RU2525734C1 - Method of plastic closing skull base defects - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: dissection of the temporal muscle is carried out with its splitting into two parts along the fibres. The anterior part is transferred into the defect cavity and sewn to the surrounding tissues. A titanium mesh is placed above the anterior part of the temporal muscle and fixed to the bones in such a way that the mesh edge performs pressure on the pedicle of the temporal muscle flap. After that, the posterior part of the temporal muscle is transferred onto the place of the anterior part, laid above the titanium mesh and fixed to the periosteum or the bones.

EFFECT: method makes it possible to improve treatment results, which is achieved due to reliable hermetisation of the intracranial space and its separation from extracranial structures, ensures elimination of a cosmetic defect in the anterior temporal area.

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Description

The invention relates to medicine, namely to neurosurgery and maxillofacial surgery, and can be used in the surgical treatment of patients with giant tumors of the base of the skull, its anterior-lateral and lateral departments with an invasive nature of growth and significant intracranial spread, as well as extensive traumatic lesion of the base anterior and middle cranial fossa.

The method of plastic closure of defects in the base of the skull using a flap based on the temporal muscle is widely known (Belov AI, Vinokurov AG Use of the temporal muscle to close postoperative defects. Questions of neurosurgery. 1998, No. 4, pp. 51-54). However, despite the technical simplicity of execution, its disadvantage is the high probability of the formation of a cosmetic defect in the form of soft tissue retraction in the temporal region, which subsequently has a significant impact on the patient's quality of life.

Closest to the claimed is a method for plastic closure of defects in the base of the skull (Raffaini M., Costa G. The temporoparietal fascial flap in reconstruction of the cranio-maxillofacial area. J. Craniomaxillofac Surg 1994, Vol.22, No. 5, P.261-267 ), adopted as a prototype, in which the temporal muscle is split along the fibers into two parts, the front part is placed in a post-resection defect and hemmed to the surrounding tissues, the back part is left in the same place.

The disadvantage of the prototype is the emerging defect of the soft tissues in the temporal region, to a greater extent of its front (free of hairline) part, after taking part of the temporal muscle, which subsequently significantly worsens the cosmetic result.

The invention is directed to the creation of a method for plastic closure of defects in the base of the skull, which ensures the elimination of a soft tissue defect in the anterior temporal region.

The specified technical result in the implementation of the invention is achieved by the fact that in the known method for plastic closing of defects of the base of the skull, the temporal muscle is dissected, it is split along the fibers into two parts, the front part is moved into the defect cavity and it is sutured to the surrounding tissues, the feature is that on top of the front of the temporal muscle, a titanium mesh is laid and fixed to the bones so that the edge of the mesh does not exert pressure on the leg of the temporal muscle flap, after which the back The temporal muscle is moved to the front part, placed on top of the titanium mesh and fixed to the periosteum or bones.

Elimination of a postoperative cosmetic defect is achieved due to the displaced posterior part of the temporal muscle to the anterior place, and the titanium mesh located underneath does not allow it to prolapse into the defect cavity. In addition, due to the presence of a multitude of holes in the titanium mesh, through which the connective tissue scar spreads during healing of the postoperative wound, additional fixation of the temporal muscle is achieved.

The method is as follows. During transzygomatic or orbitozygomatic access, the temporal muscle is dissected from the temporal fossa using a raspator. To maintain blood supply and muscle innervation, the use of monopolar coagulation should be avoided. The muscle is wrapped in a wet towel and removed for the duration of the tumor resection. After the formation of a post-resection defect or the detection of a post-traumatic defect, the temporal muscle is dissected along the fibers into two parts. The front part is placed in the cavity of the defect, hemmed to the surrounding tissues, biological glue is used for better sealing. A titanium mesh is placed on top of the laid front part of the temporal muscle and is fixed to the bone with titanium screws, simulating a bone defect so that the edge of the mesh does not exert pressure on the leg of the temporal muscle flap. In place of the front of the temporal muscle flap, its back is moved, placed on top of the titanium mesh and fixed to the periosteum, cuff of the temporal muscle or to the bone.

The inventive method was developed and passed clinical trials on the basis of the Department of Surgery of the Peripheral Nervous System of the Federal State Pedagogical Institute named after A.L. Polenova in the treatment of 5 patients.

We give an example - an extract from the medical history.

Patient B., 58 years old, and / b No. 2059-2011.

Diagnosis: Neurofibromatosis type 1. Meningioma of the left large and small wing of the sphenoid bone with intra-, extracranial distribution in the temporal, infratemporal, pterygo-palatine fossa, left orbit and sphenoid sinus.

Brain MRI from 07/06/11: volumetric formation in the area of the wings of the sphenoid bone on the left, occupying the middle cranial fossa and extending into the left orbit, temporal, infratemporal and pterygo-palatine fossa, main sinus.

Given the histological nature of the tumor, its expansive growth with the destruction of the structures of the base of the skull, progressive clinical symptoms, a scheduled surgical intervention was performed on 08/31/11 in the amount of total removal of the tumor from the left orbit-zygomatic approach, resection of part of the scales of the temporal bone, part of the large and small wings of the sphenoid bone , parts of the lateral wall of the orbit, pterygoid process of the sphenoid bone and the lateral wall of the sphenoid sinus with primary plastic base of the skull according to the present method: the temporal muscle was dissected along the fibers into two parts; the front part was laid in the cavity of the defect, hemmed to the surrounding tissues; over the laid part of the temporal muscle, a titanium mesh was fixed with titanium screws, while the edge of the mesh did not squeeze the leg of the temporal muscle flap; in place of the front part of the temporal muscle flap, its back was moved, laid over the titanium mesh and fixed to the periosteum and to the bone through additional holes.

The early postoperative period was uneventful, on the 3rd day after the operation the patient was vertical, the sutures were removed on the 8th day, wound healing by primary intention. Liquorreias were not noted. On control MRI, there is no data for encephalocele. During external examination in the early and late postoperative period, there is no cosmetic defect of soft tissues in the temporal region.

Using the proposed method for plastic closure of defects of the base of the skull allows the elimination of cosmetic defects, reliably seal the intracranial space and distinguish it from extracranial structures.

Claims (1)

A method for plastic closing defects in the base of the skull, including dissection of the temporal muscle, its splitting along the fibers into two parts, moving the front part into the cavity of the defect and suturing it to the surrounding tissues, characterized in that a titanium mesh is placed over the front part of the temporal muscle and fix it to bones so that the edge of the mesh does not exert pressure on the leg of the flap of the temporal muscle, after which the back of the temporal muscle is moved to the place of the front part, placed on top of the titanium mesh and fixed to ossuary, or bone.