Name: single-stage dynamic reanimation of the smile in irreversible facial paralysis by free functional muscle transfer
Uploaded: 2015-03-01T15:00:00.000+00:00
Duration: 19 min 53 s
Description: Watch this Scientific Journal Video about Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer at JoVE.com

Dr. Eisenhardt is funded by the German Research Foundation (DFG) # EI 866/1-1 and #EI 866/2-1.

注:在视频中显示的患者已同意公布视频材料。获得书面同意。该协议遵循弗莱堡大学人类研究伦理委员会的指导方针。虽然外科医生可能有不同的喜好，下面的协议将专注于作者的首选技术。 1.手术前后处理<ol><li>完成一个标准化的术前工作了，它由一个结构化的历史和彻底的检查精确的治疗计划。由此，请求该疾病的病因和询问功能限制。这是最重要的决定，因为发病瘫痪所经过的时间，因为这会影响治疗计划。 </li><li>就拿功能的历史，包括口服可控，流涎和言语。问病人如何，他/她是在社会生活中，由于审美和心理问题的限制。 </li><li>接下来，采取一般的国医国药升的历史，以排除任何合并症，从而影响了手术方案。 </li><li>检查从额头往下病人。评估眉下垂，dermatochalasis，眼睑闭合不全，以及外翻的程度。 </li><li>检查面中部下垂和鼻唇沟皱纹不对称和量化口头合缝的偏移。注意牙齿暴露在微笑的对称性和微笑的形状。 </li><li>检查颅神经V建立的可用性为供体神经和触诊面部及颞浅动脉脉冲，以帮助确定其可用性收件人的船只。通常在刺骨，触诊咬肌肌肉来表示一个有效的咬肌神经。如果不确定，执行EMG（肌电图）排除咬肌神经任何赤字。 </li><li>最后，采取了一系列标准化的照片或录像与处于静止状态的病人的脸病历，在与嘴角含笑打开和关闭。包括横向VIE瓦特作为单独的前视图不能捕捉运动的全部量。 </li><li>沟通的治疗方案对病人和密切地参与病人的决策过程，因为这代表着成功的关键成果。 注:在这里，我们将重点放在微笑的动态重构的患者谁与面部肌肉是没有任何候选人或不希望一个两阶段的过程中不可逆转的萎缩出现。 </li><li>示出该过程的风险，例如襟翼损失，血肿形成，感染，疼痛，疤痕，并不能令人满意术后偏移口腔合缝和从患者获得知情同意书。证明以前的患者术后的照片，因为这会给病人一个想法是什么期望，以及如何将疤痕的样子。 </li><li>为了执行在全身麻醉下操作，而不肌肉松弛，以便能够使用神经刺激器来识别咬肌神经一第二闭孔分支股薄肌。围手术期，静脉给予预防性抗生素的第二代头孢菌素（ 如 ，加入1.5g头孢呋辛）。 </li><li>将患者平卧。通过使用保护垫防止压力点。固定呼吸管与齿间缝线​​（0-0）的下颌骨，为了防止位错从手术过程中移动所述头部。 </li><li>从同侧大腿用股薄肌。应用聚维酮碘溶液（250毫升）到该已被选定为襟翼收获并使用奥替尼啶盐酸盐（500毫升）中的头部和颈部的皮肤和粘膜消毒的腿。 </li></ol> 2.面部准备注:有两个团队的方式执行程序。在这里，手术步骤描述了一个又一个。 <ol><li>打开病人的头部向健侧并根据需要，以减轻后续调整手术台的高度准备步骤。连同医用双目放大镜，一LED（发光二极管）的前灯的灯是进行面部解剖极为有用。 </li><li>小心将脂肪纱布放入耳道。这可以防止血液从流入和凝固。 注:通过发夹的应用，听到轴承头皮的剃须是没有必要的。 </li><li>纪念面部切口线。开始于头皮约2cm颅到耳上极。然后向下当然在耳前区向前向耳屏。执行的适当曝光并沿着在操作的过程中，口服合缝缝线的受控放置约1.5厘米切口线的颌下延伸。 </li><li>前切口，申请suprarenin稀释在生理盐水溶液皮下（稀释:1:20万，40毫升最大值）。这可以防止失血过多清扫过程中。等待血管收缩是可见此后不久。 </li><li>开始剥离处SMAS（浅层腱膜肌肉系统）的水平。在咬肌前缘继续剥离子SMAS，以确定面部动脉和静脉。防止由体面止血术野视觉约束在使用双极烧灼。 </li><li>优，延长清扫了到颧骨和寺庙的身体。 </li><li>找到通过表面上的颞骨的颧突的后根颞血管，从而覆盖有薄的筋膜上。 注意:如果面部血管解剖失败的，这些船只可以作为救援的血管供应，肌皮瓣。 </li><li>前方识别面部血管咬肌。识别由脉动的动脉和血管壁的厚的方面。它首先课程前方平行于下颌骨的体，然后向上弯曲。在口头合缝，它分给V血管性供应下唇。 <ol><li>定位静脉即，动脉不同于由一个薄的血管壁，从而呈现出典型的青色的方面。如果船只难以辨认，找到他们在哪里，他们越过下颌下巴。 </li></ol></li><li>继续向前剥离正上方的血管合缝和上唇。