Original Article

Reconstructive
Early Simultaneous Cross Facial Nerve Graft and
Masseteric Nerve Transfer for Facial Paralysis after
Tumor Resection
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Amanda R. Sergesketter, MD*

Ronnie L. Shammas, MD* Background: We describe a new approach for facial reanimation after skull base
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Lisa A. Massa, PT, WCS†
Brett T. Phillips, MD, MBA*
Jeffrey R. Marcus, MD*
tumor resection with known facial nerve sacrifice, involving simultaneous masseter
nerve transfer with selective cross facial nerve grafting (CFNG) within days after
tumor surgery. This preliminary study compared outcomes of this approach versus
a staged procedure involving a masseter nerve “babysitter” performed in a delayed
timeline.
Methods: Patients undergoing masseter nerve transfer and CFNG for facial
paralysis after skull base tumor resection were consented to participate in video
interviews. Facial Clinimetric Evaluation (FaCE) Scale (0–100) patient-reported
outcome, eFACE, and Facial Grading Scale scores were compared.
Results: Nine patients had unilateral facial paralysis from resection of a schwan-
noma (56%), acoustic neuroma (33%), or vascular malformation (11%). Five
underwent early simultaneous CFNG and masseter nerve transfer (mean 3.6 days
after resection), whereas four underwent two-stage reanimation including a baby-
sitter procedure (mean 218 days after resection). Postoperative FaCE scale and
Facial Grading Scale scores were similar in both groups (P > 0.05). Postoperative
mean eFACE scores were similar for both groups for smile (early: 71.5 versus
delayed: 75.5; P = 0.08), static (76.3 versus 82.1; P = 0.32), and dynamic scores (59.7
versus 64.9; P = 0.19); however, synkinesis scores were inferior in the early group
(76.4 versus 91.1; P = 0.04).
Conclusions: Early simultaneous masseter nerve transfer and CFNG provides
reanimated movement sooner and in fewer stages than a staged approach in a
delayed timeline. The early technique appears to result in similar clinician- and
patient-reported outcomes compared with delayed procedures; however, in
this preliminary study, the early approach was associated with greater synkine-
sis, meriting further investigation. (Plast Reconstr Surg Glob Open 2023; 11:e4869;
doi: 10.1097/GOX.0000000000004869; Published online 10 March 2023.)

INTRODUCTION quality of life in patients with congenital or acquired

Facial paralysis is associated with functional, aesthetic,
and social disability with implications for worsened
From the *Division of Plastic, Oral, and Maxillofacial Surgery,
Duke University, Durham, N.C.; and †Duke Department of
Physical & Occupational Therapy, Durham, N.C.
Received for publication November 30, 2022; accepted January 27,
2023.
Presented at ASRM 2021, Carlsbad, California.
Drs. Phillips and Marcus contributed equally to this work.
Copyright © 2023 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
DOI: 10.1097/GOX.0000000000004869
facial palsy.1–5 Five percent of facial paralysis cases stem
from intracranial tumor resection, which may require
sacrifice of the facial nerve and thereby necessitate facial
reanimation procedures for restoration of symmetry
and mimetic function.6 After tumor extirpation, facial
reanimation has been associated with improvements in
dynamic function, symmetry, psychologic well-being, and
social interaction.6,7 However, debate continues regarding
the optimum approach and timing of reanimation in this
population.
The cross facial nerve graft was first described after
intracranial tumor resection in 1971.8 More recently,
combined techniques using cross facial nerve grafts with
secondary motor sources such as hypoglossal or masseter
nerve “babysitters” have been introduced to overcome
Disclosure: The authors have no financial interest in rela-
tion to the content of this article.

