RU2763662C1 - Method for surgical correction of the consequences of facial nerve injury after radical operations in patients with tumors of the head, neck, posterior cranial fossa and extracerebral tumors of the skull base - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to oncology, surgery, plastic surgery and ophthalmology. Treating the skin and mucous membranes with antiseptics, marking skin incisions, performing local or general anesthesia; then, arcuate converging skin incisions are performed in the superciliary region, while the lower incision is made along the edge of the hairy part of the eyebrow, and the upper incision is accordingly performed, departing from the lower incision 1.5-2.0 cm, depending on the degree of eyebrow drooping in the patient. Wherein the healthy side of the face serves as a reference point for determining the width of the excised flap. Then the skin flap formed between the incisions is excised, and the resulting defect is sutured with cosmetic sutures. Next, a spindle-shaped incision of the skin of the upper eyelid is performed along the fold line of the upper eyelid, starting from the medial corner of the eye outward to the frontal projection of the hairy part of the eyebrow, respectively, while the excess skin is excised with the removal of excess orbital fatty tissue, the resulting defect is sutured with cosmetic sutures. Then, a through wedge-shaped resection of the skin, cartilage and conjunctiva of the lower eyelid is performed with the base directed to the marginal edge of the lower eyelid, 5 to 10 mm wide, depending on the degree of eversion of the patient's lower eyelid, layer-by-layer wound closure is performed. Next, the outer corner of the eye is raised by performing a skin incision along the ciliary edge of the lower eyelid, starting from its middle outward to the outer corner of the eye, which is continued horizontally until the projection of the outer edge of the orbit, the lower skin flap is separated from the circular muscle of the eye along the entire incision with a height of 8 mm. At the same time, the external ligament of the eyelids is exposed, which is crossed at the point of attachment to the orbit and sutured to the periosteum of the orbit above the commensurate level of the healthy side by 1-3 mm with non-absorbable sutures, and the resulting skin defect is sutured with cosmetic sutures.

EFFECT: method allows providing the possibility of correcting the consequences of damage to the facial nerve at later stages after the end of specialized treatment (chemoradiation therapy) in the presence of scarring of post-radiation fibrosis and atrophy of the facial muscles with the achievement of satisfactory aesthetic and functional results, ensuring the possibility of low trauma of surgery, which can be performed under conditions of local anesthesia, performing correction in patients when reinnervation technologies cannot be applied technically, without the use of expensive microsurgical equipment, to ensure the possibility of repeated corrective interventions, regardless of the severity of the scar process, post-radiation fibrosis.

1 cl, 2 ex, 6 dwg

Description

The claimed technical solution relates to medicine, namely to oncology, surgery, plastic surgery and ophthalmology, and can be used for surgical correction of the consequences of damage to the facial nerve after radical surgery in patients with tumors of the head, neck, posterior cranial fossa and extracerebral tumors of the skull base, causing facial imperfections.

Further, the applicant provides terms and abbreviations to avoid ambiguous understanding of the claimed materials.

National Surgical Quality Improvement Program (NSQIP) - National Surgical Quality Improvement Program in the United States. This structure is in charge of calculating surgical risks, searching for causes and ways to overcome them.

Paralysis of the facial muscles (FMA) - complete immobilization of facial muscles due to damage to the branches and trunk of the facial nerve, leading to facial defects.

Radical surgery (ablative surgery) is the performance of extended surgical interventions for malignant tumors of various localizations within healthy tissues in compliance with the principles of ablast and antiblast.

The problem of damage to the facial nerve after surgery in patients with tumors of the head, neck, posterior cranial fossa and extracerebral tumors of the skull base has not lost its relevance to date. Treatment of facial nerve injuries in this category of patients is a serious problem in modern surgery and oncology [Kayva L. Crawford, Joshua A. Stramiello, Ryan K. Orosco, Jacqueline J. Greene Advances in facial nerve management in the head and neck cancer patient. Advances in facial nerve management; Volume 28 Number 4 August 2020]. As a result of surgical treatment of tumors of these localizations, paralysis of the facial muscles often occurs. Facial paralysis (FFP) seriously impairs people's quality of life, both functionally and psychosocially.

The National Surgical Quality Improvement Program (NSQIP) databases published the results of a clinical study that included 11,057 patients who underwent partial or total parotidectomy with and without lymph node dissection. In 3.7% of cases, it was necessary to isolate and separate the facial nerve from the tumor, 24% of these patients required reconstruction of the facial nerve [Bovenzi CD, Ciolek P, Crippen M, et al. Reconstructive trends and complic_tions following parotidectomy: Incidence and predictors in 11,057 cases. J Otolaryngol - Head Neck Surg 2019; 48:1-8].

