RU2752714C1 - Method for eliminating paralysis of facial muscles - Google Patents

Abstract

FIELD: medicine, plastic surgery.SUBSTANCE: invention relates to medicine, namely to plastic surgery. On the side of the lesion, an arcuate incision is made, starting from the hairy part of the temporal region, continuing in the anterior region anteriorly from the tragus, skirting the earlobe, then passing horizontally in the posterior region and descending along the projection of the anterior edge of the nodding muscle, with a total length of up to 15 cm. Next, the skin-fat flap is mobilized, and they pass into the area of the nasolabial fold. A bed for an autograft is formed in the nasolabial fold, upper and lower lips, and recipient vessels: the facial artery and vein-are isolated at the anterior edge of the masticatory muscle. The sublingual nerve is isolated in the submandibular region. On the healthy side, an anterior incision is made, a skin-fat flap is mobilized, the buccal branch of the facial nerve is isolated, and then an autograft of the sural nerve is taken. Next, an autograft of the sural nerve is brought with the help of a neural conductor from injections from the vestibular surface of the upper lip from the healthy side to the hyoid nerve on the affected side; the previously performed autograft of the sural nerve is sewn to the buccal branch of the facial nerve of the healthy side; then, a gracilis muscle graft is taken by performing a linear incision of the skin, subcutaneous fat on the medial surface of the upper third of the thigh with a length of 11 cm, a gracilis muscle is isolated on the upper neurovascular bundle, represented by branches of the middle femoral artery and vein, the anterior branch of the obturator nerve. Next, a longitudinal cleavage of the gracilis muscle is performed along the fibers from the contralateral side from the point of entry of the neurovascular bundle, the muscle is stitched with U-shaped sutures and a transverse dissection of the muscle is performed distal to the vascular pedicle between the distal and middle third. Also, in the proximal part, the gracilis muscle is stitched with U-shaped sutures and cut off immediately after its tendon departs from the pubic symphysis with the formation of stumps for the upper and lower lip and modiolus. Then the vascular pedicle is legated and the nerve in the proximal part is cut off, the flap is cut off and transferred to the recipient zone on the face in the previously prepared autograft bed, the wound edges in the donor area are compared, sutured in layers. The gracilis muscle autograft is placed in a prepared bed in the recipient zone and fixed to the zygomatic arch and the superficial temporal fascia, the second end in the area of the commissura of the mouth, upper and lower lips. Next, the autograft of the gracilis muscle is revascularized by applying vascular anastomoses between the autograft artery and the facial artery in the “end-to-end” way and between the autograft vein and the facial vein in the “end-to-end” way. Reinnervation of the gracilis muscle autograft is performed by applying a nerve anastomosis: the distal end of the cross-facial autograft, the proximal end of the crossed fascicles of the hyoid nerve and the muscle nerve are compared, neurography is performed according to the “two ends to the end” type, stitching the distal end of the cross-facial autograft, the proximal end of the crossed fascicles of the hyoid nerve with the proximal end of the obturator nerve of the gracilis muscle, the wound edges are compared, they are sutured in layers.EFFECT: method makes it possible to obtain satisfactory functional results due to synchronous contractions of the autograft of the gracilis muscle with the healthy side and its sufficient excursion.1 cl, 1 ex, 2 dwg

Description

This invention relates to medicine, namely to maxillofacial and plastic surgery, and is intended to eliminate paralysis of facial muscles.

A known method for eliminating paralysis of facial muscles using revascularized and reinnervated autograft of a fragment of tender muscle.

According to the method, paralysis of facial muscles is eliminated using the tender muscle, the hypoglossal nerve and the buccal branch of the facial nerve of the healthy side.

The first team works on the face and conducts the formation of a subcutaneous tunnel between the corner of the mouth and the zygomatic arch of the paralyzed side; preparing recipient facial vessels for vascular anastomoses; the branches leading to the nasal wing of the buccal branch of the healthy facial nerve are identified; prepare the bed for nerve and muscle transplants, isolate the hypoglossal nerve and its descending branch.

The second team works on the hip and collects an 8 cm long piece of tender muscle on the superior neurovascular pedicle. The length of the vascular pedicle is 4 cm, the diameter of the vessels is 2.5-3 mm, and the length of the nerve is 5 cm.

The third team works on the lower leg and collects a 17 cm long sural nerve graft (the distance between the wound through which the buccal branches are exposed on the healthy side and the central buccal region of the paralyzed side of the face).

