除皱术中防止面神经下颌缘支损伤的解剖学研究

目的　为除皱术中防止面神经下颌缘支损伤提供解剖学依据。方法　选用防腐固定标本10例 (2 0侧 )和新鲜标本 5例 (10侧 ) ,观察下颌缘支的走行、分布 ,分析下颌缘支的分布特点及防止神经损伤的方法。结果　⑴下颌缘支主干出腮腺后的走行方式可分为孤立型和共干型。⑵ 6 3.33%的下颌缘支走行在下颌缘上方 (2 .1± 0 .7)cm ;2 3.33%沿下颌缘走行 ;13.33%走行在下颌缘下方 (1.8± 0 .5 )cm。⑶下颌缘支出腮腺后走行于在咬肌筋膜中 ,在咬肌前缘 ,部分下颌缘支走行并支配颈阔肌 ,部分分支向深面走行支配口下组肌群。结论　下颌缘支出腮腺后走行在以下颌角为起点 ,以下颌下缘为中线、下颌下缘上下各一横指的区域内。在SMAS 颈阔肌下平面分离到咬肌前缘位置时 ,应注意防止损伤下颌缘支。     

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。     

从解剖学角度探讨应用锯齿线行面部提升术的可行性

目的:以解剖学研究为基础,探讨应用锯齿线行面部提升术的适应证、禁忌证与手术层次。方法:对10例(20侧)防腐人头标本进行头面部逐层解剖,观察面部脂肪分布与眶上血管神经、滑车上血管神经、面神经的走行特点。结果:额正中部皮肤与皮下组织的厚度(1.9±0.2)mm,颞部发际缘处皮肤与皮下组织的厚度(2.4±0.3)mm,面颊部颊脂肪垫处皮肤与皮下组织的厚度(3.1±0.4)mm。眶上血管神经分为内侧支和外侧支,分别穿过额肌、帽状腱膜进入头皮。滑车上血管神经穿过额肌分布于近中线的额部皮肤。面神经颞支向前上方走行于颞浅筋膜深面。面神经颊支出腮腺后走行于表浅肌肉腱膜系统(SMAS)的深面,其分支相互吻合呈立体网格状。结论:额部于额肌深面、颞部于颞浅筋膜浅面、面颊部于SMAS浅面,是锯齿线的安全植入层次。     

面神经的角神经解剖学研究

目的 了解面神经的角神经解剖位置,为皱眉肌、降眉肌及降眉间肌去神经化手术寻找最佳入路提供安全保证.方法 对10具(20侧)成人新鲜尸头标本行甲醛血管灌注固定后.在10倍手术放大镜下显微解剖,寻找面神经颧支与颊支的分支,确定角神经,观察其与周围血管的位置关系,并追踪角神经到皱眉肌、降眉肌及降眉间肌的入肌点,照像留存.结果 ①按照角神经的形成及分支将角神经分为Ⅰ、Ⅱ、Ⅲ型.颊支形成复杂的吻合网后又开始形成集中向内眦方向走行,形成单一的角神经,并接收从眼轮匝肌中穿出的颧支,称为角神经Ⅰ型(20%,4/20侧);颊支吻合网与颧支吻合网在"四肌间隙"中形成1支角神经,称角神经Ⅱ型(20%,4/20侧);在"四肌间隙"中形成角神经为上下2支时,称为角神经Ⅲ型(60%,12/20侧).②3种类型的角神经在下眶部都走行于眼轮匝肌支持韧带的下方,在内眦部走行于眼轮匝肌支持韧带的内侧,并与内眦血管伴行.③角神经在内眦韧带水平上方2.19～4.28 mm即有分支进入降眉肌或降眉间肌.角神经有反折支进入上唇鼻翼提肌,最上入肌点距内眦角下方垂直距离为6.89～9.38 mm.结论 在内眦水平线上方2.19 mm至下方6.89 mm的范围内、眼轮匝肌支持韧带的内侧,对角神经进行失神经手术,是最佳的手术入路.     

