Alternative approach using the combined technique of nerve crossover and cross-nerve grafting for reanimation of facial palsy

An alternative approach, using a combination of nerve crossover and cross-nerve grafting technique in a single-stage procedure, was developed for the reconstruction of reversible facial palsy. This combined technique provides some benefits such as early facial reanimation resulting from the single-stage procedure, less morbidity and sufficient innervation with an application of the end-to-side anastomosis method, and efficient neural regeneration due to coaptation of the intratemporal facial nerve. Facial nerve rehabilitation, based on double innervation by hypoglossal and contralateral healthy facial nerves, takes advantage of reliable and physiological facial reanimation.     

Reanimation of the paralyzed face by indirect hypoglossal-facial nerve anastomosis

BACKGROUND: The results of indirect hypoglossal facial nerve anastomosis with interposition of a free nerve graft, end-to-end to the periferal facial nerve stump, and end-to-side to the hypoglossal nerve are prospectively evaluated. This technique is supposed to overcome loss of hypoglossal function. METHODS: Tongue function in 39 consecutive patients and facial reanimation in 29 patients who completed 24 months follow-up were assessed. Facial nerve function was judged using the House-Brackmann (HB) grading system. RESULTS: Tongue movements were normal in all operated on patients. Initial facial movements occurred on average 7.5 months postoperatively. The results were graded HB II in 6 (20.9%), HB III in 13 (44.6%), HB IV in 7 (24.1%), HB V in 2 (6.8%) patients, and HB VI in 1 (3.4%) patient. The results were significantly better in young patients and when a short time interval between paralysis and surgery existed. CONCLUSIONS: Indirect hypoglossal-facial anastomosis is the preferred technique in most patients for whom the classical direct hypoglossofacial anastomosis is indicated.     

Double innervation occurs in the facial mimetic muscles after facial-hypoglossal end-to-side neural repair: rat model for neural supercharge concept.

BACKGROUND: Double innervation of facial mimetic muscles by both facial and hypoglossal nerves after end-to-side neurorrhaphy has not been proven, although facial -hypoglossal end-to-side neurorrhaphy has been used in persistent incomplete facial palsy recently, and has achieved clinical evidences of recovery with rare synkinesis. We established a rat model to compare synkinesis after end-to-end and end-to-side neurorrhaphy techniques between facial and hypoglossal nerves, and confirmed double innervation using retrograde tracers. METHODS: Rats were divided into three groups (each consisting of six rats), a facial palsy group (Group A), a facial-hypoglossal end-to-end neurorrhaphy group (Group B), and a facial-hypoglossal end-to-side neurorrhaphy group (Group C). Eight weeks after surgery, synkinesis of the facial mimetic muscles was observed and recorded via video camera. In Group C, post operative, intramuscular injections of retrograde neural tracers (Fast Blue, Diamidino Yellow and DiI) into the facial mimetic muscles were performed to prove double innervation by both the facial and hypoglossal nerves. RESULTS: In Group B, all rats showed facial palsy. However while eating and drinking, their half of the face showed mass movements (strong contraction of whisker pad muscles, curved nose and eye-closure). In Group C, four rats showed no significant changes however, two rats showed synkinesis of the eyelid while eating and drinking (frequent eye-closure distinguishable from the contralateral normal side). In Group C, retrograde tracers injected in the mimetic muscles were detected in both the facial and hypoglossal motor nuclei in situ of all the rats' brain stem. CONCLUSION: This study proved that double innervation of mimetic muscles by both facial and hypoglossal nerves occurs after the end-to-side neurorrhaphy. Double-innervated mimetic muscles around the mouth after hypoglossal-facial end-to-side neurorrhaphy showed less synkinesis than the end-to-end neurorrhaphy.     

