Hemihypoglossal nerve transfer for acute facial paralysis

Clinical article

Restricted access

Object

The authors have developed a technique for the treatment of facial paralysis that utilizes anastomosis of the split hypoglossal and facial nerve. Here, they document improvements in the procedure and experimental evidence supporting the approach.

Methods

They analyzed outcomes in 36 patients who underwent the procedure, all of whom had suffered from facial paralysis following the removal of large vestibular schwannomas. The average period of paralysis was 6.2 months. The authors used 5 different variations of a procedure for selecting the split nerve, including evaluation of the split nerve using recordings of evoked potentials in the tongue.

Results

Successful facial reanimation was achieved in 16 of 17 patients using the cephalad side of the split hypoglossal nerve and in 15 of 15 patients using the caudal side. The single unsuccessful case using the cephalad side of the split nerve resulted from severe infection of the cheek. Procedures using the ansa cervicalis branch yielded poor success rates (2 of 4 cases).

Some tongue atrophy was observed in all variants of the procedure, with 17 cases of minimal atrophy and 14 cases of moderate atrophy. No procedure led to severe atrophy causing functional deficits of the tongue.

Conclusions

The split hypoglossal-facial nerve anastomosis procedure consistently leads to good facial reanimation, and the use of either half of the split hypoglossal nerve results in facial reanimation and moderate tongue atrophy.

Abbreviations used in this paper:CFNG = cross-face nerve graft; HB = House-Brackmann; HHFNT = hemihypoglossal-facial nerve transfer.

Article Information

Address correspondence to: Ayato Hayashi, M.D., Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan. email: ayhayasi@juntendo.ac.jp.

Please include this information when citing this paper: published online October 26, 2012; DOI: 10.3171/2012.9.JNS1270.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Drawing featuring the HHFNT procedure. The hypoglossal nerve is split in half longitudinally and anastomosed to the transected facial trunk in an end-to-end fashion. Printed with the permission of Akira Yanai, 2012.

  • View in gallery

    A: Schematic showing a lead plate under the hypoglossal nerve to protect adjacent tissues from injury while splitting the hypoglossal nerve. B: Schematic depicting a nerve graft made to fill the longitudinal nerve defect of the hypoglossal nerve after transfer. C: Intraoperative photograph showing uniform longitudinal dissection of the hypoglossal nerve. D: Intraoperative photograph showing transection of the facial nerve trunk and flipping it toward the split hypoglossal nerve. E: Intraoperative photograph showing suturing of the facial and split hypoglossal nerves via end-to-end neurorrhaphy. Schematics printed with the permission of Akira Yanai, 2012.

  • View in gallery

    A: Photograph showing electrical stimulation of each half of the split hypoglossal nerve. The evoked potential of the tongue is recorded via electrodes. B: Image showing the recorded evoked potential.

  • View in gallery

    Photographs illustrating tongue mobility. By observing signs of deformity, atrophy, and tongue movements, mobility was graded as exhibiting little to severe atrophy. The case of severe atrophy featured here involved complete hypoglossal nerve paralysis due to a brain tumor.

  • View in gallery

    Case 8. Images obtained in a 59-year-old man, showing the effects of facial paralysis following the removal of a vestibular schwannoma. The facial nerve was transected during surgery, and HHFNT was performed 1.5 months after paralysis using the procedure from our second period (cephalad side of hypoglossal nerve). Preoperative images obtained when the patient had HB Grade V facial nerve function: at rest (A) and on closure of the eye (D). Images obtained 2 years postoperatively when the patient had HB Grade III facial nerve function: at rest (B) and on complete closure of the eye (E). Facial symmetry was restored. Facial movement with tongue movement was possible (C). Facial reanimation was achieved without excessive movement but was somewhat synkinetic. Tongue appearance exhibited moderate atrophy (F).