There are many surgical approaches to treat this condition, with the ultimate goal of restoring facial symmetry and mobility. Radical surgery for head and neck tumors is one of the most common causes of PML. The choice of the method of reconstructive technique for the treatment of PLA is influenced by such factors as the degree of damage to the facial nerve, the age of the patient, the duration of the previous paralysis, the need for adjuvant treatment, concomitant diseases [Axel Sahovaler, David Yeh, John Yoo Primary facial reanimation in head and neck cancer. Oral Oncol. 2017 Nov;74. - P. 171-180. Epub 2017 Sep 12]. Surgical correction is very often difficult due to large soft tissue defects, resection of the facial nerve throughout, which excludes its (facial nerve) one-stage recovery [Sahovaler A, Yeh D, Yoo J. Primary facial reanimation in head and neck cancer. Oral Oncol 2017; 74:171-180. 3. Fritz M, Rolfes BN. Management of facial paralysis due to extracranial tumors. Facial Plast Surg 2015; 31:110-116].

Manipulation of the facial nerve in tumors of the head and neck, posterior cranial fossa, and extracerebral tumors of the skull base is extremely difficult. A multidisciplinary approach to the treatment of facial nerve injuries in patients with malignant neoplasms of the head and neck helps to mitigate the stress of uncertainty, providing optimal comprehensive treatment for patients, improving their quality and life expectancy.

Radical surgery on the face, neck and reinnervation of the facial muscles in case of damage to the facial nerve, with technical and technological feasibility, it is advisable to perform simultaneously. This approach is recognized as ideal by experts for the following reasons:

1) primary intervention on unchanged soft tissues of the face is the most optimal for reparative processes, taking into account the microsurgical neural suture;

2) with open surgical access, it is possible to assess the adequacy of innervation and localization of the branches of the facial nerve by electrical stimulation;

3) minimization of the postoperative period, shortening of the healing time prevents delays in special adjuvant treatment of cancer patients.

In facial plastic surgery, a neural graft for inserting a resected facial nerve can be obtained from the superficial sensory cutaneous nerves of the neck, lower leg, and thigh. Loss of sensation at donor sites should be discussed with patients in addition to the typical risks of infection, hematoma, seroma, scarring at the site of sampling. It should be discussed with the patient that if the entire facial nerve or several branches are missing, then it will not be possible to transplant each nerve or branch due to the limited length of the donor nerve and the discrepancy between the diameter of the graft and the stump of the facial nerve. As a rule, priority is given to the branches of the facial nerve for blinking and smiling, although one can try to restore as many branches of the facial nerve as possible.

Further research is needed to determine which surgical technique is best suited to stimulate facial nerve regeneration and functional recovery. Quantification of the likelihood of facial nerve repair with neural insertions is also under development.

Unfortunately, reinnervation and alternative simultaneous technologies cannot be performed in the vast majority of patients, because a specialized team of micro-neurosurgeons is required, which are available in single specialized centers in Russia and abroad; in addition, a significant prolongation of anesthesia time, especially in patients with concomitant diseases, jeopardizes not only the success of free nerve plasty, but also the life of the patient [Kayva L. Crawford, Joshua A. Stramiello, Ryan K. Orosco, Jacqueline J. Greene Advances in facial nerve management in the head and neck cancer patient. Advances in facial nerve management; Volume 28 Number 4 August 2020].

For patients with prolonged paralysis of the facial muscles (>24 months), reinnervation technologies are practically ineffective due to atrophy of the mimic muscles, irreversible scarring of the soft tissues of the face and neck.

The latest technologies in the prevention and treatment of PML, such as fluorescent labeled injectable peptides for intraoperative nerve identification and implantable neuroprosthetics, are currently only at the development stage. Therefore, it is not possible to talk about a fundamental breakthrough in reinnervation technologies in the next 10-15 years.

From the studied prior art, the applicant identified technical solutions that are analogues of the claimed method.

So, the invention was revealed according to A.S. USSR No. SU 1745220 "A method for restoring the function of facial muscles in case of facial nerve injury in patients with benign tumors of the parotid salivary gland". The essence is a method for restoring the function of the facial muscles in case of injury of the facial nerve in patients with benign tumors of the parotid salivary gland, including facial muscle massage, characterized in that, in order to reduce the treatment time, additional cryogenic exposure is carried out at 5°C for 5 minutes along the branches of the facial nerve.

The purpose of the known technical solution is to reduce the duration of treatment. The goal is achieved by massaging the muscles of the face with rotational movements with a special tip of the cryoapparatus at a temperature of 5°C for 5 minutes, the course of treatment is 7-11 sessions. This is achieved due to the fact that the procedures are performed immediately after surgery. The treatment was carried out in patients with trauma of the facial nerve, which occurred during surgery when the nerve trunk and branches were exposed due to postoperative edema of the preserved facial nerve.

