Functional Outcome of Dual Reinnervation with Cross-Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis

Abstract

Background: The combination of cross-facial nerve graft (CFNG) and masseteric nerve transfer (MNT) for reinnervation of facial paralysis may provide advantages of both neural sources. However, quantitative functional outcome reports with a larger number of patients are lacking in the literature. Here we describe our 8-year experience with this surgical technique. Methods: Twenty patients that presented with a complete facial paralysis (duration <12 months) received dual reinnervation with CFNG and MNT. The functional outcome of the procedure was evaluated with the physician-graded outcome metric eFACE. The objective artificial intelligence-driven software Emotrics and FaceReader were used for oral commissure measurements and emotional expression assessment, respectively. Results: The mean follow-up was 31.75±23.32 months. In the eFACE score, the nasolabial fold depth and oral commissure at rest improved significantly (p<0.05) towards a more balanced state after the surgery. Postoperatively, there was a significant decrease in oral commissure asymmetry while smiling (19.22±6.1mm to 12.19±7.52mm). For the emotionality expression, the median intensity score of happiness, as measured by the FaceReader software, increased significantly while smiling (0.28, IQR 0.13-0.64). In 5 (25%) patients, a secondary static midface suspension with fascia lata strip had to be performed due to an unsatisfactory resting symmetry. Older patients and patients with greater preoperative resting asymmetry were more likely to receive static midface suspension. Conclusions: Our results suggest that the combination of MNT and CFNG for reinnervation of facial paralysis provides good voluntary motion and may lessen the use of static midface suspension in the majority of patients.

Surgery for patients with facial palsy in Germany: a diagnosis-related-groups-based nationwide analysis, 2005–2019

“…Only a proportion of patients with chronic flaccid facial paralysis seem to receive surgical therapy. On the other hand, it has been proven that patients benefit from facial surgery in terms of function and improvement of quality of life [ 12 – 16 ]. In the United Kingdom, only a small proportion of patients with idiopathic paresis and long-term symptoms are referred to the specialist by the general practitioner (who treats a large proportion of patients in the acute phase in the United Kingdom) [ 8 , 17 ].…”

“…A comparison with other countries is also not possible because no such country-wide studies are available internationally. The slight increase in muscle transfer is certainly due to the increased use of free muscle transfer also in adult patients with acquired facial nerve palsies [ 16 ]. Nerve surgery or muscle transfer are often combined with measures for ocular closure [ 2 ].…”

“…Due to low case numbers, the OPS codes with the first four digits had to be used. Therefore, the different techniques of nerve surgery using different donor nerves, but also the local muscle transfer could not be differentiated from the free muscle transfer which is more important today [ 16 ]. In addition, even the 5-digit coding does not allow differentiation of a nerves surgery with an interposition from an end-to-end facial nerve suture, nor does it allow differentiation of the obsolete hypoglossal facial cross nerve suture from the hypoglossal facial jump nerve suture [ 14 ].…”

Anatomische Auffindbarkeit und Möglichkeiten des Transfers des Nervus massetericus zur Gesichtsreanimation

“…Als positiv prädiktiver Faktor für gute emotionale Kopplung wurde die präoperativ elektromyographisch gemessene Aktivierung des M. masseter bei spontanem Lächeln beschrieben [23]. Innovative neue Ansätze versuchen auch durch die Kombination von NM und CFNG die Vorteile beider Methoden zu verbinden [24,25]. Weiters wird der NM als Spendernerv bei Kindern mit Moebius-Syndrom bevorzugt verwendet [2, [26][27].…”

“…Gründe gelegentlicher Skepsis sind vergleichsweise mangelhafte Ergebnisse hinsichtlich Ruhetonus und -symmetrie sowie die vermeintlich geringere emotionale Kopplung 2 20 Letzterem widersprechen allerdings rezente Arbeiten 1 3 11 21 22 , welche die Ergebnisse hinsichtlich postoperativ spontanen Lächelns als durchaus vergleichbar einordnen. Als positiv prädiktiver Faktor für gute emotionale Kopplung wurde die präoperativ elektromyographisch gemessene Aktivierung des M. masseter bei spontanem Lächeln beschrieben 23 Innovative neue Ansätze versuchen auch durch die Kombination von NM und CFNG die Vorteile beider Methoden zu verbinden 24 25 Weiters wird der NM als Spendernerv bei Kindern mit Moebius-Syndrom bevorzugt verwendet 2 26 27…”