Ekstratemporal Fasiyal Sinir Paralizilerinde Cerrahi Tedavi

Ekstratemporal Fasiyal Sinir Paralizilerinde Cerrahi Tedavi 'U $\FDQ.D\ÕNoÕR OX 1, Dr. Gürhan Özcan 1, Dr. Abdullah Keçik 1 )DVL\DO VLQLU OH]\RQODUÕQÕQ FHUUDKL WHGDYLVLQGH IDUNOÕ FHUUDKL WHNQLNOHU X\JXODQPDNWDGÕU %X PDNDOHGH IDVL\DO VLQLU OH]\RQODUÕQÕQ FHUUDKL WHGDYLVL ]HOOLNOH IDVL\RIDVL\DO DQRVWRPR] YH PLNURYDVN OHU NDV WUDQVIHUL X\JXODPDODUÕ J ]GHQ JHoLULOPLúWLU >7XUJXW g]do 7ÕS 0HUNH]L 'HUJLVL @ Anahtar Kelimeler : Fasiyal sinir lezyonu, cerrahi tedavi Surgical therapy for extratemporal facial nerve paralysis Different surgical techniques are performed in the treatment of facial nerve lesions. In this article, surgical treatment of facial nerve lesions particularly crossface nerve graft and microvascular muscle transfer are reviewed. [Journal of Turgut Özal Medical Center 1997;4(3):345-349] Key Words : Facial nerve lesion, surgical treatment )DVL\DO VLQLU OH]\RQODUÕ ohúlwol \ QOHUL\OH EH\LQ FHUUDKODUÕ Q URORJ RIWDOPRORJ RWRODULQJRORJ YH SODVWLN FHUUDKODUÕ LOJLOHQGLUHELOHQ YH ROGXNoD ohúlwol FHUUDKL X\JXODPDODUD UD PHQ SHN orn DoÕGDQ \HWHUVL] VRQXoODUÕ\OD SUREOHPOL ELU NRQX RODUDN NDOPD\D GHYDP etmektedir. Cerrah etyoloji, yara özellikleri, geçen süre YH Q URPXVN OHU NRPSRQHQWLQ GXUXPXQD J UH IDUNOÕ \DNODúÕPODU \DSPDN ]RUXQGDGÕU 3UHRSHUDWLI G QHPGH GLNNDWOL KDVWD VHoLPL QHOHU \DSÕOÕS QHOHU \DSÕODPD\DFD ÕQÕQ SODQODQPDVÕ YH KDVWDQÕQ bilgilendirilmesi son derece önemlidir. Kombine cerrahi SURVHG UOHULQ X\JXODQPDVÕ JHQHOOLNOH PDNVLPXP VRQXFXQ DOÕQPDVÕQÕ VD ODU (OEHWWH SDUDOL]LOL ELU \ ] Q DVOD QRUPDOH JHOPH\HFHN ROPDVÕ FHUUDKL SURVHG UOHULQ EDúDUÕVÕ] ROGX X DQODPÕQGD \RUXPODQDPD] 6LQLUNDV IL]\RORMLVLQLQ GDKD L\L DQODúÕODELOPHVL LOH birlikte sinir greftleri, kraniyal sinir transferleri, serbest kas ve sinir-kas greftleri, mikronörovasküler kas WUDQVIHUOHUL NXOODQÕPD JLUPLúWLU * Q P ] HNVWUDWHPSRUDO IDVL\DO VLQLU FHUUDKLVLQGHNL JHOLúPHOHU VRQ \ÕO LoHULVLQGHNL \R XQ X UDúD GD\DQPDNWDGuU /DWKURS YH &RQOH\ VLQLU JUHIWOHUL LOH DQÕQGD UHNRQVWU NVL\RQX EDúODWPÕúODU YH ORNDO NDV WUDQVIHUOHUL YH NUDQLDO VLQLU NRDSWDV\RQODUÕ\OD LOJLOL GH HUOL odoõúpdodu \DSPÕúODUGÕU OL \ÕOODUGD 6FUDPHOOD 6PLWK YH $QGHUO fasiyofasiyal sinir