References

  • 1

    Arai HSato KYanai A: Hemihypoglossal-facial nerve anastomosis in treating unilateral facial palsy after acoustic neurinoma resection. J Neurosurg 82:51541995

  • 2

    Asaoka KSawamura YNagashima MFukushima T: Surgical anatomy for direct hypoglossal-facial nerve side-to-end “anastomosis. J Neurosurg 91:2682751999

  • 3

    Ballance CABallance HAStewart P: Remarks on the operative treatment of chronic facial palsy of peripheral origin. BMJ 1:100910131903

  • 4

    Caldwell EH: Anastomosis of the branches of the facial and spinal accessory nerves for facial paralysis. Surgery 44:978 9831958

  • 5

    Conley JHypoglossal–facial nerve anastomosis. Brackmann DE: Neurological Surgery of the Ear and Skull Base New YorkRaven Press1982. 9398

  • 6

    Conley JBaker DC: Hypoglossal-facial nerve anastomosis for reinnervation of the paralyzed face. Plast Reconstr Surg 63:63721979

  • 7

    Coombs CJEk EWWu TCleland HLeung MK: Masseteric-facial nerve coaptation—an alternative technique for facial nerve reinnervation. J Plast Reconstr Aesthet Surg 62:158015882009

  • 8

    Cusimano MDSekhar L: Partial hypoglossal to facial nerve anastomosis for reinnervation of the paralyzed face in patients with lower cranial nerve palsies: technical note. Neurosurgery 35:5325341994

  • 9

    Frey MHappak WGirsch WBittner REGruber H: Histomorphometric studies in patients with facial palsy treated by functional muscle transplantation: new aspects for the surgical concept. Ann Plast Surg 26:3703791991

  • 10

    Hammerschlag PE: Facial reanimation with jump interpositional graft hypoglossal facial anastomosis and hypoglossal facial anastomosis: evolution in management of facial paralysis. Laryngoscope 109:2 Pt 2 Suppl 901231999

  • 11

    Harii KAsato HYoshimura KSugawara YNakatsuka TUeda K: One-stage transfer of the latissimus dorsi muscle for reanimation of a paralyzed face: a new alternative. Plast Reconstr Surg 102:9419511998

  • 12

    Harii KOhmori KTorii S: Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg 57:1331431976

  • 13

    Harrison DH: The pectoralis minor vascularized muscle graft for the treatment of unilateral facial palsy. Plast Reconstr Surg 75:2062161985

  • 14

    Hayashi APannucci CMoradzadeh AKawamura DMagill CHunter DA: Axotomy or compression is required for axonal sprouting following end-to-side neurorrhaphy. Exp Neurol 211:5395502008

  • 15

    Hayashi AYanai AKomuro YNishida MInoue MSeki T: Collateral sprouting occurs following end-to-side neurorrhaphy. Plast Reconstr Surg 114:1291372004

  • 16

    House JWBrackmann DE: Facial nerve grading system. Otolaryngol Head Neck Surg 93:1461471985

  • 17

    Inoue MYanai A: [Physiological effects of longitudinallysplit hypoglossal-facial nerve anastomosis: an experimental study in dogs.]. J Jpn P R S 22:7097152002. (Jpn)

  • 18

    Iwata HYanai A: [Electrophysiological evaluation after nerve reconstructive surgery for acute facial nerve palsy.]. J Jpn P R S 26:5575652006. (Jpn)

  • 19

    Körte WBernhardt M: Ein fall von nervenpfropfung des nervus facialis auf den nervus hypoglossus. Dtsch Med Wochenschr 29:2932951903

  • 20

    Kumar PAHassan KM: Cross-face nerve graft with free-muscle transfer for reanimation of the paralyzed face: a comparative study of the single-stage and two-stage procedures. Plast Reconstr Surg 109:4514642002

  • 21

    Lee EIHurvitz KAEvans GRWirth GA: Cross-facial nerve graft: past and present. J Plast Reconstr Aesthet Surg 61:2502562008

  • 22

    Linnet JMadsen FF: Hypoglosso-facial nerve anastomosis. Acta Neurochir (Wien) 133:1121151995

