腮腺区肿物切除后面神经缺损的手术修复

目的 探讨腮腺癌、面神经肿物切除后面神经缺损修复方法的可行性,并对各种面神经缺损修复方法进行评价.方法 对腮腺恶性肿物侵袭面神经扩大切除及发生在面神经的神经源性肿物切除后面神经缺损的32例患者进行了神经移植修复.其中单纯采用耳大神经移植19例,神经长度1～2 cm;朐锁乳突肌携带耳大神经5例,修复腮腺恶性肿瘤扩大切除后骨面暴露的面神经缺损;携带筋膜面神经颈支修复下颌缘支缺损5例,携带筋膜面神经上颊支修复颧支缺损3例.所有手术均在双人双目手术显微镜下进行,用9-0及11-0无损伤缝合线吻合神经.结果 面神经恢复标准按照刘世勋面神经损伤修复评价标准进行评价.采用单纯耳大神经移植修复面神经缺损19例,术后恢复时间为6～18个月,恢复程度多数为部分功能恢复;胸锁乳突肌携带耳大神经移植修复面神经缺损5例,术后恢复时间为6～12个月,恢复效果比较理想;携带筋膜面神经颈支、上颊支修复下颌缘支、颧支缺损8例,术后恢复时间为6个月左右,恢复效果均比较理想.结论 几种神经移植修复面神经缺损,均是可行的.但采用面神经次要神经修复主要神经,修复效果比较理想.对于腮腺癌扩大切除后局部骨面外露者,采用胸锁乳突肌携带耳大神经移植修复是一种比较理想的修复方法.     

面神经颊支和下颌缘支的解剖学研究及应用

目的 观察面神经颊支与下颌缘支肌外、肌内走行分布情况，为面瘫整复术中受区神经的选择和预防神经支损伤提供依据。方法 在24侧头部标本中，分别观测颊支和下颌缘支的分支数目、吻合情况、走行中的层次、颊支与腮腺导管以及下颌缘支与下颌骨下缘、面血管的关系，结合Sihler’s肌内神经染色，明确其支配肌肉和在肌内的分布规律；并在40例面瘫手术患者受区面神经分支的寻找和选择中进行验证。结果 腮腺导管体表投影较恒定，面神经颊支以2～3支为主，占87．5％，多数分布在导管上方10．7mm和下方9．3mm的范围内，支配中面部表情肌。下颌缘支以1～2支为主，占95．9％，多数分布在下颌骨下缘上方13．4mm和下方4．8mm的范围内，跨面动脉浅面，支配下唇诸肌。结论 面神经颊支与腮腺导管、下颌缘支与面动脉及下颌骨下缘有着紧密的关系。应用改良Sihler法，可以更为清晰的显示人面部表情肌的肌内神经分布情况。     

面神经腮腺外分支的解剖学研究及其临床意义

目的 准确地描述面神经腮腺外段的分支,走行等情况,为颌面外科、头颈部整形与美容外科提供重要的形态学资料.方法 20具(40侧)新鲜成人头颈部标本,在手术显微镜下解剖观察并记录照相;利用上述形态学资料作为各种面神经损伤的诊断依据,指导相关手术的设计、分离和寻找面神经分支.结果 ①五组神经的分支数个体差异很大,平均颞支3.2支,颧支2.2支,颊支3.6支,下颌缘支1.3支,颈支恒为1支.②面神经急诊损伤探查缝合术12例,均成功.二级吻合前的损伤才具有神经缝合的条件,而二级(集中)吻合后的分支极其细小,探查、缝合基本不可能.③做面神经解剖术或者其他手术需辨清面神经各支时,颞中筋膜和咬肌筋膜是重要的标志.腮腺混合瘤切除面神经解剖术4例,跨面神经移植术2例,SMAS-颈阔肌除皱术千余例.这些手术中,发生明确的医源性面神经颧支损伤2例.结论 ①除颈支或单支的下颌缘支外,各组神经支可以被损伤或切断1～2支而不至于造成严重、永久的瘫痪;②在手术中,颞中筋膜与咬肌筋膜既是重要的保护结构,又是明确的辨别寻找标志.     