下颌舌骨神经与面神经吻合的应用解剖

目的为确保面神经与下颌舌骨神经顺利吻合提供参考.方法在25具(50例)尸头上解剖观察了下颌舌骨神经在颌下的走行、分支及双侧分支吻合情况.结果下颌舌骨神经从下齿槽神经分出后在下颌舌骨沟内至下颌骨下缘处为第一段.从下颌骨下缘向前行至第一次分支为第二段,其长度为13.61±3.09mm,直径为1.21±0.14mm.从第一次分支后分别至二腹肌前腹与下颌舌骨肌的各分支为第三段,其中至二腹肌前腹支长度为13.07±2.49mm,直径为1.03±0.12mm,至下颌舌骨肌支长度为11.21±1.75mm,直径为1.04±0.11mm.两侧之间有吻合.结论该神经易于暴露,走行及分支均较恒定.适合于进行神经吻合.     

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。     

下颌角毗邻解剖结构的定位测量

目的 对下颌角毗邻的解剖结构进行定位测量,为下颌角整形术提供可靠的参考数据.方法 解剖成人头面部尸体标本,从下颌角整形术的角度,对口内、口外入路所涉及的下颌角毗邻解剖结构进行观察并定位测量,得出平均数据.结果 面横动脉距颧点(72.0±3.0)mm,距下颌角(60.0±2.0)mm;腮腺导管距颧点(62.0±2.0)mm,距下颌角(45.0±5.0)mm;面神经上颊支距颧点(54.0±2.0)mm,距下颌角(19.0±2.0)mm;面神经下颊支距颧点(16.0±2.0)mm,距下颌角(13.0±4.0)mm;面动脉距下颌角(28.0±3.0)mm,距口角(45.0±3.0)mm;翼内肌与咬肌交叉附着于下颌支前、后缘及下颌角咬肌粗隆长(66.0±2.0)mm.结论 下颌角毗邻解剖结构的定位测量,可为下颌角整形手术提供形态学及解剖学基础.     

46例面神经瘫痪筋膜悬吊术的护理

４６例面神经瘫痪筋膜悬吊术的护理浙江省皮肤病防治研究所叶宏芬面神经是支配面部表情肌的运动神经。当一侧神经的颊支及下颌支受累，所支配的口轮匝肌、提上唇肌、口角提肌以及颊部肌肉等丧失运动功能，致患侧口角低垂、歪斜、鼻唇沟消失，鼻端偏向健侧，致面部畸形。若...     

面神经颧支支配颧肌的显微解剖学研究

目的 明确面神经颧支的终末分支进入颧肌的位置和体表标志.方法 将10具(20侧)10%甲醛固定的成人尸头标本,解剖观察面神经颧支的走行及分支情况,以经口角的水平线为X轴,经同侧外眦角的垂线为Y轴,测量并记录颧支入肌支在坐标轴上的位置并进行体表定位.结果 面神经颧支自腮腺前上缘出腮腺,分为1～3支型,以2支型为主(占65%,13侧).浅支经颧大肌头侧浅面支配眼轮匝肌,深支有2～6支为主干支,平均(3.40±1.06)支,从颧大肌上1/2深面呈节段"爪"形支配该肌,入肌神经数为3～8支,平均(6.00±1.49)支.结论 在行中面部手术时,在颧大肌下2/3表面进行分离是安全的,尽量避免在颧肌的深面进行分离,尤其是上1/2深面,极易损伤面神经颧支;在其下1/2深面分离时,应紧贴颧大肌,以免损伤从其深面经过的面神经颊支.     

面神经颅外段的走行分布及临床应用研究进展

面神经起于桥脑下部的面神经核，自茎乳孔出颅后称面神经颅外段。面神经是面部主要运动神经，支配包括颈阔肌的面部表情肌、茎突舌骨肌及二腹肌后腹。在颅外的行程中又因穿经腮腺而分为腮腺前段、腮腺内段和腮腺后段。     

Direct coaptation of extensive facial nerve defects after removal of the superficial part of the parotid gland: an anatomic study

