar-related
或 (huò) = or
退行性 (tuì xíng xìng) = involutional, degenerative
左眼 → 微笑时下睑皮肤过多（动态冗余）。
左眼 (zuǒ yǎn) = left eye
微笑 (wēi xiào) = smile, smiling
时 (shí) = when, at the time of
下 (xià) = lower, below
睑 (jiǎn) = eyelid
皮肤 (pí fū) = skin
过多 (guò duō) = excessive, too much
动态 (dòng tài) = dynamic
冗余 (rǒng yú) = redundancy, excess
目前问题
美观方面：不对称、显老态、左眼皮肤过多。
功能方面：右下睑外翻 → 流泪、巩膜暴露、甚至角膜暴露风险。
🔍 临床要点
- 右下眼睑
- 外翻可能由：多次取填充物导致的瘢痕、皮肤不足、或眼轮匝肌松弛。
- 需检查睑缘水平松弛度（回弹试验、牵拉试验）。
- 评估是否存在皮肤缺损或瘢痕牵拉。
- 左下眼睑
- 微笑时皮肤过多，提示：
- 静态冗余皮肤/眼轮匝肌。
- 或因异物取出后纤维化导致皮肤折叠。
- 需同时评估静态与动态状态。
- 微笑时皮肤过多，提示：
- 总体情况
- 多次填充和手术史 → 高度纤维化，组织平面不清。
- 修复手术难度高于初次睑成形术。
🛠️ 治疗方案选择
右眼（外翻矫正）：
- 轻度：外眦韧带悬吊或外眦条带术（lateral tarsal strip）+ 皮肤松解。
- 瘢痕性：瘢痕松解 + 中面部支持 ± 皮肤移植/皮瓣修复。
- 若眼轮匝肌无力：需做肌肉悬吊。
左眼（皮肤过多）：
- 轻度：下睑皮肤切除（皮肤掐取法）。
- 若有眼轮匝肌假性膨出：可同时行肌肉紧致。
- 注意避免过度切除 → 预防医源性外翻。
双眼（综合考虑）：
- 可根据情况合并中面部提升或眶外眦固定术以加强支持。
- 手术需循序渐进，避免再次畸形。
- 必须与患者充分沟通：由于既往瘢痕，效果有限，不可期待“完美”。
⚠️ 医患沟通要点
- 多次手术后组织条件差 → 高瘢痕风险，愈合不可预测。
- 手术目标应为：先解决功能性问题（右眼外翻），再兼顾美观。
- 需强调：修复手术为高难度，结果有限，需有现实预期。
📝 Tóm tắt ca bệnh
- Tiền sử
- Nhiều lần tiêm filler vùng mí mắt dưới (tạo hiệu ứng “dolly eye”).
- Đã trải qua nhiều lần lấy dị vật (có thể do filler tồn lưu hoặc nốt xơ).
- Biến đổi thứ phát:
- Mắt phải → lật mí dưới ra ngoài (ectropion, có thể do sẹo hoặc lão hóa).
- Mắt trái → dư da mí dưới khi cười (thừa da động).
- Vấn đề hiện tại
- Thẩm mỹ: không cân xứng, vẻ mặt mệt mỏi, dư da mí trái.
- Chức năng: mắt phải bị ectropion → chảy nước mắt, hở củng mạc, có nguy cơ hở giác mạc.
🔍 Vấn đề lâm sàng
- Mí dưới mắt phải
- Nguyên nhân ectropion: sẹo do nhiều lần lấy filler, thiếu da, hoặc cơ vòng mi yếu.
- Cần khám độ lỏng ngang của mí (snap-back test, distraction test).
- Đánh giá có thiếu da hoặc co kéo sẹo.
- Mí dưới mắt trái
- Khi cười dư da rõ rệt, gợi ý:
- Dư da/ cơ vòng mi chùng.
- Xơ hóa sau lấy filler gây gấp nếp da.
- Cần đánh giá cả ở trạng thái nghỉ và động.
