RU2702608C1 - Method of reinnervation of facial muscles - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to maxillofacial, reconstructive, plastic surgery. Skin and subcutaneous fat are dissected on an affected and healthy sides with preauricular-postaural approach. Further, along the hair growth line, delamination of the skin-fat flap to the front edge of the parotid gland with subsequent release of the muscular-aponeurotic layer, separation and mobilization of the posterior edge of the parotid gland from the cartilaginous part of the external ear – antilobium, antitragus and intertragic notch. On the involved side, the facial nerve is isolated and cut off within the exit of the thymus-like opening and the parenchyma of the parotid glands is excised. Further, the trunk and branches of the facial nerve are separated in the parotid gland and the facial nerve is divided into an upper part with temporal, bilge and cheek branches and a lower portion with marginal and cervical branches. Sublingual nerve is extracted in the area of an apex of the digastric muscle to dissect 30–40 % of its fascicles. Then the fascia-shaped case of chewing muscle is dissected, its fibers are expanded to reach a half-moon incision, the chewing branch of the trigeminal nerve in it is cut off as much as possible to a arcus zygomaticus. On a healthy side, an anterior edge of the parotid gland is separated by a buccal branch of the facial nerve with subsequent dissection of 0.5–0.75 of its diameter. That is followed by sampling of an autograft nerve that is delivered from an affected side to a healthy one under a previously isolated skin-fat flap through an oral cavity under the mucous membrane and sutured together with a buccal branch of the facial nerve, followed by layer-by-layer soft tissue suturing. Recovered autograft of nervus suralis 30–36 cm long is divided into three lengths 20–25 cm, 6.0–6.5 cm and 4.0–4.5 cm. On the healthy side, the cheek branch of the facial nerve is sutured together with the end of segment 20–25 cm long autograft from an affected side to a healthy one under a previously isolated skin-fat flap through an oral cavity under the mucous membrane. On the involved side, the other end of the segment is sutured together with an upper portion of the facial nerve and the end of a segment of the autograft nerve length of 6.0–6.5 cm, other end of a segment of an autograft nerve in length 6.0–6.5 cm is stitched with a sublingual nerve, the end of a segment of an autograft nerve end of length 4.0–4.5 cm is stitched together with a chewing branch of a trigeminal nerve, other end of the given segment is stitched with the lower part of a trunk of facial nerve.

EFFECT: method allows increasing functional and aesthetic results of treatment, as a result, patients have a high degree of facial muscle excursion.

1 cl, 1 dwg, 2 ex

Description

This invention relates to medicine, namely to maxillofacial, reconstructive, plastic surgery, and can be used to form isolated movements of the middle and lower zones of the face in patients with facial paralysis of facial muscles.

A known method of reinnervation of facial muscles using the chewing branch of the trigeminal nerve, hyoid nerve and autograft of the gastrocnemius nerve.

The dissection of the skin and subcutaneous fat on both the affected and healthy side is performed through the ear-behind-the-ear procedure, then along the hairline.

The skin-fat flap is exfoliated to the anterior edge of the parotid gland, followed by the release of the muscular aponeurotic layer (SMAS).

Allocate and mobilize the posterior edge of the parotid gland from the cartilaginous part of the outer ear - the tragus, protivokozelka and interstitial tenderloin.

On the affected side, the trunk of the facial nerve is isolated in the area of exit from the styloid opening and cut off.

The parotid parenchyma is excised and the trunk and branches of the facial nerve in the parotid gland are extracted and the trunk and branches of the facial nerve are divided into the upper part with the temporal, zygomatic and buccal branches and the lower part with the marginal and cervical branches.

The lower part of the trunk of the facial nerve with the marginal and cervical branches rotate in the region of the carotid triangle.

Further, in the region of the upper part of the biliary network, the hyoid nerve is secreted. 30–40% of its fasciculi are dissected and microsurgically sutured to the lower part of the facial nerve trunk.

Then the fascial case of the chewing muscle is dissected, its fibers are pushed apart, reaching the half-moon cut. The chewing branch of the trigeminal nerve located in the masticatory muscle after cutting is cut off as high as possible to the zygomatic arch.

The chewing branch of the trigeminal nerve and the upper part of the trunk of the facial nerve — the temporal, zygomatic, and buccal branches with an autograft of the calf nerve — are microsurgically sutured.