BACKGROUND: In the surgical repair of facial nerve paralysis, a tension-free end-to-end coaptation of the trunk or its branches with or without rerouting is functionally superior to grafting. Assuming that a lengthening of all branches of the parotid plexus can be attained by removal of the superficial part of the parotid gland and mobilization of the branches, we performed an anatomic study. METHODS: The parotid regions of 10 cadavers were dissected to investigate the length gained for the branches of the parotid plexus by this technique. Every branch at the upper and ventral border of the gland was marked by a surgical suture. After removing the superficial part of the parotid gland, the branches were cut at the suture, and the proximal stump was drawn toward the distal stump. The distance of the overlapping stumps was measured by means of an electronic gliding caliper. In addition, in five specimens only the trunk of the facial nerve was dissected by the same method, and the distance of the overlapping stumps was measured. RESULTS AND CONCLUSIONS: The results demonstrate that removing the superficial part of the parotid gland may be sufficient to enable direct coaptation without nerve grafting. Cut temporal or zygomatic branches with a gap of up to 15 mm and cut buccal or marginal mandibular branches with a gap of up to 23 mm can be bridged by mobilization of just the proximal stumps. This technique may also be used to bridge a 17-mm gap of the trunk of the facial nerve.     

Preserving the marginal mandibular branch of the facial nerve during submandibular region surgery: a cadaveric safety study

Background

The marginal mandibular branch of the facial nerve is vulnerable to iatrogenic injuries during surgeries involving the submandibular region. This leads to significant post-operative morbidity. Studies assessing accurate anatomical landmarks of the marginal mandibular branch are sparse in South Asian countries. Present study was conducted to assess the relationship between the marginal mandibular branch and the inferior border of the body of mandible.

Methods

Twenty-two preserved cadavers of Sri Lankan nationality were selected. Cadavers were positioned dorsal decubitus with necks in extension. The maximum perpendicular distance between the inferior/caudal most ramus of the marginal mandibular branch and the inferior border of the body of the mandible was recorded on both hemi faces.

Results

Recorded maximum distance was 17.65 mm on left side and 10.80 mm on right side. Mean maximum distance, was 7.12?±?2.97 mm. There was no statistically significant difference in the maximum deviation on left (7.84?±?3.41 mm) and right sides (6.44?±?2.37 mm).

Conclusion

Course of the marginal mandibular nerve is complex. If the distance of the incision in the posterior submandibular approach is less than 2 cm from the inferior border of the mandible, there is a high probability of damaging the inferior ramus of the marginal mandibular branch of the facial nerve.

     

Maxillofacial injuries: Reconstructive surgery of the dehiscent parotid duct and dehiscent peripheral facial nerve

