Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5208_Библиотеки_им_академика_М_И_Перельмана
.pdf
252
Fig. 19.8 Fascia lata
tailoring to t the face.
This patient is undergoing
nasolabial fold and alar
base suspension in addition
to sterno-omohyoid
functional free muscle
transfer
M. H. Hohman and A. G. Vincent
Fig. 19.9 Illustration of
the suture topology.
Placing the sutures through
stab incisions allows them
to bury while avoiding a
noticeable scar. The knots
are tied beneath the fascia
lata to prevent them from
becoming palpable
4. Alternatively, an incision can be made directly in the nasolabial fold and a trian-
gular section of dermis inferomedial to it deepithelialized (Fig. 19.10); this
inferiorly- based dermal tab is afxed to the fascia lata with buried 3-0 nonabsorbable sutures, and the fascia then passed into the facial wound (Fig.19.11).
The fascia lata should be sutured to the undersurface of the dermal tab, with the
knots located deep to the fascia to prevent them from being palpable. This
method leaves a visible scar but is technically more straightforward than the
minimally invasive technique described previously.
t.me/Dr_Mouayyad_AlbtousH
19 Static Facial Suspension withFascia Lata
Fig. 19.10 Alternative
direct nasolabial fold
incision
Fig. 19.11 Afxed fascia
lata graft to be passed into
the face. (Photograph
courtesy of Tessa A
Hadlock, MD)
253
5. Make the alar-facial incision and tailor the 1.5cm wide fascial ribbon to parallel
the curve of the alar-facial junction (Fig.19.12). Secure the fascia to the deep
brous tissue and sesamoid cartilages of the ala using 3-0 nonabsorbable suture
while the fascia is draped across the contralateral side of the face. This arrangement will bury the knots once the fascia is passed into the face.
6. Secure the 2cm wide fascial ribbon to the modiolus of the oral commissure with
3-0 nonabsorbable suture, taking care to place the knots deep into the fascia.
Figure19.13 depicts the inset of all three ribbons of fascia lata via a nasolabial
incision, and Fig.19.14 depicts the nal position in the face. If no nasolabial
incision is used, the oral commissure and nasolabial ribbons will be located
under the facial ap. Using a long clamp, tunnel from the facial incision to the
alar-facial incision and pass the nasal base fascial ribbon back under the ap,
taking care to avoid twisting it. Close the alar-facial incision with 6-0 absorbable
suture prior to applying tension to the fascia. Otherwise, the incision invaginates
and becomes very challenging to suture.
7. Apply tension and tack the fascia lata strips to the temporalis fascia with 2-0
nonabsorbable suture (Fig.19.15), starting with the oral commissure ribbon just
t.me/Dr_Mouayyad_AlbtousH
254
Fig. 19.12 Estimation of
fascia lata position through
alar-facial incision
Fig. 19.13 Inset of all
three ribbons of fascia lata
via a nasolabial incision
M. H. Hohman and A. G. Vincent
superior to the auricle, then the nasolabial fold ribbon superior to that, and then
the nasal base ribbon in the most superior position. Overcorrect by approximately 20% to avoid loss of suspension in the early postoperative period. Close
in layers over a drain and apply a pressure dressing unless a fresh microvascular
anastomosis is present.
t.me/Dr_Mouayyad_AlbtousH
19 Static Facial Suspension withFascia Lata
Fig. 19.14 Fascia lata
(blue arrow) in place
overlying a sternoomohyoid free muscle ap
Fig. 19.15 Tacking of
fascia lata to temporalis
fascia
255
Pearls
• Mark the nasolabial fold on the paralyzed side preoperatively with the patient
sitting upright, using the nasolabial fold on the unaffected side as a template.
• Make the posterior fascia lata harvest incision before the anterior one to prevent
vastus lateralis herniation from obstructing the view of the fascia.
• Bury all knots underneath the ribbons of fascia lata to prevent them from becom-
ing palpable.
• Close the alar-facial incision prior to applying tension to the fascia in order to
save time and effort.
• When performing a minimally invasive nasolabial fold suspension, do not over-
tighten the knots that secure the fascia lata to the dermis, as this will cause dim-
pling in the skin.
• Overcorrect facial suspension by roughly 20% and counsel patients accordingly
in order to prevent postoperative dissatisfaction.
t.me/Dr_Mouayyad_AlbtousH
256
M. H. Hohman and A. G. Vincent
• If periocular procedures are performed concomitantly with nasal base suspen-
sion, anticipate prolonged infraorbital edema due to interruption of lymphatic
drainage by the fascia lata.