The disadvantage of the known invention in comparison with the claimed technical solution is that this method is used exclusively with the preserved facial nerve, while the claimed technical solution is applied after its (nerve) intersection.

From the studied level of technology, an invention was revealed according to patent No. RU 2750746 "Method for reconstruction of the lower eyelid after wide excision of the tumor." The invention relates to reconstructive plastic surgery, ophthalmology and oncology. The essence is a method for reconstruction of the lower eyelid after a wide excision of the tumor, including a full-thickness restoration of the lower eyelid by cutting out the flap, shifting the flap to the area of the resected lower eyelid, characterized in that a skin-fascial paramedian frontal flap is formed on a feeding pedicle from supratrochlear vessels, the formed flap is moved to area of the resected eyelid and form the anterior wall of the lower eyelid, the flap is fixed along the edges of the wound, additional interrupted sutures are placed between the flap and the periosteum of the lower wall of the orbit, a bridge-like skin flap is formed from the upper eyelid and rotated into the area of the resected inner wall of the orbit, the skin area of the flap is placed in positions of the mucosa and are fixed along the edges of the remnants of the conjunctiva of the eye, then the upper edges of the flaps are sutured together with separate interrupted sutures and the bridge-like flap restores the integrity of the mucosa of the resected eyelid, after which the donor wounds are sutured in layers to with a cosmetic suture and temporary sutures are applied between the formed lower eyelid and the upper eyelid, the feeding leg of the flap is crossed after 2 months.

The disadvantage of the known invention in comparison with the claimed technical solution is that the technique is used exclusively for closing eyelid defects with the facial nerve preserved, and cannot be used when crossing the facial nerve.

From the studied level of technology, an invention was revealed according to patent No. RU 2733163 "Method for eliminating a defect in the oral mucosa". The essence is a Method for eliminating a defect in the oral mucosa, including the formation of a fasciocutaneous displaced flap on a vascular pedicle in the submental and submandibular region, removal of the primary focus, lymph node dissection on the side of the primary tumor, followed by replacement of the defect in the oral cavity with the skin area of the flap, characterized in that the diameter and location of the facial artery are assessed by ultrasound, the primary focus is removed by intraoral access, the contour of the skin-fascial flap is marked in the submandibular region of an elliptical shape, and the upper border of the flap is the lower edge of the body of the mandible, and the midpoint of its upper border is the intersection of the facial artery body of the lower jaw, the lower boundary is the level of the body of the hyoid bone, then in the submandibular region, a skin incision is made along the lower contour of the flap marking, according to figure 1, including the subcutaneous muscle of the neck in the graft, the flap is raised to the lower edge of the body of the lower jaw, and the skin incision along the upper contour of the flap in the projection of the facial vessels is made only to the subcutaneous tissue, then the skin is lifted 2 cm above the lower edge of the body of the lower jaw and 1-2 cm away from the facial artery and vein, the facial vessels are crossed and ligated distally 2 cm from the lower edge of the body of the lower jaw, then along the upper contour of the flap, a skin incision is made up to the subcutaneous muscle of the neck, inclusive, the marginal branch of the facial nerve is completely isolated and the flap is passed under it, the vascular pedicle of the flap is mobilized to the edge of the skin area , then, in a blunt and sharp way, the tissue of the skin-fascial flap is peeled off from the surrounding tissues and a flap is formed, including the skin, subcutaneous fat, subcutaneous muscle of the neck and a soft tissue sleeve around the facial artery above the lower edge of the body of the lower jaw, lymphadenectomy is performed on neck, from the submandibular region to the region of the defect in the oral cavity, a tunnel is formed and through it, using the mouth method cation, the flap is placed in the area of the defect and fixed with 4.0 Vicryl threads to the surrounding tissues, after which the resulting defect in the submandibular region is eliminated with local tissues.

The known invention relates to medicine, in particular to oncology, plastic surgery, maxillofacial surgery, dentistry, rehabilitation medicine, and can be used in the rehabilitation of cancer patients to restore tissues of the floor of the mouth, tongue, cheeks, and oropharynx.

The disadvantage of the known invention in comparison with the claimed technical solution is that the technique is used exclusively for closing defects of the oral mucosa with the preserved facial nerve, and cannot be used when crossing the facial nerve.

