RU2714180C1 - Reinnervation of facial muscles method - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: present invention refers to medicine, namely to maxillofacial, reconstructive, plastic surgery, and can be used to form isolated movements of the middle and lower face zones in the patients with facial muscle paralysis. Disclosed is a method for reinnervation of facial muscles is performed by dissecting skin and subcutaneous fat on the injured and healthy sides with pre-bovine access, further along the hair growth line, delamination of the skin-fat flap to the front edge of the parotid gland with subsequent separation of the musculo-aponeurotic layer, separation and mobilization of the parotide posterior border from the cartilaginous part of the external tragola, the anti-tracheal and intercostal incision, then, on the involved side, the facial nerve is isolated and cut off within the exit of the ligamentous opening and the parenchyma of the parotid gland is excised. Trunk and branches of the facial nerve are isolated in the parotid gland and the facial nerve is divided into an upper part with temporal, bilge and cheek branches and a lower part with marginal and cervical branches. Hypoglossal nerve is separated in the region of the anterior portion of the two-abdominal muscle, and 30–40 % of its fascicles are incised with subsequent collection of the autograft autograft. It is conducted from the affected side to the healthy one under the previously isolated skin-fat flap through an oral cavity under the mucous membrane and sutured together with a buccal branch of the facial nerve with layer-by-layer suturing of the soft tissues.

EFFECT: invention provides higher functional and aesthetic results in patients with damage of mastication branch of trigeminal nerve.

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 the healthy side is performed through the ear-behind-the-ear procedure, then along the hairline.

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

The posterior edge of the parotid gland is isolated and mobilized from the cartilaginous part of the outer ear — the tragus, anti-tragus, and interstitial notch. 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 selected 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 fascicles are dissected and microsurgically sutured to the lower part of the facial nerve trunk.

The fascial case of the chewing muscle is dissected, its fibers are pushed apart, reaching the lunar notch. 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 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 25-32 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 mucosa

a sheath carries an autograft of the gastrocnemius nerve using a neuroconductor.

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

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

Then microsurgery is performed stitching of the autograft of the calf nerve with the buccal branch of the facial nerve. 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. 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 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 reinnervation 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, especially in patients with damage to the chewing branch of the trigeminal nerve.

The technical result is achieved by the fact that in 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 muscular the aponeurotic layer, by isolating and mobilizing the posterior edge of the parotid gland from the cartilaginous part of the outer ear-tragus, protozoan tragus and interstitial notch, then excretion is performed on the affected side cutting and cutting off the trunk of the facial nerve in the area of exit from the styloid opening and excision of the parenchyma of the parotid gland, then the trunk and branches of the facial nerve in the parotid gland and the trunk 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 the cervical branches, then in the region of the upper part of the biliary network, the hyoid nerve is secreted and 30-40% of its fascicles are dissected, followed by an autograft of the calf nerve, which is carried out from the affected side healthy on under the previously selected 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, with further layer-by-layer suturing of soft tissues, a distinctive feature is that in addition to the carotid triangle, the descending branch of the hyoid nerve is isolated and cut off in the bifurcation area, the obtained gastrocnemius autograft 25-32 cm long is divided into two segments 21-25 cm and 4.0-7.0 cm long, then on the healthy side the buccal branch of the facial nerve is sutured with the end a segment of a gastrocnematic nerve graft 21-25 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 nerve trunk and the end of the calf autotransplant nerve 4.0-7.0 cm long, the other end of the calf nerve autograft segment 4.0-7.0 cm long is sutured to the hyoid nerve, the descending branch of the hyoid nerve is rotated to the lower part of the trunk facial nerve and staple with it.

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 the skin-fat flap is peeled off to the front edge (3), the parotid gland, 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 side (1), the trunk (4) of the facial nerve is isolated in the area of exit from the styloid opening (5) and cut off.

Excision of the parotid parenchyma is performed. Then, the trunk (4) and the branches of the facial nerve in the parotid gland are extracted and the trunk (4) 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, in the region of the upper part of the biliary network at the level of the intersection of the external carotid artery, the hyoid nerve (13) and its descending branch (14) are isolated. 30–40% of its fascicles are cut and its descending branch is cut off (14) in the area of its bifurcation.

On the healthy side (2) at the anterior edge (3) of the parotid gland, the buccal (9) branch of the facial nerve is isolated. Next, a dissection of 0.5-0.75 of the diameter of the buccal (9) 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 25–32 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 two segments 21-25 cm (15) and 4.0-7.0 cm (16).

Then, on the healthy (2) side, the buccal (9) branch of the facial nerve is sutured to the end of the gastrocnemic nerve autograft segment 21-25 cm long (15), carried out using a neuroconductor from the affected (1) side to the healthy (2) side under the previously isolated skin a fat flap through the vestibule of the oral cavity under the mucous membrane.

