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Original Investigation |

Transposition of the Intratemporal Facial to Hypoglossal Nerve for Reanimation of the Paralyzed Face The VII to XII TranspositionTechnique

Amit Kochhar, MD1; Monirah Albathi, MBBS2; Jeffrey D. Sharon, MD2; Lisa E. Ishii, MD, MHS2; Patrick Byrne, MD, MBA2; Kofi D. Boahene, MD2
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, University of California Los Angeles, Los Angeles
2Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland
JAMA Facial Plast Surg. 2016;18(5):370-378. doi:10.1001/jamafacial.2016.0514.
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Importance  The hypoglossal nerve has long been an axonal source for reinnervation of the paralyzed face. In this study, we report our experience with transposition of the intratemporal facial nerve to the hypoglossal nerve for facial reanimation.

Objectives  To determine the feasibility and outcomes of the transposition of the infratemeporal facial nerve for end-to-side coaptation to the hypoglossal nerve for facial reanimation.

Design, Settings, and Participants  A case series of 20 patients with facial paralysis who underwent mobilization and transposition of the intratemporal segment of the facial nerve for an end-to-side coaptation to the hypoglossal nerve (the VII to XII technique). Participants were treated between January 2007 and December 2014 at a tertiary care center.

Main Outcomes and Measures  Outcome measures include paralysis duration, facial tone, facial symmetry at rest, and with smile, oral commissure excursion, post-reanimation volitional smile, and synkinesis.

Methods  Demographic data, the effects of this technique on facial tone, symmetry, oral commissure excursion and smile recovery were evaluated. Preoperative and postoperative photography and videography were reviewed. Facial symmetry was assessed with a facial asymmetry index. Smile outcomes were evaluated with a visual smile recovery scale, and lip excursion was assessed with the MEEI-SMILE system.

Results  All 20 patients had adequate length of facial nerve mobilized for direct end-to-side coaptation to the hypoglossal nerve. The median duration of facial paralysis prior to treatment was 11.4 months. Median follow-up time was 29 months. Three patients were excluded from functional analysis due to lack of follow-up. Facial symmetry at rest and during animation improved in 16 of 17 patients. The median (range) time for return of facial muscle tone was 7.3 (2.0-12.0) months. A significant reduction in facial asymmetry index occurred at rest and with movement. The MEEI FACE-gram software detected a significant increase in horizontal, vertical, overall lip excursion and smile angle. No patient developed significant tongue atrophy, impaired tongue mobility, or speech or swallow dysfunction.

Conclusions and Relevence  Mobilization of the intratemporal segment of the facial nerve provides adequate length for direct end-to-end coaptation to the hypoglossal nerve and is effective in restoring facial tone and symmetry after facial paralysis. The resulting smile is symmetric or nearly symmetric in the majority of patients with varying degree of dental show. The additional length provided by utilizing the intratemporal segment of the facial nerve reduces the deficits associated with complete hypoglossal division/splitting, and avoids the need for interposition grafts and multiple coaptation sites.

Level of Evidence  4.

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Figure 1.
The VII to XII Technique

A, The vertical segment of the facial nerve decompression is exposed after mastoidectomy. B, The transposed facial nerve is coapted to the hypoglossal nerve anastamosis. The inset illustrates coaption with 30% to 40% neurotomy, distal to the ansa cervicalis take-off. Although the geometric configuration of the facial nerve to the hypoglossal nerve is end-to-side, the axons are oriented end-to-end. C, Intraoperative photograph showing the mobilized and transposed facial nerve (yellow arrowhead, hypoglossal nerve; white arrowhead, ansa cervicalis; blue arrowhead, transposed facial nerve). Approximately 4 cm of facial nerve length is gained with this approach for a tension-free coaptation. AC indicates ansa cervicalis; dFN, decompressed facial nerve; ESC, end-to-side coaptation; tFN, transposed facial nerve; XII, hypoglossal nerve.

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Figure 2.
Example of FAI Measurement

A, FAI = 2.6; B, FAI = 6.5; C, FAI = 0.1; D, FAI = 0.1 (at 28 months follow-up). A typical Mona Lisa smile is represented here with improved tone and contraction of the left lower eyelid, definition of the nasaolabial fold, and symmetric elevation of the oral commissure relative to the nonparalyzed right side. FAI indicates facial asymmetry index.

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Figure 3.
Correction of the FAI Following the VII to XII Procedure

The FAI measures the difference in slope between the 2 lines, each measured from the medial canthus to the oral commissure on the affected and nonaffected sides of the face. Data are presented for mean FAI scores preoperatively and postoperatively at rest (solid line) and with dynamic movement or smile (dashed line). FAI indicates facial asymmetry index.

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Figure 4.
Mean Oral Commissure Excursion

Improvement in horizontal, vertical, and overall excursion from preoperative to postoperative measurements is compared with the nonparalyzed side. The mean oral commisure excursion was evaluated using the MEEI Face-Gram software.17

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Figure 5.
Preoperative and 66-Month Postoperative Photographs After VII to XII Procedure

A-C, Preoperative photographs. D-F, Postoperative photographs. Note that the paralyzed right upper lip has nearly symmetric bulk and tone relative to the nonparalyzed left side.

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