From the studied level of technology, an invention was revealed according to patent No. RU 2391925 "Method of reconstructing the tongue with extensive defects in the oral cavity." The essence is a method for reconstructing the tongue with extensive defects in the oral cavity, carried out by closing the defect using an autograft on a supplying vascular pedicle, characterized in that the lost tissues of the tongue and oral cavity are recreated using an autograft formed from a free colonic-omental flap, and the supplying vascular pedicle is formed by creating microvascular anastomoses between the middle colic artery and vein and branches of the external carotid artery and the internal jugular vein, while the edges of the mucous membrane of the intestinal portion of the transplant are compared with the edges of the resected tongue and oral mucosa, the omental portion of the transplant replaces the volume-spatial defect of soft tissues mouth and neck.

The advantages of the known method are that in one surgical step it is possible to restore the integrity of the tongue and oral mucosa, improve tissue adaptation by matching the epithelium of the oral cavity and the mucous membrane of the intestinal flap, which reduces the frequency of fistula formation and reliably isolates the vessels of the neck due to additional covering the suture line of the mucous membranes with an omental fragment.

The disadvantage of the known invention in comparison with the claimed technical solution is that the technique is used exclusively for closing defects in the soft tissues of the tongue and oral cavity with the facial nerve preserved, and cannot be used if it is damaged.

From the studied level of technology, an invention was revealed according to patent No. RU 2546097. "Method of reconstructing the tongue and the bottom of the oral cavity." The essence is a method for reconstructing the floor of the oral cavity and tongue by moving the musculocutaneous flap of the neck, including the sternohyoid muscles, and supplied by the branches of the superior thyroid artery, characterized in that plastic surgery of the tissues of the floor of the oral cavity and tongue is carried out with a musculoskeletal flap, including the skin area of the anterior surface of the neck, sternohyoid muscles, supplied by branches of the superior thyroid artery, innervated by the descending branch of the hypoglossal nerve, while the formed flap is moved into the oral cavity with a skin platform in the position of the mucous membrane of the floor of the oral cavity and tongue, soft tissue of the bottom is restored with a muscle fragment of the flap oral cavity, tongue, submandibular region.

The disadvantage of the known invention and its prototype in comparison with the claimed technical solution is that the technique is used exclusively to restore the soft tissues of the tongue and oral cavity with the facial nerve preserved, and cannot be used when it is crossed.

From the studied level of technology, an invention was revealed according to patent No. RU 2706031 "Method for reconstructing defects in the floor of the mouth in cancer of the oral mucosa and submandibular gland." The essence is a method for the reconstruction of defects that occur during the surgical treatment of cancer of the oral mucosa and submandibular gland by using a fasciocutaneous displaced submental flap on a vascular pedicle, characterized in that the primary focus is removed, lymph node dissection is performed on the side of the primary tumor and in the presence of unilateral regional metastases the upper lateral pole of the submandibular salivary gland with the facial artery is isolated to the place where the submental artery originates from the contralateral side along the lower edge of the arch of the lower jaw with unilateral inclusion of the anterior belly of the digastric muscle, maxillohyoid muscle, followed by replacement of the defect in the oral cavity with the skin area of the flap.

The known method allows in one surgical step to restore the integrity of the tongue and the floor of the mouth without the use of complex microsurgical techniques, which allows the method to be widely used. The technical result of the known method is the preservation of the function of swallowing and speech, reducing the trauma of the main stage of surgical intervention, minimizing additional surgical interventions such as flap correction, reinnervation and reducing the length of stay of patients in the hospital. Provides sufficient blood flow in the area of the skin-fascial flap, due to a hemodynamically significant perforator from the facial artery.

The disadvantage of the known invention in comparison with the claimed technical solution is that the technique is used exclusively to restore the soft tissues of the tongue and oral cavity with the preserved facial nerve, and cannot be used when it is crossed.

The closest to the claimed technical solution in terms of the achieved technical result, chosen by the applicant as a prototype, is the invention according to the patent of the Republic of Kazakhstan No. KZ 27365. The essence of the prototype is a method for surgical correction of denervated facial muscles in case of damage to the facial nerve, including surgical transposition of the temporal muscle to the position of the circular muscles of the mouth of the face through the formed tunnel from the temporal muscle to the circular muscles of the mouth after making an incision above the temporal muscle of the face and an incision along the edge of the red border of the lips, while the temporal muscle is divided into four parts, as inserts for lengthening the four parts of the temporal muscle, the wide fascia of the thigh is used, incisions along the edge of the red border of the lips are made respectively above the upper and below the lower lip on the healthy side of the face, where two selected lower elongated parts of the temporal muscle are moved and sutured through the formed tunnel in the hypercorrection position, on the denervated side of the face you two isolated upper elongated parts of the temporal muscle are led through two longitudinal incisions along the upper and lower eyelids, respectively, into the longitudinal incision medial to the inner corner of the eye and cross-sutured to the medial ligament of the eye, and a spindle-shaped skin flap is excised on the affected side of the face along the nasolabial fold. The method allows 85% to achieve facial symmetry in case of denervation of the facial muscles, to differentiate the movements of the lips and eyelids from each other, which is more physiological for the work of the facial muscles, and also improves the aesthetic, cosmetic effect of the operation and accelerates the social rehabilitation of the patient.