www.PRSGlobalOpen.com 1

the prolonged denervation time of cross facial nerve
grafting alone. These combinations prevent atrophy
of the native facial muscles and improve power via the
secondary motor source.9,10 Compared with hypoglos-
sal transfers, masseter nerve transfers have been shown
to result in less synkinesis,11 and combined cross facial
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nerve grafts and masseter transfers have been shown to
lead to favorable functional outcomes, spontaneity, and
symmetry after tumor resection.10 However, previously,
techniques involving simultaneous masseter nerve trans-
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fer and cross facial nerve grafting have been performed
in a delayed setting.10,12
Prolonged denervation time has been associated with
inferior outcomes following facial reanimation.6,13 When
performing dual source reanimation in a delayed fash-
ion, the targets of the cross facial grafts may not receive
a motor signal for 6 months or more added to denerva-
tion time from tumor resection because the coaptations
on the paralyzed side are done downstream to the masse-
ter transfer. In addition, the coaptations on the paralyzed
side cannot be done with selectivity because the native
facial muscles cannot be stimulated. To address these
limitations, the senior author (J.R.M.) instituted an early
simultaneous nerve transfer technique for patients with
known facial nerve sacrifice following skull base tumor
resection. The approach involves one-stage masseter
nerve transfer and cross facial nerve grafting during the
same hospital admission as tumor resection. Within this
time frame, the native facial muscles are often stimulable
for several days after denervation, enabling selectivity at
the time of coaptation. Before the availability of this tech-
nique, patients underwent a two-stage approach using
the masseter nerve as a babysitter with coaptation of the
cross facial nerve grafts on the paralyzed side once the
babysitter resulted in function and stimulability. The aim
of this study was to describe this early technique, and to
compare patient- and clinician-graded outcomes between
both approaches.
METHODS
After institutional review board approval, patients
with facial paralysis after intracranial tumor resection
undergoing facial reanimation at Duke University from
2017 to 2020 were reviewed. Patients were excluded
who underwent free muscle transfer and had less than
12 months of follow-up. Patients with pre-existing facial
weakness at the time of tumor resection were not con-
sidered candidates for the early approach described.
Eligible patients were contacted by phone and consented
to participate. Consented participants were emailed
a link to complete the Facial Clinimetric Evaluation
(FaCE) scale patient-reported outcome instrument,14
and recorded video interviews were scheduled with
patients via WebEx (Cisco Systems, San Jose, CA). The
eFACE clinician-graded tool was used to score video
interviews and to score existing videos collected pre- and
postoperatively by clinicians.15,16 All videos were scored
by two independent clinicians (A.R.S. and B.T.P.), and
weighted averages were used for analyses. Sunnybrook
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PRS Global Open • 2023
Takeaways
Question: Can facial reanimation after skull base tumor
resection be performed days within tumor surgery with
simultaneous masseter nerve transfer with selective cross
facial nerve grafting (CFNG)?
Findings: Early simultaneous masseter nerve transfer and
CFNG provides reanimated movement sooner and in
fewer stages than a staged approach. The early technique
appears to result in similar clinician- and patient-reported
outcomes compared to delayed procedures.
Meaning: Early simultaenous approaches to facial reani-
mation after skull base tumor resection may result in simi-
lar outcomes, but larger studies are needed.
Facial Grading Scale17 (FGS) scores were collected by
facial paralysis physical therapists during routine post-
operative therapy appointments. Finally, retrospective
chart review was performed for variables, including age,
tumor pathology, laterality, dates of initial resection and
reanimation, operative time, and secondary procedures
performed after reanimation.
New “Early Simultaneous” Technique
The senior author developed an “early simultaneous”
approach to combined cross facial nerve grafting and
masseter transfer, performed in a single stage 3–5 days
following resection. These procedures are performed
3–5 days after and not immediately at the time of extirpa-
tion surgery given that the complete facial nerve loss is
unplanned, and this period allows for patient counseling
and consent regarding the procedure as well as coordi-
nation for additional lengthy surgery position changes.
Briefly, a sural nerve harvest is performed in prone posi-
tion to obtain maximal length sufficient for two cross
facial grafts. After position change, exposure of the facial
nerve on the paralyzed and nonparalyzed sides are per-
formed via a modified facelift approach. On the nonpara-
lyzed side, the native facial nerve is stimulated to identify
specific branches to provide (1) smile and (2) eyelid clo-
sure. Two cross facial nerve graft strands are coapted end-
to-end to the selected donor branches. On the paralyzed
side, two branches of the facial nerve are also selected as
targets to recapitulate smile and eye closure similarly to
contralateral donor branches. For target nerve selection,
Checkpoint (Checkpoint Surgical Inc., Independence,
OH) (0.5–20 mA), Neurosign 100 (Neurosign, Newport,
United Kingdom) (0.5–5 mA), and Radionics (type 433-
A) (Radionics, Inc., Burlington, MA) (0–100 Volts) nerve
stimulators are used. In most instances, when performed
early after tumor resection, the paralyzed facial nerve
branches remain stimulable. The two cross facial nerve
grafts are coapted end-to-end to the identified targets.
The masseter nerve is identified according to the tech-
nique described by the senior author.18 The masseter
nerve to facial nerve transfer is performed end-to-end by
coapting the distal masseter nerve branch of the trigemi-
nal nerve to the selected site of the proximal facial nerve
(Fig. 1).
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Fig. 1. “Early simultaneous” technique. AP view (A) and lateral view (B) of the technique involving coaptation of CFNG on nonparalyzed
(left) and paralyzed (right) sides with concurrent masseteric nerve transfer in a single stage. This approach is typically performed the
week following tumor resection.

