AUTHOR(S): Stephanian, Erick, M.D.; Sekhar, Laligam N., M.D., F.A.C.S.; Janecka, Ivo P., M.D., F.A.C.S.; Hirsch, Barry, M.D. Departments of Neurosurgery (ES, LNS) and Otolaryngology-Head and Neck Surgery (IPJ, BH), University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania Neurosurgery 31; 73-77, 1992 ABSTRACT: RESECTION OF TUMORS of the posterior cranial base may incorporate a segment of the facial nerve because of tumor infiltration, or may result in unplanned nerve injury. Immediate repair of the facial nerve by resuture or with an autogenous nerve graft is highly desirable to ensure optimal recovery of facial function. Twenty-four patients who underwent extensive surgery of the posterior skull base and facial nerve reconstruction were studied. Of these, 12 patients had preoperative facial weakness and 3 had facial palsy. All patients underwent graft reconstruction from the subarachnoid or labyrinthine portion of the facial nerve to the fallopian or extracranial segment. The greater auricular nerve was used as a graft in 14 patients, and the sural nerve in 10. Two patients died of their disease soon after surgery, and, therefore, were excluded from our follow-up. In the remaining 22 patients, the median follow-up time was 20 months. As evaluated by the House-Brackmann grading system, 45% (10/22) of the surviving patients achieved a good recovery of facial function, 36% (8/22) attained a fair recovery, and 18% (4/22) had minimal or no recovery. There was no statistical correlation between the length of the graft used and the degree or timing of clinical recovery. The surgical result obtained in all patients with complete preoperative facial palsy and in one patient with dense facial paresis was poor. KEY WORDS: Facial nerve; Nerve repair; Skull base tumor During surgery of the posterior cranial base, excision and grafting of a segment of the facial nerve may be indicated under the following conditions: 1) when the facial nerve is incorporated in the three-dimensional radical resection of extensive malignant tumors of the temporal bone; 2) when the nerve is found intraoperatively to be invaded by or firmly attached to locally infiltrative malignant or benign tumors; and 3) when there is iatrogenic injury to a segment of the 7th nerve during the surgical manipulation. Loss of facial expression can have devastating consequences for the patient; therefore, the therapeutic approach to these aggressive tumors of the skull base should include the reconstruction of the facial nerve. Immediate repair of the discontinuity in the facial
nerve is important to allow for optimal as well as timely recovery of facial function. The objectives of surgical repair of the facial nerve include reestablishment of facial symmetry and elements of facial expression, while preventing uncontrolled movements. If there is a wide gap to be bridged, and the proximal and distal stumps of the facial nerve are viable, autogenous nerve grafting provides the best results (5). Although multiple factors may contribute to the survival and success of these grafts (4,8,10,12,13), several factors are of paramount importance: the use of atraumatic microsurgical technique in the handling of neural tissues, the avoidance of tension at the anastomotic sites, and the provision of adequate vascularity to the nerve graft by means of reconstruction of the cranial base with vascularized tissue. The present report focuses on the surgical technique used, and the evaluation of results in 22 patients in whom the facial nerve was grafted after extensive skull base surgery. An overview of different surgical techniques used in facial reanimation is also presented, and the issue of a uniform grading system of recovery is discussed. PATIENTS AND MATERIALS During a 4-year period, 24 patients (14 males and 10 females) underwent reconstruction of the facial nerve with a graft during operations for cranial base lesions. These operations were performed by a neurosurgeon (LNS) and an otolaryngologist (IPJ or BH). The mean age of patients was 46 years (range, 19 months to 67 years). As seen in Table 1, 9 patients had normal preoperative facial function, 12 had mild to moderate facial paresis, and 3 had complete preoperative facial palsy. The duration of preoperative facial paresis in the 12 patients with this level of function was less than 1 year in 6 patients, 1 to 2 years in 4 patients, and more than 2 years in 2 patients. The duration of complete preoperative facial paralysis was 6 months in 2 patients and 2 months in another. Our patients harbored a variety of tumors (Table 2); most commonly, a segment of the facial nerve was incorporated within the en bloc resection of the temporal bone for malignant squamous cell