The disadvantage of the prototype in comparison with the claimed technical solution is that the known method can be performed exclusively during the initial intervention without compromising the aesthetic integrity of the face, while the immediate visual effect after the operation is guaranteed to be absent due to the fact that the temporal muscle, used as a driving force, innervated by the trigeminal nerve, like all chewing muscles. Thus, the implementation of synergistic and symmetrical facial movements before a special long-term rehabilitation is impossible with a high probability of ineffectiveness of surgical and rehabilitation manipulations. Delayed operations according to the prototype are characterized by a pronounced invasiveness, a high risk of postoperative complications (hematoma, bleeding, salivation, infection of the wound, damage to the facial nerve on the healthy side), while the risk of not achieving the goals remains very high.

Since the prototype coincides with the claimed technical solution only for its intended purpose and does not match in essential features, the formula of the claimed technical solution is drawn up without a restrictive part.

The purpose and technical result of the claimed technical solution is to eliminate the shortcomings of analogues and the prototype, namely:

1 - providing the possibility of correcting the consequences of damage to the facial nerve (facial defects) at later stages after the end of specialized treatment (chemoradiation therapy);

2 - ensuring the possibility of low invasiveness of surgical intervention, which can be performed under local anesthesia;

3 - providing the possibility of performing correction in patients after surgical treatment of tumors of the posterior cranial fossa, when reinnervation technologies cannot be applied technically;

4 - providing the possibility of performing correction without the use of expensive microsurgical equipment;

5 - ensuring the possibility of performing correction without the involvement and training of narrow specialists with the skills of neural suture, microsurgery, neurosurgery;

6 - ensuring the possibility of repeated corrective interventions, regardless of the severity of the cicatricial process, post-radiation fibrosis.

Thus, the claimed technical solution solves a total of 6 problems.

The essence of the claimed technical solution is a method of surgical correction of the consequences of damage to the facial nerve after radical operations in patients with tumors of the head, neck, posterior cranial fossa and extracerebral tumors of the base of the skull, which consists in treating the skin and mucous membranes with antiseptics, marking skin incisions, performing local or general anesthesia; then arcuate converging skin incisions are made in the superciliary region, while the lower incision is made along the edge of the hairy part of the eyebrow, and the upper incision is accordingly made, departing from the lower incision by 1.5-2.0 cm, depending on the degree of drooping of the patient's eyebrow, and as a guide to determine the width of the excised flap, the healthy side of the face is used, then the skin flap formed between the incisions is excised, and the resulting defect is sutured with cosmetic sutures; then a spindle-shaped incision of the skin of the upper eyelid is performed along the fold line of the upper eyelid, starting from the medial corner of the eye outward to the frontal projection of the hairy part of the eyebrow, respectively, while the excess skin is excised with the removal of excess orbital fatty tissue, the resulting defect is sutured with cosmetic sutures; then, a through wedge-shaped resection of the skin, cartilage and conjunctiva of the lower eyelid is performed with the base directed to the marginal edge of the lower eyelid, with a width of 5 to 10 mm, depending on the degree of eversion of the patient's lower eyelid, layer-by-layer suturing of the wound is performed; then, the outer corner of the eye is raised by making a skin incision along the ciliary edge of the lower eyelid, starting from its middle outward to the outer corner of the eye, which is continued horizontally to the projection of the outer edge of the orbit, the lower skin flap is separated from the orbicular muscle of the eye along the entire incision 8 mm high, at the same time, the external ligament of the eyelids is exposed, which is crossed at the place of attachment to the orbit and sutured to the periosteum of the orbit above the proportionate level of the healthy side by 1-3 mm with non-absorbable threads, and the resulting skin defect is sutured with cosmetic sutures.

The claimed technical solution is illustrated in Fig.1 - Fig.6.

On FIG. 1 shows a brow lift with an incision above the brow (Step 1).

On FIG. 2 shows the removal of excess skin of the upper eyelid (Step 2).

On FIG. 3 shows a wedge resection of the lower eyelid (Step 3).

On FIG. 4 shows a lateral eye lift (canthopexy of the lower eyelid) (Step 4).

On FIG. 5 presented:

5a - photo of the patient before surgery,

5b - photo of the patient after the operation.

On FIG. 6 presented:

6a - photo of the patient before surgery,

6b - photo of the patient after the operation.

The shaded areas in the figures represent the tissues to be removed.

Further, the applicant provides a description of the claimed technical solution as a whole.

