A Comparison of Surgical Techniques Used in Dynamic Reanimation of the Paralyzed Face

Facial nerve reconstruction for flaccid facial paralysis: a systematic review and meta-analysis

Objectives

To determine the functional outcome after facial nerve reconstruction surgery in patients with flaccid facial paralysis.

Methods

A systematic review and meta-analysis was performed on studies reporting outcomes after direct facial nerve suture (DFS), facial nerve interpositional graft suture (FIGS), hypoglossal-facial nerve suture (HFS), masseteric-facial nerve suture (MFS), and cross-face nerve suture (CFS). These studies were identified from PubMed/MEDLINE, Embase, and Web of Science databases. Two independent reviewers performed two-stage screening and data extraction. A favorable result was defined as a final House-Brackmann grade I-III and is presented as a ratio of all patients in percentage. Pooled proportions were calculated using random-effects models.

Results

From 4,932 screened records, 54 studies with 1,358 patients were included. A favorable result was achieved after DFS in 42.67% of the patients [confidence interval (CI): 26.05%-61.12%], after FIGS in 66.43% (CI: 55.99%-75.47%), after HFS in 63.89% (95% CI: 54.83%-72.05%), after MFS in 63.11% (CI: 38.53%-82.37%), and after CFS in 46.67% (CI: 24.09%-70.70%). There was no statistically significant difference between the techniques (Q = 6.56, degrees of freedom = 4, p = 0.1611).

Conclusions

The established facial nerve reconstruction techniques including the single nerve cross-transfer techniques produce satisfactory results in most of the patients with permanent flaccid facial paralysis. An international consensus on standardized outcome measures would improve the comparability of facial reanimation techniques.

Masseteric Nerve Transfer for Facial Paralysis Secondary to Parotid Malignancy: A Retrospective Case Series

Background: The objective outcomes of masseteric nerve transfer in the setting of parotid malignancy are unclear. Objective: To measure objective facial reanimation outcomes of masseteric nerve transfer in patients with parotid malignancy who underwent parotidectomy with facial nerve resection. Materials and Methods: Retrospective review of patients who underwent masseteric nerve transfer for facial paralysis secondary to parotid malignancy was carried out at a tertiary referral hospital from August 2017 to November 2021. Objective facial reanimation outcomes were analyzed using Emotrics. Minimal follow-up of 6 months was required for inclusion. Results: Eight patients (five males) with a median age of 75.5 years (range 53-91) met inclusion criteria. Fifty percent had metastatic squamous cell carcinoma, and 50% had primary parotid malignancy. Five patients underwent concomitant cancer resection with facial nerve reconstruction. Seven patients received postoperative adjuvant radiotherapy. After reinnervation, patients had improved oral commissure excursion (from 1.51 mm ±1.27 to 3.77 mm ±1.81; p < 0.01) and facial symmetry during smile. Conclusion: In this study, masseteric nerve transfer enhanced oral commissure excursion and facial symmetry during smile in patients with parotid malignancy and facial nerve resection.

Hypoglossal Nerve Transfer for Facial Nerve Paralysis: A Systematic Review and Meta-Analysis

Background: Hypoglossal-facial nerve (12-7) anastomosis can restore symmetry and voluntary movement on the face in patients with facial nerve paralysis. Traditional 12-7 transfer includes direct end-to-end nerve anastomosis, sacrificing the entire hypoglossal nerve. Contemporary, end-to-side anastomosis, or split anastomosis techniques limit tongue morbidity by preserving some hypoglossal nerve. Direct outcome comparisons between these techniques are limited. Objective: To compare reported outcomes of facial movement, tongue, speech, and swallow outcomes among the different types of hypoglossal-facial nerve anastomosis schemes. Evidence Review: For this systematic review and meta-analysis, a comprehensive strategy was designed to search PubMed, Scopus, and the Cochrane Database from inception to January 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, reporting guideline yielding 383 results. Any participant who underwent 12-7 transfer using any of the three techniques, with or without an interposition graft, and had documented preoperative and postoperative evaluation of facial nerve function with a validated instrument such as House-Brackmann (HB), was considered for inclusion. Secondary outcomes of synkinesis, tongue atrophy, and speech or swallowing dysfunction were also compared. Forty-nine studies met inclusion criteria, representing data from 961 total patients who underwent 12-7 transfer. Results: The proportion of good HB outcomes (HB I-III) did not differ by anastomosis type: End-to-side and end-to-end anastomosis (73% vs. 59%, p = 0.07), split and end-to-end anastomosis (62% vs. 59%, p = 0.88), and end-to-side anastomosis and split anastomosis (73% vs. 62%, p = 0.46). There was no difference in reported synkinesis rates between the anastomosis types. However, end-to-side anastomosis (z = 6.55, p < 0.01) and split anastomosis (z = 3.58, p < 0.01) developed less tongue atrophy than end-to-end anastomosis. End-to-side anastomosis had less speech/swallowing dysfunction than end-to-end anastomosis (z = 3.21, p < 0.01). Conclusion: End-to-side and split anastomoses result in similar HB facial nerve outcomes as the traditional end-to-end 12-7 anastomosis. End-to-side anastomosis has decreased complications of tongue atrophy and speech/swallow dysfunction compared to end-to-end anastomosis. In addition, split anastomosis has decreased rates of tongue atrophy compared to end-to-end anastomosis.

Contemporary Perspectives in Pathophysiology of Facial Nerve Damage in Oto-Neurological and Skull Base Surgical Procedures: A Narrative Review

During the last decades, neuro-otological surgery has progressively reduced functional morbidity, including facial nerve damage. However, the occurrence of this sequela may significantly impact on patients' quality of life. The aim of this narrative review is to provide an update on the patho-physiological and clinical issues related to facial nerve damage in oto-neurological and skull base surgery, in the light of a comprehensive therapeutic and rehabilitative approach to iatrogenic disfunctions. The narrative review is based on a search in the PubMed, Scopus, and Web of Science databases. In this surgical setting, the onset of intraoperative facial nerve damage is related to various aspects, mainly concerning the anatomical relationship between tumor and nerve, the trajectory of the surgical corridor, and the boundaries of the resection margins. Mechanisms related to stretching, compression, devascularization, and heating may play a role in determining intraoperative facial nerve damage and provide the patho-physiological basis for possible nerve regeneration disorders. Most of the studies included in this review, dealing with the pathophysiology of surgical facial nerve injury, were preclinical. Future research should focus on the association between intraoperative trauma mechanisms and their clinical correlates in surgical practice. Further investigations should also be conducted to collect and record intraoperative data on nerve damage mechanisms, as well as the reports from neuro-monitoring systems.

