5. Plan and organizational structure of lecture.

№	Basic stages of lecture and their maintenance	Type of lecture. Means of activating of students. Materials of the methodical providing	Distribution of time
1.	Preparatory stage. Determination of actuality of theme, educational aims and motivation.	An introductory, clinical lecture is with the elements of problem.	5%
2.	Basic stage. Teaching of lecture material according to plan. 1. Concept "paralysis of mimic musculature". 2. Classification of paralysis. 3. Technique of surgical treatment of paralysis of facial nerve. 4. Concept " face". 5. Basic methodologies of of hemiatrophys of face. 6. symptoms and syndromes in plastic and reconstructive surgery. 7. A concept is a maxillufacial traumatology. 8. A concept is maxillufacial oncology. 9. A concept is maxillufacial reconstructive surgery.	Clinical lecture with application of evidentness : multimedia accompaniment decision of problem situations, situatioonal tasks, thematic patients.	80%
3.	Final stage. Resumes of lecture, general conclusions. Answers are for a question. A task is for of students.	Educational literature. Methodical developments of department. A task is for.	5%

6. Table of contents of lecture material.

NEUROLOGY of MAXILLUFACIAL AREA

FACIOPLEGIAS

Etiology. Reasons of paralyses are different: neuritis of facial nerve; damage of barrel or branches of nerve; traumatic post-natal damages (when through a weak childbirth doctors on the head of lay on tongs provide luing-ins that, here the cheeks of tongs dispose in the area of joints, where the barrel of nerve will nurse from the cavity of skull a nerve injured); tumours of nerve or і tumours; violation of cerebral circulation of blood is in the area of diamond-shaped fossula; breaks of basis of skull and others like that.

The defeats of facial nerve can arise up on different anatomic levels: 1) in the cavity of skull (at the level of kernel and intracraneal part of nerve); 2) in the channel of facial nerve of temporal bone; 3) at the level of post of nerve near his exit from the cavity of skull; 4) at the level of separate branches after the of nerve.

Pathogeny of disease depends on his reason. General is a origin or realization of nervous impulse by the structures of nerve and parafunction of mimic muscles.

Classification of facioplegias is built on etiologic, and clinical signs. The nee (to 8 %) distinguish paralyses and (92 %). At the place of violation to the function of nerve distinguish the paralyses of and peripheral, one and bilateral, but the last are observed rarely.

The inspection of patients requires consultation of internist, neurologist, neuro-surgeon. Execute research of circulation of blood of cerebrum, conduct КТ, МРТ of brain and others like that.

Clinical presentation of disease is typical enough. She depends on to the type and localization of defeat of nerve, age of patient, time after the disease conducted earlier treatment.

Patients grumble about curvature of face, lacrimation and worsening of; laboured use of meal, «lump of meal» after a cheek; difficulty of broadcasting.

Objectively: asymmetry of face, or, lacrimation, an eye is not closed, the symptom of а (at closing of eyes an eyeball is displaced outside and up to the top, something outside and upwards; upwards and inward et cetera), eyelids and eyebrows, is tomentous downward; the corner of mouth is tomentous, the folds of skin of face are smoothed out;

Treatment depends on etiology of, place of defeat of nerve, age of patient, state of mimic muscles and other reasons. Distinguish conservative and surgical treatment of of facial nerve.

A testimony to conservative is a paralysis because of hypertensive, inflammatory processes (neuritis), damage of nerve with maintenance of safety of shells and others like that. For this etiologic and nosotropic treatment of basic illness, apply the methods of assistance to proceeding in a function, of nervous kernel and nerve, appoint medications, neurophilic (groups In, С), activators of metabolism and others like that. However poison-realtor of facial nerve and him peripheral structures recommence not always.

Surgical treatment is applied, when conservative methods did not give a result, and the state of patient and he require proceeding in the type of face. Distinguish:

operations are from proceeding in the function of nerve and muscles;

operations are from proceeding in a nerve and muscles and their functions;

operations;

palliative plastic operations.

