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
262
Fig. 20.7 Identication of
the masseteric nerve
M. H. Hohman and A. G. Vincent
Optional: Sural Nerve Harvest andCross-Face Nerve Grafting
forDual Innervation oftheFlap
Sural Nerve Harvest
1. Make a transverse incision 1cm superior and 1cm posterior to the lateral mal-
leolus of the ankle and identify the lesser saphenous vein within the wound .
Retract the vein and isolate the underlying sural nerve (Fig.20.8).
2. Divide the sural nerve as inferiorly as possible, but superior to its branch point,
and then pass the nerve through a tendon stripper (Fig.20.9). Maintain tension
on the nerve while advancing the stripper, gently twisting back and forth.
Resistance will be encountered when the nerve branches over the gastrocnemius
muscle. Once the stripper has been advanced roughly 30cm up the leg, it can be
twisted sharply to divide the nerve; alternatively, a stab incision over the end of
the stripper will provide access to the sural nerve for transection.
3. Retrieve the stripper and leave a hemostat on the inferior/distal end of the nerve
(Fig.20.10).
t.me/Dr_Mouayyad_AlbtousH
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
Fig. 20.8 Isolation of the
sural nerve
Fig. 20.9 Tendonstripper- assisted harvest of
the sural nerve
263
Fig. 20.10 Harvested
sural nerve with hemostat
identifying the distal end
t.me/Dr_Mouayyad_AlbtousH
264
M. H. Hohman and A. G. Vincent
Cross-Face Nerve Grafting
1. Isolate the primary branch to the zygomaticus major on the non-paralyzed side
(Fig. 20.11), according to the instructions in Chap. 17, section on “Buccal
Branch Identication”.
2. Make a stab incision in the superior gingivolabial sulcus, superior to the canine,
and advance a Wright fascia passer needle through it and into the wound on the
non-paralyzed side of the face, then suture the proximal end of the sural nerve
graft to the tip of the needle and retract the end of the nerve out through the stab
wound (Fig.20.12).
Fig. 20.11 Buccal branch
isolation
Fig. 20.12 Passing the
sural nerve across the face
t.me/Dr_Mouayyad_AlbtousH
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
Fig. 20.13 Passing the
sural nerve through the
gingiva
Fig. 20.14 Completion of
sural nerve transfer to the
contralateral face. The
distal end of the sural
nerve graft (green arrow)
is left near the proximal
end of the primary buccal
branch (blue arrow) on the
non-paralyzed side in
preparation for
neurorrhaphy
265
3. Repeat the process with a stab incision over the contralateral canine and retract
the proximal end of the nerve graft into it (Fig.20.13).
4. Repeat once more, passing the Wright needle from the wound on the paralyzed
side into the gingivolabial sulcus stab incision and retracting the proximal end of
the nerve graft into the wound (Fig.20.14).
Sterno-omohyoid Muscle Flap Harvest
1. Retract the sternocleidomastoid muscle laterally to expose the internal jugular
vein, then skeletonize the internal jugular vein in order to expose the ansa cervicalis (Fig.20.15), whose apex should lie deep to the omohyoid. Skeletonize as
t.me/Dr_Mouayyad_AlbtousH
266
Fig. 20.15 Ansa
cervicalis relationship to
internal jugular vein
Fig. 20.16 Sternohyoid
and Omohyoid
identication in the neck
M. H. Hohman and A. G. Vincent
much of the ansa cervicalis as possible, following the anterior limb to the hypoglossal nerve and the posterior limb to the cervical rootlets. Identify the inferior
branches off the apex of the ansa to the omohyoid and sternohyoid; after stimulation, divide the remaining branches off the ansa to permit mobilization.
2. Divide the omohyoid inferiorly, roughly 2cm beyond the inferior ansa branches,
through the tendon as it joins the lateral belly of the muscle. Follow the supercial surface of the omohyoid to reach the sternohyoid, then divide that at the
level of the clavicle (Fig.20.16). Follow the medial border of the sternohyoid
superiorly to the hyoid bone. If available, include an anterior jugular vein in the
ap for outow. Separate the superior ends of the sternohyoid and omohyoid
muscles from the hyoid bone.
3. Divide the ansa cervicalis as superiorly as possible and mobilize it completely,
taking care to avoid injury to any veins or branches of the superior thyroid artery.