Outcome evaluation using an artificial intelligence-based facial measurement software for facial nerve grafting in head and neck and skull base surgery

BACKGROUND

Interposition nerve grafting is an indispensable technique for facial nerve reconstruction in head and neck, and skull base surgery. The prognostic factors are inconclusive, partly due to limited objective assessment systems for facial nerve function. This study aimed to apply an artificial intelligence (AI)-based facial asymmetry measurement system to assess facial nerve grafting outcomes.

METHODS

We retrospectively reviewed data of 23 patients who underwent facial nerve grafting between 2011 and 2020. Oral asymmetry and synkinesis severity were measured using AI.

RESULTS

Oral movement recovered at 12-18 months postoperatively. Postoperative radiotherapy and a larger number of anastomosed distal stumps were significantly associated with poor and good final oral symmetry, respectively. Synkinesis severity was weakly correlated with the degree of oral movement recovery.

CONCLUSIONS

Oral function recovered without a strong correlation with synkinesis. Caution should be exercised in facial nerve grafting for cases with postoperative radiotherapy.

Long-Term Outcomes of the Electrically Unresponsive, Anatomically Intact Facial Nerve Following Vestibular Schwannoma Surgery

Objective The study aimed to determine long-term outcomes in patients with intraoperative electrical conduction block in an anatomically intact facial nerve (FN).

Methods Single center retrospective review of prospectively collected database of all vestibular schwannoma surgeries between January 1, 2008 and August 25, 2015. Operative notes were reviewed and patients with anatomically intact FNs, but complete conduction block at the end of surgery were included for analysis.

Results In total, 371 patients had vestibular schwannoma surgery of which 18 met inclusion criteria. Mean follow-up was 34.28 months and average tumor size was 28.00 mm. Seventeen patients had House-Brackmann Grade VI facial palsy immediately postoperatively and one patient was grade V. At 1 year, three patients remained grade VI (17%), two improved to grade V (11%), seven to grade IV (39%), six to grade III (33%), and one patient to grade II (6%). On extended follow-up, five patients (28%) had additional 1 to 2 score improvement in facial function. Subset analysis revealed no correlation of tumor size, vascularity, adherence to nerve, operative approach, extent of resection, splaying of FN, and recurrent tumor or sporadic tumors to the extent of FN recovery.

Conclusion Intraoperative conduction block does not condemn a patient to permanent FN palsy. There is potential for a degree of recovery comparable with those undergoing nerve grafting. Our data do not clearly support a policy of same-surgery or early-postoperative primary nerve grafting in the event of a complete conduction block, and instead we favor monitoring for recovery in an anatomically intact nerve.

Iatrogenic facial nerve injury in mastoidectomy: The impact of variables on the outcome

OBJECTIVE

To evaluate iatrogenic facial nerve injury in mastoidectomy and its paralysis improvement result after nerve injury management.

METHODS

A retrospective review of medical records of 21 patients with iatrogenic facial nerve injury following mastoidectomy who underwent nerve injury management in a tertiary referral center.

RESULTS

There were nine males and 12 females, with a mean age of 40.4 ± 15.1 years. Cholesteatoma was the most common primary pathology (76.2%). Mastoidectomy was canal wall up in 8 patients and canal wall down in 13. Nerve injury was due to drilling in 10 patients and sharp tools in 11. The tympanic segment of the facial nerve was the most common injured site (50.0%). Decompression was the most common nerve injury management method (52.4%). Other injury management methods were end-to-end anastomosis (14.3%), great auricular nerve graft (23.8%), and facial-hypoglossal nerve transfer (9.5%). No statistically significant correlation was found between facial nerve function 3-6 months after injury management and the following factors: age, gender, primary pathology, type of mastoidectomy, surgeon's experience, nerve injury site, mechanism of trauma, and nerve injury management method and timing.

CONCLUSION

Regardless of the surgeon's experience or technique applied, a meticulous approach may be more valuable in decreasing the chance of iatrogenic facial nerve injury.

A Comprehensive Approach to Facial Reanimation: A Systematic Review

Purpose: To create a systematic overview of the available reconstructive techniques, facial nerve grading scales, physical evaluation, the reversibility of paralysis, non-reconstructive procedures and medical therapy, physical therapy, the psychological aspect of facial paralysis, and the prevention of facial nerve injury in order to elucidate the gaps in the knowledge and discuss potential research aims in this area. A further aim was to propose an algorithm simplifying the selection of reconstructive strategies, given the variety of available reconstructive methods and the abundance of factors influencing the selection. Methodological approach: A total of 2439 papers were retrieved from the Medline/Pubmed and Cochrane databases and Google Scholar. Additional research added 21 articles. The primary selection had no limitations regarding the publication date. We considered only papers written in English. Single-case reports were excluded. Screening for duplicates and their removal resulted in a total of 1980 articles. Subsequently, we excluded 778 articles due to the language and study design. The titles or abstracts of 1068 articles were screened, and 134 papers not meeting any exclusion criterion were obtained. After a full-text evaluation, we excluded 15 papers due to the lack of information on preoperative facial nerve function and the follow-up period. This led to the inclusion of 119 articles. Conclusions: A thorough clinical examination supported by advanced imaging modalities and electromyographic examination provides sufficient information to determine the cause of facial palsy. Considering the abundance of facial nerve grading scales, there is an evident need for clear guidelines regarding which scale is recommended, as well as when the postoperative evaluation should be carried out. Static procedures allow the restoral of facial symmetry at rest, whereas dynamic reanimation aims to restore facial movement. The modern approach to facial paralysis involves neurotization procedures (nerve transfers and cross-facial nerve grafts), muscle transpositions, and microsurgical free muscle transfers. Rehabilitation provides patients with the possibility of effectively controlling their symptoms and improving their facial function, even in cases of longstanding paresis. Considering the mental health problems and significant social impediments, more attention should be devoted to the role of psychological interventions. Given that each technique has its advantages and pitfalls, the selection of the treatment approach should be individualized in the case of each patient.

