RU2796938C1 - Method of elimination of paralysis of mimic muscles - Google Patents

Abstract

FIELD: medicine; plastic surgery; maxillofacial surgery.

SUBSTANCE: incision is made on the affected side starting from the scalp of the temporal region, continuing in the anterior region anteriorly from the tragus to the earlobe. After that, the skin-fat flap is mobilized, the superficial temporal arteries and veins are visualized in the temporal region, the masticatory branch of the trigeminal nerve is verified and isolated in the area of the mandibular notch in the thickness of the masticatory muscle, the masticatory branch of the trigeminal nerve passes through a blunt path to the nasolabial fold area, and a bed for the autograft is formed in the parotid — masticatory, temporal region and commissure region of the mouth. An arcuate incision is made on the non-affected side, starting from the scalp of the temporal region, continuing in the anterior region anteriorly from the tragus to the earlobe, the skin-fat flap is mobilized, the buccal branch of the facial nerve is isolated by blunt dissection, then the sural nerve autograft is taken. An autoinsert from the sural nerve is made using a neuroconductor from the vestibular surface of the upper lip, the sural nerve is dissected using a microsurgical technique of 0.5 in diameter of the buccal branch of the facial nerve of the non-affected side, the previously performed autograft of the sural nerve is sutured to the buccal branch of the facial nerve of the non-affected side. After that, an autograft of the sternohyoid and scapular-hyoid muscles with a neurovascular bundle is taken, using access through a skin incision along the anterior edge of the sternocleidomastoid muscle, a fragment is included in the autograft of the sternohyoid and scapular-hyoid muscles body of the hyoid bone. The autograft of the sternohyoid and scapular-hyoid muscles is located in the previously prepared bed as follows: the upper end of the autograft of the sternohyoid and scapular-hyoid muscles, namely, a fragment of the body of the hyoid bone, is fixed in the zygomatic region, the lower end is fixed in the area of the corner of the mouth and nasolabial folds, vascular anastomoses are applied between the superior thyroid artery and vein and the superficial temporal artery and vein, respectively, then nerve anastomoses are applied between the end of the autograft nerve with the masticatory branch of the trigeminal nerve of the affected side and the second end of the sural nerve autograft. The edges of the wound are pushed together and sutured in layers.

EFFECT: method allows to bring in an additional number of motor neurons, and also allows to achieve symmetrical movements on the affected and non-affected sides of the face, which improves the aesthetic and functional results.

1 cl, 2 dwg, 1 ex

Description

This invention relates to medicine, namely to maxillofacial, reconstructive surgery, and is intended for the surgical treatment of mimic muscle paralysis more than 1.5 years old.

A known method of surgical elimination of paralysis of facial muscles prescription for more than 1.5 years.

According to the method, myoneuroplasty is performed by autotransplantation of the sternohyoid muscle.

The first step is to prepare the receiving bed. To do this, an incision is made on the affected side, starting from the scalp of the temporal region, continuing in the anterior region anteriorly from the tragus to the earlobe, 8 cm long. The skin-fat flap is mobilized. In the temporal region, the superficial temporal artery and vein are visualized. In the area of the notch of the lower jaw in the thickness of the masticatory muscle, the masticatory branch of the trigeminal nerve is verified, isolated and taken on a holder. They pass bluntly into the area of the nasolabial fold, form a bed for the autograft in the parotid-masticatory, temporal and commissural areas of the mouth with dimensions of 9 × 5 cm.

Next, an autograft of the sternohyoid muscle with a neurovascular bundle is taken using access through a horizontal skin incision along the second neck crease. The autograft of the sternohyoid muscle includes a fragment of the body of the hyoid bone.

Next, the autograft of the sternohyoid muscle is placed in the prepared bed of the autograft as follows: the upper end of the autograft of the sternohyoid muscle (a fragment of the body of the hyoid bone) is fixed in the zygomatic region, the lower end is fixed in the region of the corner of the mouth. Vascular anastomoses are applied between the superior thyroid artery and vein and the superficial temporal artery and vein, respectively. The autograft nerve is sutured to the masticatory branch of the trigeminal nerve. Wound edges are aligned and sutured in layers [Daniel S. Alam, The stemohyoid flep for facial reanimation, Facial Plast Surg Clin N Am 24 (2016) 61-69].

The disadvantage of this method is that, as a result, it allows you to get movements in only one direction along one vector, performing the function of only the large zygomatic muscle.