化学去细胞法处理犬面神经后的组织形态学观察

目的采用化学去细胞法处理犬颅外段全面神经的免疫原性成分,通过不同组织学染色,对化学去细胞神经的结构和雪旺细胞、髓鞘残留情况进行观察。方法杂种犬10只,体重(18±3)kg,处死后取新鲜犬头颅10个,解剖、分离犬颅外段双侧面神经主干及各分支(颞支、颧支、颊支、下颌缘支、颈支),共20根。将20根犬全面神经随机分为实验组(n=12)和对照组(n=8)。参照Sondell法,用3%TritonX-100和4%脱氧胆酸钠溶液对实验组犬全面神经进行化学萃取;对照组不作处理。对两组面神经分别行HE染色、Hoechst33258荧光染色及雪旺细胞P75、髓鞘相关蛋白Zero、层粘连蛋白(Laminin)免疫荧光组织化学染色观察。结果各种组织学染色观察显示,实验组面神经主要免疫原性物质、雪旺细胞和髓鞘均彻底去除,促神经生长成分Laminin保留,且神经结构保存完好。实验组犬面神经主干及5个分支具有相似的观察结果。结论化学去细胞处理后的犬全面神经,具有良好的天然面神经一主干五分支结构,可能是修复全面神经缺损的良好移植物。     

除皱术（二）

除皱术（二）高景恒（接上期）４．面神经分支的体表投影及各分支与ＳＭＡＳ的关系面神经穿出颅骨进入腮腺深浅间走行，然后分出五支穿出腮腺，即是颞支、颧支、颊支、下颌缘支和颈支。面神经各支穿出腮腺后行程范围称危险区．其外侧和后面及腮腺区为安全区。根据国外文献...     

腮腺切除术中面神经的解剖和观测

为了探讨面神经颅外段的走行,对120例由于各种原因进行保留面神经的腮腺腺叶切除术的患者,在术中对其面神经出颅后的走行、分支及其与邻近组织的关系等进行了解剖测量观察。观测包括面神经主干的长度、宽度以及各个分支发出的部位,各个分支的解剖特点。结果表明:颞支位置深在,分支较多;颧支位置深在,较粗大,分支相对较少,位置恒定;颊支分为①上下颊支型;②融为一支型;③一支再分型三种情况;下颌缘支位置较表浅,较细且走行长,分支多为2～3支。对手术时如何利用邻近解剖关系正确地寻找面神经进行了分析。     

面神经修复手术中影响疗效的相关因素分析

目的 通过对38例面神经修复手术临床资料的回顾,探讨影响面神经功能恢复的可能的相关因素.方法 对38例患者的临床资料进行采集.依据Sunny-Brook量表中面部神经动态功能的评价表,对所有患者手术前后的动态影像资料进行评价.依据神经受损的不同情况,分为颞支组(7例)、颧支组(8例)、颊支组(18例)、下颌缘支组(4例)、面神经总干组(7例)和颅内神经损伤组(6例).手术方法有神经直接吻合、神经移植、跨面神经移植和寄养.各个组中,分别对性别、瘫痪时间、神经移植、瘢痕和神经损伤位置等因素对结果的影响进行分析,并用S PSSl 3.0软件来进行统计学分析.结果 颞、颧和颊支经手术修复后功能改善明显,而下颌缘支的功能恢复较差;同侧3 cm内的神经移植对疗效无不利影响;神经入肌处和面神经出颅区域的瘢痕会对最终的功能恢复带来不良的影响;在面神经总干位置损伤后的修复疗效不及分支处损伤后的修复效果;咬肌神经作为寄养的神经,可以明显提高面部功能的恢复.结论 健康的神经两端,无张力的神经移植修复,以及咬肌神经的寄养将会给疗效的提高带来帮助.     