On the healthy side, at the anterior edge of the parotid gland, the buccal branch of the facial nerve is isolated. Next, a cross section of 0.5-0.75 diameter of the buccal branch of the facial nerve is performed.

The gastrocnemius autograft is taken by a vertical incision 2-3 cm long in the back and above the lateral ankle. An autograft of the calf nerve 25-30 cm long is isolated by blunt dissection in the vertical and upward directions. Soft tissues are sutured in layers.

From the affected side to the healthy side under the previously selected skin-fat flap through the vestibule of the oral cavity under the mucous membrane, an autograft of the calf nerve is carried out using a neuroconductor.

Microsurgical stapling of the calf nerve autograft with the buccal branch of the facial nerve is performed. Stitching of nerves is carried out with the application of fascicular, peri- and epineural sutures. Soft tissues on the healthy and affected side are sutured in layers. [Application for invention No.2019101120 / 14 “Method for the reinnervation of facial muscles” A. Nerobeev et al., А61В 17/00 dated January 16, 2019].

The disadvantage of this method is the lack of a constant bioelectric potential and an insufficient number of motor neurons in the chewing branch of the trigeminal nerve, which is microsurgically sutured with the upper part of the trunk of the facial nerve innervating the upper and middle areas of the face.

As a result, in patients operated on by this method, an insufficient functional and aesthetic result is noted due to the lack of sufficient re-conservation of facial muscles.

Corrective surgery to eliminate residual ptosis of soft tissues is required.

The technical result of the proposed method is to increase the functional and aesthetic results.

The technical result is achieved by the fact that in the method of reinnervation of the facial muscles by dissecting the skin and subcutaneous fat on the affected and healthy sides by the ear-behind-the-ear access, then along the line of hair growth, peeling the skin-fat flap to the front edge of the parotid gland, followed by the allocation of muscle the aponeurotic layer, the allocation and mobilization of the posterior edge of the parotid gland from the cartilaginous part of the outer ear-tragus, protivokozelka and interstitial tenderloin, on the affected side carry out the allocation cutting off the trunk of the facial nerve in the area of exit from the styloid opening and excising the parenchyma of the parotid gland, then isolating the trunk and branches of the facial nerve in the parotid gland and dividing the trunk of the facial nerve into the upper part with the temporal, zygomatic and buccal branches and the lower part with the marginal and cervical branches then the hyoid nerve is secreted in the region of the upper part of the biliary network and 30-40% of its fascicles are dissected, then the fascial case of the masticatory muscle is dissected, its fibers are extended, reaching the lunate lobe The hezka, the chewing branch of the trigeminal nerve located in it, is cut off as high as possible to the zygomatic arch, on the healthy side of the anterior edge of the parotid gland, the buccal branch of the facial nerve is distinguished, followed by dissection of its diameter 0.5-0.75, then the autograft of the calf nerve is taken, which they are carried out from the affected side to the healthy one under the previously selected skin-fat flap through the vestibule of the oral cavity under the mucous membrane and sutured to the buccal branch of the facial nerve, followed by layer-by-layer suturing of soft t Anya, a distinctive feature is that the selected autograft of the calf nerve 30-36 cm long is divided into three segments 20-25 cm long, 6.0-6.5 cm long and 4.0-4.5 cm long, then on the healthy side the buccal the facial nerve branch is sutured to the end of the calf nerve autograft segment 20-25 cm long, drawn from the affected side to the healthy one under the previously selected skin-fat flap through the vestibule of the oral cavity under the mucous membrane, on the affected side, the other end of this segment is sutured to the upper part of the facial trunk nerve and conc m of the gastrocnemius nerve autograft segment 6.0-6.5 cm long, the other end of the gastrocnemius nerve autograft segment 6.0-6.5 cm long is sutured to the hyoid nerve, the end of the gastrocnemius autograft segment 4.0-4.5 cm long is sutured with a chewing branch of the trigeminal nerve, the other end of this segment is sutured to the lower part of the trunk of the facial nerve.

The method is as follows (Fig. 1).