anastomozunu (cross facial nerve grafting) kullanarak fasiyal sinir cerrahisinde devrim \DUDWPÕúODUGÕU +DULL 2KPRUL 7RULL 2%ULHQ 0RUULVRQ 7HU]LV YH 0DQNWHORZ XQ QF O Q \DSWÕ Õ PLNURQ URYDVN OHU NDV WUDQVIHUOHUL LVH DWURIL\H X UDPÕú kas ünitesine sahip hasta grubunda yeterli UHNRQVWU NVL\RQX VD ODPD údqvõ \DUDWPÕúWÕU %X GHUOHPHGH IDVL\DO VLQLU FHUUDKLVLQGHNL EDúOÕFD yöntemleri gözden geçirerek, giderek artan uygulama DODQÕ EXODQ IDVL\RIDVL\DO DQDVWRPR] YH PLNURQ URYDVN OHU NDV WUDQVIHUL X\JXODPDODUÕQÕ YXUJXODPD\Õ DPDoODGÕN (.675$7(0325$/ )$6ø<$/ 6ø1ø5 )DVL\DO VLQLUOH X UDúDQ FHUUDKODUÕQ SDURWLV EH]L YH IDVL\DO VLQLU DQDWRPLVLQH KDNLP ROPDODUÕ ]RUXQOXGXU )DVL\DO VLQLULQ IRUDPHQ VWLORPDVWRLGHXPGDQ oõndudn 1 +DFHWWHSH hqlyhuvlwhvl 7ÕS )DN OWHVL 3ODVWLN YH 5HNRQVWU NWLI &HUUDKL $QDELOLP 'DOÕ $QNDUD Journal of Turgut Özal Medical Center 4(3):1997 345

Ekstratemporal fasiyal sinir paralizilerinde cerrahi tedavi $.D\ÕNoÕR OX YH DUN GD ÕOÕPÕQÕ FHUUDKL RODUDN WHVSLW HWPHN YH IDVL\DO VLQLUL ]HGHOHPHPHN LoLQ NXOODQÕODQ EDúOÕFD G UW QLUHQJL QRNWDVÕ NXOODQÕOÕU.RQNDO NÕNÕUGDN 2-Timpanomastoid sulkus 6WLORLG oõnõqwõ 'LJDVWULN NDVÕQ SRVWHULRU VHJPHQWLQLQ VW NHQDUÕ drfxnodugd PDVWRLG oõnõqwõqõq KHQ ] WDP RODUDN JHOLúPHPLú ROPDVÕQD ED OÕ RODUDN IDVL\DO VLQLULQ VWLORPDVWRLG IRUDPHQGHQ oõnõú QRNWDVÕQGD GDKD \ ]H\HO VH\UHWWL L KDWÕUODQPDOÕGÕU Fasiyal sinir parotis bezine girdikten hemen sonra LNL DQD GDOD D\UÕOÕU %XQODU WHPSRURIDVL\DO YH VHUYLNRIDVL\DO GDOODUGuU +HU LNL DQD GDOÕQ NDWNÕVÕ\OD temporal, zigomatik, bukkal, mandibüler, servikal ROPDN ]HUH GDO ROXúXU <DSÕODQ odoõúpdodugd IDVL\DO VLQLU GDOODQPDVÕQÕQ SHN orn GH LúLN SDWHUQH VDKLS ROGX X J VWHULOPLúWLU )$6ø<$/.$6/$5 Yüzde fasiyal sinir tarafìndan inerve edilen 17 çift kas mevcuttur (m. frontalis, procerus, corrugator, orbicularis oculi, nasalis, depressor septi nasi, levator labii superioris, levator anguli oris, zygomaticus major ve minor, levator labii superioris alaeque nasi, orbicularis oris, depressor anguli oris, depressor labii inferioris, mentalis, risorius, platysma). Denerve fasiyal NDVODUÕQ D\ JLEL ELU V UH ER\XQFD UHLQHUYDV\RQ SRWDQVL\HOOHULQL NRUX\DELOGLNOHUL J VWHULOPLúWLU (Q L\L VRQXoODU PHYFXW IDVL\DO NDVODUÕQ UHDQLPDV\RQX LOH mümkün olabilmektedir (1,4,6,19,21). (7<2/2-ø %DúOÕFD HW\RORMLN IDNW UOHU o DQD JUXSWD WRSODQDUDN incelenebilir (1,2,7,21) : ø175$.5$1ø<$/ %g/h0 7(0325$/.