腮腺切除术中面神经的解剖和观测

为了探讨面神经颅外段的走行，对１２０例由于各种原因进行保留面神经的腮腺腺叶切除术的患者，在术中对其面神经出颅后的走行、分支及其与邻近组织的关系等进行了解剖测量观察。观测包括面神经主干的长度、宽度以及各个分支发出的部位，各个分支的解剖特点。结果表明：颞支位置深在，分支较多；颧支位置深在，较粗大，分支相对较少，位置恒定；颊支分为①上下颊支型；②融为一支型；③一支再分型三种情况；下颌缘支位置较表浅，较细且走行长，分支多为２～３支。对手术时如何利用邻近解剖关系正确地寻找面神经进行了分析。     

腮腺切除术中面神经的解剖和观测

为了探讨面神经颅外段的走行，对１２０例由于各种原因进行保留面神经的腮腺腺叶切除术的患者，在术中对其面神经出颅后的走行，分支及其与邻近组织的关系等进行了解剖测量观察，观测包括面神经主干的长度，宽度以及各个分支发出的部位，各个分支的解剖特点，结果表明，颞支位置深在，分支较多；颧支位置深在，较粗大，分支相对较少，位置恒定，颊支分为（１）上下颊支型；（２）融主一支型；（３）一支再分型三种情况，下颌缘支位置     

腮腺外面神经颊支的应用解剖研究

目的:观测面神经颊支出腮腺后的各级分支,为相关外科手术提供解剖学依据。方法:10例(20侧)防腐人头标本,描述面神经颊支出腮腺后的走行、定位及层次。结果:面神经颊支出腮腺后分为2～4支,均走行在SMAS筋膜下;颊Ⅰ、颊Ⅱ恒定出现,其一级分支距腮腺导管分别为(1.1±0.5)cm及(0.5±0.3)cm,且分别向前走行(1.3±0.9)cm及(1.8±0.5)cm后发出二级分支。结论:面神经颊支较为恒定,在面瘫治疗中健侧面神经颊支的二级分支可以作为受体神经,可不损伤面神经颊支主干。面神经颊支的分布及走行也可指导除皱术、扩张器植入、瘢痕切除等手术的剥离范围,不致产生并发症。     

联合运用冻融法和化学法去细胞同种异体神经修复兔面神经缺损

目的：通过对去细胞同种异体神经处理方法的改进,找出一种修复兔面神经缺损的理想替代材料。方法：取24只兔子,将兔左侧面神经上颊支切断以造成面神经缺损1.0cm的模型,根据修复方法不同,随机分成2组：实验组为联合运用冻融法和化学法去细胞同种异体神经修复组,对照组为自体面神倒置修复组,每组12只。术后3个月行大体观察、神经电生理检测、有髓神经纤维计数以及电镜观察,采用SPSS17.0软件包对数据进行t检验,对面神经恢复情况进行综合评价。结果：两组兔子均存活,切口愈合良好,兔面形基本对称;实验组与对照组左侧面神经上颊支传导速度分别为（55.74±10.56）m/s及（61.34±9.72）m/s,差异无显著性（P〉0.05）;实验组与对照组移植体远端吻合口邻近4.0mm段有髓神经纤维数量分别为（18173.62±918.38）n/mm2及（18601.21±982.31）n/mm2,差异亦无显著性（P〉0.05）;电镜检查结果相似。结论：联合运用冻融法和化学法去细胞同种异体神经能满意修复一定长度的面神经缺损,可以作为自体神经的一种有效替代物。     

化学去细胞同种异体神经移植术后病人的护理

[目的]探讨对化学去细胞同种异体神经修复周围神经损伤的护理及康复。[方法]自2003年4月-2006年4月，应用化学去细胞同种异体神经移植治疗完全断裂周围神经损伤患者39例，术后及出院后进行专项护理及康复，术后6个月以上患者随访共21例，对结果进行统计分析。[结果]21例患者中，16例神经损伤恢复效果达到优良，修复优良率达到71．4％。[结论]对化学去细胞同种异体神经移植术后的患者进行康复及护理，可以获得良好的临床效果。     

Marginal mandibular branch of the facial nerve: An anatomical study

Smile is one of the most natural and important expressions of human emotion. Man uses his lips mainly to register his emotions. Thus, the slightest asymmetry or weakness around the lips and mouth may transform this pleasant expression into embarrassment and distortion. The circumoral musculature, the major part of which is supplied by the marginal mandibular branch of the facial nerve, is the main factor in this expression. Therefore, an injury to this nerve during a surgical procedure can distort the expression of the smile as well as other facial expressions. This nerve often gets injured by surgeons in operative procedures in the submandibular region, like excision of the submandibular gland due to lack of accurate knowledge of variations in the course, branches and relations. In the present study, 50 facial halves were dissected to study the origin, entire course, termination, branches, muscles supplied by it, its anastomoses with other branches of facial nerve on the same as well as on the opposite side and its relations with the surrounding structures. The marginal mandibular branch of the facial nerve was found superficial to the facial artery and (anterior) facial vein in all the cases (100%). Thus the facial artery can be used as an important landmark in locating the marginal mandibular nerve during surgical procedures. Such a study can help in planning precise and accurate incisions and in preventing the unrecognized severance of this nerve during surgical procedures.     