carcinoma. Many patients, however, had histologically benign but biologically aggressive tumors that had recurred despite multiple previous attempts at excision. Patients were selected for surgery if clinical and imaging studies (computed tomography and/or magnetic resonance imaging) disclosed extensive tumor in the middle and posterior fossa or neoplastic invasion of the temporal bone. In five cases, a lengthy segment of the facial nerve was grafted after resection of the temporal bone for invasive malignant squamous cell carcinoma. In 18 patients, a graft was performed after tumor removal including excision of a tumor-infiltrated segment of the nerve. One additional patient had the facial nerve grafted after inadvertent injury to the nerve during tumor removal. The greater auricular nerve was used as an interposition graft in 14 patients and the sural nerve was used in 10. Athough grafts of varying lengths
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Neurosurgery 1992-98 July 1992, Volume 31, Number 1 73 Facial Nerve Repair by Interposition Nerve Graft: Results in 22 Patients Clinical Study
GRAFTING TECHNIQUE After resection of the tumor with the diseased portion of the facial nerve, the nerve stumps are trimmed under the microscope until healthy neural fascicles are identified. If the nerve ends cannot be reapproximated by primary suture without tension, mobilization of the intratemporal portion is performed when possible in an attempt to gain additional length. If this is not possible, an autologous interposition graft is employed to avoid tension at the site of neurorrhaphy. Grafting should take place at the time of initial tumor resection, to give the patient the best chance of timely recovery of facial function. Scarring and local distortion of the anatomy make grafting at a later date more difficult and possibly less likely to succeed (5,15). The greater auricular nerve is preferred, since it is located in the surgical area (1) but, when this is not available, the sural nerve may be used as the graft for facial nerve repair. These nerves are both easy to access, and often larger in diameter than the facial nerve. It is of utmost importance to handle these tissues using meticulous, atraumatic technique to prevent damage to endoneurial elements. In addition, the graft should be harvested only after preparatory work on the facial nerve stumps has been completed. There is some evidence that immediate transfer of the graft minimizes the length of time that the Schwann cells are outside the body, thereby enhancing their survival and increasing the likelihood of a successful graft (8). The most important principle in the performance of these grafts is the avoidance of tension at the anastomotic sites and good approximation of the nerve stumps without intervening fibrous tissue. Tension at the suture lines results in connective tissue growth between the apposed ends, hindering axonal growth across the gap (8). On the other hand, excess graft length increases the distance for axons to travel within the conduit. The interposition graft is denuded of epineurium near the anastomotic site. Under magnification, the proximal anastomosis is performed using one or two 10-0 monofilament nylon sutures, and can be further
stabilized using autologous fibrin glue. The sutures through the graft are placed superficially through the epineurium, avoiding disruption of endoneurial channels deeper within the nerve trunk. The suturing of the graft to the stump of the proximal facial nerve in the cerebellopontine angle may be difficult due to the lack of a well-defined epineurium. This suture is usually placed through the center of the nerve. In general, three or four 10-0 nylon epineural sutures are used for the distal anastomosis, which is easier to perform. The nerve graft must be seated on a vascularized bed, usually provided by a temporalis muscle flap or another type of distant muscle flap. RESULTS Two patients died as a result of their disease 4 and 6 months after surgery, and have been excluded from the follow-up analysis. The remaining 22 patients have been followed up for a median of 20 months (range, 6-65 months). Of these 22, 10 patients (45%) were deemed to have had good recovery of facial function (House-Brackmann Grade III), 8 (36%) had a fair recovery (House-Brackmann Grade IV), and 4 (18%) had poor or no recovery of facial function whatsoever (Table 4). The group with poor results included the 3 patients with complete preoperative facial paralysis and 1 patient with moderately dense facial paresis (Table 5). A standard analysis of variance showed no statistical correlation between the timing or degree of recovery and the length of the segment grafted. Although the