SURGICAL

MANAGEMENT

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• Surgical management is divided into two major sections:
1) Primary management = When there is acute extracranial facial nerve injuries. Direct facial nerve repair, nerve grafts and nerve
sharing or transposition are included.
2) Delayed or secondary interventions aimed at facial reanimation or aesthetic improvements. Static suspension procedures and
dynamic neuromuscular transfers used to provide facial reanimation.
• Timing for open nerve injury repair
1) Immediate primary repair = Can be done when a microsurgical expertise is available.
2) Delayed primary repair = If conditions are unfavourable, repair is done within 1 week after nerve injury.
3) Early secondary repair = After appearance of granulation tissue in the wound.

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1) Neural methods
• Facial nerve decompression
• Micro-neurological surgery to resuture the damaged nerve
• Nerve graft to overcome gap
• Cross facial nerve grafting
• Nerve transfers
• Hypoglossal to facial
• Spinal accessory to facial
• Phrenic to facial

2) Musculofascial transposition
• Move new muscles and nerves into the face to take the place of the injured facial nerve
3) Facial plastic procedures
4) Prosthesis

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Surgical decompression
• Facial nerve may undergo pathological compression injury due to intraneural edema,
hematoma and a fractured bone at the fallopian canal (facial canal).
• The compressed nerve is exposed in surgical decompression. The facial nerve sheath is slit
to relieve pressure.
• When electrical tests indicate progressive nerve weakness (> 90%) facial nerve
decompression should be done at the earliest in cases of Bell’s palsy, Ramsay Hunt
syndrome and longitudinal temporal bone fracture.
• Surgical decompression may decrease oedema and allows axoplasmic flow. This procedure
is usually carried out through the middle fossa approach.
• It is preferred within 2 weeks that is before the irreversible damage to nerve fibres.
• It is not done in an only hearing ear.

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Neurorrhaphy (Direct Nerve Repair)
• When accidental nerve transection has occurred or a limited segmental nerve resection
is performed, direct repair may be feasible and delivers the best chance of delivering a
good outcome.
Indications
• End-to-end anastomosis: It is a suitable procedure for extratemporal part of facial nerve.
The gap between the severed ends of nerves are few millimeters. The two ends should
be approximated without any tension.
• Direct neurorrhaphy is especially indicated when sharp precise lacerations of the facial
nerve have occurred. Example: razor blade, knife or glass injury.
Technique
• Direct repair of the facial nerve should be accomplished by a skilled microsurgeon under
optimal conditions.
• Partial parotidectomy is often required to gain adequate exposure for nerve
anastomosis. Bipolar cautery is used where necessary within close proximity to the
nerve.
• A bloodless field is required to achieve appropriate visualization of the nerve ends. The
proximal nerve must be identified by visual inspection. Orientation and depth are key
features used to identify the nerve.
Identification of the nerve
• High levels of magnification and trimming of the nerve allow characterization of the
structure at the proximal end. These procedures and electrical stimulation can be used 5
within 3 days of transection for confirmation of the nature of the distal segment.
Suturing of the nerve
• The nerve ends are carefully and completely trimmed i.e the nerve ends should be prepared with sharp, straight
microdissecting scissors, leaving uniform ends to facilitate neurorrhaphy.
• The proximal and distal nerve stumps should be mobilized adequately to allow for a tension-free closure, but excessive
dissection should be avoided in the identified segment to prevent devascularization of the nerve.
• Direct simple perineural sutures are used to achieve approximation i.e an epineurial neurorrhaphy should be performed
with an operating microscope using 9/0 or 10/0 monofilament (nylon or prolene) suture.
• Only a few sutures are required to oppose the nerves. A surgeon’s knot and two additional square throws are adequate.
• The ideal anastomosis uses a minimal number and volume of suture to limit the inflammatory response to these materials.
A taper-cut needle has the advantage of being easy to pass while causing minimal trauma to the nerve.
• Generally, needles in the range of 50–75 µm are most applicable.
• Careful coaptation is necessary to prevent scar tissue ingrowth during the time of axonal regeneration.
• Accurate repair can be achieved by carefully aligning the vasa nervorum on each nerve stump (visible axial vessels along the
nerve sheath). Application of fibrin sealants, such as Tisseel (Baxter Healthcare Corporation, Westlake Village, CA), to the
anastomotic site may improve outcome.