New one-stage nerve pedicle grafting technique using the great auricular nerve for reconstruction of facial nerve defects

A new one-stage nerve pedicle grafting technique, employing a vascularized great auricular nerve graft, was used to repair a facial nerve defect. The facial nerve of a 39-year-old woman with facial schwannoma was resected, and an island vascularized great auricular nerve graft from the ipsilateral side was transferred to bridge a 4 cm long defect of the buccal branch. Postoperatively, rapid nerve sprouting through the vascularized nerve graft and excellent facial reanimation were obtained within 6 months after surgery. This method in one-stage using a vascularized nerve graft is technically easy, requires a short operating time, has minimal donor-site morbidity, and leads to successful nerve regeneration postoperatively.     

Adenoid cystic carcinoma of the parotid gland: Anastamosis of the facial nerve with the great auricular nerve after radical parotidectomy

Adenoid cystic carcinoma of the parotid gland is a rare and slowly growing, but highly malignant tumor. Surgical resection of a malignant parotid tumor should include resection of the facial nerve when the nerve is involved in the tumor. Facial nerve reconstruction is required after nerve resection. A 14 year-old female presented with complaints of painless enlargement of the right parotid gland and facial asymmetry. Physical examination revealed a firm mass in the region of the parotid gland as well as right facial paralysis. Biopsy obtained from the mass showed an adenoid cystic carcinoma of the parotid gland. A radical parotidectomy with a modified radical neck dissection was carried out. Grafting material for the facial reconstruction was harvested from the great auricular nerve. The proximal main trunk and each distal branch of the facial nerve were coapted with the greater auricular nerve. The patient received radiotherapy after surgery and was seen to achieve grade IV facial function one year after surgery. Thus, the great auricular nerve is appropriate grafting material for coaptation of each distal branch of the facial nerve.     

优化法去细胞大鼠神经同种异体移植修复坐骨神经缺损

[目的]以优化法去细胞大鼠神经移植,修复同种异体坐骨神经缺损,观察术后动物的免疫排斥、早期功能恢复及神经再生情况。[方法]以优化去细胞方法处理新鲜取材的成年SD大鼠坐骨神经,移植修复同种异体1.0cm坐骨神经缺损,以自体神经和新鲜异体神经移植为对照,术后1个月行坐骨神经功能指数评价、神经电生理和组织学检查,观察动物在功能恢复、免疫排斥及神经再生方面的情况。[结果]自体神经和去细胞异体神经移植组动物的坐骨神经功能指数无显著差异(P>0.05),大体观察均可见神经连续性良好。电生理检测表明2组动物移植神经均已恢复电传导能力,在传导速度(CV)上无显著差异(P>0.05),但均未达到正常神经水平(P<0.05)。组织学观察则显示2组再生神经纤维均已长入移植段远端。S-100免疫组化显示两者在雪旺氏细胞数、形态和排列等方面无明显差异。2组在CD8 T细胞和巨噬细胞免疫组化染色阳性面积百分比上差异无统计学意义(P>0.05)。计算移植神经中段轴突密度后表明两者无显著差异(P>0.05),但都比正常神经小(P<0.05),比新鲜异体神经移植组大(P<0.05)。[结论]优化去细胞神经移植组与自体神经移植组在免疫排斥、功能恢复及神经再生方面无显著差异。优化法去细胞神经在移植修复同种异体神经缺损时,可以达到免疫耐受,其早期功能恢复和神经再生情况良好,在修复周围神经缺损时可以作为自体神经移植的一种替代疗法。     