Elevate the sterno-omohyoid ap along the supercial surface of the deep strap
muscles in order to maintain the blood supply within the fascia. Identify and
t.me/Dr_Mouayyad_AlbtousH
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
267
preserve the superior laryngeal nerve. Divide the branches of the superior thyroid
artery and vein that supply the thyroid gland and the larynx. Dissect the superior
thyroid artery medially toward the ap, taking care to keep its vena comitans
intact. Include the superior thyroid artery vena comitans or superior thyroid vein
in the harvest; include any associated ranine veins as well. Ligate the superior
thyroid artery as it emerges from the external carotid artery to complete ap
harvest (Fig.20.17).
Sterno-omohyoid Muscle Flap Inset
1. Run a locked 2-0 braided, absorbable suture along the cut edges of the sternohy-
oid muscle. These sutures will constitute “neo-tendons” to help retain the inset
sutures and prevent them from pulling through the muscle once tension is
applied. Pass the two upper lip inset sutures through the tendon at the inferior
edge of the omohyoid muscle and the three oral commissure inset sutures
through the inferior cut edge of the sternohyoid muscle, behind the neo-tendon,
tying the knots on the deep surfaces of the muscles (Fig.20.18).
Fig. 20.17 Harvested
sterno-omohyoid ap
Fig. 20.18 Flap
neo-tendon placement in
the face with the modiolus
t.me/Dr_Mouayyad_AlbtousH
268
M. H. Hohman and A. G. Vincent
2. Perform the microvascular anastomosis between the superior thyroid artery and
the facial artery, ideally. Observe venous outow from the ap and select the
most appropriate vein for anastomosis to the facial vein. Consider coupling a
second outow vein from the ap to the external jugular vein as well (Fig.20.19).
Implantable Doppler probes may be useful for ap monitoring in the immediate
postoperative period.
3. Trim the cut ends of the ansa cervicalis and the masseteric nerve, then perform
the microsurgical neurorrhaphy (Fig.20.20). Coapt the nerves in an end-to-end
fashion using ne suture, such as 10-0 nylon, on a cutting needle. Only two or
three interrupted stitches are usually required at each site. Avoid overtightening
and impacting or herniating the fascicles through the neurorrhaphy. If a crossface nerve graft is included, trim the sural nerve ends and the buccal branch, and
then perform the second and third neurorrhaphies. If no cross-face graft is
planned, both ends of the ansa cervicalis should be coapted to the masseteric
nerve, and this may be facilitated with a collagen nerve wrap.
4. Fold the omohyoid to bury the upper 40%, nearest the orbit, underneath the rest of
the muscle in order to shorten it and improve contractility. Pass two 2-0 braided,
Fig. 20.19 Microvascular
anastomosis in the face.
The blue arrow indicates
the venous anastomosis,
performed with a coupler,
and the white arrow
indicates the arterial
anastomosis, which was
sutured with 9-0 nylon
Fig. 20.20 Neurorrhaphy
in the face
t.me/Dr_Mouayyad_AlbtousH
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
269
absorbable sutures through the fold and secure them to the infraorbital miniplate,
then screw down the plate completely. Stretch the sternohyoid muscle and using
2-0 nonabsorbable sutures, tack the free end of the sternohyoid muscle to the temporalis fascia in a vector directed just superior to the apex of the helix (Fig.20.21).
5. Optionally, place any additional static suspension slings at this juncture, taking
care not to overtighten them and risk compromising perfusion to the ap
(Fig. 20.22). Fascia lata ribbons should be located supercial to the
sterno- omohyoid ap in order to prevent dermal tethering and provide a glide
plane for muscle contraction.
6. Close the incisions in layers. The facial wound on the non-paralyzed side should not
require a drain if hemostasis is adequate and there is no parotid gland injury, but the
wound on the paralyzed side will require one or two suction drains, as a pressure
dressing should not be applied over fresh microvascular anastomoses. Figure20.23
depicts the nal ap position beneath the supercial structures of the face.