IN SITUATIONS WHERE DIRECT NERVE REPAIR IS NOT FEASIBLE DUE TO SEGMENTAL LOSS, REINNERVATION OF THE NATIVE
FACIAL MUSCULATURE CAN BE ACHIEVED EITHER THROUGH A NERVE GRAFT OR NERVE TRANSFER (IF NO PROXIMAL STUMP
IS AVAILABLE). 6
Guided nerve regeneration
• Placement of a conduit to guide axonal sprouting and regeneration across anerve gap from proximal to distal
portions of a nerve. This technique is successful only in short nerve gaps (<3 cm) when used in peripheral
trigeminal nerve repairs.
• An alloplastic nerve conduit (polyglycolic acid or polytetrafluoroethylene) has been used with limited success in
TN5 injuries, but only in minimal nerve gaps

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Graft neurorrhaphy (nerve graft)
• An interposition nerve graft or cable graft is indicated where both proximal and distal nerve stumps are present but cannot
be anastomosed directly i.e when the gap between severed ends is more and cannot be closed without tension by end-to-
end anastomosis.
• When the distal nerve stump has already divided into terminal branches, multiple nerve grafts (“cable grafts”) are required
to bridge the defect. There is a limit to the number of cable grafts that can be physically attached to the proximal nerve
stump in the case of multiple terminal branches. In this situation, reinnervation of essential facial movements should be
prioritized—eyelid closure, zygomatic smile, and lip closure. The branches responsible for these movements (usually three
or four) can be identified intraoperatively by use of a monopolar (bipolar if available) nerve stimulator and a cable graft
positioned for each branch
• The procedure of nerve grafting is identical to that of direct nerve repair, with the exception of requiring an additional
anastomosis for each nerve branch treated.
• Generally, nerve grafting is required following avulsive type injuries.

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Common donor sites
• There is an abundance of suitable donor nerve grafts, and selection is based on availability in
the surgical site, number of fascicles, and graft length requirement.
• In the Fallopian canal, graft may not need any suturing
• Autogenous nerve grafts remain the standard when all other treatments are compared.
• Tubulisation with alloplastic materials remains a procedure most applicable and appropriate to
the experimental microsurgical laboratory.
• Nerve graft is usually taken from greater auricular nerve, lateral cutaneous nerve of thigh or
the sural nerve
1) Greater auricular nerve— used when total length of nerve graft required is small.
 If a short interpositional segment is required, the great auricular nerve is often available locally and may
deliver graft lengths of up to 7 cm
2) Sural nerve— used following extensive injuries or resections of multiple facial nerve branches.
3) Antebrachial nerve (recently)— structure in the proximal forearm involves many branches that are
often suitable to the replacement of multiple branches of the facial nerve.
• Reproducible result of nerve graft reconstruction of facial nerve defects can be best
appreciated by comparing the procedure to immediate grafting of the facial nerve in radical
parotidectomy
• Nerve grafts are often available at the site of free tissue harvest—lateral cutaneous nerve of
the thigh and femoral nerve branches (anterolateral thigh), sural nerve (medial sural artery
flap), lateral cutaneous nerve of the forearm (radial forearm flap), and thoracodorsal nerve 9
(latissimus dorsi flap).
• Convention is to reverse the nerve graft to improve axonal catch (i.e., avoid
reinnervated axons being lost in nerve graft branches). However, evidence suggests
that reversing the nerve graft may not improve muscle function as judged by
muscle weight and functional axonal count compared with orthodromic placement.
• Vascularized nerve grafts can be taken as compound free tissue transfers with radial
forearm, anterolateral thigh, and medial sural artery free flaps.
• Evidence from experimental models suggests that vascularized nerve conduits can
deliver superior recovery of facial function compared with nonvascularized grafts.
However, in practice, it is difficult to maintain sufficient mobility of the nerve
component independent of the vascular pedicle to allow neurorrhaphy without
devascularizing the nerve. As a guide, at least 20% of the nerve graft should be
maintained in close continuity with the vascular pedicle to guarantee adequate
nerve vascularity.
• Clinical studies suggest that there is no significant impact of anterolateral thigh flap
harvest on quadriceps function at 6 months, even when the nerve is harvested with
the pedicle.