timing of initial recovery varied, there appeared to be a general trend towards a quicker recovery when the facial nerve was interrupted more distally in its course. DISCUSSION Several surgical techniques are used in reconstruction and reanimation of the facial nerve. Dott technique The use of nerve grafts for reconstructing the continuity of the facial nerve has been previously reported (2,3,6,13,14). In 1958, Dott (6) performed a simple two-stage technique for grafting the facial nerve from the subarachnoid segment to its extrapetrous segment distal to the stylomastoid foramen. The first stage entailed suture of the graft to the proximal stump of the facial nerve. The graft was then led out through the craniotomy and passed through a tunnel created between the sternocleidomastoid muscle and the splenius muscle of the head, marking its distal end with a silver clip. In the second stage, 3 months later, the distal end of the graft was anastomosed to the peripheral stump of the facial nerve. Using this technique and employing "degenerated" nerve grafts in four patients, Dott reported "excellent" recovery in two patients and "fair" recovery in another two. Later, using the Dott technique, Drake (7) was able to obtain "good" results in four patients. Samii-Draf technique A short graft method for intracranial-intratemporal repair of the facial nerve was developed by Samii (15)
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
were employed (Table 3), essentially two types of grafts were performed: 1) long grafts from the subarachnoid to the extratemporal portion of the facial nerve, and 2) short grafts from the labyrinthine segment to the mastoid segment (Fig. 1). Our followup assessment protocol consisted of serial clinical examinations at 3 and 6 months after repair, and at 6month intervals thereafter. All patients were encouraged to return for outpatient follow-up at our institution, although for a small number who lived at a distance, follow-up was provided by the referring physician. To assess the degree of recovery, photographs of the patient were taken with the face at rest, closing the eyes gently, closing the eyes tightly, pursing the lips, smiling, and attempting to raise the eyebrows. The House-Brackmann grading system was used to grade the degree of recovery of facial function based on these photographs as well as on clinical examinations (9).
Hypoglossal-facial cross-over Cross-over of the facial nerve with a neighboring nerve such as the hypoglossal is appropriate only when the stump of the proximal facial nerve is not available for autogenous grafting. In May's (11) experience with 11 patients reanimated by this technique, the procedure was reported to have been successful in 10 patients. Of these, 2 patients had "superb" results, 3 had "excellent" results, and 5 were deemed as having "good" results. Only 1 patient in this series had a "fair" recovery of facial function. However, the technique provided spontaneous facial expression in only 2 patients, whereas only 3 patients had independent eye and mouth movement. Conley (4) , with the largest experience of hypoglossal-facial anastomoses in over 147 patients, reported some return of movement in the middle area of the face in 95% of patients. The procedure provided good facial tone, but "few" patients were able to attain satisfactory facial expression. Furthermore, facial movements were gross and associated with tongue action. In addition, two patients experienced subsequent difficulty with eating and speaking, and two complained of excessive facial movement. Cross-facial anastomosis The technique of cross-facial anastomosis was developed for cases of unilateral facial paralysis, either to achieve some functional recovery after other reanimation techniques had failed, or to augment partial recovery after hypoglossal-facial anastomosis. The procedure entails use of long sural nerve grafts tunneled under the skin to connect several unparalyzed facial nerve branches to the paralyzed side. The overall success rate has been limited, and a lengthy period of time is needed for reinnervation to occur, given the length of the conduits used (16). Uniform reporting In evaluating our patients with autologous facial nerve grafts after skull base surgery for extensive tumors using the House-Brackmann grading system, we report good recovery of facial function in 45% of patients, fair recovery in 36%, and poor or no recovery in an additional 18%. In 1961, Conley (3), using his own grading system, reported "good" clinical recovery of facial function in 46% of patients after parotidectomy and facial nerve grafting. The result was poor in another 25% of his patients, and in 29%, the procedure was classified as a failure.