In retrospect, duct injuries have, for the most part, been considered quite separately with respect to methods of repair and these usually have been emphasized under two headings: (1) the immediate repair, and (2) repair of the duct with existing fistulas. With reference to the seventh nerve peripheral injuries these, too, have been considered for the most part as separate entities, notably by Furstenberg and Bunnell.With reference to Butler and Guinan's article in 1933, it is apparent that the catheter obstructed the lumen and it is quite possible that a fistulous opening alongside of the ostium was responsible for the successful repair of the wound minasmuch as no mention is made of the observation that secretion was coming from the ostmm. No mention is made of nerve injury or repair and it is possible that the horizontal wound in their case did not sever the nerve branches as is so common in the vertical wounds. Dr. T. G. Blocker recently stated that in the maxillofacial injuries in World War II involving the parotid duct, the ducts were repaired by conversion into internal fistula and peripheral facial nerve branches nearly always regenerated spontaneously.In all the above case reports no mention had been made of the study of the tributary distribution to the parotid duct with lipiodol and x-ray.It is the contention of the author that, while many cases of separate injury of the duct and facial nerve exist in consequence of injuries of a type, it is more than likely that if parotid duct injury exists peripheral nerve injury is also present and vice versa. If a lacerating, penetrating or avulsion injury involves the parotid duct, the buccal and zygomatic branches of the facial nerve will be involved.Further from the successful secondary repair by primary suture and graft exemplified in this case, the author believes that it is not necessary to convert external fistulas into internal fistulas as a method of repair, and believes that it is practicable to explore, isolate, resect and anastomose by primary suture as a method. That is better surgery in view of the nerve factors present. The author's case, after pathological resection and excision forty-three days subsequent to the primary injury, was successfully repaired despite the existence of a 30 mm. dehiscence in the duct proper and a 30 mm. dehiscence in the zygomatic branch of the facial nerve. The use of an indwelling No. 30 alloy steel wire dowel, which can be carried out through the cheek with no residual evidence of a puncture wound externally, creates a new dowel material as well as supplying a dowel unsurpassed in capillary and surface tension factor. The successful repair of the above case should nullify the opinions of those who elect to extirpate the parotid gland or destroy the gland by radiation when obstruction or fistulas exist.With reference to the nerve injury successful repair by suture and inlay nerve graft with the use of a Bunnell pull-out undulating suture, is a practical means of reinervation and regeneration of the peripheral branches of the facial nerve when involved. Contrary to many of the opinions expressed, the nerve twigs in the area anterior to the parotid gland measure approximately 1 to $\text{1}\text{1}\text{2}\text{mm}$. in diameter and by careful suture and inlay grafting successful repairs can be obtained. The method used in the author's case in which the dehiscence existed was to tie a B silk suture around the proximal and distal nerve endings to obtain the shortest diameter and a direct line continuity between the nerve endings. The next step was to resect one of the peripheral twigs of the cervicofacial nerve branch equal m length to the dehiscent area and lay the graft alongside of the the silk tract. A Bunnell undulating pullout suture was threaded through the distal end of the severed nerve, then through the graft and thence through the proximal end of the severed nerve. The silk link joining the severed ends was then removed and the nerve ends freshened by section. Where the approximation of the cut ends could be brought into continuity as in the buccal branch by mobilization from the perineural tissues, a similar Bunnell suture was utilized to facilitate reservation. The Bunnell suture is spliced through the central part of the nerve graft into the central part of the cleanly cut proximal and distal traumatized nerves. This method permits a short cut in the reinervation and reanimation of the muscles of the face and eliminates residual paralysis.Dr. Paul W. Cohen interpreted the x-ray findings of the author's case after lipiodol injections, as a cystic encapsulated swelling most likely an obstruction of the duct. Otherwise, an exudation of the parotid fluid into the subcutaneous tissues would have caused a fistula after forty days. It is significant that no injection could be made into Stenson's duct through the natural ostium showing that the distal end of the duct had been fibrosed. An injection of methylene blue had been made into the swollen cheek to observe the existence of fistula along the path of the duct. No elimination of secretion by fistula was noted and the cheek continued to swell. Frequent aspirations controlled the swelling; as much as two ounces of saliva had been collected in a few hours.The repair of external parotid fistulas by conversion into internal fistulas is an obsolete operation requiring no exceptional skill, is not anatomical, and is not comparable with surgical principles applied in general surgery in which the method of repair of fistulas is directed to the restoration of lumen continuity. Perhaps the neglect of parotid duct repairs is based upon the existence of six salivary glands so that when one gland or duct is put out of function only a proportionate amount of emphasis is placed upon its importance. However, the loss of the parotid gland, due to extirpation, because of obstruction, or atrophy from radiation therapy, will cause facial asymmetry and this is of paramount importance to the plastic surgeon, particularly when there is an associated peripheral nerve paralysis.     

采用多重标记物示踪化学去细胞异体神经修复大鼠面神经缺损

[目的]探索用荧光金、量子点、固蓝"三标"逆行示踪方法来评价化学去细胞异体神经移植修复大鼠面神经缺损后颊支、下颌缘支、颈支的再生及神经的物质运输功能。[方法]外科显微镜下解剖、分离出鼠的左侧颅外段面神经主干及各分支(颞支、颧支、颊支、下颌缘支、颈支),在出茎乳孔处离断面神经主干,分别在距该断点10 mm处离断5个分支,移植化学去细胞异体全面神经,术后2个月暴露面神经,在颊支、下颌缘支、颈支吻合口远端分别注射荧光金、量子点、固蓝,3 d后脑干取材,冰冻切片,并在荧光显微镜下观察脑干内3种示踪剂的分布情况。[结果]将发源于脑干的面神经核团进行冰冻切片,荧光显微镜下观察到被荧光金、量子点、固蓝标记的神经元分别显示出黄色、红色和蓝色。[结论]根据神经轴浆运输的原理,采用多种标记物示踪法评价异体神经移植修复面神经损伤后神经干及各分支连续性的恢复情况,操作简便,可靠易行,是一种理想的评价方法。     

Facile identification of the facial nerve branches

The buccal, mandibular, zygomatic, and temporofrontal branches of the facial nerve are easily located by the surgical methods reported herein. The buccal and mandibular branches can be safeguarded during parotid, submaxillary gland, mandibular, or double-layer face lift surgery by these nerve location techniques.     