On the affected (1) side, the other end of this segment is sutured with the upper part (6) of the facial nerve trunk and the end of the calf nerve autograft segment of 4.0-7.0 cm length (16), the other end of the calf nerve autograft segment is 4.0- 7.0 cm (16) are sutured with the hyoid nerve (13), then the descending branch (14) of the hyoid nerve (13) is rotated into the region of the lower part (10) of the facial nerve trunk and sutured.

Stitching is carried out 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 K. (b. 1976) was treated at a clinic with a diagnosis

"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: 03/22/2017, the patient underwent surgical treatment in the amount: "Removal of MMU neurinoma 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 the absence of movements of the facial muscles on the left.

At the external examination, it was noted: asymmetry of the face, a positive symptom of a tennis racket, lagophthalmus 6.5 mm, a displacement of the filter and columella by 3.0 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 hydropressed 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 anterior edge of the parotid gland, followed by the release of the muscle-aponeurotic layer. The posterior margin of the parotid gland was isolated and mobilized from the cartilaginous part of the external tragus ear, protector, 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.

Sublingual nerve and its descending branch were isolated in the upper part of the biliary network. We performed a dissection of 40% of the fascicular hyoid nerve.

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 25.0 cm long was isolated vertically and upward. Then a calf nerve autograft was divided into two segments 21.0 cm and 4.0 cm. Tissues were sutured in layers.

Then, on the healthy side, the buccal branch of the facial nerve was sewn with the end of the gastrocnemic nerve autograft segment 21 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 was stitched with the upper part of the facial nerve trunk and the end of the calf nerve autograft segment 4.0 cm long, the other end of the calf nerve autograft segment 4.0 cm long was stitched with the hyoid nerve, then the descending branch of the hyoid nerve was cut off in the region its bifurcations were rotated to the lower part of the trunk of the facial nerve and stitched.

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

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

Example 2

Patient B. (born 1987) 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: "Removing meningioma of the 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 severe 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 2.5 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 hydropressed 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 anterior edge of the parotid gland, followed by the release of the muscle-aponeurotic layer. The posterior margin of the parotid gland was isolated and mobilized from the cartilaginous part of the external tragus ear, protector, 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.

Sublingual nerve and its descending branch were isolated in the upper part of the biliary network. We performed a dissection of 30% of the fascicular hyoid nerve.

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 3 cm long in the back and above the lateral ankle. A 32 cm long autograft of the calf nerve 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 and 7.0 cm. The tissues were sutured in layers.

Then, on the healthy side, the buccal branch of the facial nerve is sutured with 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 calf nerve autograft segment with a length of 7.0 cm, the other end of the gastrocnemic nerve autograft segment with a length of 7.0 cm is sutured with the hyoid nerve, the descending branch of the hyoid nerve is cut off in the region of it bifurcations and rotate to the lower part of the trunk of the facial nerve

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

Soft tissue on the healthy and affected side sutured in layers. In the pre-ear region behind the ear for two days left drainage graduates.

The advantage of this method is the possibility of reinnervation of facial muscles and the formation of isolated movements of the middle and lower zones of the face in patients with facial paralysis of facial muscles, especially in patients with damage to the chewing branch of the trigeminal nerve, which allows to achieve a greater degree of functional and aesthetic results.

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-tragus, protivokontelka and interstitial notch, then on the affected side, the facial nerve trunk is selected and cut off in the region to exit from the styloid opening and excision of the parotid parenchyma, then the trunk and branches of the facial nerve are separated in the parotid gland 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 the sublingual muscle is secreted by the hyoid nerve and 30-40% of its fasciculi are dissected, followed by an autograft of the gastrocnemius nerve, which is carried out from the affected side to the healthy one under previously isolated skin and fat flap through the vestibule of the oral cavity under the mucous membrane and stitch it with the buccal branch of the facial nerve, with further layer-by-layer suturing of the soft tissues, characterized in that the descending branch of the hyoid nerve is isolated in the carotid triangle and cut off in the bifurcation region, the obtained autograft transplant 25-32 cm is divided into two segments 21-25 cm long and 4.0-7.0 cm, then on the healthy side the buccal branch of the facial nerve is sutured to the end of the calf nerve autograft segment 21-25 cm long, performed 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 calf nerve autograft segment 4.0-7.0 cm long , the other end of the calf nerve autograft segment 4.0-7.0 cm long is sutured with the hyoid nerve, the descending branch of the hyoid nerve is rotated to the lower part of the facial nerve trunk and sutured with it.

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