The operation is completed by one team: a muscle fragment is transferred to the face, placed subcutaneously on the paralyzed side of the face and under the necessary tension is fixed to the periosteum of the zygomatic arch and to the tissues of the corner of the mouth. Under optical magnification, vascular anastomoses are applied between the vessels of the muscle graft and the facial vessels with an 8/0 thread, in an end-to-end manner. Thread 9/0 impose perineural sutures between the main trunk of the hypoglossal nerve and the nerve of the tender muscle. The descending branch of the hypoglossal nerve is anastomosed with the peripheral segment of the hypoglossal nerve and thus its integrity is restored again. Fascicular sutures are applied between the sural nerve graft and the selected branches of the buccal branch of the healthy facial nerve. The other end of the nerve graft is carried out subcutaneously, split into separate fascicles and implanted into the abdomen of the muscle graft [RF patent for invention RU 2112442 C1, "Method for the treatment of unilateral paralysis" AI Nerobeev, Ts.M. Shurgaya, VI Malakhovskaya) ...

The disadvantage of this method is increased trauma (hemiatrophy of the tongue and peripheral motor dysarthria) due to the intersection of the hypoglossal nerve and the use of its distal part as a donor, and complete restoration of the muscles of the tongue by reinnervation using the descending branch of the hypoglossal nerve is not observed, which is explained by the smaller amount of her motor axons.

Also, the disadvantage of this method is the use of a fragment of the tender muscle on the upper neurovascular pedicle without splitting, which leads to a pronounced deformation of the contours of the face in the area of the autograft due to its excess volume.

The disadvantages of this method also include an increase in the terms of rehabilitation due to the need for corrective operations to eliminate pronounced asymmetry of the face.

The disadvantages also include neurotization of the tender muscle by fasciculations of the distal end of the cross-facial nerve autograft, which does not give the desired effect of smile symmetry, due to insufficient amplitude of contraction of the muscle autograft.

The technical result of this invention is to reduce the trauma of the method, the terms of rehabilitation, the achievement of coordinated and synchronous facial movements.

The technical result is achieved by the fact that in the method of eliminating paralysis of facial muscles by preparing the receiving bed with an arcuate incision starting from the hairy part of the temporal region, continuing in the anterior region anterior to the tragus, bending around the earlobe, then horizontally passing in the posterior region and descending along the projection of the anterior the edges of the sternocleidomastoid muscle, 15 cm long on the side of the lesion, the formation of a bed for an autograft in the area of the nasolabial fold, the upper and lower lips under the plane of the aponeurotic system of muscles, the allocation of recipient vessels at the anterior edge of the masseter muscle - the facial artery and vein, the allocation in the submandibular region by 2 cm below the edge of the lower jaw under the digastric muscle of the hypoglossal nerve, with a preauricular incision on the healthy side with reclining of the fatty skin flap, exposing the buccal branch of the facial nerve, by harvesting the gastrocnemius nerve through the skin incision and the subcutaneous cell cuts in the area of the lateral surface of the ankle 2 cm long, isolation and excision of the peripheral part of the sural nerve, isolation in the proximal direction for 30 cm and excision in the popliteal fossa, by forming a tunnel using a neuroconductor in the subcutaneous-muscular aponeurotic layer from the buccal branch of the facial nerve from the healthy side through the upper lip with incisions on the transitional fold of the mucous membrane of the vestibule of the oral cavity to the hyoid nerve of the affected side, in which a 30 cm long sural nerve autograft was performed, followed by suturing the buccal branch of the facial nerve on the healthy side with an end-to-end sural nerve autograft , by taking an autograft of the tender muscle on the superior neurovascular bundle, represented by the branches of the middle femoral artery and vein, by the anterior branch of the obturator nerve, by performing a linear incision of the skin, subcutaneous fat on the medial surface of the upper third and thighs 11 cm long, transfer of the autograft to the recipient area on the face to the previously prepared bed of the autograft in the area of the nasolabial fold, upper and lower lip, fixing the autograft of the tender muscle with one end to the zygomatic arch and superficial temporal fascia, the second end in the area of the mouth commissure, upper and the lower lip, with the imposition of vascular anastomoses between the artery and vein of the autograft of the tender muscle and the facial artery and vein, respectively, under a microscope magnification, a perineural window was formed in the highlighted section of the hyoid nerve trunk, 40% of the fascicles were dissected, the obturator nerve was tunneled to the neck, the distal end of the cross - facial autograft, the proximal end of the transected 40% of the hypoglossal nerve fascicles and the muscle nerve were matched, neuroraphy was performed according to the "two ends" type (distal end of the cross-facial autograft, the proximal end of the transected 40% of the hypoglossal nerve fascicles) to the end "(the autograft nerve of the fascia) icular and epineural sutures with further layer-by-layer suturing of wounds.