Despite the fact that a more refined classification scheme was used in the present series, our results are comparable to those of Conley. However, the results with various techniques of facial reanimation can only be usefully evaluated if a uniform scheme for grading the recovery of facial function is adopted. We believe that the House-Brackmann grading system is a straightforward and clinically useful scheme for recording the recovery and progress of facial reanimation (9). Use of this method of reporting will allow comparison of different patient series and techniques of nerve repair. Timing of repair The timing of repair is critical. We feel that grafting should take place at the time of tumor resection. Future scarring of the nerve ends and distortion of the local anatomy by scar formation may adversely affect the results of nerve grafting. Furthermore, from a purely psychological standpoint, it is more reassuring for the patient to know sooner that in time there will be recovery of facial function. Additional implementation of biofeedback techniques and a facial "exercise program" may help to enhance the results of facial nerve surgery. CONCLUSION Autologous grafting provides an adequate means of restoring the functional continuity of the facial nerve. Facial nerve grafting should, therefore, be considered in the total rehabilitative effort of patients after extensive surgery of the skull base. Finally, the House-Brackmann grading system should be uniformly adopted, since it is the simplest, yet best currently available objective scheme for grading the clinical recovery of function after facial nerve repair. ACKNOWLEDGMENTS We thank Ms. Joan Nielson and Ms. Terri Pacella for their help in the preparation of this manuscript. Received, September 16, 1991. Accepted, October 25, 1991. Reprint requests: Laligam N. Sekhar, M.D., Department of Neurosurgery, Presbyterian University Hospital, Room 9402, 230 Lothrop Street, Pittsburgh, PA 15213. REFERENCES: (1-16) 1.
2.
3. 4.
Alberti PWRM: The greater auricular nerve. Donor for facial nerve grafts: a note on its topographical anatomy. Arch Otolaryngol 76:422-424, 1962. Ballance KCMG, Duel AB: The operative treatment of facial palsy by the introduction of nerve grafts into the fallopian canal and by other intratemporal methods. Arch Otolaryngol 15:1-70, 1932. Conley JJ: Facial nerve grafting. Arch Otolaryngol 73:322-327, 1961. Conley J: Facial nerve palsy: Physiopathology and therapeutic approach, in Moldaver J, Conley J (eds): The Facial Palsies: Their
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
and Draf in 1975. They employed a 5-cm length of sural nerve, suturing the proximal end to the central stump of the facial nerve at the brain stem. The nerve graft was led through an opening in the presigmoid dura into a mastoidectomy cavity and anastomosed to either the mastoid or tympanic segment of the facial nerve. In a study of 16 patients who underwent intracranial-intratemporal grafting of the facial nerve between 1975 and 1979 using this technique, Samii (15) found "good" return of movement about the eye in all patients, "weak" frontalis function in 8 patients, and "very good" and "good" mouth movement in 6 and 2 patients, respectively.
6. 7. 8. 9. 10.
11.
12. 13. 14. 15.
16.
COMMENT The authors report the results of interposition nerve grafting in 22 patients in whom the facial nerve was resected at the time of tumor removal. They utilize both the greater auricular and the sural nerves, depending upon availability. The report includes a good review of other methods of reconstruction of the facial nerve. In 45% (10 of 22 patients) there was a "good" recovery of facial nerve function (House-Brackmann Grade III). The criteria for this grade are obvious but not disfiguring differences between the two sides, normal symmetry and tone at rest, slight to moderate movement of the forehead, complete eye closure with effort, and slightly weak movement of the mouth with maximum effort. In 36% (8 of 22) a "fair" recovery was reported (House-Brackmann Grade IV). The
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
5.