Not all operations apply through their complication or insufficient.

Operations are from proceeding in the function of nerve. Oncotomy of corner or neuroma — neuro-surgeons execute from inwardly-cranial access.

Sewing together of nerve after a trauma, break — conduct maxillufacial with participation of, sew together the pinches of nerve after their authentication.

Decompression of nerve — an operation is executed depending on that, where the constrained nerve : if in the cavity of skull are neuro-surgeons, if within the limits of channel of nerve —together with surgeons; if on face are maxillufacial surgeons.

Muscles at the tumours of parotid salivary gland conduct at the same time with the removal of tumours of gland, when it is needed to cross and delete parts of branches of facial nerve, that pass through a tumour. For this purpose after a radical oncotomy between the central and peripheral end of nerve take in nervous, that is taken, for example, on a neck from a cerviciplex. Use a мікрохірургічну technique and different types of guy-sutures for sewing together of nerves — perineural, and guy-sutures.

Cross transplantation of branches of facial nerve can be executed at presence of the ramified net of peripheral branches of facial nerve, here cross those branches of nerve, that have a secondary value for the function of muscles, and take in the central end of this branch in peripheral more functionally important branch of nerve.

Nerves of face — provide innervation from ternate or subglossal nerves on a facial nerve, id est, execute anastomoses between V and VII, or between XII and VII by the pairs of nerves, applying a technique.

A diaphragm nerve (С5) also can be taken in the peripheral end of facial nerve, a diaphragm nerve is mobilized for this purpose, destroy from a pectoral cavity and take in a peripheral end nerve.

For mobilization of nerve use an instrument that is entered through a cut on a neck in the cavity of thorax, remove layer by layer a nerve from adherent tissues, cross him near a diaphragm and destroy outside.

Operations are from proceeding in a nerve and m of 'язів and their functions. Muscles halloo—from a sural nerve. Length of transplants for innervation of branch is a 15-17 cm, cheek branch are a 13-15 cm, for a bottom lip are a 10-12 cm, for a chin are a 8 cm.

Transplantation of thin and sartorial muscles is with nerves on vascular applied for proceeding in basic face and eye on condition of maintenance of function of central end of nerve.

Operation. Executed temporal and masticatory muscles for proceeding in movable of bottom eyelid and company.

Shred from own masseter is short enough for moving to the middle of bottom lip, that is why he is prolonged in number of different ways — by a transplant from own wide of thigh, artificial as nets, filaments and their combinations.

The forehand of temporal muscle is distinguished, return the shred of, divide by two parts and take in eyelids. It is thus necessary not fibres of movable nerves, that go to the muscle. For 2-4.the carried muscles begin gradually to function, but a patient must yet learn by them to use.

It maybe to pick up thread the function of muscle of mouth a temporal muscle. For this purpose form a shred from the forehand of temporal muscle, for him tunnel with the partial resection of arc, conduct under a skin to the corner of mouth and fix in new position.

Hanging of tissues of face. In an area company of tissue filaments, that conduct round a arc (static hanging) or round a corone (dynamic hanging), tissue upwards outside and filaments string. At motions of jaw of the impression, that soft tissues move a natural way.

A bottom eyelid is sewn underneath to the albuminous shell of eyes, and when eye of, an eyelid moves upwards together with an eye and moistening him.

Palliative plastic operations. Gives an opportunity to remove skin that going to the noticeable fold on the top limit of muscle of mouth. At the same time on tissues lay on internal guy-sutures for superducting of tissues upwards.

For creation of symmetry of type of face sometimes execute a selective myotomy (crossing) or resection of mimic muscles on the healthy half of face.

The results of treatment of facioplegia depend on many factors and not always are predictable, complete and proof. More is achievement complete anatomic, functional and to the result of treatment, that is why it is often enough expedient to be oriented on the acceptable result of treatment.

