Correction of facial paralysis with temporalis muscle fascia flap transposition

The diaphragmatic tendon fascia transposition facial paralysis correction is used for the treatment of facial paralysis. This operation uses the tendon fascia to properly prolong the diaphragm, transposition to the horn and medial malleolus, and to fix it to the surrounding tissue, and to move the sacral surface by chewing. The deep peroneal nerve that innervates the diaphragmatic fascia is also derived from the mandibular branch of the trigeminal nerve. The repair principle and effect are similar to those of the chewing muscle flap. Compared with the chewing muscle flap method, this method has two major advantages: one is that the tissue volume is large, and the angle of the mouth and the eyelid area can be simultaneously restored; the second is that the angle of the diaphragmatic fascia flap is similar to that of the diaphragm. The direction of movement is more natural than the chewing muscles. The disadvantage is that the diaphragm is short, generally does not reach the corners and internal hemorrhoids, and needs to be extended with the fascia strip. In addition, after the flap is turned down, it is easy to cause swelling of the zygomatic region. Diaphragm and expression muscles. Treating diseases: facial paralysis Indication The diaphragmatic tendon fascia transposition facial paralysis correction is suitable for obvious obstruction of the nose and mouth and rabbit eye deformity caused by old peripheral and central facial paralysis. Contraindications There are no special contraindications. Preoperative preparation 1. Predetermine the position of the corrected angular position. The principle is to make the mouth angle over the orthostatic position, that is, 0.5cm above the healthy side and 0.5cm above the healthy side. Skin relaxants also need to consider the amount of skin removed at the nasolabial fold. 2. Measure the distance from the upper edge of the affected side of the zygomatic arch to the corrected posterior angle to estimate the length of the required iliac fascia flap and the tension after the fixation. 3. Regular preparation of skin, or shaved head in the perioral, parotid, and diaphragm areas. 4. Prepare blood 300ml. Surgical procedure Incision Make a 7cm longitudinal incision at the upper edge of the zygomatic arch and 1cm in front of the auricle, and use the upper end of the incision as the midpoint. Make an arc-shaped incision parallel to the cranial anterior and posterior, 7cm long, and add a nasolabial incision. ~5cm. 0.5cm inside the medial malleolus for longitudinal incision, 1cm long. 2. Exposing the fascia Cut the epidermis and subcutaneous tissue to the superficial fascia, and turn the flap at the front and back. If the superficial blood vessels are encountered, they can be ligated and cut together, or they can be picked up together with the scalp flap. The fascia is fully exposed on the fan-shaped wound surface of the zygomatic arch to the upper incision. 3. Formation of fascia flap In order to make up for the lack of diaphragm length, it is necessary to make a fascia flap at the distal end of the diaphragmatic flap to extend the diaphragmatic flap so that it can reach the affected side. The specific method is to cut the fascia and periosteum along the upper line of the iliac crest and slightly lap the flap. Then cut the superficial and periosteum of the fascia along the lateral side of the zygomatic arch, peel off the upper edge of the zygomatic arch, cut through the adipose tissue and deep fascia deep into the deep surface, and lift the fascia as wide as possible on the surface of the diaphragm. The pages of the book are turned over to the upper edge of the diaphragm. The fascia should not be separated from the superior edge of the diaphragm and the periosteum. 4. Turn up the iliac muscle flap The posterior boundary of the muscle flap is the junction of 1/3 and posterior 1/3 of the diaphragm. It should be cut along the muscle fibers to the periosteum and connected to the periosteum that has been cut at the upper iliac crest. The diaphragm is then lifted together with the periosteum from the parietal and sacral scales, and the lower border to the upper edge of the zygomatic arch. This protects the deep nerves and blood vessels located in the superficial periosteum from damage. 5. Form a tunnel A longitudinal incision was made 0.5 cm inside the medial malleolus, and the upper and lower tunnels were made along the subcutaneous tissue layer, and the incision was made through the lateral condyle and the ankle incision. Make a nasolabial incision and follow the subcutaneous tissue layer to make a tunnel wide enough in the direction of the zygomatic arch. 6. Made of fascia strip The diaphragmatic fascia flap was divided into two parts: the first 1/3 and the second 2/3. The fascia and muscle fiber lines were longitudinally cut, and the blunt dissection was used near the upper edge of the zygomatic arch. For trial rotation, do not damage the nerves in the first 1/3 of the block. Then cut the fascia of the first 1/3 piece from the center line. The fascia portion of the last 2/3 pieces was evenly divided into 5-6 pieces. In order to prevent the separation of the temporal fascia from the diaphragm and periosteum, a thick suture can be made at the end of the incision of the fascia strip to avoid tearing during fixation. The reinforced suture of the first 1/3 of the fascial incision should be made at the site equivalent to the external malleolus. 7. Traction and fixing The two fascia strips of the first 1/3 of the diaphragmatic fascia flap were respectively passed through the subcutaneous tunnel of the upper and lower jaws, and crossed under the medial malleolus ligament in the medial incision of the medial malleolus. The tension should not be too large to prevent the eyelids from deforming. The posterior 2/3 fascia strips were respectively threaded and pulled out from the corner incision through the lateral tunnel of the zygomatic arch. After adjusting the tension, they were sutured and fixed on the subcutaneous tissue and the orbicularis oculi muscle of the upper lip, the mouth and the lower lip of the affected side. . 8. Close the wound and place the drainage After completely stopping bleeding, the wound was washed with physiological saline, and the incision was sutured in the internal iliac crest, the mouth and the scalp, and the scalp incision was placed in the 1-2 scalp. 9. Bandaging After the patient is awake, the elastic bandage is used to make the head and eye monocular bandage, focusing on the pressure on the temporal region and the face. complication Deep sacral nerve injury The deep sacral nerve is generally divided into two branches, which are crossed along the superficial periosteum. There are two main causes of injury: one is to flap the periosteum; the other is to make the position of the muscle flap longitudinally too low, often cutting off the nerve branch of the first 1/3. The denervated muscles will shrink and eventually become fibrotic, failing to achieve the purpose of dynamic functional repair. Therefore, this must be avoided. 2. Parotid duct injury The cause of the damage was the anatomical plane turbulence and rough handling during the tunneling. Prevention and treatment methods: The prevention method is to analyze strictly according to the level; the blunt dissection is used in the movement of the parotid duct, and no violence is used; If damage is found, adenoids should be sutured, repaired, or even ligated to the parotid duct. 3. The fascia strip is loose Can be caused by poor suture, improper dressing, premature exercise, etc., resulting in invalid surgery. The method of processing is to re-fix. Hematoma After the tendon flap of the diaphragm is turned down, a large dead space is left in the axillary region of the zygomatic arch. The wide separation of the subcutaneous tunnel in the cheek is not easy to completely stop bleeding. In addition, the improper dressing pressure can lead to hematorrhage and hematoma formation. . In order to reduce the ineffective cavity above the zygomatic arch, a zygomatic arch can be cut off. This can also make the muscle flap easier to fall down, reduce the swelling of the ankle after surgery, and gain more. Postoperative pressure dressing should be appropriate, and the hematoma should be fully drained in time to prevent secondary infection.

The material in this site is intended to be of general informational use and is not intended to constitute medical advice, probable diagnosis, or recommended treatments.