The claimed method consists in general in the surgical correction of facial defects after damage to the facial nerve in the surgical treatment of tumors of the head, neck, posterior cranial fossa and extracerebral tumors of the base of the skull, manifested by ptosis of the eyebrows, lagophthalmos of the upper eyelid and paralytic eversion of the lower eyelid, leading to impaired circulation of the lacrimal fluid , and, as a result, dryness of the eyeball, corneal damage, limited visual fields, a significant decrease in visual function and a noticeable cosmetic defect, psychological trauma. The claimed surgical method consists in simultaneous lifting of the eyebrow with an incision above the eyebrow, removal of excess skin of the upper eyelid, if any, wedge-shaped resection of the lower eyelid with its eversion and simultaneous tightening of the outer corner of the eye by suturing the edge of the orbit to the periosteum (canthopexy of the lower eyelid).

The operation according to the claimed method is generally based on the methods known as such used in ophthalmology and aesthetic surgery, however, when used in conjunction with the claimed sequence of actions, it is possible to achieve technical results that are not obvious to a specialist, which allows to achieve a quick functional and aesthetic effect with a minimum number of surgical interventions. .

Further, the applicant shows the sequence of actions according to the claimed method.

First, a preliminary stage is carried out: the skin and mucous membranes are treated with antiseptics, skin incisions are marked, and local or general anesthesia is performed.

Then the operation is carried out in four main stages.

Stage 1

Arched converging skin incisions are performed in the superciliary region of the affected half of the face: the lower one along the edge of the hairy part of the eyebrow, the upper one, 1.5-2.0 cm away from the lower incision, depending on the degree of omission, while the healthy side of the face serves as a guide for the width of the excised flap . The skin flap is excised between the incisions. The resulting defect is sutured with cosmetic sutures.

The result is a raised eyebrow.

Stage 2

A spindle-shaped incision of the skin of the upper eyelid is performed along the fold line of the upper eyelid, starting from the medial corner of the eye outward to the frontal projection of the hairy part of the eyebrow. Excess skin is excised with the removal of excess orbital fatty tissue. The resulting defect is sutured with cosmetic sutures.

As a result, overhanging (ptosis) of the upper eyelid is eliminated.

Stage 3

A penetrating wedge-shaped (skin, cartilage and conjunctiva) resection of the lower eyelid is performed with the base directed to the marginal edge of the lower eyelid, 5 to 10 mm wide, depending on the degree of lower eyelid eversion. The wound is sutured in layers.

As a result, the eversion of the lower eyelid is eliminated.

Stage 4

Raising the outer corner of the eye (canthopexy of the lower eyelid) is performed by making a skin incision along the ciliary edge of the lower eyelid, starting from its middle outward (vertical skin incision of stage 3) to the outer corner of the eye, continued horizontally to the projection of the outer edge of the orbit. The lower skin flap is separated from the circular muscle of the eye (m.orbicularis oculi) along the entire incision 8 mm high. In this case, the external ligament of the eyelids is exposed, which is crossed at the place of attachment to the orbit and sutured to the periosteum of the orbit 1-3 mm above the level of the healthy side (hyperelevation effect) with non-absorbable threads, for example, 5-0. The resulting skin defect is sutured with cosmetic sutures.

As a result, the outer corner of the eye is raised.

The declared sequence of actions allows avoiding excessive traumatization of tissues with the restoration of the consequences of persistent long-term paralysis of the facial muscles without the involvement of expensive microsurgical equipment and qualified narrow specialists, unlike analogues, which together can significantly increase the effectiveness of surgical intervention and make it accessible to a larger circle of those in need of general surgical and oncological hospitals, significantly reducing the cost of treatment, the length of inpatient stay and rehabilitation of patients.

Thus, the claimed technical solution provides the possibility of realizing all the goals and at the same time provides, in addition to them, a significant reduction in the cost of treatment and rehabilitation.

The possibility of achieving the claimed technical results is confirmed by the following examples of specific implementation in a clinical setting.

Example 1. Carrying out the correction of facial defects according to the claimed method of patient A., 67 years old.

Patient A., 67 years old. Diagnosis: C07. Cancer of the left parotid salivary gland.

Condition after complex treatment (2014): paresis of the facial nerve on the left, eversion of the lower eyelid, trophic ulcer of the cornea of the left eye. Concomitant pathology: ischemic heart disease, HF 3-4 FC, condition after CABG, stenting of the coronary arteries. CHF FC 3. High risk of anesthesia.

Correction of facial defects was performed under local anesthesia.

On FIG. 5a shows a photograph of the patient before surgery.

The operation was performed on 06/29/2021.