实现了长时间曝光，因为这是必要的，以便对搬迁咬肌的船只容易微血管吻合股薄肌蒂。尽量避免手术剪刀准备船只。使用非创伤性钝器代替。 </li><li>应用微血管夹的面动脉和相应的静脉的近端和剪辑的末端部分。反映血管向后，以减轻皮瓣血运重建以后。 注:以下步骤是一个令人满意的结果，术后必不可少的。 </li><li>启动缝线定位对于肌肉在蜗轴接近所述口腔合缝的安全固定。地方缝线在口周萎缩肌肉的强壮有力的材料。用双臂3-0聚丙烯缝线。 </li><li>将第二缝合在下唇使得与牵引它将提升下唇。 注意:此缝线将作为非锁定颞拉出缝合手术后，以减轻在第一天，从护翼的牵引，它会被捆扎在襟翼插入后加强。拔出缝合不走肌肉咬和7术后第二天将被删除，是导致出在颞区，如步骤4.16描述。 </li><li>放置在第三和第四缝线沿面动脉的过程中的上唇。 </li><li>通过同样拉动缝线全部仔细检查放置四缝线。谐波自然的鼻唇沟折痕的存在下连同缺席外翻的皮肤或反转指示一个愉快的结果。如果唇反转的缝合线是最有可能放置过深，以防外翻最有可能过于肤浅。正确选择正确的层位置。 注意:通常情况下，一个以上的尝试是必要的最佳定位。本步骤是对程序的美学结果最关键的。认为在微笑，上唇示出了显着的颅运动的程度表示上唇缝线的重要性。 </li><li>一旦满意的缝合线的位置时，覆盖非常尾椎缝合技术便利，以不与该将被用于襟翼固定缝线混淆。仔细锁定剩余缝线和离开针到位。 </li><li>找到咬肌运动神经。因此，定义了一个点3厘米前到耳屏1厘米伪劣颧弓9。 <ol><li>从这里，开始查找由神经束膜涂层，并出现了黄釉神经希望的方面。在咬肌肌肉的后缘，神经的"点"在口头合缝，并形成了50°，颧弓的角度。解剖咬肌直言平行于用细剪刀它的纤维，尽量不舒展神经。 </li></ol></li><li>为了方便查找，剖析咬肌的起源于颧弓。 </li><li>接着，向下解剖的肌肉的底面。应用神经刺激，因为这是非常有帮助的不要混淆与其他结构的神经。使用附连到刺激源，使可变电压和频率控制的单极电探针。 </li><li>一旦确定，跟踪神经到肌肉和纤维删除连接。 注:神经开始后1厘米肌注课程分为很多分支。 </li><li>剥去神经的末梢尽可能和翻转过来趴在一个肤浅的水平显微接合。 注意:此时面对的是对肌肉移植手术做好充分的准备。 </li></ol> 3.皮瓣收获注意:股薄肌皮瓣与面部解剖同时收获。 <ol><li>解剖前，要知道，最好是在近端三分之一的大腿纤细取得收获瓣面部复苏。解剖过程中专注于这个领域。 </li><li>开始的长度为10厘米左右的股薄肌的前缘的上部大腿内侧皮肤切口。作为一个具有里程碑意义，触诊在大腿内侧的内收长肌的肌腱起源。适用于单极electrodissection去深。 注:隐静脉遇到第一和内侧回缩保存。 </li><li>揭露收筋膜并确定收长肌和股薄肌。股薄肌位于后方的内收长肌。 </li><li>一旦股薄肌遇到，找到神经血管蒂第一，从而在制备过程中，以保护它。因此，扩散到内收长肌和大收肌之间的薄筋膜这里找出神经血管蒂。随后，跟踪蒂的股薄肌的深面的种脐。 </li><li>要找到神经血管蒂，定义为约8至10厘米的距离从肌肉的原点向远侧因为这是种脐的区域。可替代地，标识也源自肺门肌肉的皮肤穿孔。 </li><li>解剖股薄肌和内收长肌间神经血管蒂。 </li><li>握住收肌肌肉放在一边，横向追踪下，收长肌蒂。 注:与内收长肌和血管连接短被凝结或结扎，并划分。 </li><li>解剖蒂近端分行内收长肌和应用血管循环届的非常近端Ë血管蒂。 </li><li>确定运动神经到这是闭孔神经进入肌肉1-2厘米优越于肺门的前支股薄。缩回内收长肌的神经容易追踪到闭孔提供最大长度。 </li><li>定义分段收获。需要注意的是肌肉移植的长度必须适于每个患者单独。从口腔合缝到耳屏加2公分的距离将给予肌肉移植将需要襟翼锚固在翼片的每一侧10 1厘米的长度。 </li><li>放置椎弓根在中点或稍远侧移除的肌肉节段，作为翼片的前端将被放置在口腔合缝和近端附近的耳屏。 </li><li>解剖的肌肉周向对中的至少2厘米过量的长度的距离所需使用手术剪。 </li><li>标记所需的肌肉segment包括在该段的中间的血管脐。不要完全解剖血管蒂的神经，因为这可能会损害血管。 </li><li>为了减少肌肉本体，收获约30％的肌肉的圆周的。理想的情况下分开是不包含在蒂的前部和后部的肌肉部分。应用神经刺激，以确认所分离的片段的完整性。强烈收缩应该是可见的。 </li><li>仔细划分船舶处于或接近它们的起源，利用微结扎夹，取出肌肉部分。 </li><li>使用双极烧灼达到止血，并通过使用无菌生理盐水溶液（250毫升）彻底灌溉手术部位。 </li><li>通过刺切口放置一个雷东漏，防止术后血肿或血清肿形成。 </li><li>关闭与可吸收间断缝合皮下（2-0）和皮内缝合聚丙烯（2-0）的伤口。 </li><li>对于先体外后体内制备的肌皮瓣，将股薄段在一个单独的手术台，彻底冲洗稀释肝素溶液的动脉（4-5毫升，10单位/ ml）以防止血管内形成血栓。 </li><li>通过应用神经刺激器的检查运动神经的完整性。肌肉的较强的收缩，必须是明显的。用无菌生理盐水冲洗频繁的隔离肌皮瓣，以防止干燥出组织。 </li><li>插入肌肉的远端进入鼻唇沟折痕。为了防止破裂，将非可吸收的缝线床垫或沿着所述末端（3-0聚丙烯）交替地连续的缝合。这些缝合线将用于锚固缝线提供稳定性。 注:这些缝线也可以放置在所述时间结束，然而不一样重要的肌肉的口服端。 </li></ol> 4.折边插入<ol><li>缝合锚缝线已放置在谅解备忘录TH通过肌肉以互锁的方式以使它们重叠的肌肉的远侧放置连续缝合。 </li><li>缝合的指导下，小心翼翼地用两个外科医生将皮瓣到面部腔。舒展之一，并安排锚缝合，而其他外科医生将皮瓣。随后取出针，为了防止二次释放紧密配合缝线。 </li><li>有护理人员此举在手术显微镜。通过使用微型剪刀把面动脉和静脉的末端夹紧在适当的位置血运重建。 </li><li>调整股薄肌蒂。通常，吻合两静脉的大，以在手术显微镜下的面部静脉。 </li><li>将一块彭罗斯流失下方的容器两端增加对比度，忍住过多的组织。 </li><li>启动血管修复与动脉和精心把容器结束在一起。 注:无压力的调整是不可缺少的，以防止血栓形成。 </li><li>使用稀释的肝素溶液（5毫升，在盐溶液中10单位/毫升）冲洗容器的内腔中。这会给内膜内皮损伤的质量的一个想法将变得可见。如果有必要，修剪后面的船只年底将受损的内皮。精心去除过多的外膜。 </li><li>利用间断9-0尼龙缝线首先调整动脉的前侧，然后打开容器端部的180°完成吻合在后侧。一定要通过血管腔的重复检查无法穿透的正面和背面侧与缝合。 </li><li>继续静脉吻合，可以要求更高。静脉血管壁都非常薄，并且动脉不同，往往冲洗后不久崩溃。使用中断9-0尼龙缝合的静脉吻合。 </li><li>经动脉和静脉的电荷的夹具脉动释放应该是可见的。为了吨Ø检查静脉足够的笔芯，使用两对显微镊抹杀静脉远端吻合的部分。然后打开近端镊子观察补给率，以排除假阳性逆行笔芯。 </li><li>监测对引流静脉瓣的应用植入式多普勒探头。因此，修剪硅氧烷袖带松散配合的探针周围的静脉。随后，确保与尼龙缝合线（9-0）11袖口。避免了静脉收缩，因为这可能促进血栓形成。 </li><li>导致的多普勒电缆从伤口，并与控制箱连接。光滑的静脉噪声应发声。如果动脉搏动，尽量搬迁袖口远​​离动脉。 </li><li>把关注的神经修复。调整股薄到所需的张力自由接合的最小的运动神经的长度。在此阶段，延长肌肉其颞fixati点上要测试的神经蒂长，需要一次肌肉完全伸展。过度的长度将延长不必要的时间来再支配。 <ol><li>使用高功率放大的接合间断9-0尼龙缝合线在epineural时尚。连续应用纤维蛋白胶，将到接合部位给予额外的稳定性。 </li></ol></li><li>关闭后使用可吸收缝合线咬肌（3-0）的肌肉筋膜，以提供一定程度的保护的接合点。避免缝合筋膜太紧，因为这可能会压迫神经。 </li><li>继神经血管修复，保护肌肉起源于颞筋膜和耳前筋膜缝合床垫（4-0聚丙烯）。提供足够的张力与肌肉瓣产生的口头合缝的横向移动。这将确保一旦发生神经再支配的口头合缝的最大动作。如果有必要，分发肌肉EVenly防止膨胀。 </li><li>转移牵出在缝合伤口的时间结束，并有足够的张力比分扳成了一个加强以保持张力过肌肉的第手术后一周。 </li><li>检查是否有出血的船只，并与双极电凝进行细致的止血。 </li><li>经过手术部位彻底冲洗，通过刺切口放置硅漏极（杰克逊 - 普拉特），以预防术后血肿形成，可能限制瓣灌注。另外，使用彭罗斯流失。 </li><li>重新定位脸颊瓣关闭与主食缝合伤口的头发轴承领域，并持续5-0尼龙缝合。 </li><li>在伤口缝合完毕，应用纤维蛋白胶到伤口腔止血蒂12和稳定性。 </li><li>用胶粘绷带固定多普勒线，并应用抗生素软膏到伤口。头部绷带然后可施加到覆盖preauricular切口区域。由于血管蒂位于前方的更多，这会不会影响皮瓣灌注。 </li></ol> 5.术后治疗和随访<ol><li>术后，离开病人在恢复室约4-6小时，然后转移到整形外科病房。保持在患者身体中的一个稍微升高的位置，以减少肿胀。动员可以在术后第一天开始。 </li><li>提供软的食物，禁止讲了三天。这可以防止所述锚固缝线松动的鼻唇沟折痕。去除面部排水两术后第二天和大腿内侧的贺东漏后输出小于30毫升/ 24小时。 </li><li>介绍护理人员如何处理多普勒控制箱和每小时控制多普勒信号。如果血流障碍是必要立即翻修手术。 </li><li>由于放电通常可以在5天之内实现，消除面部缝针加上7天后拔出缝合。手术3周后拉出的伤口中取出多普勒探头。 注:肌肉通常始于术后3个月内签订合同。患者常在自己的脸颊，这是紧随其后的嘴和笑容的角落主动运动报告"奇怪的感觉"。 </li><li>执行后续3和6个月后与患者进行彻底检查。评价口服合缝游览脸颊量，对称的对称性和识别任何联带运动。文件的自发笑容的存在。 </li><li>最后，采取了一系列标准化的照片，如步骤1.7或录像的病历描述。 </li></ol>

