Clinical Outcomes in Pediatric Dual Nerve Facial Reanimation
Molly M. McNeely, BS1, Fan Liang, MD2, Katelyn Bennet, MD1, Christian J. Vercler, MD1, William Kuzon, MD1.
1University of Michigan, Ann Arbor, MI, USA, 2University of Maryland, Baltimore, MD, USA.
PURPOSE: Dual nerve techniques in facial nerve reanimation capitalize on the synergistic effects of spontaneous motion from cross facial nerve grafting and increased excursion from ipsilateral masseteric nerve transfers. While a one-stage approach has been described, there remains concern that masseteric axons overpower cross facial axons, thereby lessening the potential for spontaneity. We propose a two-stage approach, which maximizes input from the cross facial nerve graft by delaying masseteric nerve transfer until the gracilis flap is performed, thus ensuring sufficient recipient axons for the cross facial nerve graft. The authors then sought to evaluate clinical outcomes and post-operative complications after the two-stage approach within the pediatric population.
METHODS: We retrospectively reviewed all pediatric patients who underwent two-stage dual nerve reconstruction with cross facial nerve grafts and ipsilateral masseteric nerve transfers. All procedures were performed between 2004 and 2016 by two surgeons at a single center. Both voluntary and spontaneous excursion were assessed. The degree of facial paralysis before and after surgical intervention was measured using House-Brackmann (HB) scores, and postoperative complications were reviewed.
RESULTS: A total of 9 patients with a mean age of 8.6 years (range: 5 to 15 years) at the time of surgery underwent two-stage dual nerve reconstruction. The cause of facial paralysis was either congenital (3), traumatic (3), iatrogenic (2), or idiopathic (1). Average time between cross facial nerve grafting and transfer of the free gracilis with masseteric nerve transfer was 12 months (SD 2.1). Mean follow up was 27.33 months (SD 27.31). All patients demonstrated initiation of voluntary movement on the paralyzed side by 4 months, with three demonstrating spontaneous movement by 3 months. Improvements in excursion were noted to continue at 6 months, before stabilizing around 12 months. Eight patients had initial HB scores of VI and one patient had an initial HB score of V. Final HB ratings included five patients with a score of IV, three patients with a score of III and one patient with a score of II. Post-operative complications included two hematomas, one hypertrophic scar, and one salivary leak. None required surgical intervention.
CONCLUSION: The two-stage dual innervation technique using cross facial nerve grafting and delayed ipsilateral masseteric nerve transfer with a free gracilis is a promising reconstructive option to maximize spontaneous expression. Validated, objective scoring systems for excursion are needed before a meaningful comparison can be made between this technique and one-stage approaches.
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