American Society for Peripheral Nerve

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Combination of hypoglossal nerve transfer using an interpositional nerve graft with end-to-side neurorrhaphy and masseter nerve transfer for the acute to subacute facial paralysis.
Ayato Hayashi, MD, PhD1; Hidekazu Yoshizawa, MD1; Daiki Senda, MD2; Doruk Orgun, M.D.3; (1)Juntendo University Urayasu Hospital, Urayasu-city, Chiba, Japan, (2)Department of plastic and reconstructive surgery, Juntendo University of school of medicine, Tokyo, Japan, (3)Juntendo University, School of Medicine, Bunkyo-ku, Tokyo, Japan

Objective: Nerve transfers are established surgical procedures to treat acute/subacute facial paralysis. However, reanimating entire facial mimic muscles with single motor source could create synkinetic movement and it has been a problem on the conventional method.

In this presentation, we report our experience of combining hypoglossal nerve transfer using interpositional nerve graft and masseter nerve transfer to obtain better facial expression.

Method: The operation was performed on seven patients with acute to subacute complete facial paralysis Two cases were primary reconstruction after total parotidectomy and the facial nerve trunk was not available due to tumor invasion. Five cases were subacute complete facial paralysis due to intracranial tumor resection or trauma and the duration of paralysis ranged from 7 to 14 months. The hypoglossal nerve and the interpositional nerve graft was coapted with end-to-side neurorrhaphy (with partial neurectomy) and the other side of the graft was coapted either with end-to-end neurorrhaphy to the facial nerve branches or with end-to-side neurorrhaphy to the facial nerve trunk. The masseter nerve was coapted with end-to-end neurorrhaphy to the buccal branch which selectively innervates around the mouth; however, one initial case for primary reconstruction after total parotidectomy was coapted to the zygomatic branch stump.

Results: For most of the patients who underwent coaptation of the masseter nerve with the buccal branch, we could obtain good cheek movements within 5 months without synkinetic movement; however, the movement occurred only when they bite and static appearance of the face was not improved at that period. One case we coapted masseter nerve with the zygomatic branch showed quick recovery from 3 months’ post-operation; however, the movement occurred in the entire face as synkinesis. Static tone of the facial mimic muscles has recovered after reinnervation with the hypoglossal nerve, and it took 12 to 17 months after the surgery.

Conclusion: By combining the hypoglossal nerve and the masseter nerve transfer for facial reanimation, we could successfully obtain good facial movements without synkinetic phenomenons. Masseter nerve showed quick and strong recovery; however, to improve the static appearance of the face, another motor source is required. Hypoglossal nerve transfer is effective even with interpositional nerve graft with two end-to-side neurorrhaphies at both edges, however, it took long time to obtain recovery. Each motor source has its own character and we should carefully select motor sources and facial nerves for coaptation in each situation.

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