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H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fibrin+sealant+adhesive+systems:+a+review+of+their+chemistry,+material+properties+and+clinical+applications.">Fibrin sealant adhesive systems: a review of their chemistry, material properties and clinical applications.</a> J Biomater Appl. 7 (4), 309-352 (1993).</li><li>Brien, B. M., Lawlor, D. L., Morrison, W. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microneurovascular+free+muscle+reconstruction+for+long+established+facial+paralysis.">Microneurovascular free muscle reconstruction for long established facial paralysis.</a> Ann Chir Gynaecol. 71 (1), 65-69 (1982).</li><li>Eisenhardt, S. 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U., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Salvage+Procedures+After+Failed+Facial+Reanimation+Surgery+Using+the+Masseteric+Nerve+as+the+Motor+Nerve+for+Free+Functional+Gracilis+Muscle+Transfer.">Salvage Procedures After Failed Facial Reanimation Surgery Using the Masseteric Nerve as the Motor Nerve for Free Functional Gracilis Muscle Transfer.</a> JAMA Facial Plast Surg. , (2014).</li><li>Bae, Y. 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T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Smile+reconstruction+in+adults+with+free+muscle+transfer+innervated+by+the+masseter+motor+nerve:+effectiveness+and+cerebral+adaptation.">Smile reconstruction in adults with free muscle transfer innervated by the masseter motor nerve: effectiveness and cerebral adaptation.</a> Plast Reconstr Surg. 118 (4), 885-899 (2006).</li><li>Eppley, B. L., Zuker, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Salvage+of+facial+reanimation+with+vascularized+adductor+magnus+muscle+flap:+clinical+experience+and+anatomical+studies.">Salvage of facial reanimation with vascularized adductor magnus muscle flap: clinical experience and anatomical studies.</a> Plast Reconstr Surg. 110 (7), 1693-1696 (2002).</li><li>Labbe, D., Huault, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lengthening+temporalis+myoplasty+and+lip+reanimation.">Lengthening temporalis myoplasty and lip reanimation.</a> Plast Reconstr Surg. 105 (4), 1289-1297 (2000).</li><li>Iblher, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+evaluation+tool+for+monitoring+devices+and+its+application+to+evaluate+the+implantable+Doppler+probe.">A new evaluation tool for monitoring devices and its application to evaluate the implantable Doppler probe.</a> J Reconstr Microsurg. 26 (4), 265-270 (2002).</li></ol>