Brief description of the drawings (Fig. 1-2): 1 - the side of the lesion; 2 - tender muscle autograft; 3 - healthy side; 4 - autograft of the sural nerve; 5 - nerve of the autograft; 6 - hypoglossal nerve; 7 - the proximal part of the transected 40% of the hypoglossal nerve fascicles; 8 - the buccal branch of the facial nerve of the healthy side; 9 - artery and vein of the autograft; 10 - facial artery and vein.

The method is carried out as follows (Fig. 1-2).

The receiving bed is prepared.

On the side of the lesion (1), an arcuate incision is made, starting from the hairy part of the temporal region, continuing in the anterior region anterior to the tragus, bending around the earlobe, then horizontally passing to the posterior region and descending along the projection of the anterior edge of the sternocleidomastoid muscle, with a total length of up to 15 cm. skin and fat flap. Bluntly passed into the area of the nasolabial fold, formed a bed for the autograft in the area of the nasolabial fold, upper and lower lips under the plane of the aponeurotic system of muscles. The subcutaneous muscle of the neck with the superficial fascia of the neck covering it was dissected along the entire length of the skin incision. The facial artery and vein are highlighted at the anterior edge of the masseter muscle (10). By the method of blunt and acute dissection, it was passed between the anterior edge of the sternocleidomastoid muscle and the parotid gland to the lateral surface of the posterior abdomen of the digastric muscle. The digastric muscle is taken on a holder, then the jugular vein is highlighted, retracted. The hypoglossal nerve was isolated (6), the epineurium was dissected, 40% of the fascicles of the proximal hypoglossal nerve were isolated (7), the nerve was held on a holder.

Further, on the healthy side (3), an arcuate incision is made, starting from the hairy part of the temporal region, continuing in the pre-auricular region anteriorly from the tragus to the earlobe 8 cm long. The fatty flap is mobilized. Blunt dissection is used to isolate the buccal branch of the facial nerve from the healthy side (8).

Then, an autograft of the sural nerve (4) is taken by means of a vertical incision 3 cm long behind and above the lateral ankle. By blunt dissection in the vertical and upward direction, an autograft of the sural nerve (4) 30 cm long is isolated. Soft tissues are sutured in layers.

Then, using a neuroconductor, a tunnel was formed in the subcutaneous aponeurotic layer from the buccal branch of the facial nerve on the healthy side (8) through the upper lip with incisions made in the transitional fold of the mucous membrane of the vestibule of the oral cavity to the hyoid nerve of the affected side (6), in which an autograft of the gastrocnemius nerve 30 cm long, followed by suturing the buccal branch of the facial nerve on the healthy side (8) with an end-to-end sural nerve autograft (4).

When taking an autograft of the tender muscle (2) on the upper neurovascular bundle, an 11 cm long incision is made in the skin and subcutaneous fat on the medial surface of the upper third of the thigh.Then, access to the adductor muscle group of the thigh is made, and the tender muscle is isolated on the upper neurovascular bundle represented by the branches of the middle femoral artery and vein, which are highlighted over 5 cm, by the anterior branch of the obturator nerve, highlighted over 9 cm. Further, the longitudinal splitting of the tender muscle is performed. The tender muscle is stitched with U-shaped sutures and transversely dissected distal to the vascular pedicle between the distal and middle third. In the proximal region, the tender muscle is stitched with U-shaped sutures and cut off immediately after the tendon has left the pubic symphysis. The vascular bundle will be ligated in the proximal section. The flap is cut off and transferred to the recipient area on the face. The edges of the transected muscle in the donor area are stitched with a twisted suture and fixed to a long adductor. The edges of the wound are matched, sutured in layers.

The tender muscle autograft (2) is placed in the prepared autograft bed on the face and fixed to the zygomatic arch and superficial temporal fascia, with the second end in the area of the mouth commissure, upper and lower lip.

With the help of microsurgical technique, the tender muscle autotransplant (2) is revascularized by imposing vascular anastomoses between the autograft artery (9) and the facial artery (10) according to the “end-to-end” type and between the autograft vein (9) and the facial vein (10) according to the “ end to end ". Reinnervation of the tender muscle autograft (2) is performed by applying a nerve anastamosis: the distal end of the cross-facial autograft of the sural nerve (4), the proximal end of the transected 40% of the hypoglossal nerve fascicles (7) and the autograft nerve (5) are compared, the type of neuroraphy is performed according to the end (the distal end of the cross-facial autograft of the sural nerve (4), the proximal end of the transected 40% of the hypoglossal nerve fascicles (7)) to the end ”(the autograft nerve (5)), fascicular and epineural sutures are applied with further layer-by-layer wound closure.