First, a preliminary stage was carried out - treatment of the skin and mucous membranes with antiseptics, preliminary marking of skin incisions, then local anesthesia was performed with a 0.25% solution of novocaine 50.0 ml.

Stage 1 (Figure 1). Made arcuate converging skin incisions in the superciliary region, lower along the edge of the hairy part of the eyebrow, upper, 2.0 cm away from the lower incision with the creation of symmetry with the healthy side of the face. The skin flap between the incisions is excised. The resulting defect is sutured with cosmetic sutures.

As a result, the eyebrow rose.

Stage 2 (Figure 2). A fusiform incision was made in the skin of the upper eyelid along the fold line of the upper eyelid, starting from the medial angle of the eye outward to the frontal projection of the hairy part of the eyebrow. Excess skin is excised with removal of excess orbital fatty tissue. The resulting defect is sutured with cosmetic sutures.

As a result, overhanging (ptosis) of the upper eyelid was eliminated.

Step 3 (Figure 3).

Performed wedge-shaped resection of the lower eyelid with the base to the marginal edge of the lower eyelid and a width of up to 10 mm. The wound is sutured in layers.

As a result, the eversion of the lower eyelid was eliminated.

Step 4 (Figure 4).

A skin incision was made along the ciliary edge of the lower eyelid, starting from its middle outward (vertical skin incision 3 stages) to the outer corner of the eye, continued horizontally to the projection of the outer edge of the orbit. The lower skin flap is separated from the orbicular muscle of the eye along the entire incision 8 mm high. The external ligament of the eyelids is exposed, the latter is crossed at the place of attachment to the orbit and sutured to the periosteum of the orbit above the commensurate level of the healthy side by 1 mm with non-absorbable sutures. The resulting skin defect is sutured with cosmetic sutures.

As a result, the outer corner of the eye is raised.

In the postoperative period without features, she was discharged home in the evening of that day. Wound healing by primary intention, on the 10th day the sutures were removed.

2.5 months after the operation, a pronounced aesthetic and functional effect was noted: the eversion of the eyelid was eliminated, the trophic corneal ulcer regressed, and lacrimation was not observed. The condition is satisfactory. The patient is active. Subjectively notes a significant improvement in physical and mental well-being.

On FIG. 5b shows a photo of the patient after the operation.

Example 2. Carrying out the correction of facial defects according to the claimed method of patient B., 72 years old.

Patient B., 72 years old. Diagnosis: C71. Meningioma of the posterior cranial fossa on the left.

Condition after complex treatment (2017): paresis of the facial nerve on the left, eversion of the lower eyelid, trophic ulcer of the cornea of the left eye.

Correction of facial defects was performed under general anesthesia.

On FIG. 6a shows a photograph of the patient before surgery.

The operation was carried out on 07/15/2020.

First, a preliminary stage was carried out - general anesthesia, treatment of the skin and mucous membranes with antiseptics, preliminary marking of skin incisions.

Stage 1 (Figure 1). Made arched converging skin incisions in the superciliary region, lower along the edge of the hairy part of the eyebrow, upper, 1.5 cm away from the lower incision with the creation of symmetry with the healthy side of the face. The skin flap between the incisions is excised. The resulting defect is sutured with cosmetic sutures.

As a result, the eyebrow rose.

Stage 2 (Figure 2). A fusiform incision was made in the skin of the upper eyelid along the fold line of the upper eyelid, starting from the medial angle of the eye outward to the frontal projection of the hairy part of the eyebrow. Excess skin is excised with removal of excess orbital fatty tissue. The resulting defect is sutured with cosmetic sutures.

As a result, overhanging (ptosis) of the upper eyelid was eliminated.

Step 3 (Figure 3).

Performed wedge-shaped resection of the lower eyelid with the base to the marginal edge of the lower eyelid and a width of up to 5 mm. The wound is sutured in layers.

As a result, the eversion of the lower eyelid was eliminated.

Step 4 (Figure 4).

A skin incision was made along the ciliary edge of the lower eyelid, starting from its middle outward (vertical skin incision 3 stages) to the outer corner of the eye, continued horizontally to the projection of the outer edge of the orbit. The lower skin flap is separated from the orbicular muscle of the eye along the entire incision 8 mm high. The external ligament of the eyelids is exposed, the latter is crossed at the place of attachment to the orbit and sutured to the periosteum of the orbit above the level of the healthy side by 3 mm with non-absorbable sutures. The resulting skin defect is sutured with cosmetic sutures.

As a result, the outer corner of the eye is raised.

In the postoperative period without features, he was discharged home in the evening of that day. Wound healing by primary intention, on the 10th day the sutures were removed.