The authors have nothing to disclose.

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 &#8220;criterion standard&#8221;.
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...

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。

<table><tbody><tr><td>Nylon Suture, 9-0</td><td>Serag Weissner</td><td>Z0039490</td><td>&amp;deg;</td></tr><tr><td>Polypropylene Suture&amp;nbsp;</td><td>Ethicon</td><td>-</td><td>Multiple thread sizes</td></tr><tr><td>Suprarenin 1mg/ml</td><td>Sanofi</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Cook-Swartz Doppler Probe</td><td>Cook Medical</td><td>G03014</td><td>&amp;deg;</td></tr><tr><td>DP-M350 Blood Flow Monitor</td><td>Cook Medical</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Surgical Microscope OPMI Vario</td><td>Carl Zeiss</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Microsurgical instruments lab set</td><td>S&amp;amp;T</td><td>767</td><td>&amp;deg;</td></tr><tr><td>Biemer vessel clip</td><td>Diener</td><td>64,562</td><td>&amp;deg;</td></tr><tr><td>Applying forceps</td><td>Diener</td><td>64,568</td><td>for Biemer vessel clip</td></tr><tr><td>Cefuroxim 1500mg</td><td>Fresenius</td><td>J01DC02</td><td>&amp;deg;</td></tr><tr><td>Braunoderm</td><td>Braun Melsungen</td><td>3881105</td><td>&amp;deg;</td></tr><tr><td>Octenisept</td><td>Schuelke &amp;amp; Mayr</td><td>5702764</td><td>&amp;deg;</td></tr><tr><td>ISIS Neuromonitoring System</td><td>Inomed</td><td>-</td><td>&amp;deg;</td></tr><tr><td>Tissucol</td><td>Baxter</td><td>1.33052E+12</td><td>Fibrin glue</td></tr><tr><td>Jackson-Pratt Wound Drainage</td><td>Medline</td><td>SU130-1060</td><td></td></tr><tr><td>Myacyne Ointment</td><td>Schur Pharma</td><td>-</td><td></td></tr></tbody></table>

single-stage dynamic reanimation of the smile in irreversible facial paralysis by free functional muscle transfer

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic facial paralysis (Bell&#8217;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.

<html>对于肌肉移植物的神经支配恢复的使用咬肌神经的评估在5名患者（ 表1）。其中，听神经瘤切除术是面瘫的主要原因。 3考生首选的单级的程序，而不是"金标准"分两个阶段。在两个病人，程序充当了拯救程序不够刺激后，由跨面神经移植（CFNG）。 后单级维修的股薄肌皮瓣神经再支配是3个月内检测。口服合缝偏移是令人满意的但自发的微笑只能在一个患者来...

Watch this Scientific Journal Video about Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer at JoVE.com

Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

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.

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

Unilateral facial paralysis is a common disease that is associated with significant functional, aesthetic and psychological issues. Though idiopathic ...

single-stage-dynamic-reanimation-smile-irreversible-facial-paralysis

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

105.8K 次观看.  University of Freiburg Medical Centre. 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.