Also, the disadvantage of this method is the implementation of access when performing the sampling of the autograft of the sternohyoid muscle using a horizontal skin incision along the second crease of the neck, since, firstly, this access does not provide proper visualization of the necessary anatomical structures; secondly, this operative approach is more traumatic, since a more extensive dissection of soft tissues is required to isolate the muscle to the full length; thirdly, the postoperative scar gives patients discomfort when swallowing due to soldering with the underlying structures, which creates the need for corrective surgeries to remove the scar.

Also, the disadvantage of this method is the reinnervation of the sternohyoid muscle only with the help of the masticatory branch of the trigeminal nerve, as a result of which the patient has isolated movements of the autograft on the affected side, which occur only when the teeth are compressed.

As a result, patients have an insufficient aesthetic and functional result, which creates the need for corrective surgery.

The technical result of this invention is to improve the aesthetic and functional results, the ability to achieve friendly movements of healthy and affected parties, reducing the period of rehabilitation of patients.

The technical result is achieved by the fact that in the method for eliminating paralysis of the mimic muscles by preparing the receiving bed with making an incision on the affected side, starting from the hairy part of the temporal region, continuing in the anterior region anteriorly from the tragus to the earlobe, mobilizing the skin-fat flap, visualizing in the temporal area of the superficial temporal artery and vein, verification and isolation in the area of the mandibular notch in the thickness of the masticatory muscle of the masticatory branch of the trigeminal nerve, passing in a blunt way into the area of the nasolabial fold, forming a bed for the autograft in the parotid-masticatory, temporal area and the area of the commissure of the mouth, holding an arcuate an incision on the healthy side, starting from the scalp of the temporal region, continuing in the anterior region anteriorly from the tragus to the earlobe, mobilizing the skin-fat flap, isolating the buccal branch of the facial nerve by blunt dissection, taking an autograft of the sural nerve, with the help of a neuroconductor from injections from the vestibular surface of the upper lip, an autoinsert of the sural nerve, with dissection using microsurgical technique of 0.5 diameter of the buccal branch of the facial nerve of the healthy side, stitching the previously performed autograft of the sural nerve with the buccal branch of the facial nerve of the healthy side; by taking an autograft of the sternohyoid and scapular-hyoid muscles with a neurovascular bundle using access through a skin incision along the anterior edge of the sternocleidomastoid muscle with the inclusion of a fragment of the body of the hyoid bone in the autograft of the sternohyoid and scapular-hyoid muscles; by placing the autograft of the sternohyoid and scapular-hyoid muscles in the prepared bed as follows: the upper end of the autograft of the sternohyoid (3) and scapular-hyoid (11) muscles, namely, a fragment of the body of the hyoid bone (4), is fixed in the zygomatic region, the lower end is fixed in the region of the angle of the mouth and the nasolabial fold, with the imposition of vascular anastomoses between the superior thyroid artery and vein (9) and the superficial temporal artery and vein (10), respectively, with the imposition of a neural anastomosis between the end of the nerve of the autograft (5) with the masticatory branch of the trigeminal nerve of the affected side and the second end of the sural nerve autograft with further layer-by-layer wound closure.

Brief description of drawings:

Affected side (1), healthy side (2), autograft of the sternohyoid (3) and scapular-hyoid (11) muscles, fragment of the body of the hyoid bone (4), end of the autograft nerve (5), masticatory branch of the trigeminal nerve (6) , buccal branch of the facial nerve (7), sural nerve autograft (8), superior thyroid artery and vein (9), superficial temporal arteries and veins (10).

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

Prepare the receiving bed.

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 anteriorly from the tragus to the earlobe. The skin-fat flap is mobilized. In the temporal region, the superficial temporal artery and vein are visualized (10). Bluntly passed into the area of the nasolabial fold, a bed is formed for the autograft in the parotid-masticatory, temporal and commissural regions of the mouth. In the region of the mandibular notch, in the thickness of the masticatory muscle, the masticatory branch of the trigeminal nerve (6) of the affected side (1) is verified, isolated and taken on a holder.

Further, on the healthy side (2), an arcuate incision is made, starting from the scalp of the temporal region, continuing in the anterior region anteriorly from the tragus to the earlobe. The skin-fat flap is mobilized. The buccal branch of the facial nerve (7) of the healthy side (2) is isolated by blunt dissection.

Then, an autograft of the sural nerve (8) is taken through a vertical incision 3 cm long behind and above the lateral malleolus. Using the method of blunt dissection in the direction vertically and upwards, an autograft of the sural nerve 30 cm long is isolated. Soft tissues are sutured in layers.

