Two-Stage Dual-Nerve Facial Reanimation: Outcomes and Complications in a Series of Pediatric Patients

Abstract

Background: In facial reanimation via microneurovascular muscle transfer, dual-nerve reinnervation of the muscle capitalizes on the synergistic effects of spontaneous motion from cross facial nerve grafting (CFNG) and increased excursion from masseteric nerve transfer. Two-stage approaches that delay masseteric nerve transfer until the time of the muscle flap increase spontaneity by maximizing muscle reinnervation from the CFNG. While this 2-stage, dual-nerve approach has been described in adults, we present a series of pediatric patients who underwent this reconstructive technique. Methods: We retrospectively reviewed all pediatric patients who underwent 2-stage, dual-nerve reconstruction with CFNG and ipsilateral masseteric nerve transfers. Procedures were performed between 2004 and 2016 by 2 surgeons at a single centre. Degree of facial paralysis before and after surgical intervention was measured using House-Brackmann scores. Results: Nine patients with a mean age of 8.6 (range: 5-15 years) years at time of surgery underwent 2-stage, dual-nerve reconstruction. Average time between CFNG and transfer of the free gracilis with masseteric nerve transfer was 13.3 (SD 2.4) months. Mean follow-up was 27.3 months (SD 25.7). Patients demonstrated initiation of voluntary movement on paralyzed side by 3.6 months (SD 0.6) on average, with 3 patients demonstrating spontaneous movement at 3 months. Conclusion: The 2-stage, dual innervation technique using CFNG and delayed ipsilateral masseteric nerve transfer with a free gracilis is a promising reconstructive option to maximize spontaneous expression in pediatric patients. Validated, objective scoring systems for excursion are needed before meaningful comparisons can be made to other reconstructive strategies.

Innervation options for gracilis free muscle transfer in facial reanimation

“…In 2009, Watanabe et al [39] first described providing dual innervation of a free latissimus dorsi muscle transfer using the masseteric nerve and a CFNG, with evidence of dual innervation on EMG in three patients. Several years later, Biglioli et al [16] then described this same technique of dual innervation in four patients using the GFMT instead of the latissimus dorsi muscle.…”

An ACS-NSQIP Data Analysis of 30-Day Outcomes Following Surgery for Bell’s Palsy

“…Accordingly, varying (and extreme) complication rates and treatment recommendations have been documented (Supplemental Digital Content 1, Table 1, http://links.lww.com/SCS/F487). It is important to highlight that these reports of different surgical approaches have substantially advanced FP research and broadened the therapeutic armamentarium, thereby improving the quality of care for FP patients 11,14–27 . Yet, analyses of multicenter databases may help overcome the inherent limitations of such studies and mitigate bias by pooling patient data with geographical, institutional, and demographic variance.…”

“…It is important to highlight that these reports of different surgical approaches have substantially advanced FP research and broadened the therapeutic armamentarium, thereby improving the quality of care for FP patients. 11,[14][15][16][17][18][19][20][21][22][23][24][25][26][27] Yet, analyses of multicenter databases may help overcome the inherent limitations of such studies and mitigate bias by pooling patient data with geographical, institutional, and demographic variance. Thus, based on a diverse patient population, robust data on the occurrence of postoperative complications following different surgical BP techniques can be identified.…”

Dual-Innervated Gracilis Free Functional Muscle Transfers in Facial Palsy Patients: Comparing Long-Term Outcomes between One- versus Two-Stage Procedures

“…[6][7][8][9][10][11] Over the last decade, there has been an increased interest in dually innervating the FFMT, [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] often by combining the NTM with a CFNG with the thought of utilizing the quality of both donor nerves-the NTM for power and the CFNG for tone, synchroneity, and spontaneity. [9][10][11][12][13][14][15][17][18][19]21 Although this idea has some theoretical merit, no conclusive evidence exists as to its benefits. [9][10][11][12][13][14][15][17][18][19]21 Furthermore, if any benefit for dual innervation exists, the optimal configuration and staging remain unclear.…”

“…1,[3][4][5] For this reason, many surgeons abandoned the use of CFNG in adults and preferred using an ipsilateral nonfacial nerve, most commonly the nerve to masseter (NTM) to innervate the FFMT, providing sufficient power and reliability, while sacrificing spontaneity in most patients and likely resting tone. [6][7][8][9][10][11] Over the last decade, there has been an increased interest in dually innervating the FFMT, [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] often by combining the NTM with a CFNG with the thought of utilizing the quality of both donor nerves-the NTM for power and the CFNG for tone, synchroneity, and spontaneity. [9][10][11][12][13][14][15][17][18][19]21 Although this idea has some theoretical merit, no conclusive evidence exists as to its benefits.…”