Physiopathology and Therapeutic Approaches. Springfield, IL, Charles C Thomas, 1980, pp 205-235. Conley J: Perspectives in facial reanimation, in May M (ed): The Facial Nerve. New York, Thieme, Inc., 1986, pp 645-663. Dott NM: Facial nerve reconstruction by graft bypassing the petrous bone. Arch Otolaryngol 78:426-428, 1963. Drake CG: Acoustic neuroma. Repair of facial nerve with autogenous graft. J Neurosurg 17:836-842, 1960. Fisch U: Facial nerve grafting. Otolaryngol Clin North Am 7:517- 529, 1974. House JW, Brackmann DE: Facial nerve grading system. Otolaryngol Head Neck Surg 93:146-147, 1985. May M: Methods of rehabilitation for the paralyzed face, in Graham MD, House WF (eds): Disorders of the Facial Nerve: Anatomy, Diagnosis, and Management. New York, Raven Press, 1982, pp 519-522. May M: Surgical rehabilitation of facial palsy: Total approach, in May M (ed): The Facial Nerve. New York, Thieme, Inc., 1986, pp 695777. McCabe BF: Facial nerve grafting. Plast Reconstr Surg 45:70-75, 1970. Millesi H: Nerve suture and grafting to restore the extratemporal facial nerve. Clin Plast Surg 6:333-341, 1979. Pulec JL: Facial nerve grafting. Laryngoscope 79:1562-1583, 1969. Samii M: Preservation and reconstruction of the facial nerve in the cerebellopontine angle, in Samii M, Jannetta PJ (eds): The Cranial Nerves. Berlin, Springer-Verlag, 1981, pp 438450. Tucker HM: Facial nerve crossover as an adjunct to nerve-muscle pedicle reinnervation in rehabilitation of the paralyzed face, in Graham MD, House WF (eds): Disorders of the Facial Nerve. Anatomy, Diagnosis, and Management. New York, Raven Press, 1982, pp 523-531.
Table 1. Patient Characteristics
Table 2. Types of Tumors Harbored by Patients
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Figure 1. Types of autologous interposition grafts performed in patients after resection of the facial nerve.
Table 3. Length of Graft
Table 5. Poor Functional Results of Grafting
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Table 4. Recovery of Facial Function
nerve is important to allow for optimal as well as timely recovery of facial function. The objectives of surgical repair of the facial nerve include reestablishment of facial symmetry and elements of facial expression, while preventing uncontrolled movements. If there is a wide gap to be bridged, and the proximal and distal stumps of the facial nerve are viable, autogenous nerve grafting provides the best results (5). Although multiple factors may contribute to the survival and success of these grafts (4,8,10,12,13), several factors are of paramount importance: the use of atraumatic microsurgical technique in the handling of neural tissues, the avoidance of tension at the anastomotic sites, and the provision of adequate vascularity to the nerve graft by means of reconstruction of the cranial base with vascularized tissue. The present report focuses on the surgical technique used, and the evaluation of results in 22 patients in whom the facial nerve was grafted after extensive skull base surgery. An overview of different surgical techniques used in facial reanimation is also presented, and the issue of a uniform grading system of recovery is discussed. PATIENTS AND MATERIALS During a 4-year period, 24 patients (14 males and 10 females) underwent reconstruction of the facial nerve with a graft during operations for cranial base lesions. These operations were performed by a neurosurgeon (LNS) and an otolaryngologist (IPJ or BH). The mean age of patients was 46 years (range, 19 months to 67 years). As seen in Table 1, 9 patients had normal preoperative facial function, 12 had mild to moderate facial paresis, and 3 had complete preoperative facial palsy. The duration of preoperative facial paresis in the 12 patients with this level of function was less than 1 year in 6 patients, 1 to 2 years in 4 patients, and more than 2 years in 2 patients. The duration of complete preoperative facial paralysis was 6 months in 2 patients and 2 months in another. Our patients harbored a variety of tumors (Table 2); most commonly, a segment of the facial nerve was incorporated within the en bloc resection of the temporal bone for malignant squamous cell carcinoma. Many patients, however, had histologically benign but biologically aggressive tumors that had recurred despite multiple previous attempts at excision. Patients were selected for surgery if clinical and imaging studies (computed tomography and/or magnetic resonance imaging) disclosed extensive tumor in the middle and posterior fossa or neoplastic invasion of the temporal bone. In five cases, a lengthy segment of the facial nerve was grafted after resection of the temporal bone for invasive malignant squamous cell carcinoma. In 18 patients, a graft was performed after tumor removal including excision of a tumor-infiltrated segment of the nerve. One additional patient had the facial nerve grafted after inadvertent injury to the nerve during tumor removal. The greater auricular nerve was used as an interposition graft in 14 patients and the sural nerve was used in 10. Athough grafts of varying lengths