“Delayed Babysitter” Technique is performed, where it serves as a “babysitter.” The facial

The initial steps for “delayed babysitter” approaches
are the same, including sural nerve harvest, facial nerve
exposure, masseter nerve transfer on the paralyzed side,
and identification of two donor branches on the non-
paralyzed side for smile and eye closure. The two cross
facial nerve grafts are coapted end-to-end to the selected
donor facial nerve branches and tunneled to the para-
lyzed side across the anterior maxilla in the preperiosteal
plane below the piriform and anterior nasal spine. The
distal ends of the grafts are tagged with color-coded silas-
tic markers denoting the function of the graft based on
its associated donor branch. The masseter nerve transfer
nerve in these cases is not stimulable, and the color-
coded ends of the cross facial grafts are left in anatomic
proximity to presumed targets based on patterns on the
nonparalyzed side. The second stage is performed once
clinically significant return of facial movement has been
observed from the masseter nerve transfer. The incision is
reopened, and the prior cross facial nerve grafts are iden-
tified. The facial nerve is stimulated and dissected distally
to identify ideal targets for smile and eye closure. External
neurolysis is performed to dissect the prior cross facial
grafts from scar tissue, and the two cross facial nerve grafts
are coapted end-to-end to the target branches (Fig. 2).

Fig. 2. “Delayed babysitter” technique. AP view (A) and lateral view (B) of technique involving delayed coaptation of CFNG on nonpara-
lyzed side with concurrent masseteric nerve transfer in the first stage, with tunneling of the distal ends of the CFNG to the paralyzed
side. The second stage procedure is shown in the magnified circles in Figure 2A, involving selective coaptation of CFNG distal stump
on the paralyzed side to branches for eye closure and smile.