• If performing static suspension and muscle transfer, place the fascial ribbons
supercial to the transferred muscle to act as a glide plane under the skin and
prevent muscle tethering to the dermis.
References
1. Hadlock TA, Greeneld LJ, Wernick-Robinson M, Cheney ML.Multimodality approach to
management of the paralyzed face. Laryngoscope. 2006;116(8):1385–9.
2. Hohman MH, Bhama PK, Hadlock TA.Epidemiology of iatrogenic facial neve injury: a decade
of experience. Laryngoscope. 2014;124(1):260–5.
3. Kiefer J, Braig D, Thiele JR, Bannasch H, Stark GB, Eisenhardt SU.Comparison of sym-
metry after smile reconstruction for accid facial paralysis with combined fascia lata grafts
and functional gracilis transfer for statis suspension or gracilis transfer alone. Microsurgery.
2018;38(6):634–42.
4. Faris C, Heiser A, Jowett N, Hadlock T.Minimal nasolabial incision technique for nasolabial
fold modication in patients with facial paralysis. JAMA Facial Plast Surg. 2018;20(2):148–53.
t.me/Dr_Mouayyad_AlbtousH
Functional Sterno-omohyoid Free
Muscle Transfer forFacial Reanimation
MarcH.Hohman andAuroraG.Vincent
Introduction
When patients with chronic facial paralysis of greater than 1–2years in duration
desire dynamic rehabilitation, the mimetic muscles have typically atrophied and are
no longer able to accept reinnervation for these patients and for patients with congenital facial palsy who were born with decient mimetic musculature, replacement
of the muscles as well as their motor nerves is required. Additionally, patients with
severe synkinesis may be candidates for functional free muscle transfer, which can
provide improved function and cosmesis by bypassing the injured facial nerve [1].
The choice of donor muscle is determined by patient requirements and goals,
anatomical considerations, and surgeon preference; numerous options are available.
The latissimus dorsi can provide a substantial amount of bulk, as well as overlying
skin, if necessary. The pectoralis minor is substantially slimmer and is very popular
but has a notoriously variable venous outow pattern. The gracilis muscle, rst
reported as a facial reanimation option in 1976, is the most commonly used donor
muscle for functional free tissue transfer in North America, because of its anatomical
consistency and the ease with which it can be harvested while facial surgery is
ongoing [2].
20
M. H. Hohman
Baghdad Diplomatic Support Center, Baghdad, Iraq
Department of Surgery, Uniformed Services University of the Health Sciences,
Bethesda, MD, USA
e-mail: marc.h.hohman.mil@health.mil
A. G. Vincent (*)
Eisenhower Army Medical Center, Fort Gordon, GA, USA
e-mail: aurora.g.vincent.mil@health.mil
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_20
t.me/Dr_Mouayyad_AlbtousH
257
258
M. H. Hohman and A. G. Vincent
Despite its reliability, the gracilis lacks two major features possessed by native
facial muscles: low volume and the ability to contract rapidly. It is a large postural
muscle, and when transferred to the face, it must rst undergo substantial debulking
to avoid adding noticeable excess subcutaneous volume. Aggressive debulking
removes the muscle’s fascial layer and potentially increases the chance of dermal
tethering; more importantly, debulking risks denervating the muscle and compromising its contractility. The speed with which facial muscles contract is one of their
dening characteristics however. Histologically, facial muscles have low mitochondrial counts and comprise largely type II “fast twitch” bers, in contrast to the gracilis’ high mitochondrial count “slow twitch” architecture [3]. Similar to the facial
muscles, the anterior cervical strap muscles are also made up primarily of type II
bers, and they have the advantage of being comparatively slim without requiring
debulking.
The other advantage provided by strap muscles is that more than one belly can
be harvested based on the same nerve and vascular pedicle. Transferring the sternohyoid and omohyoid together permits replacement of the zygomaticus major and
levator labii superioris simultaneously, providing a more natural, dentate smile than
can be achieved with methods that replace only the zygomaticus major muscle, such
as temporalis or traditional gracilis transfer [4]. More recently, the gracilis has been
divided into multiple individual slips of functional muscle in order to provide multiple vectors of facial movement, but doing so risks denervation and requires a large
volume of muscle [5, 6]. Likewise, the serratus anterior muscle is naturally congured with multiple slips that correspond to different ribs; however, like the gracilis,
it is much larger than native facial muscles [7]. The ability of the sterno-omohyoid
ap to produce dual-vector smile reanimation using slim, fast twitch muscles is a
major advantage. Lastly, the neural input to the strap muscle ap is the ansa cervicalis, which is long and possesses two major branches for input; both can be coapted
to the masseteric nerve to maximize reliability of the ap, or one end of the ansa
may be sutured to the masseteric nerve and the other to a cross-face nerve graft,
which potentially improves spontaneity and symmetry of the smile [8]. Loss of the
ansa cervicalis along with two strap muscles from one side of the neck has not
resulted in any reports of postoperative speech or swallowing difculties.