面神经分支在颞区的显微解剖学研究

目的 明确面神经在颞区的分布层次和范围，指导面部年轻化手术的操作入路。方法 12具(24侧)成人尸头标本，于5倍光学显微镜下行颞区的解剖观察。结果 颞区包含面神经的颞支和颧支：由面神经的上支分出，出腮腺上缘，颞支发出3～8个分支、颧支2～4个分支，行于颞浅筋膜深面。颞支越过颧弓至颞区，分布于额肌、眼轮匝肌、皱眉肌和耳周围肌等组织，主导其运动；颧支由腮腺上缘向前上方越过颧弓至外眦，支配眼轮匝肌和颧肌的运动；两支之间以及与眼神经的眶上神经和泪腺神经之间．都有交通支。结论 面神经的颞支和颧支分布在颞浅筋膜的深面和颞深筋膜的浅层之间的组织内，支配额部、眼周和耳部的表情肌运动；面部年轻化手术在分离颞区时．应避免在此层进行。     

面神经在眶周区的解剖研究

目的探讨面神经颠支、颧支的终末分支进入眼轮匝肌位置和体表解剖。方法选择6具新鲜尸体标本。观察解剖面神经颠支、颧支，辨别出进入眼轮匝肌的颠支、颧支与外眦的关系。通过外眦做一垂线和水平线，使之分别与矢状面和冠状面平行。通过外眦的垂线和水平线来确定进入眼轮匝肌的神经分支与外眦的解剖关系。结果颠支进入眼轮匝肌时．位于外眦水平线平均为2．64cm，位于外眦垂线外平均为2．40cm。在眼轮匝肌的侧缘、颞支和颧支的垂直距离平均为1.54cm。结论位于面神经走行的上或下、与其平行的切口，不易损伤面神经分支。     

Indication,technique and results of facial nerve reconstruction

Summary 160 patients with various intraor extracranial pathologies were treated by microsurgical facial nerve reconstruction at Nordstadt Neurosurgical Clinic between 1978 and 1993. Facial nerve reconstruction was accomplished along the anatomical course of the facial nerve from its origin at the brainstem, within the mastoid, at the stylomastoid foramen and within the face. Mostly, reconstruction was indicated because of nerve discontinuity (n=61), whereas facial nerve reanimation with a donor nerve such as the contralateral facial nerve or the ipsilateral hypoglossal nerve was indicated in 99 cases of loss of a proximal nerve stump. Depending on the site of the lesion reinnervation started at 5 to 15 months postoperatively lasting for 2 to 3 years with overall satisfactory results. 69% of all the patients regained good symmetry on rest, complete eye closure equivalent to House-Brackmann-Score III: Patients with complete failures either suffered of non-related diseases such as cancer leading to death before the estimated time of recovery or were exposed to radiation or received facial nerve reconstruction after long-standing facial deficit and marked muscular atrophy. The indication of the adequate method depends on the clinical course with or without preexisting facial paresis, on considering the intraoperative state of the facial nerve, the identification and microsurgical preparation of adequate nerve stumps, as well as on the adaptation techniques and the postoperative guidance of the patient. We conclude that facial nerve reconstruction by transplantation at either site of the nerve course or by reanimation with a donor nerve are effective and reliable procedures of treatment leading to satisfactory functional and cosmetic results.     

Selective facial neurectomy for spastic disorders of the facial nerve

Selective facial neurectomy in combination with bilateral musculocutaneous resection, plication brow lift, upper lid blepharoplasty, and limited rhytidectomy was performed on 18 patients with essential blepharospasm, eight with hemifacial spasm, and two with CNS vascular compression malformations. Microscopy showed the nerve tissues to be normal. Initial results were excellent. At 3 months there was a slight, persistent spastic twitching of the affected muscles in five nerves (a 14% failure rate in correcting blepharospasm). After 13 months there were four additional failures resulting from nerve regrowth in three and from one patient not completing therapy. The overall blepharospasm failure rate was 26%. On repeat neurectomy those with nerve regrowth presented with a diffuse, fine meshwork of nerve fibers reinnervating the mimetic facial musculature. In six of seven patients operated on again, spasticity was eliminated. The initial surgical failure rate has been corrected by resecting the frontal branch and the superior division of the buccal branch of the facial nerve. Only repeat neurectomy can correct long-term failures resulting from facial nerve regrowth.