Facial nerve sacrifice in lateral approaches to the skull base: Simultaneous reconstruction by graft interposition

PURPOSE

To evaluate the outcome of facial nerve (FN) cable graft interposition in lateral skull base surgery.

MATERIALS AND METHODS

A group of 16 patients who underwent FN graft interposition procedure was retrospectively considered. Postoperative FN function was evaluated using the House-Brackmann (HB) grading system, the Sunnybrook Facial Grading System (SFGS), the Facial Disability Index (FDI) and the Oral Functioning Scale (OFS) questionnaires.

RESULTS

56.2% of patients had a good postoperative FN outcome (HB grade II-III). Postoperative electromyography (EMG) showed re-innervation potentials in 60% of patients; median age of these patients was significantly lower compared to who did not manifest re-innervation (p = 0.039).

CONCLUSION

FN primary reconstruction remains the advisable rehabilitative option when the nerve is interrupted during lateral skull base surgeries, allowing to satisfactory postoperative results in more than half of patients. EMG confirmed the restoring of nerve conduction and it was more frequent in younger patients. The SFGS, the FDI and the OFS are important tools especially in the setting of a rehabilitation program.

Facial reanimation with interposition nerve graft or masseter nerve transfer: a comparative retrospective study

Both interposition nerve grafts and masseter nerve transfers have been successfully used for facial reanimation after irreversible injuries to the cranial portion of the facial nerve. However, no comparative study of these two procedures has yet been reported. In this two-site, two-arm, retrospective case review study, 32 patients were included. Of these, 17 patients (eight men and nine women, mean age 42.1 years) underwent interposition nerve graft after tumor extirpation or trauma between 2003 and 2006 in the Ear Institute, School of Medicine, Shanghai Jiao Tong University, China, and 15 patients (six men and nine women, mean age 40.6 years) underwent masseter-to-facial nerve transfer after tumor extirpation or trauma between November 2010 and February 2016 in Shanghai Ninth People's Hospital, China. More patients achieved House-Brackmann III recovery after masseter nerve repair than interposition nerve graft repair (15/15 vs. 12/17). The mean oral commissure excursion ratio was also higher in patients who underwent masseter nerve transfer than in patients subjected to an interposition nerve graft. These findings suggest that masseter nerve transfer results in strong oral commissure excursion, avoiding obvious synkinesis, while an interposition nerve graft provides better resting symmetry. This study was approved by the Institutional Ethics Committee, Shanghai Ninth People's Hospital, China (approval No. SH9H-2019-T332-1) on December 12, 2019.

Outcomes and prognostic factors of facial nerve repair: a retrospective comparative study of 31 patients and literature review

PURPOSE

To evaluate functional results of facial nerve repair by direct nerve suture or grafting, compare results between a traumatic and a tumoral group and identify prognostic factors.

METHODS

A retrospective monocentric cohort study was studied in a university ENT department. Thirty-one patients who benefited from facial nerve suture or grafting, with at least 12 months postoperative follow-up were included. Patients were divided into two groups according to the lesion type: traumatic (accident of the public road or iatrogenic) and tumoral. Preoperative data studied were sex, side, etiology documented by CT and/or MRI, facial palsy duration and grade according to House Brackmann grading system. Intraoperative data included: surgeon, age of patient, surgical technique, graft type, use of biological glue, facial nerve derivation, lesioned site. Postoperative data included: histological diagnosis, radiotherapy history, time to onset of the first signs of reinnervation, follow-up duration, and final facial function.

RESULTS

Success rate, including grade III and IV, was 68% in the whole cohort, 79% in the traumatic group and 59% in the tumoral group. Patients presenting with facial palsy evolving less than 6 months had better recovery results than those evolving longer than 6 months (p = 0.02). No other prognostic factors were identified.

CONCLUSIONS

The best outcome that can be achieved by suture or grafting of the facial nerve in traumatic or tumoral lesions is a grade III. Preoperative facial palsy duration is a prognostic factor and must be considered when establishing an operative indication.

Facial Reanimation and Reconstruction of the Radical Parotidectomy

Radical parotidectomy may result from treating advanced parotid malignancies invading the facial nerve. Survival is often enhanced with multimodality treatment protocols, including postoperative radiation therapy. In addition to the reconstructive challenge of restoring facial nerve function, patients may be left with a significant cervicofacial concavity and inadequate skin coverage. This should be addressed with stable vascularized tissue that is resistant to radiation-induced atrophy. This article describes a comprehensive strategy, includes the use of the anterolateral thigh free flap, the temporalis regional muscle transfer, motor nerve to vastus lateralis grafts, nerve to masseter transfer, and fascia lata grafts for static suspension.

Hypoglossal and Masseteric Nerve Transfer for Facial Reanimation: A Systematic Review and Meta-Analysis

Background: Hypoglossal and masseteric nerve transfer are currently the most popular cranial nerve transfer techniques for patients with facial paralysis. The authors performed a systematic review and meta-analysis to compare functional outcomes and adverse effects of these procedures. Methods: A review of online databases was performed to include studies with four or more patients undergoing hypoglossal or masseter nerve transfer without muscle transfer or other cranial nerve transposition. Facial nerve outcomes, time to reinnervation, and adverse events were pooled and studied. Results: A total of 71 studies were included: 15 studies included 220 masseteric-facial transfers, and 60 studies included 1312 hypoglossal-facial transfers. Oral commissure symmetry at rest was better for hypoglossal transfer (2.22 ± 1.6 mm vs. 3.62 ± 2.7 mm, p = 0.047). The composite Sunnybrook Facial Nerve Grading Scale was better for masseteric transfer (47.7 ± 7.4 vs. 33.0 ± 6.4, p < 0.001). Time to first movement (in months) was significantly faster in masseteric transfer (4.6 ± 2.6 vs. 6.3 ± 1.3, p < 0.001). Adverse effects were rare (<5%) for both procedures. Conclusions: Both nerve transfer techniques are effective for facial reanimation, and the surgeon should consider the nuanced differences in selecting the correct procedure for each patient.