Under endotracheal anesthesia, the surgical field is marked and the soft tissues are hydrotreated with a NaCl solution of 0.9% + Adrenaline 1: 400000 in a volume of 80 ml. The dissection of the skin and subcutaneous fat on the affected (1) and healthy (2) sides is performed through the ear-behind-the-ear procedure, then along the hairline. Then, a skin-fat flap is exfoliated to the anterior edge of the parotid gland (3), followed by the release of the muscular aponeurotic layer (SMAS). The posterior edge of the parotid gland is isolated and mobilized in the projection of the upper third of the sternocleidomastoid muscle from the cartilaginous part of the outer ear-tragus, anti-tragus and interstitial notch.

On the affected (1) side, the trunk of the facial nerve is isolated in the area of exit from the styloid opening and cut off.

The parotid parenchyma is excised. Then, the trunk (4) and the branches of the facial nerve are separated in the parotid gland (5) and the trunk of the facial nerve is divided into the upper part (6) with the temporal (7), zygomatic (8) and buccal (9) branches and the lower part (10) with marginal (11) and cervical (12) branches.

Then, the hyoid nerve is secreted in the region of the upper part of the biliary network (13) at the level of the intersection of the external carotid artery with it (14). Dissection of 30-40% of its fasciula is carried out.

Next, the fascial case of the masticatory muscle is dissected, by blunt dissection, its fibers are pushed (15), reaching a half-moon cut. The masticatory branch of the trigeminal nerve located in the masticatory muscle (16) after verification is cut off as high as possible to the zygomatic arch.

On the healthy side, the buccal branch (9) of the facial nerve is isolated at the anterior edge of the parotid gland. Next, a dissection of 0.5-0.75 of the diameter of the buccal branch of the facial nerve is performed.

The gastrocnemius autograft is taken by a vertical incision 2-3 cm long in the back and above the lateral ankle. An autograft of the calf nerve 30–36 cm long is isolated by blunt dissection in the vertical and upward directions. Tissues are sutured in layers. Then the calf nerve autograft is divided into three segments 20-25 cm (17), 6.0-6.5 cm (18) and 4.0-4.5 cm (19).

Next, on the healthy (2) side, the buccal (9) branch of the facial nerve is sutured to the end of the gastrocnemic nerve autograft segment with a length of 20-25 cm (17), carried out using a neuroconductor from the affected (1) side to the healthy (2) under the previously isolated skin with a fatty flap through the vestibule of the oral cavity under the mucous membrane On the affected (1) side, the other end of this segment (17) is sutured with the upper part (6) of the facial nerve trunk and the end of the gastrocnemius nerve autograft segment 6.0-6.5 cm long (18) , the other end of the gastrocnemius autograft segment a 6.0-6.5 cm long nerve (18) is sutured to the hyoid nerve (14), the end of a gastrocnemius autograft segment is 4.0-4.5 cm long (19) is sutured to the chewing branch of the trigeminal nerve (16), the other end this segment (19) is sewn with the lower part (10) of the facial nerve trunk.

Stitching is performed with the application of fascicular, peri-and epineural sutures. Soft tissues on the affected (1) and healthy (2) sides are sutured in layers. In the anterior and posterior regions, drainage graduates leave for two days.

Example 1

Patient S. (born 1976) was undergoing treatment in a clinic with a diagnosis of Mimic Muscle Paralysis on the Left. Condition after removal of the neurinoma of the bridge-cerebellar angle (MMU) on the left.

From the anamnesis: 01/18/2019, the patient underwent surgical treatment in the amount: "Removing meningioma MMU on the left." When the formation was removed, the facial nerve was damaged.

At the time of admission to the clinic, the patient had pronounced facial asymmetry, lagophthalmos and lack of tone of facial muscles on the left.

At the external examination, it was noted: asymmetry of the face, a positive symptom of a tennis racket, lagophthalmos 7 mm, displacement of the filter and columella by 2.8 mm to the healthy side.

In the clinic, after a complete clinical and laboratory examination, under endotracheal anesthesia, the operation of the proposed method was performed.

The surgical field was marked and the soft tissues were hydrotreated with a NaCL solution of 0.9% + Adrenaline 1: 400000 in a volume of 80 ml.

