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

Abstract

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.

Fibrovascular Tumor-Like Lesions of the Facial Nerve

“…They may be reactive lesions, either a reparative lesion following inflammation or hemorrhage, or the involution of a previous neural or vascular neoplasm entirely replaced by fibrovascular tissue. The wide age range of the patients at presentation (5-76 years) in our case series is similar to that described in other studies on intrinsic FNTs [Prasad et al, 2018]. This wide age range leads us to question the existence of a unique hypothesis to explain these fibrovascular lesions.…”

“…Conversely, most schwannomas and hemangiomas are hyperintense on MRI T2-weighted images [Lahlou et al, 2016b]. Surgical resection with FN repair has traditionally been the standard management for patients with HB grades worse than III, especially those with total paralysis [Prasad et al, 2018]. In the series of cases presented here, a lesion arising from the FN was identified in all 4 patients, and tumor resection was followed by FN reconstruction.…”

Editorial. Outcomes of facial nerve repair using nerve grafts applied immediately following nerve discontinuity in skull base surgery

“…8,25 The present study uses fibrin glue for coaptation in most patients, with microsutures reserved for only extratemporal coaptations. 21 The results are comparable to those of many other studies in which microsutures were primarily used for coaptation. Hence, it would seem reasonable to presume that the two techniques are equally effective.…”

“…Prasad et al should be applauded for sharing their enormous experience with facial nerve grafting in 213 consecutive patients, which will definitely add to the existing literature. 21 Unlike the authors of most other studies, Prasad and colleagues have been able to classify, segregate, and analyze their grafting results based on pathology and various other factors using multivariate analysis, which is the most important contribution of their paper. Most of their results are in keeping with those in the available literature.…”

Effect of Motor versus Sensory Nerve Autografts on Regeneration and Functional Outcomes of Rat Facial Nerve Reconstruction

“…Given lack of full recovery of the transected or resected nerve after reconstruction of the nerve defect, there remains significant room for improvement through scientific experimentation 14 . Current considerations for selecting an autograft include donor site morbidity (loss of sensation, pain, paresthesia, or loss of motor function arising from removal of a nerve for use in grafting), branching pattern, length of nerve required to reconstruct the defect, caliber-match of the nerve, ease of harvest, and need for incisions 15 .…”