Efficacy of surgical repair for the functional restoration of injured facial nerve

Background

Early surgical repair to restore nerve integrity has become the most commonly practiced method for managing facial nerve injury. However, the evidence for the efficacy of surgical repair for restoring the function of facial nerves remains deficient. This study evaluated the outcomes of surgical repair for facial nerve lesions.

Methods

This retrospective observational study recruited 28 patients with the diagnosis of facial nerve injury who consecutively underwent surgical repairs from September 2012 to May 2019. All related clinical data were retrospectively analyzed according to age, sex, location of the facial nerve lesion, size of the facial nerve defect, method of repair, facial electromyogram, and blink reflex. Facial function was then stratified with the House-Brackmann grading system pre-operation and 3, 9, 15, and 21 months after surgical repair.

Results

The 28 patients enrolled in this study included 17 male and 11 female patients with an average age of 34.3 ± 17.4 years. Three methods were applied for the repair of an injured facial nerve, including great auricular nerve transplantation in 15 patients, sural nerve grafting in 7 patients, and hypoglossal to facial nerve anastomosis in 6 patients. Facial nerve function was significantly improved at 21 months after surgery compared with pre-operative function (P = 0.008). Following surgical repair, a correlation was found between the amplitude of motor unit potential (MUP) and facial nerve function (r = -6.078, P = 0.02). Moreover, the extent of functional restoration of the facial nerve at 21 months after surgery depended on the location of the facial nerve lesion; lesions at either the horizontal or vertical segment showed significant improvement(P = 0.008 and 0.005), while no functional restoration was found for lesions at the labyrinthine segment (P = 0.26).

Conclusions

For surgical repair of facial nerve lesions, the sural nerve, great auricular nerve, and hypoglossal-facial nerve can be grafted effectively to store the function of a facial nerve, and MUP may provide an effective indicator for monitoring the recovery of the injured nerve.

Free Functional Gracilis Flaps for Facial Reanimation in Elderly Patients

Importance: The free functional gracilis flap (FFGF) is a versatile procedure in reanimating the paralyzed face, yet its application in seniors is limited by perceptions of morbidity and inefficacy. Objective: The study objective was to compare the morbidity and effectiveness of FFGF reanimation among senior and younger patients. Design, Setting, and Participants: A retrospective chart review was performed on 20 consecutive patients aged 60 years and above (seniors) and 35 patients aged 40 years and below (juniors) who underwent FFGF for facial reanimation. Among this group, 16 senior and 22 junior patients with available long-term follow-up data were analyzed for functional outcomes. Main Outcomes and Measures: The length of postoperative stay and postoperative complications were compared with assess immediate results. A second analysis for functional outcomes was assessed by resting and smile facial asymmetry index (FAI), as well as maxillary dental display to compare facial tone and lip excursion. Results: The average age of seniors was 67 ± 5 years and that of juniors was 27 ± 10 years. Mean lengths of postoperative stay were 4 ± 2 versus 3 ± 1 days in seniors versus Juniors, respectively (p = 0.16). There were no intraoperative complications and postoperative complications in one (5%) senior and four (11%) juniors (p = 0.64). There was functional muscle recovery in all cases, with more pronounced correction of both resting (Δ3.0 mm vs. Δ2.4 mm, p = 0.66) and dynamic (Δ5.2 mm vs. Δ4.2 mm, p = 0.37) FAI in seniors than in juniors. Among patients who underwent a multivector FGFF, there was an additional three versus one visualized maxillary teeth (p = 0.03) in seniors versus juniors, respectively. Conclusions and Relevance: The FFGF is effective for facial reanimation among seniors and can be performed with minimal morbidity. Age alone should not preclude the application of the FFGF in seniors with a preference for more dynamic options.

Evaluation of VIIth-XIIth cranial nerve anastomosis results by age

OBJECTIVE

To evaluate VIIth-XIIth cranial nerve (hypoglossal-facial nerve) anastomosis results by age.

METHOD

A total of 34 patients who attended a follow-up visit in 2016, aged 20-63 years, were enrolled. The House-Brackmann facial nerve function grading system and the Facial Clinimetric Evaluation scale were applied.

RESULTS

Regarding post-anastomosis facial nerve function, in the group aged 40 years or less, 14 patients (78 per cent) had House-Brackmann grade III and 4 patients (22 per cent) had House-Brackmann grade IV facial nerve function post-anastomosis. In the group aged over 40 years, nine patients (56 per cent) had House-Brackmann grade III and seven patients (44 per cent) had House-Brackmann grade IV facial nerve function post-anastomosis. There was a statistically significant difference between the two groups in mean facial movement domain scores (p = 0.02). Analysis between age and facial movement score in all 34 patients demonstrated a moderate negative correlation (Pearson correlation coefficient: -0.38) and statistical significance (p = 0.02).

CONCLUSION

Facial reanimation yielded better results in younger than in older patients.

Facial nerve repair: the impact of technical variations on the final outcome

OBJECTIVES

To analyze the outcome of facial nerve (FN) reconstruction, the impact of technical variations in different conditions and locations, and the importance of additional techniques in case of suboptimal results.

STUDY DESIGN

Retrospective study.

SETTING

University-based tertiary referral center.

PATIENTS

Between 2001 and 2017, reconstruction of the FN was performed on 36 patients with varying underlying diseases.

INTERVENTIONS

FN repair was performed by direct coaptation (n = 3) or graft interposition (n = 33). Microsurgical sutures were used in 17 patients (47%) and fibrin glue was used in all cases. Additional reinnervation techniques (hypoglossal-facial or masseter-facial transfers) were performed in five patients with poor results after initial reconstruction.

MAIN OUTCOME MEASURES

FN function was evaluated using the House-Brackmann (HB) and the electronic clinician-graded facial function (eFACE) grading systems. Minimum follow-up was 12 months.

RESULTS

FN reconstruction yielded improvement in 83% of patients, 21 patients (58.3%) achieving a HB grade III. The eFACE median composite, static, dynamic and synkinesis scores were 69.1, 78, 53.2, and 88.2 respectively. A tendency towards better outcome with the use of sutures was found, the difference not being significant. All patients undergoing an additional reinnervation procedure achieved a HB grade III, eFACE score being 74.8.