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
Neurosurgery 1992-98 July 1992, Volume 31, Number 1 73 Facial Nerve Repair by Interposition Nerve Graft: Results in 22 Patients Clinical Study
GRAFTING TECHNIQUE After resection of the tumor with the diseased portion of the facial nerve, the nerve stumps are trimmed under the microscope until healthy neural fascicles are identified. If the nerve ends cannot be reapproximated by primary suture without tension, mobilization of the intratemporal portion is performed when possible in an attempt to gain additional length. If this is not possible, an autologous interposition graft is employed to avoid tension at the site of neurorrhaphy. Grafting should take place at the time of initial tumor resection, to give the patient the best chance of timely recovery of facial function. Scarring and local distortion of the anatomy make grafting at a later date more difficult and possibly less likely to succeed (5,15). The greater auricular nerve is preferred, since it is located in the surgical area (1) but, when this is not available, the sural nerve may be used as the graft for facial nerve repair. These nerves are both easy to access, and often larger in diameter than the facial nerve. It is of utmost importance to handle these tissues using meticulous, atraumatic technique to prevent damage to endoneurial elements. In addition, the graft should be harvested only after preparatory work on the facial nerve stumps has been completed. There is some evidence that immediate transfer of the graft minimizes the length of time that the Schwann cells are outside the body, thereby enhancing their survival and increasing the likelihood of a successful graft (8). The most important principle in the performance of these grafts is the avoidance of tension at the anastomotic sites and good approximation of the nerve stumps without intervening fibrous tissue. Tension at the suture lines results in connective tissue growth between the apposed ends, hindering axonal growth across the gap (8). On the other hand, excess graft length increases the distance for axons to travel within the conduit. The interposition graft is denuded of epineurium near the anastomotic site. Under magnification, the proximal anastomosis is performed using one or two 10-0 monofilament nylon sutures, and can be further
stabilized using autologous fibrin glue. The sutures through the graft are placed superficially through the epineurium, avoiding disruption of endoneurial channels deeper within the nerve trunk. The suturing of the graft to the stump of the proximal facial nerve in the cerebellopontine angle may be difficult due to the lack of a well-defined epineurium. This suture is usually placed through the center of the nerve. In general, three or four 10-0 nylon epineural sutures are used for the distal anastomosis, which is easier to perform. The nerve graft must be seated on a vascularized bed, usually provided by a temporalis muscle flap or another type of distant muscle flap. RESULTS Two patients died as a result of their disease 4 and 6 months after surgery, and have been excluded from the follow-up analysis. The remaining 22 patients have been followed up for a median of 20 months (range, 6-65 months). Of these 22, 10 patients (45%) were deemed to have had good recovery of facial function (House-Brackmann Grade III), 8 (36%) had a fair recovery (House-Brackmann Grade IV), and 4 (18%) had poor or no recovery of facial function whatsoever (Table 4). The group with poor results included the 3 patients with complete preoperative facial paralysis and 1 patient with moderately dense facial paresis (Table 5). A standard analysis of variance showed no statistical correlation between the timing or degree of recovery and the length of the segment grafted. Although the timing of initial recovery varied, there appeared to be a general trend towards a quicker recovery when the facial nerve was interrupted more distally in its course. DISCUSSION Several