Figure 50-4 demonstrates an example of a

vascularized nerve graft (nerve to vastus lateralis). The
nerve was placed orthodromically taking advantage of
a distal branching pattern to anastomose to multiple
facial nerve branches (one buccal, two zygomatic).

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Great auricular nerve
• Great auricular nerve is easily identified in relation to the external jugular vein
(posterior and parallel).
Surface marking
• A useful additional external reference is produced by dropping a
perpendicular line at the midpoint of a line drawn from the mastoid to the
angle of the mandible.
• A cervical skin crease is used to camouflage the donor site incision.
Technique
• The degree of elevation of skin platysma flaps along the superficial plane of
the superficial layer of the deep cervical fascia depends on the length of nerve
required.
• In general, a maximum useful nerve length is 6–8 cm.
• The nerve is isolated posterior to the jugular vein and dissected to its entrance
into the parotid. Branching of the nerve can prove useful in the nerve defect
site and this should be used to its full advantage.
• Proximal dissection of the nerve is typically limited by the passage of the
nerve deep to the posterior border of the sternocleidomastoid muscle.
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Sural nerve
• Sural nerve is the branch of tibial nerve in the middle of the popliteal fossa. It supplies skin on the lower half
of the back of the leg and whole of the lateral border of the foot up to the tip of the little toe.
• The greatest advantage of using sural nerve in facial nerve grafting is its abundant length. As much as 40 cm
of nerve is available for harvest, the diameter of the nerve is approximate to that of most of the cranial
nerves. The most ideal use is in the case of multiple facial nerve defects in the separate branches of facial
nerve or in extracranial defects involving the facial nerve trunk only.
Indication
• Where no donor nerve is readily available in the surgical site, the sural nerve provides an abundance of
length (up to 35 cm), suitable for more cable grafts, with low donor site morbidity. The sural nerve has a
greater number of fascicles than the great auricular nerve and is, therefore, a better match to the facial
nerve with all things being equal.
• Cases in which the defect originates at the trunk and extends to multiple branches are most well suited to
reconstruction with either the greater auricular nerve or antebrachial cutaneous nerve. A branching pattern
of the sural nerve can be harvested from its extreme distal course, but this requires incision and dissection
across the ankle joint.
Technique
• The sural nerve segment that is typically harvested is the distal portion of the lower leg after the point at
which it becomes superficial to the muscular fascia overlying the gastrocnemius. In this position, it is easily
identified adjacent (medial) to the lesser saphenous vein posterior to the lateral malleolus. Serial small
horizontal incisions or a single longitudinal incision is used. Particular attention should be given to the
management of the proximal nerve stump. This should be placed into a pocket within adjacent muscle and
secured by suture.
Complication
• Neuroma formation on a superficially located nerve stump can be a source of considerable patient 12
Medial antebrachial cutaneous nerve
• Medial antebrachial cutaneous nerve can be harvested from the upper extremity with minimal morbidity.
• It originates from the medial cord of the brachial plexus in the majority of cases (78%).
• The nerve is relatively easy to identify secondary to its location adjacent to the basilic vein.
• Near the antecubital fossa the nerve typically divides into the anterior and posterior branches.
Indications
• The anterior branch is most useful for facial nerve reconstruction because it has multiple branches suitable to the
replacement of the facial nerve.
Technique
• Harvest of the medial antebrachial cutaneous nerve is accomplished by making a cutaneous incision parallel to the plane
formed by the fascial plane separating the biceps and triceps muscles. The depths of incision and dissection must remain
within the subcutaneous plane. The nerve is easily found along the course of the basilic vein. It is appropriate to dissect the
nerve distally to the point of numerous branches to identify a pattern and size most consistent with the demands of the
facial nerve defect.