CONCLUSIONS

FN reconstruction offers acceptable functional results in most cases. No significant differences are expected with technical variations, different locations or conditions. In patients with poor initial results, additional reinnervation techniques should be always considered. The eFACE adds substantial information to the most used HB scale.

Facial Nerve Injury and Repair: A Practical Review for Cutaneous Surgery

BACKGROUND

The facial nerve and its branches are at risk of injury during dermatologic surgery. Few publications in the dermatologic literature discuss facial nerve injury and management.

OBJECTIVE

To review facial nerve injury and management, including static and dynamic repair techniques, and to review outcomes in facial nerve reconstruction.

METHODS

Two detailed literature reviews were performed using PubMed. First, articles reporting facial nerve injury and/or management in the dermatologic literature were identified. In addition, articles pertaining to outcomes in facial nerve reconstruction with a minimum of 20 patients were included.

RESULTS

Fifty-three articles reporting outcomes in facial nerve reconstruction were identified and consist of retrospective reviews and case series. Most patients achieve improvement in facial symmetry and movement with nerve repair.

CONCLUSION

Timing of facial nerve repair is an important consideration in management of facial nerve injury, with earlier repairs achieving better outcomes. Facial nerve repair does not result in normal facial movement, and improvements may require a year or more to be realized. Many options exist for facial nerve reconstruction, and patients with long-standing facial nerve injuries may still benefit from treatment.

Controversies in Contemporary Facial Reanimation

Facial palsy is a devastating condition with profound functional, aesthetic, and psychosocial implications. Although the complexity of facial expression and intricate synergy of facial mimetic muscles are difficult to restore, the goal of management is to reestablish facial symmetry and movement. Facial reanimation surgery requires an individualized treatment approach based on the cause, pattern, and duration of facial palsy while considering patient age, comorbidities, motivation, and goals. Contemporary reconstructive options include a spectrum of static and dynamic procedures. Controversies in the evaluation of patients with facial palsy, timing of intervention, and management decisions for dynamic smile reanimation are discussed.

Surgical technique and results of cable graft interpositioning of the facial nerve in lateral skull base surgeries: experience with 213 consecutive cases

OBJECTIVE The aim in this study was to review the technique and outcomes of cable graft interpositioning of the facial nerve (FN) in lateral skull base surgeries. METHODS The authors retrospectively evaluated data from patients who had undergone cable graft interpositioning after nerve sacrifice during skull base tumor removal between June 1987 and May 2015. All patients had undergone lateral skull base approaches to remove tumors at a quaternary referral center in Italy. Facial nerve function was evaluated before and after surgery using the House-Brackmann (HB) grading system. RESULTS Two hundred thirteen patients were eligible for study. The mean follow-up was 44.3 months. The most common pathology was vestibular schwannoma (83 cases [39%]), followed by FN tumor (67 cases [31%]). Facial nerve tumors had the highest incidence of nerve interruption (67 [66%] of 102 cases). Preoperative FN function was normal (HB Grade I) in 105 patients (49.3%) and mild (HB Grade II) in 19 (8.9%). At the last postoperative follow-up, 108 (50.7%) of the 213 patients had recovered to Grade III nerve function. Preoperative HB grading of the FN was found to have a significant effect on outcome (p = 0.002). CONCLUSIONS Cable graft interpositioning is a convenient and well-accepted procedure for immediate restoration of the FN. The study results, over a large number of patients, showed that the stitch-less fibrin glue-aided coaptation technique yields good results. The best possible postoperative result achieved was an HB Grade III. The chances of a good postoperative result increase when FN function is normal preoperatively. Slow-growing tumors of the cerebellopontine angle had a favorable outcome after grafting.

Hypoglossal-Facial Nerve Anastomosis: A Meta-Analytic Study

Objectives:

A meta-analysis was conducted on the outcome of facial nerve function after hypoglossal-facial nerve anastomosis in humans. The roles of the timing of and the underlying cause for surgery, the type of the repair, and previous facial nerve function in the final result were analyzed.

Methods:

Articles were identified by means of a PubMed search using the key words “facial-hypoglossal anastomosis,” which yielded 109 articles. The data were pooled from existing literature written in English or French. Twenty-three articles were included in the study after we excluded those that were technical reports, those describing anastomosis to cranial nerves other than the hypoglossal, and those that were experimental animal studies. Articles that reported facial nerve function after surgery and timing of repair were included. Facial nerve function had to be reported according to the House-Brackmann scale. If there was more than 1 article by the same author(s), only the most recent article and those that did not overlap and that matched the above criteria were accepted. The main parameter of interest was the rate of functional recovery of the facial nerve after anastomosis. This parameter was compared among all groups with Pearson's X2 test in the SPSS program for Windows. Statistical significance was set at a p level of less than .05.

Results:

Analysis of the reports indicates that early repair, before 12 months, provides a better outcome. The severity of facial nerve paralysis does not have a negative effect on prognosis. Gunshot wounds and facial neuroma are the worst conditions for favorable facial nerve recovery after anastomosis. Transection of the hypoglossal nerve inevitably results in ipsilateral tongue paralysis and atrophy. Modification of the anastomosis technique seems to resolve this problem. Nevertheless, the effect of modified techniques on facial reanimation is still unclear, because the facial nerve function results were lacking in these reports.

Conclusions:

Hypoglossal-facial nerve anastomosis is an effective and reliable technique that gives consistent and satisfying results.

Intracranial Facial Nerve Grafting in the Setting of Skull Base Tumors: Global and Regional Facial Function Analysis and Possible Implications for Facial Reanimation Surgery

BACKGROUND

Reconstructive surgeons may encounter patients presenting after intracranial facial nerve resection and grafting in the setting of skull base tumors, who inquire regarding progression, final facial function, and need for future operations. Study goals were to analyze global and regional facial function using established grading systems and videography, while examine variables possibly affecting outcomes.

METHODS

Between 1997 and 2012, 28 patients underwent intracranial nerve grafting. Fifteen were prospectively evaluated by three facial nerve physical therapists with the Facial Nerve Grading System 2.0 and the Sunnybrook Facial Grading Score for function and the Facial Disability Index for quality of life. Still photographs and videography were used to assess quality of motion and tone, while demographic and medical variables were analyzed regarding their effect on end results.