surgical techniques are used in reconstruction and reanimation of the facial nerve. Dott technique The use of nerve grafts for reconstructing the continuity of the facial nerve has been previously reported (2,3,6,13,14). In 1958, Dott (6) performed a simple two-stage technique for grafting the facial nerve from the subarachnoid segment to its extrapetrous segment distal to the stylomastoid foramen. The first stage entailed suture of the graft to the proximal stump of the facial nerve. The graft was then led out through the craniotomy and passed through a tunnel created between the sternocleidomastoid muscle and the splenius muscle of the head, marking its distal end with a silver clip. In the second stage, 3 months later, the distal end of the graft was anastomosed to the peripheral stump of the facial nerve. Using this technique and employing "degenerated" nerve grafts in four patients, Dott reported "excellent" recovery in two patients and "fair" recovery in another two. Later, using the Dott technique, Drake (7) was able to obtain "good" results in four patients. Samii-Draf technique A short graft method for intracranial-intratemporal repair of the facial nerve was developed by Samii (15)
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
were employed (Table 3), essentially two types of grafts were performed: 1) long grafts from the subarachnoid to the extratemporal portion of the facial nerve, and 2) short grafts from the labyrinthine segment to the mastoid segment (Fig. 1). Our followup assessment protocol consisted of serial clinical examinations at 3 and 6 months after repair, and at 6month intervals thereafter. All patients were encouraged to return for outpatient follow-up at our institution, although for a small number who lived at a distance, follow-up was provided by the referring physician. To assess the degree of recovery, photographs of the patient were taken with the face at rest, closing the eyes gently, closing the eyes tightly, pursing the lips, smiling, and attempting to raise the eyebrows. The House-Brackmann grading system was used to grade the degree of recovery of facial function based on these photographs as well as on clinical examinations (9).
Hypoglossal-facial cross-over Cross-over of the facial nerve with a neighboring nerve such as the hypoglossal is appropriate only when the stump of the proximal facial nerve is not available for autogenous grafting. In May's (11) experience with 11 patients reanimated by this technique, the procedure was reported to have been successful in 10 patients. Of these, 2 patients had "superb" results, 3 had "excellent" results, and 5 were deemed as having "good" results. Only 1 patient in this series had a "fair" recovery of facial function. However, the technique provided spontaneous facial expression in only 2 patients, whereas only 3 patients had independent eye and mouth movement. Conley (4) , with the largest experience of hypoglossal-facial anastomoses in over 147 patients, reported some return of movement in the middle area of the face in 95% of patients. The procedure provided good facial tone, but "few" patients were able to attain satisfactory facial expression. Furthermore, facial movements were gross and associated with tongue action. In addition, two patients experienced subsequent difficulty with eating and speaking, and two complained of excessive facial movement. Cross-facial anastomosis The technique of cross-facial anastomosis was developed for cases of unilateral facial paralysis, either to achieve some functional recovery after other reanimation techniques had failed, or to augment partial recovery after hypoglossal-facial anastomosis. The procedure entails use of long sural nerve grafts tunneled under the skin to connect several unparalyzed facial nerve branches to the paralyzed side. The overall success rate has been limited, and a lengthy period of time is needed for reinnervation to occur, given the length of the conduits used (16). Uniform reporting In evaluating our patients with autologous facial nerve grafts after skull base surgery for extensive tumors using the House-Brackmann grading system, we report good recovery of facial function in 45% of patients, fair recovery in 36%, and poor or no recovery in an additional 18%. In 1961, Conley (3), using his own grading system, reported "good" clinical recovery of facial function in 46% of patients after parotidectomy and facial nerve grafting. The result was poor in another 25% of his patients, and in 29%, the procedure was classified as a failure.