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Nerve transfer or transposition
• In situations where no proximal facial nerve stump is available or identified, a nerve transfer using an adjacent motor can be
used and anastomosed to the severe peripheral end of the facial nerve to power the native facial muscles
• It improves the muscle tone and permits some movements of facial muscles
• Common local donor nerves include the hypoglossal nerve, the accessory nerve, and the nerve to masseter.
• Two situations exist where in nerve transposition can prove exceptionally useful:
 The first such condition is when there has been isolated segmental injury to a crucial (mandibular or zygomatic) branch of the facial nerve.
In such cases, transposition of a less critical segment of the facial nerve (frontal, cervical) can be accomplished and direct anastomosis can
be completed to the distal portion of the injured nerve.
 The second of these conditions is that in which extreme proximal facial nerve is injured. The hypoglossal nerve can be transposed and
sutured to the trunk of the distal facial nerve. In these cases, major drawback is mass movement of the face, but the outcome compares
favourably with that of microvascular neuromuscular transfer and cross-facial nerve grafting
Hypoglossal-facial nerve transfer
• Most popular technique due to ease of harvest, length of nerve available, and consistent outcome.
• Hypoglossal nerve substitutions tend to deliver good resting tone and therefore, symmetry at rest.
• However, the tongue donor site is poor (tongue atrophy, functional disability). In addition, synkinesis of the facial muscles is
often problematic. Variations in technique have been developed to circumvent this problem through partial hypoglossal nerve
harvest (leaving 40% to 50% nerve width) or use of a jump graft between facial and hypoglossal nerves, thereby leaving the
hypoglossal nerve in continuity. These modified techniques can deliver adequate results with reduced synkinesis and donor site
morbidity
Synkinesis = Abnormal involuntary facial movement that
occurs with voluntary movement of a different muscle group 14
.Nerve to masseter-facial nerve transfer
• The nerve to masseter-facial nerve transfer is a recently developed
technique that is gaining popularity due to the potential to deliver
powerful reinnervation and favorable donor site.
• It has an abundance of axons (similar to the facial nerve in number), which
is thought to contribute to the degree of facial movement achieved.
• The nerve to masseter (a trigeminal nerve derivative) is located within the
muscle at a point 3 cm anterior to the tragus and 1 cm inferior to the
zygomatic arch.
• It is found quite deep inside the muscle and with careful dissection, 2 or 3
cm in length can be isolated, allowing it to be delivered into the wound
and anastomosed without tension onto the distal facial nerve stump or
selected distal branches.
Postoperative physiotherapy involving cognitive retraining is essential to the
outcome of nerve transfers. Patients have to learn to smile or close their eyes Figure 50-5 demonstrates a nerve to
again while performing the primary donor nerve function (tongue movement masseter facial nerve transfer in a 72-
or biting). year-old female patient following facial
nerve resection for an external auditory
meatus squamous cell carcinoma (SCC).

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 Conditions for Successful Nerve Function Post Repair
• End-to-end facial nerve repair confers the best chance of functional recovery
followed by interposition nerve graft, which in turn is superior to nerve
transfer techniques
• Continued improvements may occur as long as 2 years postsurgical repair.
• Although there is a potential risk of radiotherapy affecting outcome, studies
have demonstrated that a good nerve and facial recovery can still occur
despite postoperative radiotherapy.