RESULTS

Average patient age was 41.9 years (range, 22 to 66 years), and there were 10 women and five men. Average time interval between nerve grafting and evaluations was 42.9 months (range, 12 to 146 months). Both grading scores demonstrated best outcomes in the periorbita and worst outcomes in the brow. Buccinator muscle tone also improved. The average total Facial Disability Index was 67.5 percent. Although not statistically significant, the data suggest that nerve gap length affected total resting symmetry and voluntary movement, whereas preoperative palsy and age may affect total resting symmetry. Perioperative radiation therapy, tumor type, donor nerve, and coaptation technique were not found to affect outcomes.

CONCLUSIONS

Intracranial facial nerve grafting largely provides better resting tone and facial symmetry, potentially improving end results of future intervention; however, overall voluntary facial motion is poor.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Treatment of complete facial palsy in adults: comparative study between direct hemihypoglossal-facial neurorrhaphy, hemihipoglossal-facial neurorrhaphy with grafts, and masseter to facial nerve transfer

BACKGROUND

The hypoglossal (with or without grafts) and masseter nerves are frequently used as axon donors for facial reinnervation when no proximal stump of the facial nerve is available. We report our experience treating facial nerve palsies via hemihypoglossal-to-facial nerve transfers either with (HFG) or without grafts (HFD), comparing these outcomes against those of masseteric-to-facial nerve transfers (MF).

METHOD

A total of 77 patients were analyzed retrospectively, including 51 HFD, 11 HFG, and 15 MF nerve transfer patients. Both the House-Brackmann (HB) scale and our own, newly-designed scale to rate facial reanimation post nerve transfer (quantifying symmetry at rest and when smiling, eye occlusion, and eye and mouth synkinesis when speaking) were used to enumerate the extent of recovery.

RESULTS

With both the HB and our own facial reanimation scale, the HFD and MF procedures yielded better outcome scores than HFG, though only the HGD was statistically superior. HGD produced slightly better scores than MF for everything but eye synkinesis, but these differences were generally not statistically significant. Delaying surgery beyond 2 years since injury was associated with appreciably worse outcomes when measured with our own but not the HB scale. The only predictors of outcome were the surgical technique employed and the duration of time between the initial injury and surgery.

CONCLUSIONS

HFD appears to produce the most satisfactory facial reanimation results, with MF providing lesser but still satisfactory outcomes. Using interposed grafts while performing hemihypoglossal-to-facial nerve transfers should likely be avoided, whenever possible.

Transforming growth factor-β3 promotes facial nerve injury repair in rabbits

The present study investigated the effects of transforming growth factor (TGF)-β3 on the regeneration of facial nerves in rabbits. A total of 20 adult rabbits were randomly divided into three equal groups: Normal control (n=10), surgical control (n=10) and TGF-β3 treatment (n=10). The total number and diameter of the regenerated nerve fibers was significantly increased in the TGF-β3 treatment group, as compared with in the surgical control group (P<0.01). Furthermore, in the TGF-β3 treatment group, the epineurial repair of the facial nerves was intact and the nerve fibers, which were arranged in neat rows, were morphologically intact with visible myelin swelling. However, in the surgical control group, the epineurial repair was incomplete, as demonstrated by: Atrophic nerve fibers, partially disappeared axons and myelin of uneven thickness with fuzzy borders. Electron microscopy demonstrated that the regenerated fibers in the TGF-β3 treatment group were predominantly myelinated, with clear-layered myelin sheath structures and axoplasms rich in organelles. Although typical layered myelin sheath structures were observed in the surgical control group, the myelin sheaths of the myelinated nerve fibers were poorly developed and few organelles were detected in the axoplasms. Neuro-electrophysiological examination demonstrated that, as compared with the surgical control group, the latency period of the action potentials in the TGF-β3 treatment group were shorter, whereas the stimulus amplitudes of the action potentials were significantly increased (P<0.01). The results of the present study suggest that TGF-β3 may improve the regeneration of facial nerves following trauma or injury.

Motor Nerve Transfers

Brachial plexus and peripheral nerve injuries are exceedingly common. Traditional nerve grafting reconstruction strategies and techniques have not changed significantly over the last 3 decades. Increased experience and wider adoption of nerve transfers as part of the reconstructive strategy have resulted in a marked improvement in clinical outcomes. We review the options, outcomes, and indications for nerve transfers to treat brachial plexus and upper- and lower-extremity peripheral nerve injuries, and we explore the increasing use of nerve transfers for facial nerve and spinal cord injuries. Each section provides an overview of donor and recipient options for nerve transfer and of the relevant anatomy specific to the desired function.

Hypoglossal-facial nerve 'side'-to-side neurorrhaphy using a predegenerated nerve autograft for facial palsy after removal of acoustic tumours at the cerebellopontine angle

TRIAL DESIGN

Hypoglossal-facial nerve (HN-FN) neurorrhaphy is a method commonly used to treat facial palsy when the proximal stump of the injured FN is unavailable. Since the classic HN-FN neurorrhaphy method that needs to section the injured FN is not suitable for incomplete facial palsy, we investigated a modified method that consists of HN-FN 'side'-to-side neurorrhaphy, retaining the remaining or spontaneously regenerated FN axons while preserving hemihypoglossal function.

METHODS

To improve axonal regeneration, we used for the first time a predegenerated sural autograft for performing HN-FN 'side'-to-side neurorrhaphy followed by postoperative facial exercise. We treated 12 patients who had experienced FN injury for 1-18 months as a result of acoustic tumour removal. All patients experienced facial grade V-VI paralysis according to the House-Brackmann scale, but their FN was anatomically preserved. No spontaneous facial reinnervation was detected before repair.

RESULTS

Although we did not perform fresh nerve grafts and HN-FN 'side'-to-end neurorrhaphy as controls for ethical reasons, the reparative outcomes after nerve reconstruction were remarkable: functional improvements were detected as soon as 3 months after repair, House-Brackmann grade II or III FN functions were achieved in five and four patients, respectively, and there were no apparent signs of synkinesis. The three patients who experienced less satisfactory outcomes had exhibited facial palsy for more than 1 year accompanied by muscle atrophy, consistent with a need for rapid surgical intervention.