Atrophy of faceEtiology of disease until now fully is not certain. Consider that violations result in atrophy and diminishing to the volume of tissues of different departments of face, including nervous trophism as a result of reasons of central or peripheral action.

To such reasons take the different types of violation as a result of action of those від-ділів of the central or peripheral nervous system, that directly one hundred innervations of tissues of face, maxillufacial area. More often defeat of V — VII of pair of craniocerebral nerves.

Neuritises predetermine a disease with violation of regional trophism, trauma of skull and peripheral nerves that can arise up by chance or during surgical operations, different and, including viral, different dystrophic processes in the departments of the vegetative nervous system, autoimmune defeats of the nervous system and others like that.

It should be noted that atrophy of face can be or by the syndrome of defeat of the central nervous system, or independent disease. In neurology analogical after etiology diseases have the name lateral amyotrophic syndrome, illness.

Pathogeny: because of violation of trophism of certain department of face there are processes of atrophy of all tissues, that are in the area of defeat — skin, cellulose, muscles, glands, bones and others like that. Takes place to the height and development of tissues. It arises up one, bilateral deformation of, asymmetry, here the limits of atrophy of tissues are determined clearly enough and answer the limits of innervation of tissues a concrete nerve.

Rate of development of disease — rapid or slow. The phase of stabilizing of process, when he clinically does not make progress already, arises up usually then of hormonal alteration and sexual development of organism sick.

Classification. After localization: 1) one-sided (a hemiatrophy is one-sided); 2) bilateral.

Bilateral atrophy after localization and degree of zones of defeat is divided into symmetric and asymmetrical.

All departments of one half of face can be damaged or some, not all his parts that determine as or partial atrophy of half of face.

After progress of process distinguish the phase of progress and phase of.

On age patients, when the basic signs of disease, that force first to apply for help, develop: 1) for children (in a period the height of viscerocranium); 2) for adults (after completion the period of height of viscerocranium).

It should be noted that in age 17 and anymore people have to decide the question of organization of the personal life, that is why patients, women, give to treatment and normalization of original appearance of of very large value.

Patients grumble about curvature, asymmetry of face, different «volume» of face, laboured use of meal, different type of skin, psychological and others like that.

Clinical presentation of flow of illness depends on age, when a disease began, but such external signs are always marked: asymmetry of, part of face less than, than other half; skin of face of, sad-coloured, easily going to the fold; the asymmetric carried, covered the nostrils of different sizes; lips are asymmetric and different volume; fatty hypoderm atrophic, her very small, fine-grained, it can be fully; an eye crack is distorted, an eyeball is allegedly pulled out forward, for the diminishing to the volume of eye socket; mimic muscles atrophic, function of, there can be a lacrimation from eyes; masseters atrophic

looked clearer, relief at reduction, more accessible palpations, hypertone and myopachynsis on a healthy side; line of closing of lips of, lip a bit displaced in a healthy side; the height of hair is broken; the of face a skin is asymmetrical, tongue and soft palate of after a form, sizes and function, displaced in a healthy side.

If a disease arose up in the period of height of viscerocranium, then the height of bones is violated and it is additionally possible to define that a supramaxillary bone, eye socket and genyantrum, is less in sizes; a bottom jaw has the underdeveloped body and branch shortened,, a chin is displaced in the staggered side; a bite is broken through deformation of jaws, but adapted (more often deep); some teeth can be located, and others like that.

Differential diagnostics is conducted with many processes, that: innate vices (syndromes of branchial arcs and others like that); system defeats of connecting tissue (scleriasis,), lipodystrophy, muscular and other

An inspection of patients is typical and consists in finding out of the state of all involved organs and tissues. Execute except the general clinical methods of: sciagraphy methods of research of bones (that—skull in a line and lateral projections with decoding, of bottom jaw and other); (determines bones); photos and models of face; electro-myography of masseters; study properties of skin — her elasticity, movable, color, (by means of, thermography — there will be a thermal face), innervation (after the level of skin sensitiveness); study the state of teeth, bite after the models of jaws (in an articulator); is given—can show the parafunction of others like that. It is desirable also to conduct, From and viscerocranium, to create с models for more clear study of local status and planning of treatment. If necessary conduct МРТ and research МРТ-ЗО.