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Cross-facial nerve grafting (use of the normal facial nerve on the uninjured)
• In such cases, patient re-education to achieve nerve stimulation is not required.
• The principle is really quite simple. A branch of the normal facial nerve is sacrificed
(a buccal branch being the most appropriate) and a sural nerve graft passed
through a subcutaneous tunnel to allow either neurorrhaphy or to serve as a
nerve conduit to use in conjunction with or without a microvascular
neuromuscular transfer at the opposite side
• In contrast to nerve transfer, cross-facial nerve grafts, taken from the intact
contralateral facial nerve can deliver truly spontaneous movement.
• However, in the immediate setting, cross-facial nerve grafts are rarely indicated
due to oncologic concerns (surgical dissection into adjacent uninvolved tissues
may affect radiotherapy field planning) or patient factors (principally age and
comorbidity).
• Cross-facial nerve grafts are most commonly used in the setting of free functional
muscle transfers in young healthy patients with a congenital or developmental
facial nerve disability or where other methods (nerve repair, grafts, or transfers)
have failed.
• Having said that, there is an emerging trend for dual reinnervation techniques—
for example, coapting a cross-facial nerve graft end-to-side onto a nerve to
masseter-facial nerve transfer. In theory, this approach combines spontaneity with
powerful contraction, although the long-term results have yet to be evaluated.
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Neuromuscular transfer or Dynamic Muscle Transfers
• In most cases, there is no indication for dynamic reanimation with regional muscle or free functional muscle transfer in the acute setting (cancer ablation or trauma). These reconstructive procedures
are best performed as secondary delayed procedures when oncological clearance has been confirmed or initial nerve reconstructive techniques have failed.
• There are some surgeons who advocate primary dynamic reanimation (such as, a temporalis tendon transfer at the time of tumor ablation), but this is not the convention
• The gracilis muscle has been popularised for dynamic facial reanimation.Other muscles used for this purpose include serratus anterior and pectoralis minor. This is primarily of historical note because
of the current popularity of
the gracilis transfer. A significant decrease in the muscle bulk can be achieved
by selective harvest of that portion of the muscle innervated by the anterior
branch of the obturator nerve. Intraoperative identification of this portion of
the muscle is easily accomplished by selective use of a nerve stimulator. This
procedure often follows an initial cross-face facial nerve graft procedure by a
number of months. The muscle is inset in a manner much the same as that of static suspension.

Correction must be made for the contraction of the muscle following

transection in the process of the transfer. This is commonly accomplished by
marking the muscle with vascular staples at predetermined lengths prior to
transection. The muscle is then stretched to the original dimension at the time
of inset. Microvascular anastomosis is typically accomplished using the facial
artery and vein as recipient vessels.
In most cases, neural anastomosis is accomplished to a cross-face facial
nerve graft. Many critical variables in the surgical technique have a significant
effect on the overall outcome. Experience with this procedure is therefore
necessary to achieve an acceptable result. Indications for this procedure are
rare. It is recommended that patients requiring this procedure can be managed
at a selected few referral centres experienced in its execution