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Table 1. Demographics, Tumor Characteristics, and Secondary Procedures by CFNG Timing

Early Simultaneous Delayed Babysitter
(n = 5) (n = 4) P
Age, mean (SD) 45.4 (17.3) 36.0 (14.9) 0.42
Pathology, n (%) 0.17
 Schwannoma 4 (80.0%) 1 (25.0%)
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 Acoustic neuroma 1 (20.0%) 2 (50.0%)

 Vascular malformation 0 (0%) 1 (25.0%)
Laterality, n (%) 0.29
 Right 2 (40.0%) 3 (75.0%)
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 Left 3 (60.0%) 1 (25.0%)

Time from resection to reanimation, d, mean (SD) 3.6 (2.2) 218.3 (66.0) <0.001
Operative time – index reanimation surgery (min), mean (SD) 474.8 (48.2) 414.5 (7.9) 0.04
Operative time – second stage reanimation surgery (min), mean (SD) — 158.8 (20.0)
Total operative time (min), mean (SD) 474.8 (18.0) 573.3 (26.2) 0.008
Secondary procedures after reanimation
 Functional botox, n (%) 3 (60.0%) 2 (50.0%) 0.76
 Platinum weight placement, n (%) 4 (80.0%) 1 (25.0%) 0.10
 Ectropion repair, n (%) 3 (60.0%) 3 (75.0%) 0.63

Statistical Analysis and Figure  3. Composite scores for Smile, Static, and
Demographic and clinical characteristics were sum- Dynamic subsections improved postoperatively for both
marized with numbers and percentages for categorical cohorts, with Synkinesis scores worsening after reanima-
variables and mean (SD) for continuous variables. Scaled tion. Comparing postoperative scores obtained more than
(0–100) eFACE, FaCE Scale, and Facial Grading System 12 months after reanimation, there was no significant
scores were calculated as appropriate for each respective difference between the cohorts in postoperative mean
instrument14–17 and used for all comparisons. For all scales, eFACE Smile (early versus delayed) (71.5 versus 75.5; P =
calculated scores for each domain range from 0 (severe 0.08), static (76.3 versus 82.1; P = 0.32), or dynamic scores
dysfunction) and 100 (normal function). Differences (59.7 versus 64.9; P = 0.19). Synkinesis scores were worse
between techniques were tested using the chi-square test among those undergoing early simultaneous approaches
for categorical variables, and the analysis of variance or (early, 76.4 versus delayed, 91.1; P = 0.04; Fig. 3).
Kruskal-Wallis test for continuous variables, as appropri- FGS scores obtained from physical therapists at post-
ate. A P value less than 0.05 was considered significant, operative therapy visits were then compared (Table 3 and
with no adjustments made for multiple comparisons. Fig. 4). FGS scores overall improved from the first to the
Data analysis was performed with JMP, version 13 (SAS
Institute Inc., Cary, N.C.) or Graph-Pad Prism, version 8.0
Table 2. eFACE Clinician-graded Scores Obtained Preresec-
(GraphPad Software, Inc., La Jolla, Ca.).
tion, Postresection, and Postreanimation
Early Delayed
Simultaneous Babysitter
RESULTS eFACE Subsection (n = 5) (n = 4) P
Of the 15 eligible patients, nine met study inclusion cri-
Smile score, mean (SD)
teria and consented to participate. Five patients underwent
 Preresection 82.6 (6.7) 61.3 (6.7)
an early simultaneous approach, whereas four underwent  Postresection 51.4 (12.5) 49.3 (2.4)
delayed babysitter approaches. Demographics and clinical  Post-one stage — 68 (1.4)
characteristics are shown in Table  1. Patients underwent  Postoperative 71.5 (2.1) 75.5 (3.7) 0.08
reanimation for acquired unilateral facial paralysis resulting Static score, mean (SD)
from resection of a schwannoma (56%), acoustic neuroma  Preresection 84.5 (4.8) 70 (4.8)
(33%), or vascular malformation (11%). Demographic and  Postresection 50.0 (11.2) 63.5 (10.6)
clinical characteristics were similar between both techniques,  Post-one stage — 64.3 (3.9)
including mean (SD) age [early: 45.4 (17.3) years; range:  Postoperative 76.3 (8.3) 82.1 (8.0) 0.32
20–61 years versus delayed: 36.0 (14.9); range 18–54 years; P = Dynamic score, mean (SD)
0.42], tumor pathology (P = 0.17), and laterality (P = 0.29).  Preresection 73.5 (15.1) 35 (18.4)
Additionally, occurrence of secondary procedures  Postresection 33.4 (14.2) 14.7 (2.6)
after reanimation were similar, including platinum weight  Post-one stage — 55.8 (1.8)
placement, functional Botox, and lower lid suspension (all  Postoperative 59.7 (5.3) 64.7 (2.4) 0.19
P > 0.05). By design, patients undergoing early approaches Synkinesis score, mean (SD)
had a significantly lower mean time from resection to  Preresection 97.4 (5.8) 93.5 (5.8)
reanimation (3.6 versus 218.3 days; P < 0.001; Table 1).  Postresection 89.5 (15.3) 94.0 (12.1)
 Post-one stage — 94 (3.5)
Clinician-graded eFACE scores for the Smile, Static,
 Postoperative 76.4 (10.2) 91.1 (6.4) 0.04
Dynamic, and Synkinesis subsections are shown in Table 2