Necessary are consultations of neurologist, neuro-surgeon, endocrinology, internist, other specialists.

Treatment sick depends on the phase of disease, age of patient, him social status and marital status, degree of local violations and others like that.

In the phase of progress illnesses appoint, as a rule, the conservative treatment, sent to the improvement of the state of the nervous system, trophism of of the staggered area, that is conducted mainly by neurologists. methods of proceeding in the functions of the nervous system (vitamins of Вь В6, В12, ATP and other preparations). Locally on the zones of defeat of tissues appoint that it directionally on the improvement of blood supply of this zone. Before treatment succeeded usually after stopping of progress of, however, at the special terms surgical treatment can be and in the phase of progress of illness (marital, social status of patient).

In the phase of stabilizing illnesses apply the mainly surgical methods of treatment — corrections of type of face and proceeding in functions. Thus preparation foresees realization of short course of or supporting neurophilic therapy.

The surgical methods of treatment consist in renewal:

only contours of face (due to proceeding in the contours of soft) are the so-called contour plastic arts of soft tissues;

contours and anatomic structure of face (soft tissues and bones of skull).

The contour plastic arts of face are executed since olden times, applying or methods of increase of volume of tissues, or the plastic arts autological or by soft tissues and bone.

The injection methods of correction of form of face foresee careful before the operation of limits and volume of introduction liquid to the implant. For this purpose at first on models and photos, then on face of patient draw the limits of the staggered area. Conduct preparation of patient and local anaesthetizing (not local!, as will be distorted to local deformation), whereupon in tissues enter a liquid implant (paraffin, silicon, collogen, different gels) to the level of symmetry with a healthy side. After it lay on an aseptic sticker into place of puncture of skin. a method and materials presently apply rarely.

The contour plastic arts of face by introduction of the canned tissues (albuminous or shell, , own or canned fatty cellulose, in т. ч.), plastic implants cartilaginous and of, autotransplants is used more often. She is executed so: before an operation plan a place, form and sizes of future implants or transplants and prepare them in accordance with the requirements of situation. Then under anaesthetizing through operative dissection enter them in tissues, fix in a necessary place and a wound is sewn. After an operation after a patient look after as usually, appoint a local functional calmness. After the wound healing, through 2-4., if were applied biological tissues solvent to cause the reactions of tearing away of add necessary medicamental accompaniment sometimes.

The contour plastic arts by soft tissues, foremost by the tissues of stem of Phil, is the used method that is applied and presently. For this purpose a stem of (with the supply of tissues) is on a front abdominal wall, him on a face and after form fatty of stem the new contours of atrophic departments of face.

This method does not give the reactions of tearing away, allergization of organism, but him can be not very much proof as a result of displacement of tissues, them and possible suppuration and others like that. Taking into account it can more reliable transference of difficult shreds of soft tissues on vascular anastomoses, for what use shreds with including of muscles of back, fatty cellulose, stuffing-box (coif) and others like that.

Original is the use of stuffing-box for the contour plastic arts of face and removal of defects and deformations of him soft tissues. Technique of execution : after an inspection and determination of necessary volume of tissues do (from small access), find one end of artery, that stuffing-box, destroy an artery outside and her with the artery of corresponding overhead extremity of patient. Through 2-3., when circulation of blood was normalized, cross the end of artery of stuffing-box to other, destroy a stuffing-box from an abdominal region, use him for proceeding in the contours of face and an artery from artery on face or neck. Through 2-4., when a new anastomosis already began to work, an anastomosis on overhead extremity of patient is crossed, free a hand, and the free end of artery is again sewn underneath in an area by faces.