Fig. 20.21 The
sternohyoid muscle has
been inset; the omohyoid
muscle is buried beneath
the skin ap, situated
medially in the face and
inferior to the orbit. The
masseteric nerve is
indicated by the yellow
arrow, the cross-face nerve
graft by the gray arrow, the
venous outow by the blue
arrow, and the arterial
inow by the green arrow
Fig. 20.22 A band of
fascia lata (blue arrow) was
placed to suspend the
nasolabial fold
t.me/Dr_Mouayyad_AlbtousH
270
Fig. 20.23 Final Flap
position beneath the face
M. H. Hohman and A. G. Vincent
Pearls
• Insist on the use of no long-acting paralytics during intubation for patients under-
going sterno-omohyoid functional free muscle transfer, or indeed any facial
nerve procedure. Loss of stimulability of trigeminal and facial nerve branches
during these cases increases the risk of iatrogenic injury.
• Avoid local anesthetic use in this procedure. The rate of metabolism of these
agents varies tremendously among patients, and stimulability of the relevant
nerve branches may be lost for hours following injection.
• Sacrice of the primary motor branch to the zygomaticus major on the non-
paralyzed side for cross-face nerve grafting does not typically result in any
noticeable change in the appearance of the smile; if it were to weaken the smile
subtly, however, it would serve to improve overall facial symmetry.
• Cross-face nerve grafting may be employed as an alternative to nerve transfer,
but due to the low axon count (300–900 bers), is better used for zonal facial
reinnervation than hemifacial reinnervation, and outcomes are superior in
younger patients due to their higher axon counts.
t.me/Dr_Mouayyad_AlbtousH
20 Functional Sterno-omohyoid Free Muscle Transfer forFacial Reanimation
271
• Reversing the direction of the sural nerve graft, as described above, helps to
reduce axonal loss by preventing axonal growth out of the graft via
microbranches.
• When harvesting the ap, remember that the branches that control the sternohy-
oid and omohyoid come off the very bottom of the ansa cervicalis, so extreme
care should be taken when dissecting in this area in order to avoid denervating
the ap.
• Include two or three veins in the ap if possible; the best outow can be selected
after arterial anastomosis is complete by determining which vein bleeds most
briskly.
• The ap inset described is the ideal situation; however, vascular considerations
may necessitate adjustment of the surgical plan. Short vascular pedicles or the
use of the supercial temporal artery may mandate reorientation of the ap. It
does not matter which muscle is used for which vector.
• Because the ap is buried, monitoring will be performed using palpation and
Doppler signals. The face and ap will swell over the rst several days, but the
ap should remain supple if it is viable. Duplex ultrasonography may be per-
formed on postoperative day 1 to conrm ap perfusion and outow.
References
1. Lindsay RW, Bhama P, Weinberg J, Hadlock TA.The success of free gracilis muscle transfer to
restore smile in patients with nonaccid facial paralysis. Ann Plast Surg. 2014;73(2):177–82.
2. Harii K, Ohmori K, Torii S. Free gracilis transplantation with microneurovascular anas-
tomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg.
1976;57(2):133–43.
3. Alam DS. The sternohyoid ap for facial reanimation. Facial Plast Surg Clin North Am.
2016;23(1):61–9.
4. Vincent AG, Bevans SE, Robitschek JM, Groom KL, Herr MW, Hohman MH. Sterno-
omohyoid free ap for dual-vector facial reanimation. Ann Otol Rhinol Laryngol.
2020;129(2):195–200.
5. Boahene KO, Owusu J, Ishii L, Ishii M, Desai S, Kim I, Kim L, Byrne P.The multivector gracilis
free functional muscle ap for facial reanimation. JAMA Facial Plast Surg. 2018;20(4):300–6.
6. Ein L, Hadlock TA, Jowett N.Dual-vector gracilis muscle transfer for smile reanimation with
lower lip depression. Laryngoscope. 2021;131(8):1758–60.
7. Sakuma H, Tanaka I, Yazawa M, Shimizu Y. Multivector functioning muscle transfer using
supercial subslips of the serratus anterior muscle for longstanding facial paralysis. J Plast
Reconstr Aesthet Surg. 2019;72(6):964–72.
8. Dusseldorp JR, van Veen MM, Guarin DL, Quatela O, Jowett N, Hadlock TA. Spontaneity
assessment in dually innervated gracilis smile reanimation surgery. JAMA Facial Plast Surg.
2019;21(6):551–7.
t.me/Dr_Mouayyad_AlbtousH
Соседние файлы в папке Библиотека им академика М.И. Перельмана