With the help of a neuroconductor, an autograft of the gastrocnemius seal (8) is carried out from the vestibular surface of the upper lip from the affected (1) to the healthy side (2). Using microsurgical technique, 0.5 diameter of the buccal branch of the facial nerve (7) of the healthy side (2) is dissected, then the previously performed sural nerve autograft (8) is sutured to the buccal branch of the facial nerve (7) of the healthy side (2).

When taking an autograft of the sternohyoid (3) and scapular-hyoid (11) muscles on the side of the lesion (1), a skin incision is made along the anterior edge of the sternocleidomastoid muscle. The subcutaneous muscle of the neck, the superficial plate of the cervical fascia are dissected. The anterior edge of the sternocleidomastoid muscle is visualized. Then the sternocleidomastoid muscle is retracted posteriorly in order to visualize the main vessels: the trunks of the common carotid artery and the internal jugular vein, and the cervical loop. Next, the scapular-hyoid (11) muscle is allocated to the lower edge of the tendon insert. At this level, along the lower edge of the tendon insert, the fibers of the scapular-hyoid (11) muscle are dissected. After dissection, a cervical loop is found under it, which at the same level gives its branches to the scapular-hyoid (11), sternothyroid and sternohyoid muscles. The cervical loop is allocated along the entire length from the place of origin from the hypoglossal nerve to the place of origin of the branches from it to the sternohyoid (3) and scapular-hyoid (11) muscles. Further, the method of blunt and acute dissection visualizes the internal jugular vein, which is allocated upwards up to the place of origin of the superior thyroid vein, which joins the artery of the same name and goes to the sternohyoid (3) and scapular-hyoid (11) muscles. Then the common carotid artery is visualized, which also stands out upwards up to the bifurcation. Immediately after the bifurcation, the superior thyroid artery departs from the external carotid artery. The above vessels: the superior thyroid vein and the superior thyroid artery (9), under a microscope magnification, were isolated along the distal direction until their branches entered the sternohyoid (3) and scapular-hyoid (11) muscles. The superior thyroid artery and vein have a number of branches: a large branch to the thyroid gland, branches to nearby muscles, which must be ligated along the vascular pedicle.

The sternohyoid (3) muscle is allocated towards the hyoid bone to the place of its attachment. Mobilization of the muscle also continues towards the sternum until it is attached. The flap includes a part of the body of the hyoid bone, when the flap of the sternohyoid (3) and scapular-hyoid (11) muscles is cut off at the upper border, the suprahyoid muscles are retracted, and the area of the hyoid bone to which the sternohyoid (3) and scapular muscles are attached. the hyoid (11) muscle is sawn out, and thus is part of the flap.

Also, the lower edge of the sternohyoid (3) muscle is cut off from the sternum. The lower edge of the autograft of the sternohyoid (3) and scapular-hyoid (11) muscles is sutured with U-shaped sutures. Produced ligation of the vascular bundle in the proximal. The flap is cut off, transferred to the recipient area on the face. The edges of the wound and the donor area are compared, sutured in layers.

The autograft of the sternohyoid (3) and scapular-hyoid (11) muscles is placed in the prepared bed in the recipient zone in such a way that the upper end of the autograft, namely the fragment of the body of the hyoid bone (4), is fixed in the zygomatic region, the lower end of the sternohyoid (3) the muscle is fixed in the area of the corner of the mouth, and the lower end of the scapular-hyoid (11) muscle is fixed in the area of the nasolabial fold.

Using a microsurgical technique, the autograft of the sternohyoid (3) and scapular-hyoid (11) muscles is revascularized by applying vascular anastomoses between the superficial temporal artery (10) and the superior thyroid artery (9) in an end-to-end fashion and the superficial temporal vein ( 10) and superior thyroid vein (9) end-to-end. Reinnervation of the sternohyoid (3) and scapular-hyoid (11) muscles occurs by applying a neural anastomosis: the end of the autograft nerve (5) is sutured to the masticatory branch of the trigeminal nerve (6) of the affected side and the second end of the sural nerve autograft (8). The edges of the wound are compared, sutured in layers.

Example 1

Patient B. was in the department of maxillofacial surgery of the Federal State Budgetary Institution "TsNIIS and ChLH" with a diagnosis of "Paralysis of the mimic muscles on the left."