Thus, it is possible to attain the correction of small and considerable losses of soft tissues of face the marked methods, remove the danger of the immunological tearing away, suppuration, excessive scarring and postoperative displacement of tissues. However these methods, though is effective enough, not state of bone structures of face, bite, state of lines of closing of lips of. That is why in case of their application it is impossible fully to satisfy requirements and desires of patients and doctors.

Taking into account marked, from 80th of XX of century in our clinic (then this to do and abroad) execute such order of curative measures, that presently gets все more supporters and is used more often, :

and the stage is a reconstruction, normalization of viscerocranium : bottom (sizes of branch, body, of corner), supramaxilla (and asymmetrical osteotomies after And, II, III), then —bone (osteotomies with a bone autotransplant).

and the stage is a reconstruction of soft tissues of face any of higher methods.

Such order of operative measures allows:

to normalize a form and position of jaws, bite, bone contours of, positions of soft tissues of face (eye, mouth crack);

to define the real volume of deficit of soft tissues of face;

to decrease the volume of the soft tissues or transplants, necessary for a final contour correction soft tissues transplanted on a face.

It is needed to take into account also and that a supramaxilla in the period of height and development of viscerocranium can go after something the height then of bottom jaw that removes a requirement in her further reconstruction or diminishes the degree of excalation.

The reconstruction of bottom jaw, proceeding in the sizes of her body and branch, normal position it is expedient to conduct the methods of osteotomy in the area of her corner from operative access on the type of portable radio.

For the correction of position of bones of middle zone of face effective are osteotomies on the levels of ФОР And (symmetric osteotomies) and ФОР II, III (osteotomies) with the transferring of supramaxilla and bone to correct position. Sometimes expediently bone of in correct position separately, using free bone autotransplants for her fixing.

The results of treatment depend on the phase of disease, degree of general violations of organism, atrophy of tissues and other patients are needed In any case, that the temporal positive effect of treatment and plastic renewal (improvement of kind) of face takes place mainly at to progress-bath of illness, and stable positive result — in the phase of stabilizing of process. But the results of treatment it follows to determine taking into account status of patient and decision of basic questions him own life.

BASES of MAXILLUFACIAL RECONSTRUCTIVELY-RESTORATION SURGERY

Divisions of maxillufacial surgery :

A maxillufacial traumatology is treatment of the united damages of facial and cerebral skull and their consequences (deformations). All types of breaks of bones of viscerocranium (middle area of person, complex, bones of nose) belong here, that with the breaks of bones of neurocranium (breaks of his vault and basis, breaks of frontal bone, walls of frontal bosom, area and others like that), and also the closed craniocerebral traumas that combine with the breaks of bones of viscerocranium.

Maxillufacial oncology foresees the removals of tumours, that spread to a few anatomic areas, in particular or providing of surgical access to the tumour that is situated in the cavity of skull or spreads from the cavity of skull in other anatomic area, id est in maxillufacial, or vice versa.

Such surgery is required by patients with tumours in the area of bottom of middle and front cranial fossulas, by tumours in the area of basis of skull, hypophysis, of an eye cavity, temporal bone, and fossulas, overhead departments of nasal part of and other localizations.

Maxillufacial reconstructively-restoration (plastic) surgery — removal of nee anomalies and purchased deformations of facial and cerebral skull, frequency of that increases lately.

In 1975 on congress in Rio de Janeiro Paul Тесe reported that 1100 patients, from what 700 operated, thus 350 from them — with access. On the basis of generalization of the experience and development of surgery in the developed countries of the world he reported that on 50 millions a population must be one such specialized medical center. Therefore, in Ukraine must be, at least, one such center of surgery.

Due to the achievements of maxillufacial surgery practical хірур-ги got many new organizational and technical works in relation to the inspection of patients, planning of their treatment, conduct of period and others like that. It allowed to return to valuable life of many patients that were before considered inoperable and.