  • 23

    Martins RSSocolovsky MSiqueira MGCampero A: Hemihypoglossal-facial neurorrhaphy after mastoid dissection of the facial nerve: results in 24 patients and comparison with the classic technique. Neurosurgery 63:3103172008

  • 24

    May MSobol SMMester SJ: Hypoglossal-facial nerve interpositional-jump graft for facial reanimation without tongue atrophy. Otolaryngol Head Neck Surg 104:8188251991

  • 25

    Nishida M: [End-to-side neurorrhaphy with nerve grafting: an experimental study of rats.]. J Jpn P R S 18:6446511998. (Jpn)

  • 26

    O'Brien BMFranklin JDMorrison WA: Cross-facial nerve grafts and microneurovascular free muscle transfer for long established facial palsy. Br J Plast Surg 33:2022151980

  • 27

    Pensak MLJackson CGGlasscock ME IIIGulya AJ: Facial reanimation with the VII–XII anastomosis: analysis of the functional and psychologic results. Otolaryngol Head Neck Surg 94:3053101986

  • 28

    Pitty LFTator CH: Hypoglossal-facial nerve anastomosis for facial nerve palsy following surgery for cerebellopontine angle tumors. J Neurosurg 77:7247311992

  • 29

    Rochkind SShafi MAlon MSalame KFliss DM: Facial nerve reconstruction using a split hypoglossal nerve with preservation of tongue function. J Reconstr Microsurg 24:4694742008

  • 30

    Sawamura YAbe H: Hypoglossal-facial nerve side-to-end anastomosis for preservation of hypoglossal function: results of delayed treatment with a new technique. J Neurosurg 86:2032061997

  • 31

    Scaramella LF: Anastomosis between the two facial nerves. Laryngoscope 85:135913661975

  • 32

    Seno H: [Functional and histological evaluation of the tongue after hypoglossal nerve splitting: experimental study using dogs.]. J Jpn P R S 20:1731782000. (Jpn)

  • 33

    Shirasawa TYanai A: [Anatomy of hypoglossal nerve for hypoglossal-facial nerve anastomosis.]. J Jpn P R S 21:3003042001. (Jpn)

  • 34

    Sood SAnthony RHomer JJVan Hille PFenwick JD: Hypoglossal-facial nerve anastomosis: assessment of clinical results and patient benefit for facial nerve palsy following acoustic neuroma excision. Clin Otolaryngol Allied Sci 25:2192262000

  • 35

    Terzis JK: Pectoralis minor: a unique muscle for correction of facial palsy. Plast Reconstr Surg 83:7677761989

  • 36

    Terzis JKNoah ME: Analysis of 100 cases of free-muscle transplantation for facial paralysis. Plast Reconstr Surg 99:190519211997

  • 37

    Terzis JKOlivares FS: Long-term outcomes of free-muscle transfer for smile restoration in adults. Plast Reconstr Surg 123:8778882009

  • 38

    Terzis JKOlivares FS: Long-term outcomes of free muscle transfer for smile restoration in children. Plast Reconstr Surg 123:5435552009

  • 39

    Terzis JKOlivares FS: Use of mini-temporalis transposition to improve free muscle outcomes for smile. Plast Reconstr Surg 122:172317322008

  • 40

    Yamamoto YSekido MFurukawa HOyama ATsutsumida ASasaki S: Surgical rehabilitation of reversible facial palsy: facial—hypoglossal network system based on neural signal augmentation/neural supercharge concept. J Plast Reconstr Aesthet Surg 60:2232312007

  • 41

    Yoleri LSongür EYoleri OVural TCağdaş A: Reanimation of early facial paralysis with hypoglossal/facial end-to-side neurorrhaphy: a new approach. J Reconstr Microsurg 16:3473562000

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 201 201 47
Full Text Views 204 204 5
PDF Downloads 131 131 5
EPUB Downloads 0 0 0

PubMed

Google Scholar