Triple nerve transfers for the management of early unilateral facial palsy
Keywords:Facial paralysis, nerve transfer, peripheral nerves, nerve-to-masseter, cross-face nerve graft, hypoglossal nerve, facial reanimation
Background: Early onset facial paralysis is usually managed with cross-face nerve grafts, however the low number of axons that reach the target muscle may result in weakness or failure. Multiple-source innervation, or ‘supercharging’, seeks to combine the advantages of different donor nerves while minimizing their weaknesses. We propose a combination of cross-face nerve grafts with local extra-facial nerve transfers to achieve earlier facial reanimation in our patients.
Methods: A retrospective cohort including all patients with early unilateral facial palsy (<12 months evolution) who underwent triple nerve transfer between 2019 and 2021 was conducted. We performed single-stage procedure including zygomatic-to-zygomatic and buccal-to-buccal cross-face grafts, a nerve-to-masseter to bucozygomatic trunk transfer, and a mini-hypoglossal to marginal branch transfer. Results were evaluated using the clinician-graded facial function scale (eFACE).
Results: Fifteen patients were included (eight females, seven males), mean age at the time of surgery was 48.9 ± 13.3 years. Palsy was right-sided in eight cases. The mean time from palsy onset to surgery was 5.5 ± 2.8 months. Patients showed improvement in static (70.8 ± 21.9 vs. 84.15 ± 6.68, p = 0.002) and dynamic scores (20 ± 16.32 vs. 74.23 ± 7.46, p < 0.001), as well as periocular (57.33 ± 15.23 vs. 74 ± 7.18, p = 0.007), smile (54.73 ± 11.93 vs. 85.62 ± 3.86, p < 0.001), mid-face (46.33 ± 18.04 vs. 95 ± 7.21, p < 0.001) and lower face scores (67.4 ± 1.55 vs. 90.31 ± 7.54, p < 0.001).
Conclusion: The triple nerve transfer technique using cross-face nerve grafts, the nerve-to-masseter, and the hypoglossal nerve, is an effective and reproducible technique to obtain middle and lower face reanimation in cases of early facial palsy.
Chávez-Serna E, Telich-Tarriba JE, Altamirano-Arcos C, Nahas-Combina L, Cárdenas-Mejía A. Facial paralysis, etiology and surgical treatment in a tertiary care center in plastic and reconstructive surgery in Mexico. Cir Cir. 2021;89(6):718–727. https://doi.org/10.24875/CIRU.20000916 DOI: https://doi.org/10.24875/CIRU.20000916
Kim IA, Maxim T, Echanique K. Modern cross-facial nerve grafting in facial paralysis. Op Tech Otol Head Neck Surg. 2022;33(1):20–28. https://doi.org/10.1016/j.otot.2022.02.004 DOI: https://doi.org/10.1016/j.otot.2022.02.004
Garcia RM, Hadlock TA, Klebuc MJ, Simpson RL, Zenn MR, Marcus JR. Contemporary solutions for the treatment of facial nerve paralysis. Plast Reconstr Surg. 2015;135(6):1025e–1046e. https://doi.org/10.1097/PRS.0000000000001273 DOI: https://doi.org/10.1097/PRS.0000000000001273
Jandali D, Revenaugh PC. Facial reanimation: an update on nerve transfers in facial paralysis. Curr Opin Otolaryngol Head Neck Surg. 2019;27(4):231–236. https://doi.org/10.1097/MOO.0000000000000543 DOI: https://doi.org/10.1097/MOO.0000000000000543
Yoshioka N. Differential reanimation of the midface and lower face using the masseteric and hypoglossal nerves for facial paralysis. Oper Neurosurg (Hagerstown). 2018;15(2):174–178. https://doi.org/10.1093/ons/opx217 DOI: https://doi.org/10.1093/ons/opx217
Owusu JA, Truong L, Kim JC. Facial nerve reconstruction with concurrent masseteric nerve transfer and cable grafting. JAMA Facial Plast Surg. 2016;18(5):335–339. https://doi.org/10.1001/jamafacial.2016.0345 DOI: https://doi.org/10.1001/jamafacial.2016.0345
Yoshioka N, Tominaga S. Masseteric nerve transfer for short-term facial paralysis following skull base surgery. J Plast Reconstr Aesthet Surg. 2015;68(6):764–770. https://doi.org/10.1016/j.bjps.2015.02.031 DOI: https://doi.org/10.1016/j.bjps.2015.02.031