Example 1

Patient C, was in the Department of Maxillofacial Surgery of the Federal State Budgetary Institution "TsNIIS and Maxillofacial Surgery" with a diagnosis: "Paralysis of the facial muscles on the left. Condition after hemorrhagic stroke. Removal of the cavernous malformation of the pons of the brain on the left ”.

From the anamnesis it is known that the patient suffered a hemorrhagic stroke with the formation of an acute intracerebral hematoma in the brain stem on the left. Surgical assistance was provided in the following volume: “Median suboccipital craniotomy. Removal of the cavernous malformation of the pons of the brain. In the postoperative period, the patient began to notice the absence of movements of the mimic muscles on the left, numbness of the left half of the face, decreased hearing and vision on the left.

At the time of admission, the patient had a complete absence of movements of the facial muscles on the left for two years.

On clinical examination, facial asymmetry is noted during mimic movements due to paralysis of the left half of the face. When performing facial tests, the eyelids of the left eye do not close, with a smile, the immobility of the upper and lower lips on the left, the smoothness of the left nasolabial folds. The axis of the face is deviated to the right by 4 mm. Filtrum is shifted to the right by 3 mm. The corner of the mouth on the left is lowered by 2 mm. Tennis racket symptom is positive. The movements of the tongue are coordinated, there is no deviation of the tip of the tongue.

In the clinic, after a complete clinical, laboratory and instrumental examination under conditions of combined endotracheal anesthesia, an operation was performed to eliminate the paralysis of the facial muscles.

Prepared a receptive bed.

On the side of the lesion, an arcuate incision was made, starting from the hairy part of the temporal region, continuing in the anterior region of the tragus, bending around the earlobe, then horizontally passing to the posterior region and descending along the projection of the anterior edge of the sternocleidomastoid muscle, with a total length of up to 15 cm. flap. Bluntly passed into the area of the nasolabial fold, formed a bed for the autograft in the area of the nasolabial fold, upper and lower lips under the plane of the aponeurotic system of muscles. The subcutaneous muscle of the neck with the superficial fascia of the neck covering it was dissected along the entire length of the skin incision. At the anterior edge of the masseter muscle, the facial artery and vein are highlighted. Using the method of blunt and acute dissection, it was passed between the anterior edge of the sternocleidomastoid muscle and the parotid gland to the lateral surface of the posterior abdomen of the digastric muscle. The digastric muscle is taken on a holder, then the jugular vein is highlighted, retracted. The hypoglossal nerve was isolated, the epineurium was dissected, 40% of the proximal nerve fascicles were isolated, the nerve was held on a holder.

Further, on the healthy side, an arcuate incision was made, starting from the hairy part of the temporal region, continuing in the pre-auricular region anteriorly from the tragus to the earlobe, 8 cm long. A skin-fat flap was mobilized. The buccal branch of the facial nerve from the healthy side was isolated by blunt dissection.

Then an autograft of the sural nerve was taken through a vertical incision 3 cm long behind and above the lateral ankle. A 30 cm long autograft of the sural nerve was isolated by blunt dissection in the vertical and upward direction. The soft tissues were sutured in layers.

Next, using a neuroconductor, a tunnel was formed in the subcutaneous aponeurotic layer from the buccal branch of the facial nerve on the healthy side through the upper lip, with incisions made on the transitional fold of the mucous membrane of the vestibule of the oral cavity to the sublingual nerve of the affected side, in which an autograft of the sural nerve 30 cm long was performed, followed by stitching the buccal branch of the facial nerve on the healthy side with an end-to-end sural nerve autograft.

When taking an autograft of the tender muscle on the upper neurovascular bundle, an 11 cm long incision was made in the skin and subcutaneous fat on the medial surface of the upper third of the thigh.Then access was made to the adductor group of the thigh muscles, the tender muscle was isolated on the upper neurovascular bundle, represented by the branches the middle femoral artery and vein, which are isolated over 5 cm, by the anterior branch of the obturator nerve, isolated over 9 cm. Further, the longitudinal splitting of the tender muscle was performed. The tender muscle is stitched with U-shaped sutures and transversely dissected distal to the vascular pedicle between the distal and middle third. In the proximal region, the tender muscle was sutured with U-shaped sutures and cut off immediately after the tendon had detached from the pubic symphysis. Produced ligation of the vascular bundle in the proximal section. The flap was excised and transferred to the recipient area on the face. The edges of the transected muscle in the donor area were sewn with an upholstery suture and fixed to a long adductor. The edges of the wound are matched, sutured in layers.

