以去神经肌肉游离移植为主的方法综合治疗晚期面瘫的基础研究和临床应用

【作者】 黄渭清；

【导师】 凌诒淳； 李森恺；

【作者基本信息】 中国协和医科大学 ， 整形外科， 1996， 博士

【摘要】 近十几年来，肌肉游离移植治疗面瘫一直被国内外学者广泛应用于临床，治疗效果明显，但没有单独的一个方法可达到矫正全部畸形的目的。本文对治疗面瘫的发展做了历史性回顾，并对有关的解剖、动物实验及临床手术方法进行了研究。 应用解剖学资料主要了解颞肌、咬肌的神经、血管分布，旨在选择适当的颞肌瓣转移、咬肌隧道成形部位来修复眼部及口角畸形；同时对拇，、趾短伸肌解剖也加以研究。所得结果表明：颞深动脉及神经伴行，呈扇形于颧弓上方，呈60°角将颞肌三等分发出两个分支，转移的前1／2肌瓣内既有可靠的神经血管，又能保证转移后的功能。咬肌的对角线型血管、神经分布，可指导术者在其前后形成隧道，并将移植物与其紧密接触，利于三叉神经长入移植物内。足部拇、趾短伸肌神经支配有三型，肌腱有变异，有时与长腱合并。 动物实验是为了验证移植肌的存活及神经的长入。我们用灵长类恒河猴做实验，以拇、趾短伸肌去神经后游离移植，定期取标本做组织化学及形态学检查，证明了去神经后组织代谢有改变，电镜观察亦见改变。在移植后8周肌肉再生明显，12周神经支配趋于完善，为临床提供了理论依据。 临床手术学研究中，提出了该术式对Thompson方法的改良、手术适应征、肌肉成活与神经再生理论、手术设计的悬吊点及具体方式改良等优点；手术采用去神经后两周再移植的方法，加快了神经长入的速度及可能性，减少了肌肉及神经挛缩的时间，使肌肉在萎缩前能成活，且神经在肌肉纤维化前即长入。对12例多种原因形成的面瘫，我们均采用此法，除一例效果不够理想外，11例效果良好。 本文结论：以拇、趾短伸肌去神经后两周游离移植为主的综合方法治疗面瘫，近期可达静态恢复，远期可达动态恢复，是面瘫修复的理想术式，值得临床更多还原

【Abstract】 Free muscle graft to reconstruct facial paralysis has been widely used in clinic in recent 10 years. Although the result is obvious,not a single method can restore all the deformity. The history review, anatomy and animal experiment about facial paralysis have been discussed in this article,so do the operation study.The anatomy is managed in the nerve and blood vessel distribution of temporalis and masseter to select proper temporal flap for transferring and masseter tunnel position,which help to reconstruct the deformity of eyes and oral commissure. The anatomy of extensor digitorum brevis (EDB)and extensor hallucis brevis(EHB)is also dicussed. The result shows:Deep temporal nerve and blood vessel is fan-shaped above the zygomatic arch,distributing at an angle of 60 degrees which divide the temporalis into 3 parts. There is reliable blood and nerve supply in the transferred anterior half muscle flap assuring its funtion after being transferred. The masseter receive blood and nerve supply at its opposing angle line,guiding the operater to make tunnel at the line anteriorly or posteriorly,and make the graft connected with mas-secter tightly in order to benifit the trigeminal nerve to penetrate the graft. There are 3 types nerve distribution of EDB and EHB. There is also variation of muscle tendon. It is sometimes comebined with the longus tendon. The observation will be benifit to the muscle being denerved and free transplanted.The animal experiment is done to verify the free muscle surviving and nerve regeneration after being transplanted. A monkey is taken to receive free transplantation of EDB and EHB after being denerved. We make the muscle biopsy to do histollogical,hischemical and electromicroscopical exam-更多还原