Despite seeming like an ideal reconstructive option, the strap ap does have two
notable disadvantages. The rst is that because it is harvested ipsilaterally to the
facial paralysis, simultaneous harvest and recipient site preparation is challenging.
The second is that the vascular anatomy is variable, and while the superior thyroid
artery is generally reliably located, the venous outow is highly variable as it is with
the pectoralis minor ap. Outow typically drains through the vena comitans of the
superior thyroid artery, the superior thyroid vein, the middle thyroid vein, or a ranine
vein. Herein, the technique of sterno-omohyoid harvest and inset as well as sural
nerve harvest and cross-face nerve graft placement are detailed. For a description of
masseteric nerve dissection for innervation of the strap ap, please see Chap. 17.
t.me/Dr_Mouayyad_AlbtousH
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
259
Recipient Site Preparation
Ensure that no long-acting paralytic agents will be used during induction of general
anesthesia, and inject the face with plain epinephrine for hemostasis, avoiding any
local anesthetic in order to prevent loss of nerve stimulation. Add 1mL of 1:1000
(1mg/mL) epinephrine to a 100mL bag of normal saline to produce plain 1:101,000
epinephrine. Mark the letter “P” on the paralyzed side of the face to avoid confusion
while the patient remains under general anesthesia.
1. Make a modied Blair incision, running from within the temporal hair tuft down
to the lobule and then down the lateral neck, joining a transverse skin crease to
travel to the midline, approximately 2cm superior to the clavicle. Then, raise a
sub-SMAS (supercial musculoaponeurotic system) ap (Fig.20.1) extending
to the oral commissure and around the upper lip, exposing the orbicularis oris
muscle; continue the ap elevation in a subplatysmal plane 2–3cm past the midline of the neck.
2. Identify and isolate the recipient vessels (Fig.20.2), preferably the distal facial
artery and vein superior to the inferior margin of the mandible. The supercial
temporal vessels and/or the external jugular vein are viable alternatives.
3. Place a 6-hole titanium miniplate at the inferior orbital rim via a preseptal, trans-
conjunctival approach.
(a) Incise the conjunctiva 2–3mm below the inferior margin of the tarsal plate,
from the punctum medially out to the lateral canthus. Carry the incision
through the capsulopalpebral fascia (Fig.20.3).
(b) Place a tension suture through the capsulopalpebral fascia and retract it over
the cornea with a hemostat, then continue the dissection, separating the orbicularis oculi muscle from the orbital septum (Fig.20.4) until the infraorbital
rim is reached.
(c) Expose the maxilla and place the 6-hole titanium miniplate just inferior to
the infraorbital rim (Fig.20.5), but do not tighten the screws completely,
leaving room for needle and suture passage later in the operation.
Fig. 20.1 Flap elevation
t.me/Dr_Mouayyad_AlbtousH
260
Fig. 20.2 Recipient vessel
isolation
Fig. 20.3 Incision through
conjunctiva and
capsulopalpebral fascia
M. H. Hohman and A. G. Vincent
Fig. 20.4 Dissection
between orbicularis oculi
and orbital septum to
orbital rim
4. Place 2-0 braided, absorbable inset sutures: one at the modiolus of the oral com-
missure, one just inferior to it, and one just superior to it, then two more farther
medially along the orbicularis oris muscle of the upper lip. Apply superolateral
t.me/Dr_Mouayyad_AlbtousH
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
Fig. 20.5 Titanium plate
placement
Fig. 20.6 Adjustment of
suture placement until the
appearance of the smile is
appropriate and there is
neither unnatural dimpling
of the skin nor eversion of
the lip
261
tension to the three lateral sutures towards the superior margin of the auricular
helix while applying tension to the two medial sutures over the infraorbital miniplate; adjust suture placement until the appearance of the smile is appropriate
and there is neither unnatural dimpling of the skin nor eversion of the lip
(Fig.20.6).
5. Identify and isolate the masseteric nerve, as described in Chap. 17 (Fig.20.7).
t.me/Dr_Mouayyad_AlbtousH
Соседние файлы в папке Библиотека им академика М.И. Перельмана