CONCLUSIONS

Based on fundamental concepts and our experimental results, this new surgical method represents a major advance in the rehabilitation of FN injury.

TRIAL REGISTRATION NUMBER

JS2013-001-02.

Stitchless fibrin glue-aided facial nerve grafting after cerebellopontine angle schwannoma removal: technique and results in 15 cases

AIM OF THE STUDY

To evaluate the results of facial nerve (FN) grafting using great auricular cable graft and fibrin glue without suturing to palliate FN disruption after removal of large cerebellopontine angle (CPA) vestibular schwannoma (VS) or facial nerve schwannoma (FNS). To assess whether tumor size and origin influenced the results.

STUDY DESIGN AND SETTING

Retrospective review of all patients having undergone removal of FNS/VS and needing intraoperative FN repair between 2001 and 2011.

INTERVENTION

FN was rehabilitated using great auricular nerve cable graft and fibrin glue (Tisseal) without stitching suture.

MAIN OUTCOME MEASURES

All data recorded were reviewed to access age, sex, tumor type, and tumor size according to the Koos classification and presenting symptoms. FN function was evaluated preoperatively and at 18 months using the House-Brackmann (HB) grading system.

RESULTS

Among the 595 patients operated for CPA schwannomas in this period, 15 patients (2.5%) underwent FN repair, including 7 cases of FNS and 8 cases of VS. Tumor removal was total in all cases. FN recovery was HB3 in 13 cases (86.7%) and HB4 in 2. The mean time to the first clinical signs of facial reinnervation was 10 months (6-12 mo). No significant relation was found between postoperative facial function and tumor size or type, even if all cases of preoperative FP were noted in FNS.

CONCLUSION

Immediate FN reconstruction with fibrin glue-aided greater auricular nerve graft can effectively restore FN function with excellent outcomes. The results seem better than those observed by other authors using sutured grafts or delayed hypoglossal-facial nerve anastomosis.

Reconstruction of facial nerve after radical parotidectomy

CONCLUSION

Most patients benefitted from immediate facial nerve grafting after radical parotidectomy. Even weak movement is valuable and can be augmented with secondary static operations. Post-operative radiotherapy does not seem to affect the final outcome of facial function.

OBJECTIVES

During radical parotidectomy, the sacrifice of the facial nerve results in severe disfigurement of the face. Data on the principles and outcome of facial nerve reconstruction and reanimation after radical parotidectomy are limited and no consensus exists on the best practice.

METHOD

This study retrospectively reviewed all patients having undergone radical parotidectomy and immediate facial nerve reconstruction with a free, non-vascularized nerve graft at the Helsinki University Hospital, Helsinki, Finland during the years 1990-2010. There were 31 patients (18 male; mean age = 54.7 years; range = 30-82) and 23 of them had a sufficient follow-up time.

RESULTS

Facial nerve function recovery was seen in 18 (78%) of the 23 patients with a minimum of 2-year follow-up and adequate reporting available. Only slight facial movement was observed in five (22%), moderate or good movement in nine (39%), and excellent movement in four (17%) patients. Twenty-two (74%) patients received post-operative radiotherapy and 16 (70%) of them had some recovery of facial nerve function. Nineteen (61%) patients needed secondary static reanimation of the face.

Comparison of Direct Side-to-End and End-to-End Hypoglossal-Facial Anastomosis for Facial Nerve Repair

BACKGROUND

The hypoglossal facial anastomosis (HFA) is the gold standard for facial reanimation in patients with severe facial nerve palsy. The major drawbacks of the classic HFA technique are lingual morbidities due to hypoglossal nerve transection. The side-to-end HFA is a modification of the classic technique with fewer tongue-related morbidities.

OBJECTIVES

In this study we compared the outcome of the classic end-to-end and the direct side-to-end HFA surgeries performed at our center in regards to the facial reanimation success rate and tongue-related morbidities.

METHODS

Twenty-six successive cases of HFA were enrolled. In 9 of them end-to-end anastomoses were performed, and 17 had direct side-to-end anastomoses. The House-Brackmann (HB) and Pitty and Tator (PT) scales were used to document surgical outcome. The hemiglossal atrophy, swallowing, and hypoglossal nerve function were assessed at follow-up.

RESULTS

The original pathology was vestibular schwannoma in 15, meningioma in 4, brain stem glioma in 4, and other pathologies in 3. The mean interval between facial palsy and HFA was 18 months (range: 0-60). The median follow-up period was 20 months. The PT grade at follow-up was worse in patients with a longer interval from facial palsy and HFA (P value: 0.041). The lesion type was the only other factor that affected PT grade (the best results in vestibular schwannoma and the worst in the other pathologies group, P value: 0.038). The recovery period for facial tonicity was longer in patients with radiation therapy before HFA (13.5 vs. 8.5 months) and those with a longer than 2-year interval from facial palsy to HFA (13.5 vs. 8.5 months). Although no significant difference between the side-to-end and the end-to-end groups was seen in terms of facial nerve functional recovery, patients from the side-to-end group had a significantly lower rate of lingual morbidities (tongue hemiatrophy: 100% vs. 5.8%, swallowing difficulty: 55% vs. 11.7%, speech disorder 33% vs. 0%).

CONCLUSION

With the side-to-end HFA technique the functional restoration outcome is at least as good as that following the classic end-to-end HFA, but the complications related to the complete hypoglossal nerve transection can be avoided. Best results are achieved if this procedure is performed within the first 2 years after facial nerve injury. Patients with facial palsy of longer duration also have the chance for good functional restoration after HFA.

Current thoughts and developments in facial nerve reanimation

PURPOSE OF REVIEW

To present the most current literature regarding the management of acute and chronic facial paralysis. This review will focus primarily on smile reanimation in the setting of acute and chronic facial paralysis. The management of the flaccid and the hypertonic face will be discussed.

RECENT FINDINGS

Recent developments include advances in neural repair with fibrin glue and the use of cadaveric nerve grafts as interposition grafts. Advances in nerve substitutes have been shown to limit donor-site morbidity and provide similar outcomes to autografts. Techniques for muscle transfer continue to evolve to improve smile outcomes.