From the anamnesis it is known that in 2015 an operative intervention was performed in the volume "Removal of the acoustic neuroma" on the left, immediately after which the phenomena of paralysis of the mimic muscles on the left, anacusia on the left appeared. He did not receive any treatment for mimic muscle paralysis.

At the time of admission to the clinic, the patient had a pronounced asymmetry of the face, lagophthalmos, and the absence of mimic muscle tone on the left.

An external examination determines the asymmetry of the face due to the deformation of the left half of the face. Ptosis of the soft tissues of the left half of the face is noted. When performing mimic tests, there is a complete absence of mimic activity of the left half of the face.

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 mimic muscles.

Prepared the receiving bed.

On the side of the lesion, an arcuate incision is made, starting from the scalp of the temporal region, continuing in the anterior region anteriorly from the tragus to the earlobe. The skin-fat flap is mobilized. In the temporal region, the superficial temporal artery and vein are visualized. Bluntly passed into the area of the nasolabial fold, a bed is formed for the autograft in the parotid-masticatory, temporal and commissural regions of the mouth. In the region of the mandibular notch, in the thickness of the masticatory muscle, the masticatory branch of the trigeminal nerve of the affected side is verified, isolated and taken on a holder.

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

Then, the sural nerve autograft is taken through a vertical incision 3 cm long behind and above the lateral malleolus. Using the method of blunt dissection in the direction vertically and upwards, an autograft of the sural nerve 30 cm long is isolated. Soft tissues are sutured in layers.

With the help of a neuroconductor, an autograft of the gastrocnemius seal from the affected side to the healthy side is carried out from the injections from the vestibular surface of the upper lip. Using microsurgical technique, 0.5 diameter of the buccal branch of the facial nerve of the healthy side is dissected, then the previously performed sural nerve autograft is sutured to the buccal branch of the facial nerve of the healthy side.

When taking an autograft of the sternohyoid and scapular-hyoid muscles on the side of the lesion, a skin incision is made along the anterior edge of the sternocleidomastoid muscle. The subcutaneous muscle of the neck, the superficial plate of the cervical fascia are dissected. The anterior edge of the sternocleidomastoid muscle is visualized. Then the sternocleidomastoid muscle is retracted posteriorly in order to visualize the main vessels: the trunks of the common carotid artery and the internal jugular vein, and the cervical loop. Next, the scapular-hyoid muscle is allocated to the lower edge of the tendon insert. At this level, along the lower edge of the tendon insert, the fibers of the scapular-hyoid muscle are dissected. After dissection, a cervical loop is found under it, which at the same level gives its branches to the scapular-hyoid, sternothyroid and sternohyoid muscles. The cervical loop is allocated along the entire length from the place of origin from the hypoglossal nerve to the place where branches from it branch to the sternohyoid and scapular-hyoid muscles. Further, the method of blunt and acute dissection visualizes the internal jugular vein, which is allocated upwards up to the place of origin of the superior thyroid vein, which joins the artery of the same name and goes to the sternohyoid and scapular-hyoid muscles. Then the common carotid artery is visualized, which also stands out upwards up to the bifurcation. Immediately after the bifurcation, the superior thyroid artery departs from the external carotid artery. The above vessels: the superior thyroid vein and the superior thyroid artery, under microscope magnification, were identified along the distal extent until their branches entered the sternohyoid and scapular-hyoid muscles. The superior thyroid artery and vein have a number of branches: a large branch to the thyroid gland, branches to nearby muscles, which must be ligated along the vascular pedicle.

The sternohyoid muscle is allocated towards the hyoid bone to the place of its attachment. Mobilization of the muscle also continues towards the sternum until it is attached. The flap includes a part of the body of the hyoid bone, when the flap of the sternohyoid and scapular-hyoid muscles is cut off at the upper border, the suprahyoid muscles are retracted, and the area of the hyoid bone, to which the sternohyoid and scapular-hyoid muscles are attached, is sawn out, and thus enters into the flap.

Also, the lower edge of the sternohyoid muscle is cut off from the sternum. The lower edge of the autograft of the sternohyoid and scapular-hyoid muscles is sutured with U-shaped sutures. Produced ligation of the vascular bundle in the proximal. The flap is cut off, transferred to the recipient area on the face. The edges of the wound and the donor area are compared, sutured in layers.

The autograft of the sternohyoid and scapular-hyoid muscles is placed in the prepared bed in the recipient zone in such a way that the upper end of the autograft, namely the fragment of the hyoid bone body, is fixed in the zygomatic region, the lower end of the sternohyoid muscle is fixed in the region of the corner of the mouth, and the lower the end of the scapular-hyoid muscle is fixed in the region of the nasolabial fold.

