Early Simultaneous Cross Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis after Tumor Resection

Abstract

Background: We describe a new approach for facial reanimation after skull base tumor resection with known facial nerve sacrifice, involving simultaneous masseter nerve transfer with selective cross facial nerve grafting (CFNG) within days after tumor surgery. This preliminary study compared outcomes of this approach versus a staged procedure involving a masseter nerve “babysitter” performed in a delayed timeline. Methods: Patients undergoing masseter nerve transfer and CFNG for facial paralysis after skull base tumor resection were consented to participate in video interviews. Facial Clinimetric Evaluation (FaCE) Scale (0–100) patient-reported outcome, eFACE, and Facial Grading Scale scores were compared. Results: Nine patients had unilateral facial paralysis from resection of a schwannoma (56%), acoustic neuroma (33%), or vascular malformation (11%). Five underwent early simultaneous CFNG and masseter nerve transfer (mean 3.6 days after resection), whereas four underwent two-stage reanimation including a babysitter procedure (mean 218 days after resection). Postoperative FaCE scale and Facial Grading Scale scores were similar in both groups (P > 0.05). Postoperative mean eFACE scores were similar for both groups for smile (early: 71.5 versus delayed: 75.5; P = 0.08), static (76.3 versus 82.1; P = 0.32), and dynamic scores (59.7 versus 64.9; P = 0.19); however, synkinesis scores were inferior in the early group (76.4 versus 91.1; P = 0.04). Conclusions: Early simultaneous masseter nerve transfer and CFNG provides reanimated movement sooner and in fewer stages than a staged approach in a delayed timeline. The early technique appears to result in similar clinician- and patient-reported outcomes compared with delayed procedures; however, in this preliminary study, the early approach was associated with greater synkinesis, meriting further investigation.

Nerve guide conduits, nerve transfers, and local and free muscle transfer in facial nerve palsy

“…As such, CFNG is usually only considered as a single-stage procedure within 6 months from the time of facial nerve injury. It is important to note, however, that the limited donor axons may achieve somewhat unpredictable results as a single-stage procedure, and as such even in cases of limited facial injury and denervation of less than 6 months, CFNGs may be placed at the same time as an ipsilateral motor nerve transfer, such as the masseteric nerve, to provide more reliable axonal delivery and improve resting facial tone and oral commissure excursion [27,28]. In patients with denervation time of greater than 6 months, a two-stage procedure is required whereby the first stage involves using an ipsilateral motor donor to provide strong innervation to salvage the facial musculature while the CFNGs are growing across the face.…”

“…Clinical outcomes were good to excellent, with voluntary contraction observed after 2–4 months, and spontaneous contraction was achieved in 7–13 months postoperatively. Sergesketter et al [28] studied patients who had skull base tumor resection and known facial nerve sacrifice, and compared simultaneous masseter nerve transfer with selective CFNG within days from their skull base surgery, with a staged procedure involving the masseter nerve as a ‘babysitter’ and CFNG. They found that the early technique appeared to result in similar clinician-reported and patient-reported outcomes compared with the delayed procedure, although synkinesis was higher in the earlier approach group.…”