- Khi cười dư da rõ rệt, gợi ý:
- Tổng quan
- Tiền sử tiêm filler và phẫu thuật nhiều lần → xơ hóa cao, mặt phẳng mô không rõ.
- Phẫu thuật chỉnh sửa khó hơn rất nhiều so với cắt mí lần đầu.
🛠️ Lựa chọn điều trị
Mắt phải (chỉnh ectropion):
- Trường hợp nhẹ: phẫu thuật treo dải mí ngoài (lateral tarsal strip) + giải phóng da.
- Trường hợp do sẹo: giải phóng sẹo + treo hỗ trợ midface ± ghép da/ vạt da nếu thiếu.
- Nếu cơ vòng mi yếu: cần làm treo cơ.
Mắt trái (dư da):
- Cắt da mí dưới tối thiểu (kỹ thuật “skin pinch”).
- Nếu có phì đại giả của cơ vòng mi: có thể kết hợp siết cơ.
- Tránh cắt quá mức để không gây ectropion thứ phát.
Hai mắt (tổng thể):
- Có thể kết hợp treo góc mắt ngoài hoặc nâng midface nếu cần thêm sự hỗ trợ.
- Cần tiếp cận thận trọng, từng bước → tránh biến dạng mới.
- Phải giải thích trước với bệnh nhân: kết quả hạn chế do sẹo, không thể “hoàn hảo”.
⚠️ Điểm cần nhấn mạnh khi tư vấn
- Nhiều phẫu thuật trước đó → nguy cơ sẹo cao, lành thương khó dự đoán.
- Mục tiêu ưu tiên: sửa chức năng (ectropion mắt phải) trước, thẩm mỹ sau.
- Cần nhấn mạnh đây là phẫu thuật chỉnh sửa khó, kết quả có giới hạn, bệnh nhân phải có kỳ vọng thực tế.
ชอบดึงผม และ ได้ยา amitryp
อาการ ชอบดึงผม (Trichotillomania – โรคดึงผมตัวเอง) เป็นหนึ่งใน โรค Obsessive-Compulsive Related Disorder (กลุ่มที่เกี่ยวข้องกับย้ำคิดย้ำทำ) ตามเกณฑ์ DSM-5
โรคดึงผม (Trichotillomania)
- ผู้ป่วยมีความอยากดึงผมแรง ๆ จนห้ามตัวเองไม่ได้
- มักดึงผมศีรษะ คิ้ว ขนตา หรือขนตามร่างกาย
- ทำให้เกิด ผมร่วงเป็นหย่อม ๆ และมีผลกระทบต่อรูปลักษณ์ ความมั่นใจ และการเข้าสังคม
- มักสัมพันธ์กับความเครียด วิตกกังวล หรืออารมณ์ไม่มั่นคง
ยาที่ใช้รักษา
คุณบอกว่าได้ยา Amitriptyline ซึ่งเป็นยาในกลุ่ม Tricyclic Antidepressant (TCA)
- Amitriptyline ช่วยเรื่องอาการซึมเศร้า วิตกกังวล และช่วยให้นอนหลับดีขึ้น
- แต่ โดยตรงแล้วไม่ใช่ first-line สำหรับโรคดึงผม
- ยาที่มีการศึกษามากกว่า ได้แก่ SSRI (เช่น fluoxetine, sertraline) หรือ N-acetylcysteine (NAC) รวมถึงการใช้ พฤติกรรมบำบัด (Habit Reversal Training, CBT)
แนวทางการดูแล
- พบจิตแพทย์หรือนักจิตบำบัด เพื่อวางแผนการรักษา (ยา + จิตบำบัดร่วมกัน)
- ติดตามผลข้างเคียงของ Amitriptyline เช่น ง่วง ปากแห้ง ใจเต้นเร็ว ความดันต่ำเมื่อลุกขึ้น
- ใช้วิธีการบำบัดพฤติกรรม เช่น การหากิจกรรมอื่นแทนเวลาจะดึงผม, ใส่หมวก/ถุงมือ, ฝึกสมาธิ/ผ่อนคลาย
Trichotillomania (Hair-Pulling Disorder)
- This condition belongs to the group of Obsessive-Compulsive Related Disorders (OCD spectrum).
