在不可逆面瘫的微笑通过免费功能肌肉交接单级动态Reanimation来
Summary
The use of the masseteric nerve as donor nerve represents a single-stage alternative to the criterion standard two-stage procedure of cross-facial nerve grafting and free muscle transfer in facial paralysis. We provide a detailed description to safely perform this technique with a gracilis muscle transfer and discuss indications and limitations.
Abstract
Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic facial paralysis (Bell’s palsy) is the most common diagnosis, patients can also present with a history of physical trauma, infectious disease, tumor, or iatrogenic facial paralysis. Early repair within one year of injury can be achieved by direct nerve repair, cross-face nerve grafting or regional nerve transfer. It is due to muscle atrophy that in long lasting facial paralysis complex reconstructive methods have to be applied. Instead of one single procedure, different surgical approaches have to be considered to alleviate the various components of the paralysis.
The reconstruction of a spontaneous dynamic smile with a symmetric resting tone is a crucial factor to overcome the functional deficits and the social handicap that are associated with facial paralysis. Although numerous surgical techniques have been described, a two-stage approach with an initial cross-facial nerve grafting followed by a free functional muscle transfer is most frequently applied. In selected patients however, a single-stage reconstruction using the motor nerve to the masseter as donor nerve is superior to a two-stage repair. The gracilis muscle is most commonly used for reconstruction, as it presents with a constant anatomy, a simple dissection and minimal donor site morbidity.
Here we demonstrate the pre-operative work-up, the post-operative management, and precisely describe the surgical procedure of single-stage microsurgical reconstruction of the smile by free functional gracilis muscle transfer in a step by step protocol. We further illustrate common pitfalls and provide useful tips which should enable the reader to truly comprehend the procedure. We further discuss indications and limitations of the technique and demonstrate representative results.
Introduction
面神经参与眼保护，关节运动，口服可控并极大地影响该面的美观。这种神经损伤与显著的发病率和社会退缩，因此相关。尽管在治疗中显著的进步，许多与瘫痪面部相关联的问题只能定位用的附加程序的广谱。共同所有的外科技术是需要一个确切的解剖知识。
面神经解剖
面神经由鳃电机组件自愿电机控制面部肌肉和内脏电机组件的泪腺，颌下腺的副交感神经控制，和舌下腺。此外，还有对于外耳道的神经支配和用于前两个第三舌的味觉2感官组件。面神经的过程中可以BË分为三个部分：颅内，颞骨内和extratemporal。在颅内段，神经元的上组支配额肌和periauricular区域接收双侧皮质输入。神经元支配剩余的面部肌肉完全接受对侧皮质输入。其结果是，额功能被维持在同侧核上性病变。的颞骨内段可进一步分为三段。在迷路段，岩大神经离开主干提供泪腺与副交感神经纤维1。
在乳突段，薄镫骨肌神经跑到记者肌肉。副交感神经分支支配颌下腺，舌下和前舌腺体，而前三分之二的舌头与味觉纤维（鼓索）提供。面神经的主干退出骨管通过茎乳孔。这是extratemporal段的开始，但arborisation不进入腮腺之前启动。神经首先被分成了形成intraparotid丛，并最终引起颞，颧，颊，下颌和颈支2 3〜4电机的分裂。
面瘫的鉴别诊断
面瘫的病因很广，很难进行分类，即影响了部门应首先考虑。
颅内面瘫可以通过腔隙性脑梗死或颅内腔肿瘤引起的。细菌和病毒感染，胆脂瘤和贝尔氏麻痹可能是原因，颞骨内神经损伤。肿瘤恶性肿瘤和相关的手术治疗是主要的原因extratemporal面瘫。虽然贝尔氏麻痹是最常见的诊断在面瘫患者，大多数患者完全恢复，无后遗症，不需要手术治疗3。面瘫的第二个最常见的原因是外伤。这里，骨折的颞骨是主要的创伤机构4。