视频: Single-stage Dynamic Reanimation of the Smile in Irreversible Facial Paralysis by Free Functional Muscle Transfer

In Vivo Canine Muscle Function Assay

We describe a minimally-invasive and reproducible method to measure canine pelvic limb muscle strength and muscle response to repeated eccentric 
contractions. The pelvic limb of an anesthetized dog is immobilized in a stereotactic frame to align the tibia at a right angle to the femur. Adhesive wrap affixes the 
paw to a pedal mounted on the shaft of a servomotor to measure torque. Percutaneous nerve stimulation activates pelvic limb muscles of the paw to either push (extend) or 
pull (flex) against the pedal to generate isometric torque. Percutaneous tibial nerve stimulation activates tibiotarsal extensor muscles. Repeated eccentric (lengthening) 
contractions are induced in the tibiotarsal flexor muscles by percutaneous peroneal nerve stimulation. The eccentric protocol consists of an initial isometric contraction 
followed by a forced stretch imposed by the servomotor. The rotation effectively lengthens the muscle while it contracts, e.g., an eccentric contraction. During 
stimulation flexor muscles are subjected to an 800 msec isometric and 200 msec eccentric contraction. This procedure is repeated every 5 sec. To avoid fatigue, 4 min rest 
follows every 10 contractions with a total of 30 contractions performed.

In Vivo Canine Muscle Function Assay

We describe a minimally-invasive and painless method to measure canine hindlimb muscle strength and muscle response to repeated eccentric contractions.

在犬体内的肌肉功能测定

We describe a minimally-invasive and reproducible method to measure canine pelvic limb muscle strength and muscle response to repeated eccentric 
...

科研

医学

The Use of Primary Human Fibroblasts for Monitoring Mitochondrial Phenotypes in the Field of Parkinson's Disease

Parkinson's disease (PD) is the second most common movement disorder and affects 1% of people over the age of 60 1. Because ageing is the most important risk factor, cases of PD will increase during the next decades 2. Next to pathological protein folding and impaired protein degradation pathways, alterations of mitochondrial function and morphology were pointed out as further hallmark of neurodegeneration in PD 3-11.
After years of research in murine and human cancer cells as in vitro models to dissect molecular pathways of Parkinsonism, the use of human fibroblasts from patients and appropriate controls as ex vivo models has become a valuable research tool, if potential caveats are considered. Other than immortalized, rather artificial cell models, primary fibroblasts from patients carrying disease-associated mutations apparently reflect important pathological features of the human disease.
Here we delineate the procedure of taking skin biopsies, culturing human fibroblasts and using detailed protocols for essential microscopic techniques to define mitochondrial phenotypes. These were used to investigate different features associated with PD that are relevant to mitochondrial function and dynamics. Ex vivo, mitochondria can be analyzed in terms of their function, morphology, colocalization with lysosomes (the organelles degrading dysfunctional mitochondria) and degradation via the lysosomal pathway. These phenotypes are highly relevant for the identification of early signs of PD and may precede clinical motor symptoms in human disease-gene carriers. Hence, the assays presented here can be utilized as valuable tools to identify pathological features of neurodegeneration and help to define new therapeutic strategies in PD.

Fibroblasts from patients carrying mutations in Parkinson's disease-causing genes represent an easily accessible ex vivo model to study disease-associated phenotypes. Live cell imaging gives the opportunity to study morphological and functional parameters in living cells. Here we describe the preparation of human fibroblasts and subsequent monitoring of mitochondrial phenotypes.

利用人类纤维原细胞线粒体表型的监测领域的帕金森氏病

Parkinson's disease (PD) is the second most  common movement disorder and affects 1% of people over the age of 60 1. Because ageing is  the most important ...

Facial Nerve Surgery in the Rat Model to Study Axonal Inhibition and Regeneration

This protocol describes consistent and reproducible methods to study axonal regeneration and inhibition in a rat facial nerve injury model. The facial nerve can be manipulated along its entire length, from its intracranial segment to its extratemporal course. There are three primary types of nerve injury used for the experimental study of regenerative properties: nerve crush, transection, and nerve gap. The range of possible interventions is vast, including surgical manipulation of the nerve, delivery of neuroactive reagents or cells, and either central or end-organ manipulations. Advantages of this model for studying nerve regeneration include simplicity, reproducibility, interspecies consistency, reliable survival rates of the rat, and an increased anatomic size relative to murine models. Its limitations involve a more limited genetic manipulation versus the mouse model and the superlative regenerative capability of the rat, such that the facial nerve scientist must carefully assess time points for recovery and whether to translate results to higher animals and human studies. The rat model for facial nerve injury allows for functional, electrophysiological, and histomorphometric parameters for the interpretation and comparison of nerve regeneration. It thereby boasts tremendous potential toward furthering the understanding and treatment of the devastating consequences of facial nerve injury in human patients.

