Hemihypoglossal nerve transfer for acute facial paralysis

Clinical article

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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.


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.


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.


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.



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    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.

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    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.

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    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.

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    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.

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    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).


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