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Fig. 3. eFACE scores for total smile, static, dynamic, and synkinesis obtained preresection, postresection, and postreanimation.

Table 3. Facial Grading Scale Scored by Facial Paralysis Table 4. FaCE Scale Patient-reported Outcome Instrument
Physical Therapists at Postoperative Therapy Visits (n = 9) Subsections between Early and Delayed Groups (n = 9)
Early Delayed Early
Facial Grading Scale Simultaneous Babysitter Simultane- Delayed
Composite Score (n = 5) (n = 4) P ous Babysitter
FaCE Scale Subsection (n = 5) (n = 4) P
First postoperative, 46.6 (12.8) 41.4 (6.5) 0.44
mean (SD) Total score, mean (SD) 59.7 (5.8) 52.2 (17.8) 0.40
Last postoperative, 75 (10.7) 66.2 (11.7) 0.28 Facial movement score, mean (SD) 43.8 (15.8) 38.9 (12.7) 0.68
mean (SD) Facial comfort score, mean (SD) 70.0 (27.4) 50.0 (22.0) 0.33
Oral function score, mean (SD) 72.5 (10.5) 66.7 (26.0) 0.66
Eye comfort score, mean (SD) 50 (8.8) 25 (33.1) 0.14
Social function score, mean (SD) 76.3 (16.8) 60.4 (28.9) 0.35

last therapy session for all patients. When comparing early

Fig. 4. FGS scores scored by facial paralysis physical therapists at
first vs. last postoperative therapy visits between early simultane-
ous and delayed babysitter groups.
and delayed techniques, there was no statistically signifi-
cant difference in mean FGS scores for the first postopera-
tive visit (early, 46.6 versus delayed, 41.4; P = 0.44) or the
last postoperative visit (early, 75 versus delayed, 66.2; P =
0.28) between both cohorts (Fig. 4).
Finally, patient-reported outcomes scores from the
FaCE scale more than 12 months after reanimation were
compared (Table 4 and Fig. 5). Overall, there was no sig-
nificant difference in any FaCE scale subsection scores
between cohorts (mean early versus delayed), including
total score (59.7 versus 52.2; P = 0.40), facial movement
(43.8 versus 38.9; p=0.68), facial comfort (70.0 versus 50.0;
P = 0.33), oral function (72.5 versus 66.7; P = 0.66), eye

