facial accessory nerve cross anastomosis

The earliest recorded facial paraneoplastic anastomosis was performed by Drobnik (1897). The characteristics and nature of this procedure are basically the same as the face-hypoglossal nerve anastomosis, except that the dysfunction left by surgery is not as obvious as the latter. Treating diseases: facial paralysis Indication 1. Old central facial paralysis, or Bell facial paralysis, the surrounding structure of the facial nerve still exists, the facial expression muscle has not been severely atrophied. 2. Injury or defect caused by surgical injury or inflammation in the facial nerve to the neck surface, dry or damaged, facial muscles have not been severely atrophied. 3. No other brain damage. Contraindications The old facial paralysis, the facial expression muscle has been severely atrophied, the peripheral nerve branch has lost its anatomical structure and cannot be used for nerve anastomosis. Preoperative preparation 1. Ask the medical history in detail, paying special attention to the time of the disease. 2. Learn in detail about the patient's psychological tolerance to surgery, especially the concerns of sacrificing sublingual sequelae, such as temporary half-sided tongue. Make necessary and sufficient explanations. 3. It can be used as a direct electrical stimulation of facial expression muscles to understand the functional status of the muscles. 4. The facial parotid gland and submandibular area are routinely prepared for skin. Surgical procedure Incision The incision design can be bent from the front of the earlobe to the middle of the anterior border of the sternocleidomastoid muscle, about 7 cm long. 2. Flap Cut the skin, subcutaneous tissue and platysma and flip the flap forward in the shallow side of the parotid gland muscle fascia. If the external jugular vein is encountered on the surface of the sternocleidomastoid muscle, it can be ligated and cut. 3. Reveal the facial nerve The blunt dissection between the posterior and posterior margins of the parotid gland and the mastoid and sternocleidomastoid muscles was performed, and the sternocleidomastoid muscle was pulled back to reveal the posterior abdomen of the second abdominal muscle. Then, about 1 cm above the tip of the mastoid, the blunt dissection was carefully performed deep in the deep part of the angle between the posterior abdomen of the second abdominal muscle and the external cartilage. The direction of blunt dissection should be consistent with the total dryness of the facial nerve to avoid damage to the facial nerve. The total surface of the facial nerve is usually found at a depth of about 1 cm (from the surface of the mastoid). In the superficial surface of the total facial nerve, it can be seen that the posterior auricular artery slanted across the upward direction and needs to be ligated and cut. When looking for deep facial separation, the depth of the facial nerve must not exceed the depth of the styloid process. In addition, during the operation, it can be seen that the large ear nerves traverse the surgical field and can be cut off. 4. Separation of facial nerve trunks and branches Carefully and bluntly separating and cutting the parotid gland along the total dry surface, the two main trunks of the temporal and cervical branches can be exposed, and the branches can be carefully dissected to the distal end. It should be noted that in addition to the common bifurcation type, the facial nerve bifurcation has three types of bifurcation, four-fork type, five-fork type and trunk type. Therefore, care should be taken when dissecting the facial nerve to avoid damage to the facial nerve branch. It should also be noted that under normal circumstances, there is a complete nerve membrane on the outside of the facial nerve, which does not adhere to the parotid gland and is not difficult to separate. However, in the case of pathological adhesion, separation is difficult, and special care is required. 5. Exposing the accessory nerve The anterior border of the sternocleidomastoid muscle is retracted posteriorly in the plane of the hyoid bone. The parasitic god often enters the sternocleidomastoid muscle in the plane along the central axis of the muscle. At the same time, the trapezius muscle branch is separated and protrudes slightly upward to the midpoint of the posterior margin of the muscle, obliquely backward and downward, and enters the trapezius muscle at the middle and lower 1/3 junction of the trapezius muscle front. 6. Neuronal transposition There are two kinds of indexing methods according to the accessory site of the accessory nerve: 1 If the upper segment of the trapezius muscle branch of the accessory nerve is to be used for surgery, it should be separated along the sternocleidomast muscle branch to the central side, and the posterior abdomen and stem of the second abdominal muscle. The deep surface of the lingual muscle is free of sufficient length, and the nerve is cut at the nerve gate of the sternocleidomastoid muscle and turned up. If necessary, the nerve endings can be passed through the gap between the posterior abdomen of the second abdominal muscle and the scapulohumeral muscle to the total surface of the facial nerve. The disadvantage of this approach is that the sternocleidomast muscle and the trapezius muscle are uniform. 2 If the parasitic muscle branch of the accessory nerve is to be transposed, the trapezius muscle branch should be found behind the sternocleidomastoid branch of the accessory nerve and dissected along the peripheral side. In order to be clear, the posterior margin of the sternocleidomastoid muscle can be picked up, and the trapezius muscle branch can be freed for a sufficient length in the deep deep cervical fascia of the posterior triangle of the neck, and then cut with a sharp knife to break the central side of the nerve. The posterior margin of the transthoracic papillary muscle turns to the total surface of the facial nerve. This practice only causes the trapezius tendon. 7. Anastomotic nerve The central end of the accessory nerve was made to coincide with the peripheral side of the total facial nerve. 8. Close the wound Rinse the wound, completely stop bleeding, suture the parotid gland tissue, suture the platysma, subcutaneous tissue and skin layered, place the semi-tube drainage strip, and pressurize the dressing. complication Nerve re-rupture: the causes may be: 1 insufficient nerve detachment, tension at the anastomosis; 2 flushing to stop bleeding or detecting hemostasis; 3 poor neck braking, excessive activity and so on. Unless it is found in time and re-integrated in time, it is generally not easy to find early re-fracture after surgery. After half a year to one year, it is often too late to probe for signs of recovery from nerve function. Therefore, we should focus on preventing the occurrence of nerve re-rupture. The preventive measures are: 1 fully free the nerve, so that the anastomosis is tension-free; 2 the sublingual nerve trunk and the descending branch of the central lateral membrane and muscle fixation suture should be reliable; 3 flushing hemostasis should be gentle, close the wound before the examination of the nerve anastomosis; 4 The neck is properly braked after surgery to limit activities.

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