Dallas, Texas; and Uppsala, Sweden From the Department of Plastic Surgery, The University of Texas Southwestern Medical Center at Dallas, and the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital.
Plast Reconstr Surg. 2013 May;131(5):1057-1064. doi: 10.1097/PRS.0b013e3182865d47.
Single-stage facial reanimation with a partial gracilis muscle coapted to the contralateral facial nerve seems an optimal surgical solution yet has not supplanted the two-stage approach. Insufficient obturator nerve length may limit reach to sizable contralateral facial nerve branches (possibly necessitating interposition nerve grafting), compromise optimal muscle positioning, or risk nerve coaptation under tension. This study evaluates whether retroperitoneal obturator nerve dissection would effectively lengthen the nerve, thus obviating the aforementioned limitations.
Ten hemifaces and obturator nerves of five cadavers were dissected. Facial measurements included modiolus to contralateral facial nerve branches of sufficient size at the vertical line of the lateral orbital rim. Obturator nerve measurements included gracilis neurovascular hilum to (1) obturator canal entry point (ab), (2) intraobturator canal point where additional adductor branches are inseparable by internal neurolysis (ac), and (3) retroperitoneal point of separation between anterior and posterior obturator branches (ad). Obturator nerve reach for cross-facial nerve coaptation was assessed.
Successful coaptation was achieved with obturator nerve dissection to point b approximately 20 percent of the time, to point c 60 to 70 percent of the time, and to retroperitoneal point d 90 to 100 percent of the time
Successful coaptation to large contralateral facial nerve branches is feasible in 90 to 100 percent of cases if the entire anterior obturator branch is harvested. However, the increased risk of retroperitoneal dissection and sacrifice of additional adductor branches decreases the viability of this approach. Obturator canal dissection (point c) provides reach in 60 to 70 percent of cases, but short interposition nerve grafting may prove necessary.
单阶段面部分区再表情似乎是一种最佳的手术解决方案，但尚未取代两阶段方法。由于坐骨神经长度不足，可能会限制其与足够大的对侧面神经分支的吻合（可能需要神经移植），影响最佳肌肉定位，或导致神经在张力下吻合。本研究评估了腹膜后坐骨神经解剖是否能有效地延长神经，从而避免上述限制。
对五具尸体的十半面和坐骨神经进行解剖。面部测量包括从面神经主干到侧眶缘垂直线上足够大小的对侧面神经分支的神经主干。坐骨神经测量包括从坐骨神经血管神经干到（1）坐骨神经管入口点（ab），（2）坐骨神经管内无法通过内部神经松解分离的额外内收肌分支的点（ac），和（3）前、后坐骨神经分支之间腹膜后分离点（ad）。评估了用于面神经吻合的坐骨神经的可达性。
成功吻合的坐骨神经解剖至 b 点的成功率约为 20%，至 c 点的成功率约为 60%至 70%，至 d 点的成功率约为 90%至 100%。
如果能采集整个前侧坐骨神经分支，则 90%至 100%的情况下可实现与大的对侧面神经分支的成功吻合。然而，腹膜后解剖和额外内收肌分支的牺牲增加了该方法的风险。坐骨神经管解剖（c 点）可使 60%至 70%的情况下达到可达性，但可能需要短距离神经移植。
