Maxillo-Facial Surgery Department. (Head: Professor F. Biglioli), San Paolo Hospital, University of Milan, via di Rudini' 8, Milan, Italy.
Maxillo-Facial Surgery Department. (Head: Professor C. Marchetti), Sant'Orsola-Malpighi Hospital, University of Bologna, via Albertoni 15, Bologna, Italy.
J Craniomaxillofac Surg. 2018 May;46(5):868-874. doi: 10.1016/j.jcms.2018.03.003. Epub 2018 Mar 14.
Recent facial paralyses, in which fibrillations of the mimetic muscles are still detectable by electromyography (EMG), allow facial reanimation based on giving new neural stimuli to musculature. However, if more time has elapsed, mimetic muscles can undergo irreversible atrophy, and providing a new neural stimulus is simply not effective. In these cases function is provided by transferring free flaps into the face or transposing masticatory muscles to reinstitute major movements, such as eyelid closure and smiling. In a small number of cases, patients affected by paralysis are referred late - more than 18 months after onset. In these cases, reinnervating the musculature carries a high risk of failure because some or all of the mimetic muscles may atrophy irreversibly while axonal ingrowth is taking place. A mixed reanimation technique to address this involves a neurorrhaphy between the masseteric nerve and a facial nerve branch for the orbicularis oculi, to ensure a stronger innervation to that muscle, associated with the transposition of the temporalis muscle to the nasiolabial sulcus. This gives good symmetry in the rest of the midface, while smiling movement is achievable, but not guaranteed. This one-time facial reanimation is particularly indicated for those who refuse major free-flap surgery or when that may be risky, as in previously operated and irradiated fields. More extensive procedures based on utilizing a free flap to recover smiling, while adding a cross-face nerve graft to restore blinking, may be proposed for motivated patients. Between 2010 and 2015, five patients affected by complete unilateral facial palsy underwent this technique in the Maxillofacial Surgery Department, San Paolo Hospital (Milan, Italy). Symmetry of the middle-third of the face at rest and recovery of smiling was quite good. Complete voluntary eyelid closure was obtained in all cases. Combining temporalis flap rotation and a masseteric-to-orbicularis-oculi-facial-nerve branch neurorrhaphy seems to be a valid solution for those medium-term referred patients.
最近的面瘫病例中，通过肌电图（EMG）仍可检测到表情肌的纤颤，这使得我们可以通过向肌肉提供新的神经刺激来实现面部再活动。然而，如果时间更长，表情肌可能会发生不可逆转的萎缩，而提供新的神经刺激根本无效。在这些情况下，可以通过将游离皮瓣转移到面部或将咀嚼肌移位来重新建立主要运动，例如眼睑闭合和微笑。在极少数情况下，面瘫患者就诊较晚 - 在发病后 18 个月以上。在这些情况下，由于在轴突生长过程中，一些或全部表情肌可能会不可逆转地萎缩，因此再神经支配肌肉的风险很高。一种混合的再活动技术涉及将咬肌神经与眼轮匝肌的面神经分支进行神经吻合，以确保该肌肉得到更强的神经支配，并将颞肌移位到鼻唇沟。这可以使中面部的其余部分达到良好的对称性，同时可以实现微笑运动，但不能保证。这种一次性面部再活动特别适用于那些拒绝进行大型游离皮瓣手术或认为该手术有风险的患者，例如在先前手术和放射治疗的区域。对于有动力的患者，可以提出更广泛的基于利用游离皮瓣恢复微笑，同时添加面神经交叉移植恢复眨眼的程序。在 2010 年至 2015 年期间，5 名完全单侧面瘫患者在意大利米兰圣保禄医院的颌面外科接受了这种技术。休息和恢复微笑时，面部中部的对称性相当好。所有病例均获得完全自愿的眼睑闭合。将颞肌瓣旋转和咬肌至眼轮匝肌面神经分支神经吻合似乎是对这些中期就诊患者的有效解决方案。