This protocol describes a reproducible approach to facial nerve surgery in the rat model, including descriptions of various inducible patterns of injury.

大鼠模型中的面部神经外科研究同氧抑制与再生

This protocol describes consistent and reproducible methods to study axonal regeneration and inhibition in a rat facial nerve injury model. The facial ...

神经科学

An Implantable System For Chronic In Vivo Electromyography

Electromyography (EMG) measures the muscle response to electrical stimulation or spontaneous activity of motor units and plays an important role in assessing neuromuscular function. Chronic recording of EMG activity reflecting a muscle&#8217;s reinnervation status after nerve injury has been limited, due to the invasive nature of traditional EMG recording techniques. In this regard, an implantable system is designed for long-term, in vivo EMG recording and nerve stimulation. It has been applied and tested in a study on reinnervation of laryngeal muscles. This system consists of 1) two bipolar electrode nerve cuffs and leads for stimulating each of two nerves: the recurrent laryngeal nerve (RLN) and internal branch of the superior laryngeal nerve (SLN); 2) two EMG recording electrodes and leads for each of the two laryngeal muscles: posterior cricoarytenoid (PCA) muscle and thyroarytenoid-lateral cricoarytenoid (TA-LCA) muscle complex; and 3) a skin receptacle interfacing all implanted lead terminals to an external recording preamplifier and stimulator using a connection cable. The wire leads are Teflon-coated, multi-filament, type 316 stainless steel. They are coiled and can stretch during body movement of the awake animal to prevent lead breakage and electrode migration. This system is implanted during an aseptic surgery. Afterwards, baseline EMG recordings are performed before the RLN is transected in the second surgery to study muscle reinnervation. Throughout the study, multiple physiological sessions are conducted in the anesthetized animal to obtain evoked and spontaneous EMG activity that reflects the reinnervation status of laryngeal muscles. The system is compact, free of infection over the course of the study, and highly durable. This implantable system can provide a reliable platform for research in which long-term recording or nerve stimulation is required in an anesthetized or freely moving animal.&#160;

Presented here is a protocol for the manufacturing of an implantable system for in vivo chronological recording of evoked and spontaneous electromyographic potentials. The system is applied to the investigation of reinnervation of laryngeal muscles following nerve injury. &#160;&#160;

慢性活体电成像的植入系统

Electromyography (EMG) measures the muscle response to electrical stimulation or spontaneous activity of motor units and plays an important role in ...

Structured Motor Rehabilitation After Selective Nerve Transfers

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning.
Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation.

Here, we present a protocol for the motor rehabilitation of patients with severe nerve injuries and selective nerve transfer surgery. It aims at restoring the motor function proposing several stages in patient education, early-stage therapy after surgery and interventions for rehabilitation after successful re-innervation of the nerve&#8217;s target.

选择性神经转移后的结构化运动康复

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on ...

<meta charset="utf8"></head><body>使用大鼠模型评估颅面 VML 损伤中的生物材料

Rodent Model of Masseter Volumetric Muscle Loss for Studying Bioengineering Materials

Craniofacial volumetric muscle loss (VML) injuries can occur as a result of severe trauma, surgical excision, inflammation, and congenital or other acquired conditions. Treatment of craniofacial VML involves surgical, functional muscle transfer. However, these procedures are unable to restore normal function, sensation, or expression, and more commonly, these conditions go untreated. Very little research has been conducted on skeletal muscle regeneration in animal models of craniofacial VML. This manuscript describes a rat model for the study of craniofacial VML injury and a protocol for the histological evaluation of biomaterials in the treatment of these injuries. Liquid hydrogel and freeze-dried scaffolds are applied at the time of surgical VML creation, and masseters are excised at terminal time points up to 12 weeks with high retention rates and negligible complications. Hematoxylin and eosin (HE), Masson's Trichrome, and immunohistochemical analysis are used to evaluate parameters of skeletal muscle regeneration as well as biocompatibility and immunomodulation. While we demonstrate the study of a hyaluronic-acid-based hydrogel, this model provides a means for evaluating subsequent iterations of materials in VML injuries.

<meta charset="utf8"></head><body>用于研究生物工程材料的咬肌体积损失的啮齿动物模型

Here, we describe a protocol for the surgical creation of a volumetric muscle loss (VML) injury in the rat masseter, providing a reproducible and accessible model for the study of craniofacial muscle injuries and their treatment using biomaterials such as the novel hydrogel.

用于研究生物工程材料的咬肌体积损失的啮齿动物模型

Craniofacial volumetric muscle loss (VML) injuries can occur as a result of severe trauma, surgical excision, inflammation, and congenital or other ...