(0ø. 6(*0(17 3-EKSTRATEMPORAL BÖLÜM -Parotis malign tümörleri -Travma ø\dwurmhqln -Fasiyal sinirin primer tümörleri -Mandibula, pterigoid bölge ve derinin maligniteleri &(55$+ø 7('$9ø 35ø0(5 6ø1ø5 7$0ø5ø 0LNURFHUUDKL \ QWHPOHULQ NXOODQÕPÕ LOH VLQLU XoODUÕQÕQ NDUúÕOÕNOÕ JHWLULOPHVLGLU (Q SRS OHU RODQ HSLQ UDO V W U WHNQL LGLU %DúOÕFD GLNNDW HGLOHFHN QRNWDODU úxqodugõu 0LNURFHUUDKL WHNQL H X\JXQ RODUDN HSLQ UDO V W U X\JXODQPDVÕ 2-Sinir fasiküllerinin tam koaptasyonu 6 W U KDWWÕQGD JHUJLQOL LQ D]DOWÕOPDVÕ 6ø1ø5 *5()7ø %H\LQ FHUUDKODUÕ YH RWRORJODU WDUDIuQGDQ PLNURFHUUDKL WHNQLNOHU NXOODQÕODUDN EH\LQ VDSÕ LOH HNVWUDWHPSRUDO IDVL\DO VLQLU DUDVÕQGD NDODQ VHJPHQWH nervus auricularis magnus veya daha büyük defektler için nervus suralis interpoze edilerek rekonstrüksiyon VD ODQDELOPHNWHGLU (NVWUDWHPSRUDO IDVL\DO VLQLU JUHIWOHUL VÕNOÕNOD PDOLJQ SDURWLV W P UOHULQLQ HNVL]\RQX VRQUDVÕQGD ROXúDQ IDVL\DO VLQLU GHIHNWOHULQL UHNRQVWU NWH HWPHN DPDFÕ\OD NXOODQÕOPDNWDGÕU.5$1ø<$/ 6ø1ø5 75$16)(5/(5ø 0LPLN NDVODUÕQ KHQ ] DWURIL\H X UDPDPDPÕú ROGX X SURNVLPDO IDVL\DO VLQLULQ LUUHYHUVLEO KDVDUODUÕQGD EX NDVODUD LQHUYDV\RQ VD ODPDN DPDFÕ\OD NUDQLDO VLQLUOHULQ distal segmente koaptasyonudur. Bu amaçla hipoglossal VLQLU YH DNVHVXDU VLQLU VÕNOÕNOD NXOODQÕODQ NDID oliwohulglu Bir kraniyal sinir olmamakla beraber, frenik sinir de daha seyrek olarak fasiyal sinir inervasyonunda tercih edilebilmektedir. Bu yöntem transfer edilen sinire ait NDVODUGD IRQNVL\RQ ND\EÕ \DUDWDFD Õ JLEL VD ODGÕ Õ IDVL\DO KDUHNHWLQ GH VÕQÕUOÕOÕ Õ YH NDUúÕ \ ] \DUÕVÕ LOH ED DQWÕVÕ]OÕ Õ GH]DYDQWDMODUÕQD VDKLSWLU )$6ø<2)$6ø<$/ $1$67202= &5266)$&( NERVE GRAFT) Fasiyofasiyal anastomoz ilk kez Scramella WDUDIuQGDQ \ÕOÕQGD JHUoHNOHúWLULOPLúWLU 7HNQLN GDKD sonra Smith, Anderl, Fisch, Freilinger, Samii tarafìndan JHOLúWLULOPLúWLU 6D ODP WDUDI IDVL\DO VLQLU GDOFÕNODUÕQÕQ \H YDUDQ OLIOHULQLQ GHQHUYDV\RQD \RO açmadan kesilebilmesi ve bu feda edilen sinir GDOFÕNODUÕQD ELU VLQLU JUHIWL LOH \DSÕODQ DQDVWRPR] VRQUDVÕQGD SDUDOL]LOL \ ] \DUÕVÕQD LQHUYDV\RQXQ WDúÕQPDVÕ HVDVÕQD GD\DQÕU øon DúDPDGD VD ODP WDUDIWD IDVL\DO VLQLULQ EXNNDO GDOODUÕ L]ROH HGLOLU 6LQLU X\DUÕFÕVÕ 346 7XUJXW g]do 7ÕS 0HUNH]L 'HUJLVL