The tender muscle autograft is placed in the prepared bed of the autograft on the face and fixed to the zygomatic arch and superficial temporal fascia, with the second end in the area of the mouth commissure, upper and lower lip.

With the help of microsurgical technique, the tender muscle autotransplant was revascularized by imposing vascular anastomoses between the autograft artery and the facial artery in the end-to-end manner and between the autograft vein and the facial vein in the end-to-end manner. Reinnervation of the delicate muscle autograft was performed by applying a nerve anastamosis: the distal end of the cross-facial autograft, the proximal end of the transected 40% of the hypoglossal nerve fascicles and the muscle nerve were aligned, neuroraphy was performed according to the “two ends” type (distal end of the cross-facial autograft, the proximal fasciculum of the hypoglossal nerve) to the end ”(the end of the obturator nerve of the slender muscle), fascicular and epineural sutures were imposed with further layer-by-layer suturing of the wounds.

The proposed method has a number of the following advantages.

Reducing trauma due to the preservation of 60% of the hypoglossal nerve fascicles, which allows avoiding such phenomena as hemiatrophy of the tongue and peripheral motor dysarthria in the postoperative period.

The splitting of the tender muscle autograft avoids pronounced deformation of the facial contours, which leads to a more satisfactory aesthetic result.

Creation of a nerve anastomosis of the “two ends to end” type, namely, the comparison of the distal end of the cross-face autograft of the sural nerve and the proximal end of the transected 40% of the hypoglossal nerve fascicules to the end of the autograft nerve with subsequent neuroraphy, allows to obtain satisfactory functional results due to synchronous autograft contractions tender muscle with a healthy side and its sufficient excursion.

Claims (1)

A method for eliminating paralysis of facial muscles is that on the side of the lesion, an arcuate incision is performed, starting from the hairy part of the temporal region, continuing in the anterior region anterior to the tragus, bending around the earlobe, then horizontally passing in the posterior region and descending along the projection of the anterior edge of the sternocleidomastoid muscle , with a total length of up to 15 cm, then mobilize a skin-fat flap, pass into the area of the nasolabial fold, form a bed for an autograft in the area of the nasolabial fold, upper and lower lip, isolate recipient vessels at the anterior edge of the masseter muscle - the facial artery and vein, isolate into In the submandibular region, the hypoglossal nerve, a pre-auricular incision is made on the healthy side, a skin-fat flap is mobilized, the buccal branch of the facial nerve is isolated, then an autograft of the sural nerve is taken, then the autograft of the sural nerve is carried out with the help of a neuroconductor from the injections from the vestibular from the healthy side to the hypoglossal nerve on the affected side; a previously performed autograft of the sural nerve is sutured to the buccal branch of the facial nerve of the healthy side; then the graft of the tender muscle is taken by means of a linear incision of the skin, subcutaneous fat on the medial surface of the upper third of the thigh 11 cm long, the tender muscle is isolated on the upper neurovascular bundle, represented by the branches of the middle femoral artery and vein, the anterior branch of the obturator nerve, then longitudinal splitting of the tender muscle along the fibers from the contralateral side from the place of entry of the neurovascular bundle is performed, the muscle is stitched with U-shaped sutures and a transverse dissection of the muscle distal to the vascular pedicle between the distal and middle third is performed, as well as in the proximal part the tender muscle is stitched with U-shaped sutures and cut off immediately after the detachment of its tendon from the pubic symphysis with the formation of stumps for the upper and lower lip and modiolus, then the vascular pedicle is doped and the nerve is cut off in the proximal section, the flap is cut off and transferred to the recipient area on the face in the previously prepared bed autotransplant tata, the edges of the wound in the donor area are compared, sutured in layers, then the tender muscle autograft is placed in the prepared bed in the recipient zone and fixed to the zygomatic arch and superficial temporal fascia, with the second end in the area of the mouth commissure, upper and lower lip, then the soft muscle autograft is revascularized by imposing vascular anastomoses between the artery of the autograft and the facial artery in the end-to-end manner and between the vein of the autograft and the facial vein in the end-to-end manner; reinnervation of the tender muscle autograft is performed by applying a nerve anastamosis: the distal end of the cross-facial autograft, the proximal end of the transected fascicles of the hypoglossal nerve and the muscle nerve are matched, neuroraphy is performed according to the "two ends to end" type, stitching the distal end of the cross-facial autograft transected the fasciculum of the hypoglossal nerve with the proximal end of the obturator nerve of the slender muscle, the edges of the wound are matched, sutured in layers.

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