Despite the fact that a more refined classification scheme was used in the present series, our results are comparable to those of Conley. However, the results with various techniques of facial reanimation can only be usefully evaluated if a uniform scheme for grading the recovery of facial function is adopted. We believe that the House-Brackmann grading system is a straightforward and clinically useful scheme for recording the recovery and progress of facial reanimation (9). Use of this method of reporting will allow comparison of different patient series and techniques of nerve repair. Timing of repair The timing of repair is critical. We feel that grafting should take place at the time of tumor resection. Future scarring of the nerve ends and distortion of the local anatomy by scar formation may adversely affect the results of nerve grafting. Furthermore, from a purely psychological standpoint, it is more reassuring for the patient to know sooner that in time there will be recovery of facial function. Additional implementation of biofeedback techniques and a facial "exercise program" may help to enhance the results of facial nerve surgery. CONCLUSION Autologous grafting provides an adequate means of restoring the functional continuity of the facial nerve. Facial nerve grafting should, therefore, be considered in the total rehabilitative effort of patients after extensive surgery of the skull base. Finally, the House-Brackmann grading system should be uniformly adopted, since it is the simplest, yet best currently available objective scheme for grading the clinical recovery of function after facial nerve repair. ACKNOWLEDGMENTS We thank Ms. Joan Nielson and Ms. Terri Pacella for their help in the preparation of this manuscript. Received, September 16, 1991. Accepted, October 25, 1991. Reprint requests: Laligam N. Sekhar, M.D., Department of Neurosurgery, Presbyterian University Hospital, Room 9402, 230 Lothrop Street, Pittsburgh, PA 15213. REFERENCES: (1-16) 1.
2.
3. 4.
Alberti PWRM: The greater auricular nerve. Donor for facial nerve grafts: a note on its topographical anatomy. Arch Otolaryngol 76:422-424, 1962. Ballance KCMG, Duel AB: The operative treatment of facial palsy by the introduction of nerve grafts into the fallopian canal and by other intratemporal methods. Arch Otolaryngol 15:1-70, 1932. Conley JJ: Facial nerve grafting. Arch Otolaryngol 73:322-327, 1961. Conley J: Facial nerve palsy: Physiopathology and therapeutic approach, in Moldaver J, Conley J (eds): The Facial Palsies: Their
Redistribution of this article permitted only in accordance with the publisher’s copyright provisions.
and Draf in 1975. They employed a 5-cm length of sural nerve, suturing the proximal end to the central stump of the facial nerve at the brain stem. The nerve graft was led through an opening in the presigmoid dura into a mastoidectomy cavity and anastomosed to either the mastoid or tympanic segment of the facial nerve. In a study of 16 patients who underwent intracranial-intratemporal grafting of the facial nerve between 1975 and 1979 using this technique, Samii (15) found "good" return of movement about the eye in all patients, "weak" frontalis function in 8 patients, and "very good" and "good" mouth movement in 6 and 2 patients, respectively.
6. 7. 8. 9. 10.
11.
12. 13. 14. 15.
16.
COMMENT The authors report the results of interposition nerve grafting in 22 patients in whom the facial nerve was resected at the time of tumor removal. They utilize both the greater auricular and the sural nerves, depending upon availability. The report includes a good review of other methods of reconstruction of the facial nerve. In 45% (10 of 22 patients) there was a "good" recovery of facial nerve function (House-Brackmann Grade III). The criteria for this grade are obvious but not disfiguring differences between the two sides, normal symmetry and tone at rest, slight to moderate movement of the forehead, complete eye closure with effort, and slightly weak movement of the mouth with maximum effort. In 36% (8 of 22) a "fair" recovery was reported (House-Brackmann Grade IV). The
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5.
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Table 1. Patient Characteristics
Table 2. Types of Tumors Harbored by Patients
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Figure 1. Types of autologous interposition grafts performed in patients after resection of the facial nerve.
Table 3. Length of Graft
Table 5. Poor Functional Results of Grafting
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Table 4. Recovery of Facial Function
![[Repair of a facial nerve substance loss by interposition of a collagen neurotube].](/assets/img/hold.png)