.D\ÕNoÕR OX $ et al. Surgical therapy for extratemporal facial paralisis \DUGÕPÕ\OD GDOODUÕQ LQHUYDV\RQ DODQODUÕ VDSWDQÕU YH VXUDO sinir kesitine uygun bir dal feda edilerek sinir greftine NRDSWDV\RQ JHUoHNOHúWLULOLU %D]HQ VXUDO VLQLU fasiküllerine uygun birkaç dal feda edilerek greftin her IDVLN O EDúND ELU GDOD GD DQDVWRPR]H HGLOHELOLU ùhnlo 1) 7HN ELU VLQLU JUHIWL \DQÕVÕUD ELUGHQ ID]OD JUHIW LOH birkaç bant halinde fasiyofasiyal anastomoz da \DSÕODELOPHNWHGLU 6ÕNOÕNOD VW GXGDN ohqh DOWÕ YH IURQWDO E OJHGH KD]ÕUODQDQ W QHOOHUOH FLOW DOWÕQGDQ JHoLULOHQ JUHIWOHU NDUúÕ \ ] \DUÕVÕQD WDúÕQÕUODU 6LQLU UHMHQHUDV\RQXQXQ NDUúÕ \ ] \DUÕVÕQD WDúÕQPDVÕ D\OÕN ELU G QHPL LoHULU %X EHNOHPH SHUL\RGX LoHULVLQGH SHUN V\RQ LOH SR]LWLI 7LQHO EXOJXVX DUDúWÕUÕODUDN VLQLU UHMHQHUDV\RQX WDNLS HGLOHELOLU 7HN EDúÕQD 7LQHO EXOJXVX sinir rejenerasyonunun izlemi için yeterli RODELOPHNWHGLU $QFDN ú SKHGH NDOÕQDQ ROJXODUGD LNLQFL RSHUDV\RQGD VLQLU JUHIWLQLQ GLVWDO XFXQGDQ KD]ÕUODQDFDN "frozen section" ile rejenerasyonun distal uca ilerleyip LOHUOHPHGL L NHVLQ RODUDN J VWHULOHELOLU %X VHDQVWD VLQLU JUHIWL X\JXQ IDVL\DO VLQLU XoODUÕQD YH\D PLPLN NDVODUÕQÕQ LUUHYHUVLEO KDVDUÕ V ] NRQXVX RODQ ROJXODUGD UHNRQVWU NVL\RQX VD ODPDN ]HUH E OJH\H WDúÕQDQ fonksiyonel kasa ait motor sinire anastomoze edilebilir (1,8-10,18,21). %g/*(6(/.$6 75$1632=ø6<21/$5, 0LPLN NDVODUÕQÕQ LUUHYHUVLEO RODUDN IRQNVL\RQXQX ND\EHWWL L GXUXPODUGD NXOODQÕODELOHFHN ELU \ QWHPGLU %X DPDoOD NXOODQÕODQ EDúOÕFD LNL NDV P PDVVHWHU YH P WHPSRUDOLVWLU %X NDVODUÕQ YDVN ODUL]DV\RQX YH LQHUYDV\RQX NRUXQDUDN J ] YH D Õ] ohyuhvl NDVODUÕQ IRQNVL\RQXQX NRPSDQVH HWPHN LoLQ NXOODQÕPODUÕ \DQÕVÕUD VDGHFH YDVN ODUL]DV\RQODUÕ NRUXQDUDN IDVL\RIDVL\DO ELU DQDVWRPR] LOH NDUúÕ WDUDI IDVL\DO VLQLULQGHQ LQHUYDV\RQODUÕ GD VD ODQDELOPHNWHGLU 6ø1ø5.$6 3('ø.h/ <g17(0/(5ø Bu teknik intakt motor bir sinirin küçük bir donör kas bloku ile birlikte inerve edilmek istenen kasa DNWDUÕPÕ HVDVÕQD GD\DQÕU 2PRK\RLG VWHUQRK\RLG JLEL kaslardan bir segmentin ansa hipoglossi inervasyonu ile WDúÕQPDVÕ VÕNOÕNOD NXOODQÕODQ ELU UQH LGLU 6(5%(67.