An INSPECTION of PATIENTS is With PATHOLOGY of MAXILLUFACIAL AREA

An inspection of patients with cranial-facial pathology is a difficult enough task. Apply not only to the type for reconstructively- morioplasty of viscerocranium research methods, but also additional, by the necessity of study and operative intervention on the bones of neurocranium.

For participating in the inspection of patients, except maxillufacial and surgeons, different specialists that have attitude toward the study of concrete pathology are attached, in particular, , neuro-surgeons, emergency anaesthetists-physicians, , roentgenologists, oculists, medical, internists, psychiatrists, vascular surgeons some other specialists with bringing in of modern informing methods of research and planning of operation.

Necessarily apply the modern informing methods of inspection : КТ, МРТ, КТ-ЗБ reconstruction of structures of face, creation of solid-state models of facial and cerebral skull and others like that.

The tasks of inspection are studies of form of skull, staggered anatomic structures — bones, bosoms, in particular frontal, soft, nerves and others like that.

MAXILLUFACIAL TRAUMATOLOGY

Treatment of patients must be with cranial-facial breaks, on possibility, radical, , exhaustive. Operative execute after stabilizing vitally of important functions and removal of threat to life of patient, usually not later than 15-ї twenty-four hours then. However experience of leading world centers of cranial-facial surgery of, that most patients can be operated already in 3-5 days after a trauma.

Classification of cranial-facial breaks distinguishes such basic breaks: united. Thus examine the breaks of bones of as only damage. At surgical it gives an opportunity to plan the reconstruction of middle and overhead area of person for such patients.

Breaks arise up at influence of force in the area of forehead, carried root of nose. Connections of breaks of frontal and latticed bones (bases of skull), bones of nose departments of eye socket and supramaxilla assume — mostly it is a break of bottom eye socket edge.

Cranial-facial breaks arise up under act of force, that area of bone and lateral departments of skull. To this group break of complex, asymmetric breaks of supramaxilla (middle area of person) frontal and bones, often — in combination from of parietal and 'temporal bones, bones of basis of skull.

The breaks of bones of cerebral and facial skull, middle and external departments of viscerocranium are united usually the heaviest and mainly show by itself connection of middle and breaks.

A reconstruction of frontal bosom and adherent bone structures of as one of key moments is in treatment of middle breaks. The breaks of walls of frontal bosom are observed in 2-15 % suffering with breaks bones of viscerocranium. More often they arise up because of ДТП, heavy work or criminal accident.

Classification of breaks of walls of frontal bosom on г, Еуаш and other such breaks: front wall of bosom, back wall of bosom, bottom of bosom (frontal-basic breaks).

In accordance with classification of , breaks are: front wall of breaks, breaks of frontal scale with distribution

bosom. (with the damage of skin) and closed breaks of walls of bosom are separately examined.

8іап1еу distinguishes the breaks of wall of frontal bosom; breaks of front and back wall; breaks of back wall; plural breaks of walls of frontal bosom.

Choice of surgical tactics and terms of realization of interference with it is determined the area of frontal bosom by many factors: by character of front and back her walls, by the degree of change of her fragments, presence of, damages and limitations of hard cerebral, by the presence of, degree of obstruction of channel, damage of the central nervous system and state vitally important functions of organism, by expressiveness of falling back of bone structures in the area of forehead and bridge of the nose, presence of wounds of frontal area, and also general of.

Looks to treatment of breaks of walls of frontal bosom are contradictory, that it is related to the difficult anatomy of this zone and risk of heavy, threatening for life complications at inadequate surgical treatment.

Basic types of operative interventions and their components that apply at the breaks of walls of frontal bosom :

Foresees the complete removal of front and back walls of bosom together with her mucous membrane.

Assumes the removal of back wall of bosom, mucous membrane of channel. At it frontal parts of brain fill space that appeared, up to the Front wall of frontal bosom.