SUMMARY

The goal of facial reanimation surgery is to restore meaningful facial movement. The goal should be to have quality-driven clinical practice guidelines to better facilitate patient care. This process must be initiated by facial reanimation surgeons deciding to use consistent outcome measures to report their results. Currently, it is impossible to make a direct comparison between different surgical techniques because of inconsistent methods of evaluation. Despite the lack of consistent quantitative evaluation, there have been many exciting advances in the field.

Long-Term Outcomes of Facial Nerve Function in Irradiated and Nonirradiated Nerve Grafts

Objectives:

We reviewed the long-term results of facial nerve repair in a tertiary head and neck institution in the north of England.

Methods:

We performed a case notes review of patients who had facial nerve repair over a 10-year period and had completed 24 months of follow-up.

Results:

The study population comprised 18 female patients and 24 male patients, with an overall mean age of 53.2 years (range, 16 to 80 years). Of the 24 patients who had a cable nerve graft, the greater auricular nerve was used in 15 cases. The sural nerve was used as the donor in a cross-facial nerve graft in 9 patients. Sixteen patients had transposition nerve repair: Hypoglossal and ansa cervicalis in 7 and 9 cases, respectively. Two patients had primary anastomosis after surgery for extensive malignant tumors. In this series, no patients achieved a House-Brackmann (HB) grade of II. Overall, the HB grades III, IV, and V were the best postoperative facial nerve functions achieved in 11.9%, 33.3%, and 26.2% of patients, respectively. Failure (HB grade VI) was observed in 28.6% of patients. More than half of patients (62.5%) who had either a sural nerve cable graft or a faciohypoglossal transposition had a good outcome (HB grade III or IV).

Conclusions:

In the present series, 45% of patients had an HB grade of III or IV at long-term follow-up. The best outcome (HB grade III) was observed after cross-facial grafting with the sural nerve.

The anatomically intact but electrically unresponsive facial nerve in vestibular schwannoma surgery

BACKGROUND

Permanent facial nerve (FN) paresis after vestibular schwannoma surgery is distressing to both the patient and surgeon. Intraoperative electrophysiological testing has proven invaluable in reducing the incidence of FN injury and may assist in prognosticating long-term function.

OBJECTIVE

To report definitive FN outcomes among a cohort of patients with an unevokable but anatomically intact seventh nerve after microsurgical vestibular schwannoma resection.

METHODS

All patients undergoing vestibular schwannoma surgery between 2000 and 2010 at a single tertiary academic referral center were identified. Intraoperative FN monitoring data and definitive FN outcomes were reviewed, and all patients with an anatomically intact but electrically unresponsive FN were included.

RESULTS

Eleven patients met the inclusion criteria. The median preoperative and definitive postoperative FN scores were House-Brackmann grades 1 and 3, respectively. The median time to definitive FN recovery was 9.4 months.

CONCLUSION

These data demonstrate that even among this extreme subset, modern electroprognostic testing strategies are incapable of reliably predicting poor outcomes. Therefore, if FN continuity is maintained, attempts at same-surgery FN repair should not be pursued.

Facial nerve anastomosis in the mastoid portion using a cable graft. Case report

We describe a case of a 52-year-old woman in whom surgery for two tumours located in the cerebellar hemisphere and in the posterior petrous bone was complicated by interruption of the facial nerve (CN VII). During the same procedure, anastomosis of CN VII, using a cable graft harvested from the great auricular nerve, was performed. Seven months later the first signs of reinnervation of the facial muscles were noticed. Two and a half years after surgery, CN VII function was assessed as grade II/III according to the House-Brackmann scale. The authors emphasize the significance of immediate repair of CN VII in modern skull base surgery but also the importance of a patient's self-training to obtain the best functional outcome of the facial reanimation. Reconstruction using the great auricular nerve has two significant advantages: first, the patient avoids further procedures for nerve repair, and second, the harvested nerve is located in direct proximity to the operation area.

Reconstruction of the paralyzed face

Facial nerve paralysis can be difficult to treat because it presents a variety of functional, aesthetic, and psychosocial challenges. The goals of treatment include facial symmetry at rest, corneal protection, oral competence, restoration of voluntary and spontaneous facial movements, and minimal synkinesis. A multitude of static and dynamic procedures have been used to achieve these goals. Facial nerve reapproximation or interpositional grafting is associated with the best end results. The results of dynamic procedures are generally better than those of static procedures. Optimal reconstruction of the paralyzed face usually requires multiple surgeries with both types of procedures. Patients must be extensively counseled regarding expected results before they embark on what is an oftentimes lengthy reconstructive process. In this article, we discuss the anatomy of the facial nerve, the etiologic factors associated with facial nerve paralysis, the evaluation of the patient with facial paralysis, and the various surgical options for static and dynamic reconstruction of the paralyzed face. We also review the literature.

The impact of radiotherapy on facial nerve repair

OBJECTIVE

To study the impact of radiotherapy on the success of primary facial nerve repair and cable nerve grafts.

STUDY DESIGN

Retrospective review.

METHODS

Pre- and postoperative facial nerve function were assessed using the House-Brackmann (HB) grading system.

RESULTS

Thirty-nine patients were identified who had undergone facial nerve repair: 5 patients (13%) underwent primary repair, and 34 patients (87%) underwent nerve grafting. Radiotherapy was administered postoperatively to 34 patients (87%). Preoperative HB scores were I = 18, II = 11, III = 3, IV = 3, V = 3, and VI = 1. Postoperative scores were HB I = 1, II = 4, III = 16, IV = 6, V = 3, and VI = 9. Only patients with single-branch deficits recovered to HB I or II function. Good facial function (HB I-III) was achieved in 17 of 34 patients (50%) who received postoperative radiotherapy compared to 4 of 5 patients (80%) who did not receive postoperative radiotherapy (P = .349). Among the patients who had either HB I or II function preoperatively, 59% achieved good postoperative function (HB I-III). Four out of 10 patients (40%) with significantly compromised preoperative facial function (HB III-VI) were able to achieve HB III function.

CONCLUSIONS

Postoperative radiotherapy appears not to prevent achieving good facial function after a nerve repair, especially when normal or near-normal function is present preoperatively. Some patients with fair to little function preoperatively can achieve reasonable postoperative function with facial nerve reconstruction.