3 months after the operation, a pronounced aesthetic and functional effect was noted: the eversion of the eyelid was eliminated, the trophic corneal ulcer regressed, and lacrimation was not observed. The condition is satisfactory. The patient is active. Subjectively notes a significant improvement in physical and mental well-being.

On FIG. 6b shows a photo of the patient after the operation.

At the same time, the applicant explains that with unsatisfactory functional and aesthetic results of corrective interventions due to the severity of the cicatricial process, post-radiation fibrosis, after the primary intervention, repeated corrective interventions can be performed by the claimed method, regardless of the severity of the cicatricial process, post-radiation fibrosis.

Thus, two patients underwent secondary and tertiary corrective interventions by the claimed method. At the same time, a satisfactory condition was observed, the patients were active.

Thus, from the above, we can conclude that the applicant has achieved all the goals and declared technical results, namely:

1 – it is possible to correct the consequences of damage to the facial nerve (facial defects) at the later stages after the end of specialized treatment (chemoradiation therapy) in the presence of post-radiation fibrosis scarring and mimic muscle atrophy with the achievement of satisfactory aesthetic and functional results;

2 – the possibility of a low invasiveness of surgical intervention is provided, which can be performed under conditions of local anesthesia – in some patients with severe concomitant pathology, the correction of the consequences of damage to the facial nerve was performed under local anesthesia with minimal invasiveness without compromising the results;

3 - it is possible to perform correction in patients after surgical treatment of tumors of the posterior cranial fossa, when reinnervation technologies cannot be applied technically - in patients after surgical treatment of tumors of the posterior cranial fossa, the consequences of damage to the facial nerve are corrected according to the claimed method, while the possibility of using reinnervation technologies did not have;

4 – it is possible to perform correction without the use of expensive microsurgical equipment;

5 – it is possible to perform correction without the involvement and training of narrow specialists with the skills of neural suture, microsurgery, neurosurgery – all patients were operated on in a general surgical hospital;

6 - the possibility of repeated corrective interventions is provided regardless of the severity of the cicatricial process, post-radiation fibrosis - with unsatisfactory functional and aesthetic results of corrective interventions due to the severity of the cicatricial process, post-radiation fibrosis after the primary intervention, two patients underwent secondary and tertiary corrective interventions.

Based on the foregoing, it seems possible to conclude that the claimed technical solution allows reaching a higher level of quality of medical care.

The claimed technical solution complies with the "novelty" patentability condition for inventions, since no technical solutions have been identified from the studied prior art that have the claimed set of distinctive features that ensure the achievement of the claimed results.

The claimed technical solution satisfies the "inventive step" patentability condition for inventions, since the applicant has not identified technical solutions from the studied state of the art that have features that coincide with the distinctive features of the claimed invention, and the known effect of distinctive features on the specified technical result has not been established.

The claimed technical solution complies with the "industrial applicability" patentability requirement for inventions, as it can be implemented using standard equipment and known techniques.

Claims (1)

A method for surgical correction of the consequences of damage to the facial nerve after radical operations in patients with tumors of the head, neck, posterior cranial fossa and extracerebral tumors of the skull base, which consists in treating the skin and mucous membranes with antiseptics, marking skin incisions, performing local or general anesthesia; then arcuate converging skin incisions are made in the superciliary region, while the lower incision is made along the edge of the hairy part of the eyebrow, and the upper incision is accordingly made, departing from the lower incision by 1.5-2.0 cm, depending on the degree of drooping of the patient's eyebrow, and as a guide to determine the width of the excised flap, the healthy side of the face is used, then the skin flap formed between the incisions is excised, and the resulting defect is sutured with cosmetic sutures; then a spindle-shaped incision of the skin of the upper eyelid is performed along the fold line of the upper eyelid, starting from the medial corner of the eye outward to the frontal projection of the hairy part of the eyebrow, respectively, while the excess skin is excised with the removal of excess orbital fatty tissue, the resulting defect is sutured with cosmetic sutures; then, a through wedge-shaped resection of the skin, cartilage and conjunctiva of the lower eyelid is performed with the base directed to the marginal edge of the lower eyelid, 5 to 10 mm wide, depending on the degree of eversion of the patient's lower eyelid, layer-by-layer suturing of the wound is performed; then, the outer corner of the eye is raised by making a skin incision along the ciliary edge of the lower eyelid, starting from its middle outward to the outer corner of the eye, which is continued horizontally to the projection of the outer edge of the orbit, the lower skin flap is separated from the orbicular muscle of the eye along the entire incision 8 mm high, at the same time, the external ligament of the eyelids is exposed, which is crossed at the place of attachment to the orbit and sutured to the periosteum of the orbit 1-3 mm higher than the healthy side, with non-absorbable threads, and the resulting skin defect is sutured with cosmetic sutures.

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