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Original Investigation |

Early Nerve Grafting for Facial Paralysis After Cerebellopontine Angle Tumor Resection With Preserved Facial Nerve Continuity

Monirah Albathi, MBBS1; Sam Oyer, MD1; Lisa E. Ishii, MD, MHS1; Patrick Byrne, MD1; Masaru Ishii, MD1; Kofi O. Boahene, MD1
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University, Baltimore, Maryland
JAMA Facial Plast Surg. 2016;18(1):54-60. doi:10.1001/jamafacial.2015.1558.
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Importance  Preserving facial nerve function is a primary goal and a key decision factor in the comprehensive management of vestibular schwannoma and other cerebellopontine angle (CPA) tumors.

Objective  To evaluate the use of the pattern of facial paralysis recovery in the early postoperative months as a sole predictor in selecting patients for facial nerve grafting after CPA tumor resection when cranial nerve VII is uninterrupted.

Design, Setting, and Participants  Sixty-two patients with facial paralysis and uninterrupted cranial nerve VII who developed facial paralysis after CPA tumor resection at The Johns Hopkins Hospital were followed up prospectively to assess for spontaneous recovery and to determine candidacy for facial reanimation surgery. The study dates and dates of analysis were January 1, 2009, to March 31, 2015.

Interventions  After a minimum of 6 months of clinical follow-up and no signs of clinical recovery, patients underwent facial nerve exploration and a masseteric or hypoglossal nerve transfer. Intraoperative direct nerve stimulation was performed to assess for the presence of subclinical reinnervation. Patients were followed up for a minimum of 18 months after surgery to evaluate outcomes.

Main Outcomes and Measures  Facial function and recovery were studied objectively with a Smile Recovery Scale, Facial Asymmetry Index, and House-Brackmann (HB) grading system. Other outcome measures included the duration of paralysis, time to recovery, and evidence of synkinesis.

Results  Sixty-two patients (33 men, 29 women; mean age 51.8 years) with uninterrupted facial nerves after CPA tumor resection developed HB grade IV, V, or VI facial paralysis. Ten patients underwent nerve grafting by 12 months, 9 patients received grafting after 12 months, and 8 patients had no intervention. Thirty-five patients spontaneously recovered. In all patients who underwent nerve grafting, there were no detectable facial muscle movements or electromyographic response to direct facial nerve stimulation suggestive of occult reinnervation. Overall, early facial reanimation surgery resulted in a shorter total duration of paralysis. Masseteric nerve grafting resulted in earlier recovery compared with hypoglossal nerve grafting (5.6 vs 10.8 months, P = .005). Patients who showed no signs of recovery by 6 months after CPA surgery but declined facial reanimation surgery demonstrated at best HB grade V recovery after 18 months of observation.

Conclusions and Relevance  The recovery pattern in the early postoperative period among patients who develop facial paralysis after CPA tumor resection is a useful clinical tool in selecting patients for facial reanimation surgery. Patients can be counseled for facial reanimation surgery as early as 6 months after surgery because satisfactory facial functional recovery is unlikely to occur when there is no clinical evidence of spontaneous nerve regeneration in the first 6 months.

Level of Evidence  3.

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Figure 1.
Facial Asymmetry Index Marked on an Image After Calibration

The medial canthus is used as a fixed-point reference, and straight lines are drawn to the angles of the mouth.

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Figure 2.
Masseteric Nerve Transfer 9 Months After the Onset of Paralysis, With Signs of Recovery by 3 Months After Facial Reanimation Surgery

A-D, Views before reanimation surgery are shown at rest (A), attempting a Mona Lisa smile (B), attempting a Duchenne smile (C), and attempting a Duchenne smile with maximal dental show (D). E-H, Views after reanimation surgery are shown at rest (E), attempting a Mona Lisa smile (F), attempting a Duchenne smile (G), and attempting a Duchenne smile with maximal dental show (H).

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