The dissection of the skin and subcutaneous fat on both the affected and healthy sides was performed through the ear through the ear behind the ear, then along the hairline. Then the skin-fat flap was exfoliated to the front edge of the parotid gland, followed by the release of the muscular-aponeurotic layer. The posterior edge of the parotid gland was isolated and mobilized from the cartilaginous part of the outer ear-tragus, anti-tragus and interstitial notch.

On the affected side, the trunk of the facial nerve was isolated in the area of exit from the styloid opening and cut off.

The parotid parenchyma was excised and the trunk and branches of the facial nerve were extracted and the trunk of the facial nerve was divided into the upper part with the temporal, zygomatic and buccal branches and the lower part with the marginal and cervical branches.

Next, in the region of the upper part of the biliary network, the hyoid nerve was isolated. We performed a dissection of 40% of the fascicles.

Then the fascial case of the masticatory muscle was dissected, pushing its fibers to the lunate notch, where the masticatory branch of the trigeminal nerve was isolated, and after verification, it was cut as far as possible to the zygomatic arch.

On the healthy side, the buccal branch of the facial nerve was isolated at the anterior edge of the parotid gland. Next, a cross section of 0.5 diameter of the buccal branch of the facial nerve trunk was performed.

The gastrocnemius autograft was taken by a vertical incision 2 cm long in the back and above the lateral ankle. Using a blunt dissection method, a calf nerve autograft 30 cm long was isolated vertically and upward. Then a calf nerve autograft was divided into three segments 20 cm, 6.0 cm and 4.0 cm. The tissues were sutured in layers.

Next, on the healthy side, the buccal branch of the facial nerve is sutured to the end of the gastrocnemic nerve autograft segment 20 cm long, drawn from the affected side to the healthy side under the previously selected skin-fat flap through the vestibule of the oral cavity under the mucous membrane.

On the affected side, the other end of this segment is stitched with the upper part of the facial nerve trunk and the end of the gastrocnemius nerve autograft segment 6.0 cm long, the other end of the gastrocnemic nerve autograft segment 6.0 cm long is sutured with the hyoid nerve, the end of the calf nerve autograft segment is 4. 0 cm is stitched with the chewing branch of the trigeminal nerve, the other end of this segment is stitched with the lower part of the trunk of the facial nerve.

Nerve suturing was performed with fascicular, peri-and epineural sutures.

Soft tissues on the healthy and affected side were sutured in layers. In the anterior and behind-the-ear areas for two days left drainage-graduates.

Example 2

Patient A. (born 1985) was treated in a clinic with a diagnosis of “Paralysis of facial muscles on the left”. Condition after removal of the neurinoma of the bridge-cerebellar angle (MMU) on the left.

From the anamnesis: The patient underwent surgical treatment in the amount of: "Removal of MMU meningioma on the left." When the formation was removed, the facial nerve was damaged.

At the time of admission to the clinic, the patient had pronounced facial asymmetry, lagophthalmos and lack of tone of facial muscles on the left.

At the external examination, it was noted: asymmetry of the face, a positive symptom of a tennis racket, lagophthalmos 6 mm, a mixture of filtrum and columella 3 mm in the healthy direction.

In the clinic, after a complete clinical and laboratory examination, under endotracheal anesthesia, the operation of the proposed method was performed.

The surgical field was marked and the soft tissues were hydrotreated with a NaCL solution of 0.9% + Adrenaline 1: 400000 in a volume of 80 ml.

The dissection of the skin and subcutaneous fat on both the affected and the healthy side was performed through the ear through the ear behind the ear, then along the hairline. Then the skin-fat flap was exfoliated to the front edge of the parotid gland, followed by the release of the muscle-aponeurotic layer. The posterior edge of the parotid gland was isolated and mobilized from the cartilaginous part of the outer ear-tragus, anti-tragus and interstitial notch.

On the affected side, the trunk of the facial nerve was isolated in the area of exit from the styloid opening and cut off.

The parotid parenchyma was excised and the trunk and branches of the facial nerve were extracted and the trunk of the facial nerve was divided into the upper part with the temporal, zygomatic and buccal branches and the lower part with the marginal and cervical branches.

Next, in the region of the upper part of the biliary network, the hyoid nerve was isolated. We performed a dissection of 30% of the fascicles.

