American Society for Peripheral Nerve

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Implications of Intracranial Facial Nerve Grafting in the Setting of Facial Reanimation
Bridget Harrison, MD; Khalil Chamseddin, MS; Gangadasu Sagar Reddy, MD; Shai Rozen, MD
UT Southwestern Medical Center

BACKGROUND: Most intracranial tumors involving the facial nerve are extirpated with nerve preservation, but when resected, and if feasible, intracranial facial nerve grafting is performed. Results likely depend on multiple factors such as age, anatomic location, pre-operative facial palsy, radiation, and gap-length. Results can vary from complete palsy to varying degrees of tonicity, synkinesis, effective motion, and ocular protection.

Purpose: Evaluate the varying degrees of facial reanimation by facial region after intracranial nerve grafting and identify implications for future facial reanimation and pre-operative consultation.

Methods: Between the years 1997-2012, twenty-seven patients underwent intracranial nerve grafting after tumor extirpation. Of the 26 candidates, 14 completed evaluations. All patients were prospectively evaluated by three physical therapists specializing in facial nerve rehabilitation and scored with Facial Disability Index (FDI), and two regional grading systems - Facial Nerve Grading System 2.0 (FNGS 2.0), and SunnyBrook Facial Grading Score (SFGS). Additionally, all patients underwent still photos and videography to assess quality of motion and tonicity in repose. Demographic and surgical variables were analyzed as to their possible effect on end results.

Results: The average age was 43 (22-66). The average time interval between nerve grafting to evaluations was 44 months (12-146). Average total FDI was 67.5% comprised of the Physical Function and Social/Well-Being portions averaging 62.8% and 72.6% respectively. Subdivisions of the physical function score with worst outcomes were eye dryness/tearing and difficulty speaking. Best outcomes were recorded in teeth brushing, eating, and drinking. FNGS 2.0 demonstrates best outcomes in Eye and Oral Commissure portions and worse in Brow and Nasolabial fold. Final FNGS 2.0 grade average was 4.3 (1-5) i.e. moderately severe dysfunction. The SFGS reveals 64.3% have oral resting symmetry, but only 28.6% resting symmetry in eye and nasolabial fold. Symmetry in voluntary movement revealed gentle eye closure and lip pucker as best 3.6 and 3.0 respectively, while brow lift as worst - 1.0 and open mouth smile at 2.0 (5-25). Total synkinesis score averaged low at 3.6 (0-15).

Conclusion: Intracranial nerve grafting does not provide consistently good facial animation but may provide periocular protection, although not symmetry. It does afford good symmetry of the midface in repose, thus potentially improving results of midface reanimation surgery by providing improved baseline tonicity with minimal synkinesis. This information is important during patient discussions if intracranial facial nerve resection and grafting is anticipated or in the interim between nerve grafting and planned future facial reanimation.

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