The latter should therefore be delayed 1 year from the time of surgery unless the facial nerve has been severed. Post-operative electroneu-ronography 1 week post-operatively has been shown to be of prognostic value. Incomplete degeneration is associated with a Grade I or II outcome whereas complete degeneration forecasts a protracted, incomplete recovery .
If the facial nerve is divided at operation a primary repair is the procedure of choice. This may be feasible due to stretching of the nerve by the tumor and by mobilization of the nerve within the petrous bone. A posterior auricular or sural nerve cable graft is useful if a primary repair is technically not possible. Where a reanimation procedure is subsequently performed, a variety of options exist. Several groups currently favor hypoglossal-facial nerve anastomosis. The principal drawback of this operation, namely hemiatrophy of the tongue, is small compared with other potential donor nerves such as the glossopharyngeal, spinal accessory and phrenic. A hypoglossal-facial anastomosis can either be performed by complete division of the hypoglossal nerve, or by fashioning a bifurcation in the nerve at the level of the descendens hypoglossi, leaving some innervation to the tongue intact. In a meta-analysis, good results were reported in 65% of more than 500 cases. After nerve transfer procedures, motor activity takes 6 months to commence and may improve over a few years. The patient needs to learn that manipulating the tongue results in facial movements.
Involuntary and emotional movements of the face do not occur as a result of hypoglossal-facial anastomosis. Such movements require innervation from the facial nerve nucleus in the brainstem. A cross-facial nerve transfer consists of a peripheral nerve interposition graft (usually sural nerve) between a distal facial branch on the normal side to a complementary branch on the affected side. This procedure can improve expressive movements of selected facial muscle groups.
Nerve transfer procedures require relatively lengthy surgery with uncertain, often disappointing, results that take months or even years to achieve a desirable result. A careful selection process is pertinent in performing these procedures. We reserve reanimation surgery for young, well motivated patients with a robust psychological approach to their disease. Static and dynamic cosmetic procedures are more suitable for the majority of patients with severe permanent facial nerve palsy.
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