|Year : 2021 | Volume
| Issue : 2 | Page : 310-313
Dual nerve transfer for facial reanimation
Deekshith Rajmohan1, Deviprasad Sulli2, MK Mohammed Jasim1, Arjun Suresh1
1 Department of ENT, Yenepoya Medical College, Mangalore, Karnataka, India
2 Department of Plastic Surgery, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Submission||23-Jun-2021|
|Date of Decision||08-Sep-2021|
|Date of Acceptance||09-Sep-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Arjun Suresh
Department of ENT, Yenepoya Medical College, Deralakatte, Mangalore - 575018
Source of Support: None, Conflict of Interest: None
The facial nerve is the 7th cranial nerve and carries nerve fibers which control facial movement and expression. This nerve also carries fibers that are involved for the production of taste from the anterior 2/3rd of the tongue and tears from the lacrimal gland. Facial asymmetry is a debilitating condition to treat, and over the years, different techniques have been devised for improving facial asymmetry and function. Dual nerve transfer is the combination of hypoglossal nerve transfer and massetric nerve transfer. This technique is proven to correct facial asymmetry and helps restore facial tone without affecting much of tongue functionality. This case report helps understand the effectiveness of facial reanimation that was conducted on a patient with Grade VI facial nerve paralysis and follow-up after 6 months postsurgery shows drastic change in the outcome.
Keywords: Facial paralysis, facial reanimation, hypoglossal-facial nerve anastomosis, masseteric nerve transfer, vestibular Schwannoma
|How to cite this article:|
Rajmohan D, Sulli D, Mohammed Jasim M K, Suresh A. Dual nerve transfer for facial reanimation. Arch Med Health Sci 2021;9:310-3
| Introduction|| |
Surgeons, research scientists, and biomedical engineers have done extensive research on facial reanimation due to esthetic and functional implications of facial nerve paralysis. Facial and hypoglossal nerves have a close proximity which makes it suitable substitute. Many variations of facial reanimation have happened throughout the years, mainly focusing on preserving hypoglossal nerve function.
Surgery for vestibular schwannoma (VS) carries the risk of facial nerve (CN VII) palsy. Hypoglossal facial nerve anastomosis remains one of the most popular techniques since it was introduced in 1901 Korte due its relatively low morbidity and high effectiveness compared to the use of other nerves. In our case, hemihypoglossal-facial anastomosis (HHFA) technique is used to restore function of the mimetic muscles. Eye closure and facial symmetry can be expected in 75% patients who undergo hypoglossal-facial nerve anastomosis (HFA) after surgery for VS. Risk of facial muscle atrophy increases with increase in time taken for surgery from the time of injury. However, early anastomosis eliminates the chances of physiologic regeneration with better cosmetic results.
However, in every case of long-lasting paralysis, the main clinical concerns are eye problems. The risk for ophthalmic complications persists quite long, and some authors advocate simultaneous transposition of the temporal muscle, masseter muscle, or both. Hemihypoglossal-facial nerve anastomosis (HHFA) is an effective treatment modality for facial palsy, especially in patients who cannot tolerate compromises in tongue function. Recent studies have shown hypoglossal nerve (CN XII) to be one of the most effective donors for facial reanimation, and only a few fibers of CN XII are used instead of the entire nerve. With this technique, the risk of tongue atrophy and problems related to swallowing are minimized. Simple end-to-end anastomosis is still performed but sacrifices the function of the donor nerve. A multidisciplinary team approach is required for the management of such cases.
| Case Report|| |
A 35-year-old male underwent craniotomy on September 2020 [Figure 1] with gross total excision of VS on the right side by the department of neurosurgery. Preoperative MRI scan showed a large mass in the right cerebellopontine angle cisternal space measuring (3.4 cm × 3.96 cm × 2.9 cm) in maximum dimension. Although facial nerve monitor was used, it was difficult to identify and preserve it. Following the surgery, the patient developed redness, watering, and inability to close the right eye and was diagnosed with facial nerve palsy [Figure 2]. ENT consultation was sorted for further management. On ENT examination, he had a right-sided profound hearing loss with House Brackmann Grade 6 facial nerve palsy. The patient was planned for right-sided facial nerve reanimation with the help of plastic surgeon. After obtaining an informed consent from the patient, we planned for a dual nerve technique after a period of 1 month from previous surgical date.