Lee YS, Ahn JH, Park HJ, et al. Dual coaptation of facial nerve using masseteric branch of trigeminal nerve for iatrogenic facial palsy: preliminary reports. Ann Otol Rhinol Laryngol. 2020;129(5):505–511. https://doi.org/10.1177/0003489419893722 DOI: https://doi.org/10.1177/0003489419893722
Biglioli F, Allevi F, Rabbiosi D, et al. Triple innervation for re-animation of recent facial paralysis. J Craniomaxillofac Surg. 2018;46(5):851–857. https://doi.org/10.1016/j.jcms.2018.02.014 DOI: https://doi.org/10.1016/j.jcms.2018.02.014
Chong LSH, Eviston TJ, Low TH, Hasmat S, Coulson SE, Clark JR. Validation of the clinician-graded electronic facial paralysis assessment. Plast Reconstr Surg. 2017;140:159–167. https://doi.org/10.1097/PRS.0000000000003447 DOI: https://doi.org/10.1097/PRS.0000000000003447
Terzis JK, Tzafetta K. The ‘babysitter’ procedure: minihypoglossal to facial nerve transfer and cross-facial nerve grafting. Plast Reconstr Surg. 2009;123(3):865–876. https://doi.org/10.1097/PRS.0b013e31819ba4bb DOI: https://doi.org/10.1097/PRS.0b013e31819ba4bb
Mabvuure NT, Pinto-Lopes R, Bolton L, Tzafetta K. Lower lip depressor reanimation using anterior belly of digastric muscle transfer improves psychological wellbeing in facial palsy patients. Br J Oral Maxillofac Surg. 2022;60(3):299–307. https://doi.org/10.1016/j.bjoms.2021.07.025 DOI: https://doi.org/10.1016/j.bjoms.2021.07.025
Bassilios Habre S, Googe BJ, Depew JB, Wallace RD, Konofaos P. Depressor reanimation after facial nerve paralysis. Ann Plast Surg. 2019 May;82(5):582–590. https://doi.org/10.1097/SAP.0000000000001616 DOI: https://doi.org/10.1097/SAP.0000000000001616
Vejbrink Kildal V, Tee R, Reissig L, Weninger WJ, Tzou CJ, Rodriguez-Lorenzo A. Selective ansa cervicalis nerve transfer to the marginal mandibular nerve for lower lip reanimation: An anatomical study in cadavers and a case report. Microsurgery. 2023; 43(2): 142–150. https://doi.org/10.1002/micr.30992 DOI: https://doi.org/10.1002/micr.30992
Biglioli F, Guerra MB, Rabbiosi D, Ciardiello C, Allevi F. Comparison of results utilizing one-step and two-step triple innervation techniques. J Craniomaxillofac Surg. 2021;49(7):628–634. https://doi.org/10.1016/j.jcms.2021.03.006 DOI: https://doi.org/10.1016/j.jcms.2021.03.006
Admass BA, Ego BY, Tawye HY, Ahmed SA. Preoperative investigations for elective surgical patients in a resource limited setting: systematic review. Ann Med Surg (Lond). 2022 23;82:104777. https://doi.org/10.1016/j.amsu.2022.104777 DOI: https://doi.org/10.1016/j.amsu.2022.104777
Telich-Tarriba JE, Velazquez E, Theurel-Cuevas A, et al. Upper extremity patterns of injury and management at a plastic and reconstructive surgery referral center in Mexico City. Ann Plast Surg. 2018;80(1):23–26. https://doi.org/10.1097/SAP.0000000000001182 DOI: https://doi.org/10.1097/SAP.0000000000001182
Varelas AN. Use of three or more concomitant nerve transfers for facial nerve reanimation. In: 14th international facial nerve symposium. Seoul, Korea, April 28–30, 2022. The Charles Bell Society, Soul, Korea.
Dauwe PB, Hembd A, De La Concha-Blankenagel E, et al. The deep temporal nerve transfer: an anatomical feasibility study and implications for upper facial reanimation. Plast Reconstr Surg. 2016;138(3):498e–505e. https://doi.org/10.1097/PRS.0000000000002482 DOI: https://doi.org/10.1097/PRS.0000000000002482
How to Cite
Copyright (c) 2023 Jose E. Telich-Tarriba, David F. Navarro-Barquin, Genesis Pineda-Aldana, Alexander Cardenas-Mejia
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Acta Chirurgica Scandinavica Society owns the copyright for all material published until Volume 57 (2023) unless otherwise specified. As from Volume 58 (2023) all published articles, unless otherwise specified, are published under CC-BY-NC licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.