Using a microsurgical technique, the autograft of the sternohyoid and scapular-hyoid muscles is revascularized by applying end-to-end vascular anastomoses between the superficial temporal artery and superior thyroid artery and the superficial temporal vein and superior thyroid vein in an end-to-end manner. Reinnervation of the sternohyoid and scapular-hyoid muscles occurs by applying a nerve anastomosis: the end of the autograft nerve is sutured to the masticatory branch of the trigeminal nerve of the affected side and the second end of the sural nerve autograft. The edges of the brine are matched, sutured in layers.

In the postoperative period, infusion, antibacterial, anti-inflammatory, analgesic, anticoagulant therapy, dressings were performed.

As a result of the operation, autotransplantation of the sternohyoid and scapular-hyoid muscles was performed in the surgical treatment of mimic muscle paralysis.

The proposed method has a number of the following advantages.

According to this technique, to eliminate paralysis of mimic muscles, surgery is performed using the sternohyoid and scapular-hyoid muscles as an autograft, which as a result allows obtaining multivector movements in different directions, performing the function of not only the zygomatic major, but also the zygomatic minor muscles. As a result, it turns out to achieve a significant improvement in both aesthetic and functional results.

Since the sternohyoid muscle and the upper belly of the scapular-hyoid muscle have a common origin from the hyoid bone, one source of blood supply and venous outflow at the level of the great vessels and a common innervation from the cervical loop, the sampling of the upper belly of the scapular-hyoid muscle as part of the sterno- the hyoid muscle does not appear to be difficult and incurs minimal donor damage.

A more optimal approach when taking an autograft of the sternohyoid and scapular-hyoid muscles allows you to get the greatest control over the main vessels and nerves and their branches. It also eliminates the appearance of discomfort in the patient in the postoperative period, which eliminates the need for surgical interventions to remove the scar.

Carrying out the reinnervation of the autograft of the sternohyoid and scapular-hyoid muscles using the masticatory branch of the trigeminal nerve on the affected side and the buccal branch of the facial nerve of the healthy side through the sural nerve autoinsertion introduces an additional number of motor neurons, and also allows achieving symmetrical movements on the affected and healthy side of the face, which improves aesthetic and functional results.

Claims (1)

A method for eliminating paralysis of mimic muscles, which consists in making an incision on the side of the lesion from the scalp of the temporal region, continuing in the anterior region anteriorly from the tragus to the earlobe, then mobilizing the skin-fat flap, visualizing superficial temporal arteries and veins in the temporal region, the masticatory branch of the trigeminal nerve is verified and isolated in the region of the lower jaw cut in the thickness of the masticatory muscle, passes bluntly into the region of the nasolabial fold, a bed is formed for the autograft in the parotid-masticatory, temporal region and the commissure region of the mouth, characterized in that an arcuate incision is made on a healthy side, starting from the hairy part of the temporal region, continuing in the anterior region anteriorly from the tragus to the earlobe, the skin-fat flap is mobilized, after which the buccal branch of the facial nerve is isolated by blunt dissection, the sural nerve autograft is taken, performed using a neuroconductor from injections with on the vestibular surface of the upper lip, an autoinsert from the sural nerve is dissected using a microsurgical technique of 0.5 diameter of the buccal branch of the facial nerve of the healthy side, the previously performed autograft of the sural nerve is sutured to the buccal branch of the facial nerve of the healthy side; then, through the skin incision along the anterior edge of the sternocleidomastoid muscle, an autograft of the sternohyoid and scapular-hyoid muscles with a neurovascular bundle is taken, while a fragment of the body of the hyoid bone is included in the autograft of the sternohyoid and scapular-hyoid muscles; after that, the autograft of the sternohyoid and scapular-hyoid muscles is placed in the previously prepared bed as follows: the upper end of the autograft of the sternohyoid and scapular-hyoid muscles, namely, a fragment of the body of the hyoid bone, is fixed in the zygomatic region, the lower end is fixed in the corner of the mouth and nasolabial folds, impose vascular anastomoses between the superior thyroid artery and vein and superficial temporal artery and vein, respectively, then impose nerve anastomoses between the end of the nerve of the autograft with the masticatory branch of the trigeminal nerve of the affected side and the second end of the autograft of the sural nerve; the edges of the wound are compared, sutured in layers.

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