Under general anesthesia, procedure was planned. Postaural approach was used. Classical transmastoid canal wall down mastoidectomy procedure was done. Facial nerve was identified from the labyrinthine segment to mastoid segment till the stylomastoid foramen [Figure 3]a. Incus was removed to identify the first genu of the facial nerve and labyrinthine segment of the facial nerve was sliced at the level of the processes cochleariformis and rerouted through the stylomastoid foramen after removing the tip of mastoid. The hypoglossal nerve was identified in the neck and was divided longitudinally and the lower division was anastomosed with facial nerve in an end-to-side fashion. All the branches of facial nerve were identified, and upper buccal branch of the facial nerve was later anastomosed to the right lateral masseteric nerve in an end-to-end anastomosis [Figure 3]b.
|Figure 3: (a) Labyrinthine and mastoid segment of facial nerve (*). (b) Representation - facial nerve rerouted|
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Lateral masseteric nerve was identified 1 cm deep and anterioinferior to the coronoid notch of mandible while separating fibers of masseteric muscle. The masseteric nerve was identified and stimulated intraoperatively using Braun Stimuplex HNS12 Nerve Stimulator. Blind sac closure of the external auditory canal was done at the end of procedure. Tension free nerve anastomosis was performed at the free end. The lagophthalmos was managed by right upper eye lid gold plating (1.5 g) through a skin crease incision.
| Discussion|| |
Surgically corrected anastomosis remains one of the best treatment modalities for facial paralysis correction. A detailed history about the onset, duration of paralysis, initial degree of paralysis, and associated signs symptoms are mandatory as primary approach to the case. Physical examination includes careful observation and recording (especially video recording and photographic documentation) of the facial asymmetries at rest, during voluntary, and reflex emotional movement. Signs such as lid laxity, corneal opacities, oral competence, brow ptosis, and synkinesis should be noted, in addition to assessment of other cranial nerve deficits.
There are various etiologies for facial paralysis: Congenital, infectious, neoplastic, traumatic and idiopathic causes have been described in literature. The management of facial paralysis is complex and sometimes requires multidisciplinary approach. The treatment strategy of facial paralysis consists of a detailed investigation and mixture of medical management with surgical correction followed by physiotherapy and rehabilitation. Different static and dynamic techniques have been described for the treatment of facial paralysis such as facial nerve decompression, nerve transfers, facial nerve repair, cross-face nerve grafting, regional and free muscle transfers depending on the duration, etiology, static and dynamic functional integrity of the nerve, and to restore the cosmetic and functional deficits in these patients. Facial nerve reanimation is usually done for complete facial nerve paralysis. Many of the times, patients do not understand the need for rehabilitation and the probable need for adjuvant therapy. Adjuvant therapy includes the use of Botulinum toxin and physiotherapy. The primary aim of facial reanimation surgery is the restoration of the tone, symmetry and movement of the paralyzed face, and subsequent improvement in the quality of life.
Facial reanimation using Hypoglossal-Facial anastomosis (HFA) is the most widely accepted technique. The procedure should be done within 1 year of the injury to obtain the desired results. Depending on the patient's condition, various treatment options have to be put forward, and the need for long-term rehabilitation has to be explained.
The primary aim of the surgery was to reduce cosmetic deformity and prevent the orbital complications due to facial palsy. Our team consisted of ENT, plastic surgeon for surgery. In our case, we have mobilized labyrinthine segment of the facial nerve from first genu and rotated inferiorly to allow additional extra length of the facial nerve and allow direct coaptation to the hypoglossal nerve in the neck (HHFA). This reduces the unnecessary tension over the free edge of facial nerve while anastamosing with donor nerve, in some cases it also avoids the additional usage of jump graft. Postoperative management includes the team of ophthalmology, ENT, plastic surgery, and physiotherapy. The preoperative and postoperative follow-up showed significant cosmetic benefits in terms of symmetry and orbital complications. As such there was no functional deficits observed and very minimal atrophy of tongue seen postoperatively.
Initial clinical and radiological examination should be done for patients with facial palsy. Based on the severity and considering the patients general condition, different treatment modalities have to be offered to them. Many of the times, patients do not understand the need for rehabilitation and the probable need for adjuvant therapy. Adjuvant therapy includes use of Botulinum toxin and physiotherapy HFA has no benefit if done after 1 year of facial paralysis as it leads to atrophy of facial musculature. Most of the times, the procedure cannot be done at the scheduled time as its most often delayed due to patient hesitation.
Although direct nerve transfers are the most ideal, other techniques of nerve transfer offer good results in the treatment of facial nerve palsy. Specifically, masseteric nerve helps provide good motion and hypoglossal nerve helps provide good tone. According to a study by Henstorm in 2014, masseteric nerve is identified in the subzygomatic triangle. Masseteric nerve is used due to its close proximity to facial nerve, due to its optimal length and faster rates of reinnervation, thereby correcting facial asymmetry at a faster rate but can lead to unwanted movements during mastication. Facial reanimation with the masseteric nerve can be done through direct neurotization and in neuromuscular free tissue transfers. Post operatively, patient showed tremendous improvement when followed up at 1st month and 6 months after the procedure [Figure 4].
| Conclusion|| |
Facial palsy is a disfiguring cosmetic problem which can affect emotional and mental health of patients. With the advancement of technologies and techniques, these challenges and burden on the patient can be significantly reduced. A well-planned strategic treatment plan of dual nerve facial nerve transfer has proven to be a better outcome for the patient in our case. There is no specific time period for facial reanimation; however, outcome assessment needs a minimum period of 1 year. The patient is still under follow-up.
Declaration of patient consent
The authors certify that they have obtained appropriate patient consent forms. In the forms, patient has given his consent and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]