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Fig. 5. FaCE scale patient-reported outcome scores between early and delayed groups.
comfort (50.0 versus 25.0; P = 0.14), or social function
(76.3 versus 60.4; P = 0.35; Fig. 5).
DISCUSSION
In this study, an early simultaneous technique for facial
reanimation for patients with known facial nerve sacrifice
after skull base tumor resection is introduced, involving
simultaneous cross facial nerve grafting and masseter
transfer days after extirpation. We find that this approach
produces comparable patient- and clinician-graded out-
comes compared with a staged technique utilizing a
masseter nerve babysitter. By design, the new approach
minimizes denervation time and delivers facial movement
back to the patient in less time, retaining the advantage
of target specificity but eliminating a second-stage pro-
cedure. However, this study also demonstrated that the
early approach was associated with a greater degree of
synkinesis.
Since the earliest description of facial reanimation
surgery using a hypoglossal nerve transfer in 1903,19
techniques for facial reanimation have evolved signifi-
cantly. Today, techniques are tailored to patient char-
acteristics, including age, denervation time, and facial
paralysis etiology.20 Reanimation procedures are dichoto-
mized into neurotization procedures (to restore existing
facial muscle function) versus free muscle transfers (to
replace congenitally absent or permanently denervated
mimetic muscles).20 The masseter to facial nerve transfer
was described by Spira et al in 197821 as a neurotization
technique resulting in a greater smile spontaneity com-
pared with hypoglossal transfers, with reduced donor
site morbidity and synkinesis.11,22–25 Cross facial nerve
grafts were described in 1971 by Scaramella et al for
facial palsy patients after tumor resection.8,26 However,
the prolonged axonal generation (4–6 months) required
by cross facial nerve grafts led to the inception of dual
motor reanimation procedures combining nerve trans-
fers with cross facial nerve grafts.11 A “babysitter” proce-
dure was first described by Terzis et al in 1984 using the
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PRS Global Open • 2023
hypoglossal nerve,9 and the principle was more recently
adapted using the masseteric nerve as the babysitter, with
favorable reported outcomes in patients following tumor
extirpation.10
Denervation time is a key consideration in outcomes
of neurotization procedures for facial paralysis patients.20
In retrospective reviews of patients with unilateral facial
paralysis secondary to tumor extirpation undergoing rean-
imation, both and Zhang et al and Terzis et al found that
shorter denervation time was associated with improved
return of function after reanimation.6,13 Combined cross
facial nerve graft and masseter nerve transfer in a single
stage have been previously described by Biachi et al and
Yoshioka et al with favorable outcomes after tumor resec-
tion.10,27 However, these single stage procedures were per-
formed in a delayed setting an average of 6 to 10 months
after resection,10,27 a time period that in turn also prolongs
denervation.
With the goal of reducing denervation time in the
posttumor extirpation facial paralysis population, the
senior author proposed a one-stage early simultaneous
procedure with simultaneous masseter nerve transfer and
cross facial nerve grafting performed days after skull base
tumor resection. In this small pilot study of nine patients
undergoing either the early simultaneous or delayed baby-
sitter approach, we found that both techniques result in
comparable patient-reported and clinician-graded out-
comes over 1 year after surgery. Most patients were satis-
fied with reanimation results as measured using the FaCE
scale. Both eFACE and Facial Grading System scores as
measured by clinicians and physical therapists, respec-
tively, improved after surgery and reached levels compa-
rable to pre-resection. Moreover, patients undergoing
early one-stage reanimation experienced a shorter time to
return of mimetic function.
The results of this study suggest that an early one-
stage approach may be a feasible option to improve
functional outcomes after tumor resection. However,
although most clinician-graded outcomes were statisti-
cally equivalent, we noted greater synkinesis in the early
 Sergesketter et al • Early Facial Reanimation after Tumor Resection
one-stage group. The finding is difficult to explain and
somewhat unexpected, as the masseteric coaptation was
performed identically in both groups; we have hypoth-
esized that it is possible that a greater proportion of the
masseteric nerve fibers reached targets early, whereas
the stimulation-guided, selected targets that were
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coapted more distally to cross facial grafts were await-
ing renervation for a longer period and were subjected
to longer denervation. Given the small sample size in
