Vergleichende Untersuchung des Cross Face Nerve Graft und des N. massetericus als Spendernerven für den freien funktionellen Muskeltransfer zur dynamischen Mundwinkelreanimation bei Fazialisparese

Zusammenfassung

Zur Rekonstruktion der Mundwinkelmotilität bei Fazialisparese gilt das 2-zeitige Vorgehen mit Crossface Nerve Graft (CFNG) und freiem funktionellen Muskeltransfer als “Gold-Standard”. Eine einzeitige Alternative ist der Anschluss des Muskels an den N. massetericus, einem motorischen Endast aus dem N. trigeminus. In einer retrospektiven Analyse untersuchten wir acht Patienten die eines der beiden Verfahren (jeweils 4 Patienten pro Gruppe) zur Mundwinkelreanimation erhalten hatten. Als funktioneller Parameter wurde die Verkürzung des Abstandes vom Tragus zur oralen Commisur als Maß der Muskelkontraktion gemessen.

Der Masseteranschluss führt innerhalb von 3 Monaten zur Reinnervation des Muskels, bei dem zweizeitigen Verfahren vergehen in allen Fällen über 12 Monate. Ein spontanes Lachen kann beim Masseteranschluss nicht in allen Patienten erzielt werden. Es kann mit beiden Verfahren eine symmetrische Mundwinkelexkursion beim Lachen erzielt werden. Die Kontraktion der N. massetericus innervierten Muskeln und damit die Mundwinkel­exkursion ist in unserem Patientenklientel größer als die der CFNG-innervierten Muskeln. Die Mehrzahl der Patienten mit Masseteranschluss unterzogen sich einem Folgeeingriff zur Lappenausdünnung bei großem Restvolumen des Muskels.

Zusammenfassend ist der Anschluss an den Masseternerv eine einzeitige Alternative für freie funktionelle Muskellappenplastiken. Der Masseteranschluss führt in der Regel zu einer stärkeren Kontraktion des Muskels und damit zur größeren Mundwinkelexkursion und zur schnelleren Wiederherstellung der Funktion bei eingeschränkter Spontanität des Lachens.

Abstract

Several surgical techniques have been proposed for the reconstruction of the smile in facial paralysis. The 2-stage approach utilising a cross-facial nerve graft (CFNG) and subsequent free functional muscle transfer represents the “gold standard”. A single-stage alternative is the use of the masseteric nerve as donor nerve. Here we have retrospectively analysed the outcome of 8 patients who were treated with either of these procedures (4 per treatment group). We compared the oral commisure excursion between the 2 groups. Use of the masseteric nerve led to reinnervation of the muscle graft within 3 months. The 2-stage procedure required more than 12 months from the first procedure until first muscle contractions could be observed. A spontaneous smile could not be achieved in all patients when the masseteric nerve was used. The oral commisure excursion was symmetrical when compared to the healthy side in both groups, however the excursion was significantly higher in the masseteric nerve group compared to the CFNG group of patients. Most patients with the masseteric nerve as a donor nerve underwent a secondary procedure, which involved thinning of the muscle flap. In conclusion, the use of the masseteric nerve as a donor nerve for facial reanimation surgery is a single-stage alternative to the use of a CFNG as donor nerve. It delivers reliable results with strong muscle contractions with limitations in regard to achieving a spontaneous smile.

Schlüsselwörter

freie Lappenplastiken - Gesicht - Kopf - Kopf-Hals-Chirurgie

Key words

free flaps - face - head - head and neck surgery

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