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Static suspension or Static Sling
• The utilisation of static procedures following facial nerve injury is the oldest of the accepted methods of secondary
management of facial nerve injuries.
• Static suspension of the face can achieve acceptable reconstruction of the nasolabial fold and labial commissure that hides the
deformity, except during facial animation.
• Autogenous tissue is preferred for facial suspension. Most commonly, the fascia lata is used. The fascia is harvested as a wide
strip that can then be adapted to provide a number of sites of inset for the suspension.
The flaccid facial musculature can also be suspended to the zygoma using
sutures.
• The superior portion of a face-lift incision is used with subcutaneous dissection accomplished to the sites of planned inset.
Separate incisions at the insertion sites are required to secure the fascia to the dermis. Permanent
sutures are used to secure the fascia at these distal sites first. Appropriate
tension is then placed on the graft and it is sutured to the superficial
musculoaponeurotic system (SMAS) or temporal fascia. It is generally
preferable to apply tension in such a manner as to place the nasolabial fold,
oral commissure and lips in a position approximating the midpoint of a smile.
Allowances must be made for the relaxation that occurs as a result of
gravitational effects and skin creep. Patients must be aware of this prior to
surgery because the immediate postoperative appearance can resemble that of
a snarl.
Previous methods that attempted to use temporalis muscle and fascia were
reported to result in animation of the face. The true outcome of such cases was
generally equal to that of static suspension because preservation of the
neurovascular supply to the muscle and achieving appropriate relaxed tension
were extremely difficult.
• A static sling is a simple procedure that can be performed at the time of primary surgery to improve cosmesis and function in
the early phases of reinnervation or in some cases as a permanent solution.
• There are many techniques and sling materials described.
• Fascia lata is an excellent donor choice when an anterolateral thigh flap is being simultaneously harvested.
• Palmaris longus tendon is another autologous option.
• More recently, acellular dermal matrices have been used as static slings and offer the advantage of absent donor site morbidity.
• My own observation suggests that recurrent laxity is more of an issue than with autologous grafts, especially in the setting of
postoperative radiotherapy.
• Static slings aim to replicate the natural vector of zygomaticus major. It is important to mark the anticipated vector of
zygomaticus pull preoperatively.
• The fascial graft is anchored to orbicularis oris at three points (commissure, mid nasolabial fold, and alar base). Tension is
applied to ensure an adequate lip elevation effect. The graft is then sutured superiorly to the deep temporal fascia or zygomatic 19
arch via drill holes. It is important to over tension the sling because it will relax with time.
Ocular Protection
• To achieve eyelid closure, the functional loss in both upper and lower eyelids needs to be addressed adequately. Although excursion is the key function of the upper eyelid, tone in the
lower eyelid is critical to overall eyelid performance.
• Traditionally, a lateral tarsorrhaphy (suturing the lateral
• upper and lower eyelid margins closed) was commonly performed
• for globe protection. However, by shortening the horizontal
• palpebral fissure, it leads to a very stigmatized look and inferior esthetic result.
• Lid loading with either gold weights or platinum chains is
• an effective means of achieving upper eyelid closure. The
• weights passively counteract the intact levator palpebrae superioris
• muscle (oculomotor nerve) and depend on gravitational forces to work. They work best when the patient is upright and
• for voluntary movements rather than the blink reflex. Gold isinert, dense, and not significantly affected by magnetic fields,
• which is critical for patients who require magnetic resonance
• imaging (MRI) for disease surveillance. Visibility and extrusion are the two main complications.24 Platinum is denser than gold,
• and therefore a lower profile weight can be used for the same
• effect resulting in a less conspicuous appearance but at a greater expense.
• In either case, an upper eyelid crease incision is made. Dissection proceeds through skin and orbicularis oculi. Blunt dissectionwith tenotomy scissors is used to create a pocket superficial
to the tarsal plate. The weight is inserted and fixed to the tarsal plate through plate holes (usually three) with 7/0 nonabsorbable suture.
• Levator lengthening offers an alternative approach to lid
• loading. In this technique, originally described by Tessier, a fascial interposition graft (e.g., from deep temporal fascia) is
• placed between the tarsal plate and the levator aponeurosis to
• lengthen the aponeurosis. It can deliver similar functionalresults to a gold weight with potentially superior esthetic results
• and should be considered in younger patients.25
• Lower eyelid laxity is best addressed by a lateral tarsal strip or tendon sling procedure. In a lateral tarsal strip, a lateral cantholysis
• is performed; the lateral canthal tendon is then isolatedand sutured to the internal lateral orbital rim with a Prolene or
• PDS suture. The result is tightening and repositioning of the lateral canthal tendon and a decrease in vertical palpebral aperture. In a lower eyelid suspension procedure, a tendon or20
fascial graft is tunneled subcutaneously from the medial canthus to the lateral orbital wall, leading to static suspension and elevation of the lower eyelid.