$6 *5()7/(5ø 'DKD QFHGHQ GHQHUYH HGLOHUHN KD]ÕUODQDQ NDV JUHIWLQLQ DOÕFÕ DODQGD LQHUYH YH YDVN ODUL]H NDV LOH WHPDVWD EÕUDNÕODUDN IRQNVL\RQ ND]DQDELOHFH L HVDVÕQD GD\DQÕU * Q P ]GH orn ID]OD NXOODQÕPÕ ROPD\DQ ELU X\JXODPDGÕU 0ø.521g529$6.h/(5.$6 75$16)(5/(5ø ùhnlo.duúõ \ ] VLQLU JUHIWL Fasiyal paralizinin reanimasyonunda fasiyofasiyal anastomozlarla birlikte mikronörovasküler kas WUDQVIHUOHULQLQ NXOODQÕPÕ IDVL\DO SDUDOL]L FHUUDKLVLQGH VRQ \ÕOODUÕQ HQ QHPOL JHOLúPHVLGLU ùhnlo. Mimik NDVODUÕQÕQ LUUHYHUVLEO IRQNVL\RQ ER]XNOX XQXQ V ] NRQXVX ROGX X KDVWD JUXEXQGD NRQWUROO YRO QWHU IDVL\DO KDUHNHWL VD D\DELOPHVL DoÕVÕQGDQ W P GL HU WHNQLNOHUGHQ VW QG U 3HN orn NDVÕQ PLNURQ URYDVN OHU DNWDUÕPÕ GHQHQPLúWLU DQFDN J Q P ]GH NXOODQÕODQ NDVODUÕQ EDúOÕFDODUÕ úxqodugõu 1-*UDFLOLV NDVÕ: Güvenilir ve yeterli bir nörovasküler pediküle sahiptir. Kitlesi yeterli olmakla ELUOLNWH DúÕUÕ X]XQGXU.DVÕQ GH LúLN NÕVÕPODUÕQuQ IDUNOÕ IDVLN OOHUFH LQHUYH HGLOL\RU ROPDVÕ VHJPHQWOHUH D\UÕODUDN NXOODQÕPÕQD RODQDN YHUPHNWHGLU E \OHOLNOH NDV LVWHQLOHQ ER\XWWD KD]ÕUODQDELOPH DYDQWDMÕQD NDYXúPDNWDGÕU (1,11,13,18,19). 2-3HFWRUDOLV PLQRU NDVÕ <HWHUOL D ÕUOÕNWD DQFDN X]XQ ELU NDVWÕU <DVVÕ úhnol \ ]H NROD\ X\JXODQPDVÕQÕ VD ODU 1 URYDVN OHU SHGLN O NRPSOHNV YH GH LúNHQGLU 5HLQHUYDV\RQXQGD SUREOHP RUWD\D oõndelophnwhglu % OJHQLQ \ ]H \DNÕQOÕ Õ LNL HNLELQ odoõúpdvõqõ J oohúwluphnwhglu 3-/DWLVVLPXV GRUVL YH VHUUDWXV DQWHULRU NDVODUÕ: Güvenilir nörovasküler pedikülleri ve longitudinal Journal of Turgut Özal Medical Center 4(3):1997 347

Ekstratemporal fasiyal sinir paralizilerinde cerrahi tedavi $.D\ÕNoÕR OX YH DUN Fasiyal paralizili hastalarda, uygun cerrahi \ QWHPOHULQ VHoLPL YH JHUH LQGH NRPELQH NXOODQÕPÕ LOH IRQNVL\RQHO YH HVWHWLN DoÕGDQ EHOLUJLQ ELU LOHUOHPH HOGH HGLOHELOGL L NHVLQGLU 'DKD NRPSOLNH YH LNL DúDPDOÕ FHUUDKL LúOHP JHUHNWLUPHOHULQH UD PHQ IDVL\RIDVL\DO anastomoz ve mikronörovasküler kas transferleriyle WDWPLQNDU VRQXoODU DOÕQDELOPHNWH YH VD ODP \ ] \DUÕVÕ LOH EHOLUOL Oo GH NRRUGLQDV\RQ VD ODQDELOPHNWHGLU +DVWDODUOD RODVÕ VRQXoODUÕQ WDUWÕúÕOPDVÕ YH \HWHULQFH bilgilendirilmeleri, postoperatif dönemde hasta tatmin düzeyini olumlu etkileyecektir. REFERANSLAR ùhnlo Mikronörovasküler serbest kas transferi ile