面瘫的治疗类型
众多的手术方案存在面瘫的治疗，他们可分为神经再支配，重建的静态和动态重构。典型地，二十年被认为是从损伤的时间，其中神经支配恢复后函数可以重新获得令人满意reinnervating程序5。后来，面部肌肉失神经支配萎缩排除它们的用途进行进一步改造。神经再支配可以通过初级神经修复，interpositional神经移植，跨面神经移植术或颅神经传递获得。静态重建技术被引导到正确的功能性残疾，（保护角膜，改善鼻腔气流，并防止流口水）和提高对称性在休息。典型的程序browlift的眉下垂，或canthoplasty对于下睑外翻。静态重建优先老年显著合并症或大规模面部瑕疵继发于外伤或肿瘤切除术。
动态重构的手术技术可以细分为区域肌肉转移和免费microneurovascular肌肉传递与任何接合到咬肌运动支或跨面神经移植术。后者表示在面瘫的微笑重建标准的标准，因为没有其他的治疗方案可靠地实现了自然的笑容是至关重要的，以提高社会障碍。接合到咬肌运动支是首选的治疗方式的患者双侧瘫，但有迹象显示分机结束，如老年患者或患者显著合并症通常喜欢的单级过程6。
股薄肌皮瓣
局部解剖学
股薄肌是大腿内侧的肤浅的肌肉，代表着内收肌的肌肉最长。它源于较低耻骨和耻骨的上下支。运行远侧，肌肉变得狭窄，并插入远侧上的胫骨的膝关节，使大腿不仅收而且膝关节屈曲。股薄肌有和张欢后纳海一个II型循环模式与主导和一些小的血管蒂7动脉供应。占主导地位的动脉退出肌肉在肺门向横向当然，通常终止于内侧回旋支。很少，主要的动脉终止直接在股深动脉。在GRA静脉供应cilis肌肉是通过两个络脉comitantes通常实现的，即当然深内收长肌遵循的主导动脉。肌肉的神经支配是通过闭孔神经进入肌肉1-2厘米优到肺门的前支实现。
临床使用
股薄肌是一种宝贵的捐助肌肉的显微重建，已成为首选许多外科医生进行功能免费肌肉转移的肌肉。这是欠的事实，即很少有供区的发病率和折片显示最佳比例与问候肌肉偏移和分别血管蒂的尺寸。长单神经支配运动神经功能缓解皮瓣收获8。
我们在这里展示的49岁女性，最初表现为左侧周围性面瘫的全貌谁的情况下切除声的神经瘤（前庭神经鞘瘤）2年前。该患者最颜面不对称，特别是微笑的时候折磨。其他已存在的合并症没有记录。
经临床检查，病人表现为额肌的完整麻痹，但在休息了满意的额头对称性。盖闭合不足左侧5毫米和贝尔的现象眼睑闭合不全。角膜刺激和外翻的迹象都没有。在休息时，患者表现为口为11厘米的权利，在休息11.5厘米左边一耳屏，蜗轴距离的角落适度不对称。在微笑，耳屏，蜗轴距离缩小至9厘米的右侧和细长的左侧〜12厘米。经过广泛的咨询，患者希望的笑容的单上演动态重构使用咬肌作为供体神经的免费功能纤细转移。病人还了解到各种忒盖闭合重建chniques，但是拒绝外科治疗在这个阶段。在治疗过程中是不复杂的。神经再支配的迹象首次发现3个月术后。手术四个月后，病人出现沿原修饰整容手术切口线瘢痕不显着。对称性在休息和故意微笑是优秀的鼻唇沟皱纹的令人满意的定义。患者也表现出了完全自发的笑容。在嘴角的漂移前和9个月的术后范围内被记录了录像。
Protocol
Representative Results
Discussion
Even though different surgical techniques have been described to regain a dynamic smile in patients with long standing facial paralysis, the two-stage repair with initial cross facial nerve grafting and consecutive free gracilis muscle transfer is seen as the “criterion standard”.
Although a two-stage procedure, the technique allows for spontaneity of the smile which is seen as a crucial factor to overcome the social handicap associated with facial palsy13.In cases of bi…
Disclosures
The authors have nothing to disclose.
Acknowledgements
Dr. Eisenhardt is funded by the German Research Foundation (DFG) # EI 866/1-1 and #EI 866/2-1.
Materials
| Name of Material/ Equipment | Company | Catalog Number | Comments/Description |
| Nylon Suture, 9-0 | Serag Weissner | Z0039490 | ° |
| Polypropylene Suture | Ethicon | – | Multiple thread sizes |
| Suprarenin 1mg/ml | Sanofi | – | ° |
| Cook-Swartz Doppler Probe | Cook Medical | G03014 | ° |
| DP-M350 Blood Flow Monitor | Cook Medical | – | ° |
| Surgical Microscope OPMI Vario | Carl Zeiss | – | ° |
| Microsurgical instruments lab set | S&T | 767 | ° |
| Biemer vessel clip | Diener | 64,562 | ° |
| Applying forceps | Diener | 64,568 | for Biemer vessel clip |
| Cefuroxim 1500mg | Fresenius | J01DC02 | ° |
| Braunoderm | Braun Melsungen | 3881105 | ° |
| Octenisept | Schuelke & Mayr | 5702764 | ° |
| ISIS Neuromonitoring System | Inomed | – | ° |
| Tissucol | Baxter | 1.33052E+12 | Fibrin glue |
| Jackson-Pratt Wound Drainage | Medline | SU130-1060 | |
| Myacyne Ointment | Schur Pharma | – |
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