- The person feels an irresistible urge to pull out their hair, often from the scalp, eyebrows, eyelashes, or body hair.
- It leads to patchy hair loss, distress, and impairment in self-confidence or social functioning.
- It is often associated with stress, anxiety, or emotional tension.
Medication
You mentioned Amitriptyline, which is a tricyclic antidepressant (TCA).
- It mainly helps with depression, anxiety, and insomnia.
- However, it is not considered a first-line treatment for trichotillomania.
- Medications with stronger evidence include:
- SSRIs (e.g., fluoxetine, sertraline)
- N-acetylcysteine (NAC)
- Still, medication works best when combined with behavioral therapy.
Management Approach
- Consult a psychiatrist or psychologist – treatment usually combines medication + therapy.
- Monitor side effects of amitriptyline – common ones include sleepiness, dry mouth, constipation, fast heartbeat, or dizziness when standing up.
- Behavioral therapy (Habit Reversal Training / CBT) – the most effective approach. Examples:
- Replace hair-pulling with another action (holding a stress ball, fidget toy).
- Wearing a hat, gloves, or bandage on fingers to reduce pulling.
- Stress management and mindfulness techniques.
拔毛癖（Trichotillomania，毛发拔除症）
拔 (bá) = pull out, pluck
毛 (máo) = hair, fur
癖 (pǐ) = habit, addiction, compulsive behavior
毛发 (máo fà) = hair (formal medical term)
拔除 (bá chú) = removal, extraction
症 (zhèng) = condition, syndrome, disorder
该病属于 强迫症相关障碍（OCD 相关）。
该 (gāi) = this, the aforementioned
病 (bìng) = disease, disorder, condition
属于 (shǔ yú) = belongs to, is classified as
强迫症 (qiáng pò zhèng) = obsessive-compulsive disorder (OCD)
相关 (xiāng guān) = related, associated
障碍 (zhàng ài) = disorder,障碍
患者会有难以抑制的拔毛冲动，常见部位包括头皮、眉毛、睫毛或身体其他部位的体毛。
可导致局灶性脱发、情绪困扰，并影响自信与社交功能。
常与压力、焦虑或情绪紧张相关。
药物治疗
你提到正在使用 阿米替林（Amitriptyline），属于 三环类抗抑郁剂（TCA）。
- 主要用于治疗抑郁、焦虑及改善睡眠。
- 但 并非拔毛癖的一线药物。
- 在拔毛癖中有较多证据支持使用的包括：
- 选择性5-羟色胺再摄取抑制剂（SSRIs），例如 fluoxetine（氟西汀）、sertraline（舍曲林）等。
- N-乙酰半胱氨酸（N-acetylcysteine, NAC）。
- 通常药物与心理行为疗法联合使用效果最好。
治疗与照护要点
- 建议就诊精神科或心理治疗师，以制定包含药物与心理治疗的综合方案。
- 注意阿米替林的副作用，常见有嗜睡、口干、便秘、心悸、直立性低血压（起立头晕）等，应定期随访并监测。
- 行为治疗 — 习惯逆转训练（Habit Reversal Training, HRT / CBT） 是最有效的方法之一，举例包括：
- 将拔毛动作替换为其他动作（例如握握力球或使用可摆弄的小物件）。
- 在容易拔毛的时间/部位戴帽子、手套或包扎手指以减少拔毛机会。
- 压力管理、正念与放松训练帮助降低诱发拔毛的紧张情绪。
你要不要我把这段做成（选一）：
- a) 给病人的简易说明单（中文，短句、易懂）；或
- b) 专业摘要（面向医务人员，含参考用语与建议方案）？
告诉我想要哪种版本，我马上给你。