rekonstrüksiyon LQWUDPXVN OHU SDWHUQOHUL PHYFXWWXU /DWLVVLPXV NDVÕ VHJPHQWDO RODUDN NXOODQÕODELOLU 6HUUDWXV NDVÕQÕ LQHUYH HGHQ VLQLU NÕVDGÕU %X NDVÕQ DOW NÕVPÕQGDNL G UW VHJPHQWL IDVL\DO SDUDOL]L UHDQLPDV\RQXQGD NXOODQÕODELOPHNWHGLU DQFDN DOW VHJPHQWOHULQ KD]ÕUODQPDVÕ VÕUDVÕQGD PRWRU VLQLULQ NÕVD \DSÕVÕQD ED OÕ RODUDN VW VHJPHQWOHU denerve edilebilir (1). 4-5HFWXV DEGRPLQLV NDVÕ: Uzun, güvenilir vasküler SHGLN O YH ODWHUDO ED]OÕ VHJPHQWDO VLQLU LQHUYDV\RQX YDUGÕU.LWOHOL YH X]XQ ELU NDVWÕU SDUVL\HO RODUDN NXOODQÕODELOLU 5-Extensor digitorum brevis: Yeterli kas NRQWUDNVL\RQXQXQ ROPDPDVÕ QHGHQL\OH VD ODGÕ Õ UHNRQVWU NVL\RQODU EDúDUÕVÕ] ROGX X QH V U OPHNWHGLU (17). 6-Tensor fascia lata ve WUDSH]LXV NDVODUÕ da fasiyal SDUDOL]LGH PRWRU QLWHQLQ UHNRQVWU NVL\RQX DPDFÕ\OD NXOODQÕODELOHQ GL HU NDVODUGÕU 67$7ø. <g17(0/(5 Günümüzde çok az tercih edilen bir yöntem JUXEXGXU YH RWRMHQ YH\D DOORSODVWLN ohúlwol PDWHU\DOOHUOH DVNÕ X\JXOD\DUDN GHIRUPLWHQLQ JLGHULOPHVL DPDoODQÕU (1,21). Selektif nörektomi, selektif myektomi, kantoplasti, VW J ] NDSD ÕQD D ÕUOÕN \HUOHúWLULOPHVL \ ] JHUPH JLEL SHN orn GL HU SURVHG U WHN EDúÕQD YH\D UHNRQVWU NWLI prosedürlerle kombine olarak fasiyal paralizi WHGDYLVLQGH NXOODQÕODELOLU 1. Baker CD. Facial Paralysis. In: Plastic Surgery, McCarthy JG(ed), WB Saunders Company, Philadelphia, 1990:2237-9. 2. Conley J, Baker DC. Hypoglossal-facial nerve anastomosis for reinervation of the paralysed face. Plast Reconstr Surg 1979;63: 63-72. 3. Evans DM. Hypoglossofacial anastomosis in the treatment of facial palsy. Br J plast Surg 1974;27: 251-87. 4. Lee KK, Terzis JK. Management of acute extratemporal facial nerve palsy. Clinics in Plastic Surgery 1984;11: 203-10. 5. McCabe BF. Facial nerve grafting. Plast Reconstr Surg 45: 1970:70-5. 6. Sade J. Facial nerve reconstruction and its prognosis. Ann Otol 1975;84: 695-703. 7. Zuker RM, Manktelow RT. A smile for the Mobius syndrome patient. Annals of Plastic Surgery 1989;22: 188-94. 8. Bobo AG, Fuentes JM, et al. Cross facial nerve anastomosis in the treatment of facial paralysis: A preliminary report on 10 cases. Br J Plast Surg 1980;33: 195-201. 9. Bobo AG, Fuentes JM. Long term follow up report on cross facial nerve grafting in the treatment of facial paralysis. Br J Plast Surg 1983;36: 48-50. 