跨面神经-带神经血管股薄肌游离移植分期治疗晚期面瘫

Cross-face nerve grafting followed by free functional gracilis muscle transplantation in patients with long-standing facial paralysis

目的:探讨跨面神经-带神经血管股薄肌游离移植分期治疗晚期面瘫的效果。方法:回顾性分析2014年1月至2020年12月,中国医学科学院整形外科医院整形二科应用跨面神经-带神经血管股薄肌游离移植分期治疗晚期面瘫的临床资料。一期行跨面神经移植术,二期行带神经血管股薄肌游离移植术。术后随访手术效果,评估患者双侧中下面部对称性变化。应用改良House-Brackmann面神经功能分级评估患者术前、后口角运动程度,通过Adobe Photoshop 2021测量患者术前、后静态和动态双侧口角连线与面中线的夹角(口角动度客观测量),并应用配对t检验进行比较,P<0.05表示差异有统计学意义。结果:共纳入26例晚期面瘫患者,男10例,女16例,年龄(24.8±3.5)岁(16~28岁)。分期手术间隔时间为6~12个月。术后随访(34.9±11.7)个月(1~3年),所有游离移植物均成活,没有严重并发症,其中2例患者二期术后1年因患侧面部臃肿行移植肌肉修薄术,1例患者二期术后1年因股薄肌固定止点位置不佳进行了肌肉止点位置调整术,1例患者二期术后2年因口角动度不足行咬肌神经跨面神经端侧吻合术。所有患者术后面部对称性改善,患侧全部出现口角上提运动。改良House-Brackmann面神经功能分级评估口角动度:优秀15例,良好9例,一般2例。口角动度客观测量结果显示,患者术后静态角度较术前提升(86.4°±3.3°vs.82.3°±2.7°),差异具有统计学意义(t=5.27,P=0.017);术后动态角度较术前提升(86.9°±2.8°vs.80.1°±3.3°),差异具有统计学意义(t=7.55,P<0.001)。结论:跨面神经-带神经血管股薄肌游离移植分期治疗晚期面瘫效果良好。

Objective To investigate the clinical effect of stage treatment for long-standing facial paralysis with free functional gracilis transfer innervated by cross-face nerve grafting(CFNG).Methods A retrospective study was carried out focusing on the case data of patients with long-standing facial paralysis who were treated by the free functional gracilis transfer innervated by CFNG in the Second Department of Plastic Surgery Hospital of the Chinese Academy of Medical Sciences from January 2014 to December 2020.CFNG was performed in the first stage approach and free functional gracilis transfer in the second stage approach.Auther utilized the modified House-Brackmann grading scale to record the patients’lip angle movements postoperatively and measured the static and dynamic angle formed between the horizontal line of both lip corners and the vertical midline before and after surgery objectively.Paired t-test was utilized to evaluate the bilateral middle and lower facial symmetry changes,so as to estimate the surgical effect.The significance level was set at 0.05.Results A total of 26 patients with long-standing facial paralysis were enrolled in this study,including 10 males and 16 females,aged from 16 to 28 years,with an average age of(24.8±3.5)years.The interval of staging operation was 6 to 12 months.The postoperative follow-up was 1-3 years,with an average of(34.9±11.7)months.All grafts survived well.No major complication occurred.2 patients underwent gracilis muscle debulking due to the paralysis side facial bulking one year after the second stage operation.1 patient underwent muscle fixation position adjustment due to the poor position of gracilis muscle fixation one year after the second stage operation.1 patient underwent masseter nerve-CFNG end-to-side anastomosis 2 years after the second stage operation due to insufficient movement of the mouth.The facial symmetry of all patients was improved after the two-staged operations.The movement of lip corners was classified as excellent in 15 cases,good in 9 cases,and fair in 2 cases in terms of the modified House-Brackmann grading scale.According to the objective evaluation of oral angle movement,the static lip angle after surgery was higher than that before surgery(86.4°±3.3°vs.82.3°±2.7°)and the difference was statistically significant(t=5.27,P=0.017);the dynamic lip angle after surgery was higher than that before surgery(86.9°±2.8°vs.80.1°±3.3°),and the difference was statistically significant(t=7.55,P<0.001).Conclusion Free functional gracilis transfer innervated by CFNG is an ideal technique for long-standing facial paralysis.It can effectively improve the facial dynamic of the affected side.