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     

完全经口内镜下甲状腺切除术的解剖学研究

目的 确定经口路径的解剖通路、层次和相关的神经、血管结构,为舌下联合口腔前庭的完全经口内镜下甲状腺切除提供一个安全可行的经口入路.方法 2009年11月至2011年5月,在25具固定标本上,行颈前部、下颌骨表面、口底解剖,确定经口路径的解剖通路、层次和相关的神经、血管结构.在20具冰冻新鲜标本上,模拟经口内镜甲状腺切除术,术后解剖标本,观察有无神经、血管的损伤.结果 内镜通道为自舌下中线处开口,经颏舌骨肌、下颌舌骨肌、二腹肌前腹,至颈阔肌下.操作通道为口腔前庭处,第一磨牙根部纵行矢状切口,于面动脉、面静脉、面神经下颌缘支深面,颏神经外侧,紧贴下颌骨骨膜面,进入颈阔肌下.颏神经与下颌骨正中线的距离为(25.8±0.9)mm,颏神经与面动脉的距离为(29.4±0.9)mm.20例模拟手术,术后解剖观察,无神经、血管和口底肌的损伤.完全经口内镜通路中,可切除的甲状腺长径达50 mm.结论 舌下联合口腔前庭的完全经口入路具有解剖学的可行性,可安全到达甲状腺区并完成甲状腺的切除.     

Facial nerve in rhytidoplasty: anatomic study of its trajectory in the overlying skin and the most common sites of injury

The anatomic study of the facial nerve is closely related to the prevention of nerve injury that may occur in facial surgeries. The purpose of this study is to analyze the most susceptible areas in the face regarding the probability of facial nerve injury, based on the demarcation of its trajectory in the overlying skin. Three hundred cadaveric hemifaces were dissected (172 male, 128 female) and the facial nerve trajectory was followed from the stylomastoids foramen to the mimic muscles. The trajectory of the facial branches was delimited in the overlying skin by six diverging lines, with the following reference points: the upper and lower portions of the tragus, the most cranial wrinkle of the frontal region, the lower facial wrinkle of the frontal muscle, the nasal midpoint, an imaginary point 1 cm caudal to the oral commisura, another imaginary point also caudal to the oral commisura at the lower margin of mandible, and the clavicle midpoint. The temporal branches have the highest probability of being injured, followed by the mandibular marginal and buccal branches. The areas with greater risk of injury are the temporofrontal region (between the hairline and the lateral limit of the frontal muscle), the area near the angle of the mandible, and the preparotid region.     

下颌角区域主要血管、神经解剖学研究及其临床意义

目的：研究下颌角区域主要血管、神经的解剖学特点。方法：选取10例成人头颅标本,对下颌角区域主要血管、神经进行解剖观察和测量。观察内容包括：主要血管、神经的走行及其与下颌角的位置关系。结果：面动、静脉在下颌骨下缘水平距下颌角（30．06±4．25）mm、（27．55±4．02）mm;下颌后静脉距下颌骨升支后缘（3．00±0．56）mm,距下颌角（12．20±1．09）mm;面神经下颌缘支出腮腺位置距离下颌角（10．36±0．41）mm。结论：对下颌角区域主要血管、神经解剖学特点研究,总结一般规律,为下颌角区域手术提供解剖学依据。     

Surgical treatment of the "marginal mandibular lip" deformity

Unilateral permanent paralysis of the lower lip after section or compression of the marginal mandibular branch of the facial nerve is not rare. It may occur after trauma or as a result of parotid, ear, or upper neck surgery. Surgical treatment of the deformity--which we term the marginal mandibular lip--is indicated to improve cosmesis and restore oral competence during eating and speech. We describe our experience with partial resection of the paralyzed lower lip as an effective yet simple method of surgical correction. We also review the alternate methods of treatment for comparison.