生物工程

Force Assessment of Rat Masseter Muscle After VML Injury

In Vivo Functional Assessment of Rat Masseter Muscle Following Surgical Creation of a Volumetric Muscle Loss (VML) Injury

Volumetric Muscle Loss (VML) is prevalent in civilian and military populations and represents a debilitating skeletal muscle injury surpassing the body&#39;s natural regenerative capacity. These injuries disrupt not only muscle fibers but also nerves, blood vessels, and the extracellular matrix, overwhelming the regenerative capacity of skeletal muscle and leading to severe fibrosis and permanent deficiencies in muscle structure and function. Current clinical management has many limitations, and thus, research is ongoing to develop more effective therapeutic approaches. Notably, however, much of the preclinical emphasis on VML injuries has focused on limb and trunk muscles, with limited investigation into craniofacial muscles. Differences in developmental biology and regenerative capacity between craniofacial and limb/trunk muscles may provide crucial insights that drive more injury-specific VML treatment options. Moreover, evaluation of functional recovery is critical to establishing therapeutic efficacy. In this regard, in vivo testing of muscle contraction with percutaneous nerve stimulation is a minimally invasive method that allows for repeated functional assessment over the course of a study - in the same animal. In light of these considerations, this paper describes a method for the in vivo assessment of muscle function in the rat masseter muscle before and after a VML injury. This protocol is the first published instance to detail the creation and functional evaluation of a biologically relevant craniofacial VML injury in the rat.

Volumetric muscle loss (VML) injuries exceed endogenous regenerative ability, resulting in permanent functional deficits. Current VML research primarily focuses on limb and trunk muscles. To extend mechanistic studies of VML to craniofacial muscles, this article describes an in vivo method for longitudinal assessment of masseter muscle function pre- and post-VML injury.

Volumetric Muscle Loss (VML) is prevalent in civilian and military populations and represents a debilitating skeletal muscle injury surpassing the ...

<meta charset="utf8"></head><body>小鼠耳长提肌电穿孔和神经损伤

Combined In Vivo Electroporation and Short&#45;Term Reinnervation of the Cranial Levator Auris Longus Skeletal Muscle

The neuromuscular junction (NMJ) is the peripheral synapse controlling the contraction of skeletal muscle fibers to allow the coordinated movement of many organisms. At the NMJ, a presynaptic motor axon terminal contacts a muscle postsynaptic domain and is covered by terminal Schwann cells. The integrity and function of the NMJ is compromised under several conditions, including aging, neuromuscular diseases, and traumatic injuries. To analyze the potential contribution of muscle-derived proteins to NMJ maintenance and regeneration, an in vivo gene transfer strategy has been combined with the denervation of the cranial levator auris longus (LAL) muscle after mechanical nerve injury. Previous findings showed that the forced expression of control fluorescent proteins does not alter NMJ organization or neurotransmission. This procedure aims to describe a detailed method of in vivo electroporation of the LAL muscle followed by transection or crushing of the specific branch of the facial nerve innervating cranial muscles, leading to NMJ denervation and reinnervation, respectively. The combination of these experimental strategies in the convenient LAL muscle constitutes an efficient method to study the potential contribution of muscle protein overexpression or silencing in the context of short-term NMJ reinnervation.

<meta charset="utf8"></head><body>作者聚焦：肌肉蛋白在神经损伤后神经肌肉接头的再生作用

Here, we present a protocol that combines in vivo electroporation and denervation of the cranial levator auris longus (LAL) muscle. This procedure enables the study of the potential role of muscle-derived proteins in the regeneration of the neuromuscular synapse.

颅提肌耳长骨骼肌的体内电穿孔和短期神经再支配相结合

The neuromuscular junction (NMJ) is the peripheral synapse controlling the contraction of skeletal muscle fibers to allow the coordinated movement of many ...

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

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在犬体内的肌肉功能测定

利用人类纤维原细胞线粒体表型的监测领域的帕金森氏病

大鼠模型中的面部神经外科研究同氧抑制与再生

慢性活体电成像的植入系统

选择性神经转移后的结构化运动康复

用于研究生物工程材料的咬肌体积损失的啮齿动物模型

用于研究生物工程材料的咬肌体积损失的啮齿动物模型

用于研究生物工程材料的咬肌体积损失的啮齿动物模型

In Vivo Functional Assessment of Rat Masseter Muscle Following Surgical Creation of a Volumetric Muscle Loss (VML) Injury

颅提肌耳长骨骼肌的体内电穿孔和短期神经再支配相结合