Then the fascial case of the masticatory muscle was dissected, pushing its fibers to the lunate notch, where the masticatory branch of the trigeminal nerve was isolated, after its verification, they were cut as far as possible to the zygomatic arch.

On the healthy side, the buccal branch of the facial nerve was isolated at the anterior edge of the parotid gland. Next, a cross section of 0.75 diameters of the buccal branch of the facial nerve trunk was performed.

The gastrocnemius autograft was taken by a vertical incision 2.5 cm long in the back and above the lateral ankle. An autograft of the calf nerve 36 cm long was isolated vertically and upward by the method of blunt dissection. Then, the autograft of the calf nerve was divided into three segments 25 cm, 6.5 cm and 4.5 cm. The tissues were sutured in layers.

Next, on the healthy side, the buccal branch of the facial nerve is sutured to the end of the calf nerve autograft segment 25 cm long, drawn from the affected side to the healthy side under the previously selected skin-fat flap through the vestibule of the oral cavity under the mucous membrane.

On the affected side, the other end of this segment is sutured with the upper part of the facial nerve trunk and the end of the gastrocnemius nerve autograft segment 6.5 cm long, the other end of the gastrocnemic nerve autograft segment 6.5 cm long is sutured with the hyoid nerve, the end of the gastrocnemal nerve autograft segment has a length of 4, 5 cm are stitched with the chewing branch of the trigeminal nerve, the other end of this segment is stitched with the lower part of the trunk of the facial nerve.

Nerve suturing was performed with fascicular, peri-and epineural sutures.

Soft tissues on the healthy and affected side were sutured in layers. In the anterior ear region, drainage graduates left for two days.

The advantage of this method is the constant bioelectric potential in the sublingual nerve, which is microsurgically sutured with the upper part of the trunk of the facial nerve innervating the middle zone of the face. As a result, patients operated on by this method have a high degree of facial muscle excursion, which entails a high functional and aesthetic result. Patients do not need corrective operations to eliminate residual ptosis of soft tissues.

Claims (1)

The method of reinnervation of facial muscles by dissecting the skin and subcutaneous fat on the affected and healthy sides by the ear-behind-the-ear access, then along the hairline, exfoliating the skin-fat flap to the front edge of the parotid gland, followed by the allocation of the muscular aponeurotic layer, the allocation and mobilization of the posterior the edges of the parotid gland from the cartilaginous part of the outer ear — the tragus, protivocitus and interstitial notch; on the affected side, the facial nerve trunk is selected and cut off in the region the passage from the styloid opening and excision of the parotid parenchyma, then the trunk and branches of the facial nerve in the parotid gland are selected and the facial trunk is divided into the upper part with the temporal, zygomatic and buccal branches and the lower part with the marginal and cervical branches, then in the upper part the sublingual muscle secrete the hyoid nerve and dissect 30-40% of its fascicles, then dissect the fascial sheath of the chewing muscle, push its fibers, reaching the lunate tenderloin, located in it chewing branch t of the coronary nerve is cut off as high as possible to the zygomatic arch, on the healthy side near the anterior edge of the parotid gland, the buccal branch of the facial nerve is distinguished, followed by dissection of 0.5-0.75 of its diameter, then the calf nerve autograft is taken, which is carried out from the affected side to a healthy under previously allocated skin-fat flap through the vestibule of the oral cavity under the mucous membrane and stitch it with the buccal branch of the facial nerve, followed by layer-by-layer suturing of soft tissues, characterized in that the selected autot the calf nerve implant 30-36 cm long is divided into three segments 20-25 cm, 6.0-6.5 cm and 4.0-4.5 cm long, then on the healthy side the buccal branch of the facial nerve is sutured to the end of the calf autograft section a nerve length of 20-25 cm, drawn from the affected side to the healthy one under the previously selected skin-fat flap through the vestibule of the oral cavity under the mucous membrane, on the affected side, the other end of this segment is sutured with the upper part of the facial nerve trunk and the end of the gastrocnemius nerve autograft segment 6 , 0-6.5 cm, other the end of the calf nerve autograft segment 6.0-6.5 cm long is sutured with the hyoid nerve, the end of the calf nerve autograft segment 4.0-4.5 cm long is sutured with the chewing branch of the trigeminal nerve, the other end of this segment is sutured with the lower part of the trunk facial nerve.

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