10. Ferreira MC. Cross facial nerve grafting. Clinics in Plastic Surgery 1984;11: 211-4. 11. Gantz BJ. Microneurovascular free muscle transplantation for management of facial paralysis. In: Microsurgical Reconstruction of the Head and Neck, Baker SR(ed), Churchill Livingstone, New York 1989:313-26. 12. Hamilton SGL, Terzis JK. Surgical anatomy of donor sites for free muscle transplantation to thr paralyzed face. Clinics in Plastic Surgery 1984;11: 197-201. 13. Harii K, Ohmori K, et al. Free gracilis muscle transplantation with nörovascular anastomoses for the treatment of facial paralysis. Plast Reconstr Surg 1976;57: 133-43. 14. Harrison DH. The pectoralis minor vascularized muscle graft for the treatment of unilateral fascial palsy. Plast Reconstr Surg 1985;75: 206-13. 15. Hata Y, Yano K, et al. Treatmant of chronic facial palsy by transplantation of the neurovascularised free rectus abdominis muscle. Plast Reconstr Surg 1990;86: 1178-87. 348 7XUJXW g]do 7ÕS 0HUNH]L 'HUJLVL

.D\ÕNoÕR OX $ et al. Surgical therapy for extratemporal facial paralisis 16. Manktelow RT. Free muscle transplantation for facial paralysis. Clinics in Plastic Surgery 1984;11: 215-20. 17. Mayou BJ, Watson JS, et al. Free microvascular and microneural transfer of the extensor digitorum brevis muscle for the treatment of unilateral facial palsy. Br J Plast Surg 1981;34: 362-7. 18. O'Brien B, Franklìn JD, et al. Cross facial nerve grafts and microneurovascular free muscle transfer for long established facial palsy. Br J Plast Surg 1980;33: 202-15. 19. O'Brien B, Pederson WC, et al. Results of management of facial palsy with microvascular free muscle transfer. Plast Reconstr Surg 1990;86: 12-22. 20. Ryan RM, Waterhouse N, et al. The innervated trapezius flap in fascial paralysis. Br J Plast Surg 1988;41: 344-8. 21. Swartz WM, Banis JC. Head and Neck Microsurgery. Williams & Wilkins, Baltimore, 1992:250-65. 22. Tolhurst DE, Bos KE. Free revascularised muscle grafts in facial palsy. Plast Reconstr Surg 1982;69: 760-9. <D]ÕúPD DGUHVL: Aycan.$<,.d,2ö/8 0' 7DúNHQW 6RNDN.XUWXOXú $1.$5$ Journal of Turgut Özal Medical Center 4(3):1997 349