Einzeitige mikrochirurgische Rekonstruktion bei Fazialisparese unter Verwendung des N. massetericus – Erste Erfahrungen

Zusammenfassung

Eines der anspruchsvollsten Gebiete der plastischen Chirurgie stellt die Rekonstruktion bei Fazialisparese dar. Eine Vielzahl von operativen Verfahren sind zur Rekonstruktion des Lächelns vorgestellt worden. Das Standardvorgehen ist ein zweizeitiges Verfahren mit Vorlegen eines Cross-Face Nerventransplantates (CFNT) und anschließend sekundärem freien funktionellen Muskeltransfer mit Anschluss an das CFNT. Aufgrund der mit diesem Vorgehen verbundenen Limitationen haben wir eine einzeitige Rekonstruktion durchgeführt, bei welcher der motorische Ast des N. trigeminus zum M. masseter als Spendernerv verwendet wurde. Es wurden vier Patienten, bei denen wir zwischen Juli 2007 und Mai 2008 einen einzeitigen freien funktionellen Transfer des M. gracilis mit Anschluss an den N. massetericus durchgeführt haben, nachuntersucht. Insbesondere interessierte uns das funktionelle Ergebnis sowie die Patientenzufriedenheit. Bei allen Patienten verlief die Operation komplikationslos. Lediglich bei einer Patientin musste eine kleinflächige Wundheilungsstörung konservativ behandelt werden. Alle Patienten zeigten eine regelrechte willkürliche Muskelkontraktion innerhalb von durchschnittlich 2,5 Monaten und waren mit dem funktionellen Ergebnis zufrieden. Die Verwendung des N. massetericus als Spendernerv im Rahmen der mikrochirurgischen Rekonstruktion bei Fazialisparese erlaubt eine einzeitige Rekonstruktion mit reproduzierbaren Ergebnissen.

Abstract

One of the most demanding areas in plastic surgery is reconstruction of the smile in the setting of facial palsy. A multitude of surgical techniques and approaches have been proposed with variable success rates. The most frequently applied treatment algorithm is a two-stage approach with placement of a cross-facial nerve graft (CFNG) initially and subsequent free functional muscle transfer. As this approach has several limitations, the authors have performed single-stage reconstructions utilising the motor nerve to the masseter as the donor nerve. Four patients underwent this single-stage reconstruction for facial palsy between July 2007 and May 2008. In all patients free functional transfer of the gracilis muscle was performed using the motor nerve to the masseter as the donor nerve. Outcome measures were functional result as well as patient satisfaction. The intraoperative as well as postoperative course was uneventful in all patients. In only one patient we encountered a small area of delayed wound healing which was amenable to conservative treatment. In all patients voluntary contraction of the gracilis muscle was visible after a mean period of 2.5 months. All patients displayed a high level of satisfaction with the functional result. Utilising the motor nerve to the masseter muscle as a donor nerve allows single-stage microsurgical reconstruction of the smile in the setting of facial palsy with reproducible results.

Mikrochirurgie - Chirurgie der peripheren Nerven - Gesicht - freie Lappenplastiken - Fazialisparese

microsurgery - surgery of peripheral nerves - face - free flaps - facial palsy

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