this study, it is not possible to ascertain whether this
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observation would hold true in a larger study popula-
tion. Subsequent to the study period, we have observed
a similar degree of synkinesis in the delayed approach
as well. The synkinesis finding is important because
it may influence the overall result in the context of a
dynamic symmetry goal. It also underscores the impor-
tance of dynamic assessment in general for ascertaining
outcomes in facial reanimation. Synkinetic movement
significantly influences an observer’s subjective impres-
sions of the subject during a personal interaction, but it
is easily concealed and even difficult to portray in still
photographs, which remain a standard in published
reporting.
Two-stage approaches provide two important advan-
tages: (1) identification of the viable fascicles at the dis-
tal end of the nerve graft months later, and (2) ability
to stimulate the facial nerve branches that have recov-
ered after input from babysitter procedures, allowing
for more precise micro-coaptation between viable and
functional fascicles.27 We attempted to mitigate the lat-
ter disadvantage by performing reanimation immedi-
ately after resection while the paralyzed muscles are still
stimulable, enabling identification of discrete branches
for smile and eye closure. In traditional teaching, facial
nerve stimulation may become lost after 24 hours follow-
ing denervation; however, we have found the branches to
be stimulable 3 to 4 days later. Not all intraoperative stim-
ulators produce an amplitude that will generate move-
ment at 3+ days. For example, most disposable devices
offer amplitudes of 0.5, 1.0, and 2.0 mA; some re-usable
systems, such as those used for anesthesia blocks, offer
up to 5.0 mA.28 Other commercially available devices can
produce up to 20 mA. Based on these findings, we believe
that this technique may only be undertaken by those with
access to higher amplitude intraoperative stimulation. In
addition, if a patient is not stimulable at the time of sur-
gery, then branch selection would not be possible, and we
would favor pivoting to a two-stage approach. Under such
circumstances, we still would have the significant time
advantage of providing new nerve input with the most
minimal denervation time.
This study has limitations with implications for its
interpretation. First, our study population is small.
Although this study is intended to serve as a feasibility
study for the early simultaneous technique, the num-
ber of patients limits comparison. Second, videos were
not taken at controlled time points after surgery, limit-
ing comparison of time to return of mimetic function
between the groups. Measurements (including the
eFACE) are subject to inter-reviewer variability. Finally,
within the confines of this clinical study, we were unable
to assess how factors including the increased inflamma-
tory cytokine cascade and pro-inflammatory milieu after
extirpative surgery could potentially influence outcomes
of the early simultaneous approach, a consideration that
has previously been associated with modulated nerve
healing within the context of peripheral nerve injury.29
Finally, the finding of increased synkinesis warrants fur-
ther investigation, as synkinesis is highly associated with
the final outcome of reanimation. However, this study
serves as the first report of one-stage cross facial nerve
grafts and masseter nerve transfer immediately after
intracranial tumor resection. We aim for these data to
highlight the benefits and potential drawbacks of early
approaches following resection, and ultimately aim for
this study to inform the design of multi-institutional
studies on optimal timing of neurotization procedures
in these patients.
CONCLUSIONS
In this study, an early simultaneous technique for
patients with facial paralysis after tumor resection is pro-
posed, involving masseter nerve transfer and cross facial
nerve grafting performed during the same hospital admis-
sion as intracranial tumor resection. We found that this
approach produced comparable patient-reported out-
comes and clinician-graded smile, static, and dynamic func-
tion compared with a delayed babysitter technique, with
reduced number of procedures and time interval between
resection and reanimation. However, synkinesis scores
were worse among patients undergoing early simultaneous
approaches. We aim for these data to highlight the benefits
of early intervention for facial paralysis after tumor resec-
tion, and to serve as a foundation for multi-institutional
studies on timing of neurotization in this population.
Jeffrey R. Marcus, MD
Division of Plastic, Oral, and Maxillofacial Surgery
Duke University Medical Center
Durham, NC 27710
E-mail: jeffrey.marcus@duke.edu
ACKNOWLEDGMENT
The authors acknowledge Lauren Halligan, CMI, medical
illustrator from Duke University, for the included illustrations.
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