One-stage removal of residual intracanalicular acoustic neuroma and hemihypoglossal-intratemporal facial nerve anastomosis: technical note

OBJECTIVE AND IMPORTANCE: Incomplete removal of residual intracanalicular tumor and injury to the facial nerve are the main problems associated with surgery of large acoustic neuromas via the retromastoid suboccipital approach. In patients with residual or recurrent intracanalicular neuromas, the translabyrinthine approach is the preferred surgical route, allowing complete tumor removal; it may eventually also be used for exposure of the intratemporal portion of the facial nerve for a hemihypoglossal-facial nerve anastomosis when a postoperative facial palsy exists This one-stage procedure has not been described previously. CLINICAL PRESENTATION: Three patients with postoperative facial palsy and residual intracanalicular tumor after surgical removal of a large acoustic neuroma via the retromastoid suboccipital approach underwent reoperation via the translabyrinthine approach and one-stage removal of the residual tumor and hemihypoglossal-facial nerve anastomosis. All three patients had a complete facial palsy of House-Brackmann Grade VI and a residual tumor of 8 to 12 mm. TECHNIQUE: A classic translabyrinthine approach was used to open the internal auditory canal and remove the residual intracanalicular tumor. The facial nerve was exposed in its mastoid and tympanic parts, mobilized, and transected; then, the long nerve stump was transposed into the neck and used for an end-to-side anastomosis into the hypoglossal nerve. The operation resulted in variable improvement of the facial muscle function up to Grade III (one patient) and Grade IV (two patients). CONCLUSION: Reoperation via the translabyrinthine approach is indicated for removal of residual intracanalicular acoustic neuroma and realization of a hypoglossal-facial nerve anastomosis in a single procedure. It is suggested that this type of anastomosis may also be used during the initial operation for acoustic neuroma removal when the facial nerve is inadvertently sectioned.     

Hemihypoglossal nerve transfer in brachial plexus repair: technique and results

OBJECTIVE: In multiple avulsions of the brachial plexus, the search for extraplexal donor nerves in the hope of achieving motor neurotization is a major goal. We explored the possibility of using the hypoglossal nerve as a transfer point to reanimate muscles in the upper limb. METHODS: The hypoglossal nerve was used as a donor nerve for neurotization in seven patients with avulsive injuries of the brachial plexus. The surgical technique--an end-to-side microsuture using approximately half of the nerve fascicles--is basically the same as that used in the hypoglossal nerve-facial nerve jump graft, which is a well-known technique in facial nerve reanimation. The recipient nerves were the suprascapular (two patients), the musculocutaneous (one patient), the posterior division of the upper trunk (two patients), and the medial contribution to the median nerve (two patients). RESULTS: In spite of a connection documented by electromyography and selective activation in three of seven patients, the functional results in our patients were extremely disappointing: no patient had an outcome better than M1 in the reinnervated muscles. CONCLUSION: This technique was of no help to the patients and thus has been abandoned at our institution.     

Surgical results of the Hypoglossal-Facial nerve Jump Graft technique

Summary   Background. The Hypoglossal-Facial nerve crossover has appeared as a surgical option for those scenarios where the facial nerve is injured in its intracranial course, but the conventional technique unequivocally leads to twelfth cranial nerve deficit. In recent years a number of different surgical approaches have been introduced with a view to avoiding the complete section of the hypoglossal nerve, such as the Jump Graft technique. This paper aims to present the results of the Hypoglossal-Facial nerve Jump Graft technique in relation to facial musculature reanimation capability and hemitongue function preservation. Methods. A retrospective analysis of the records of eight patients submitted to Hypoglossal-Facial nerve Jump Graft technique was performed. The surgical approach was characterised by the interposition of a short graft sutured to the distal stump of the transected facial nerve and sutured end-to-side to the hypoglossi, with cutting of only a third of the diameter of the latter. Findings. The facial nerve injuries were secondary to temporal bone trauma in five cases and to cerebellopontine angle tumour surgery in three. Grafts were harvested from the greater auricular nerve in six patients and from the sural nerve in two. The results of facial reanimation demonstrated facial symmetry and improvement in the facial tone in all cases, and classified as House-Brackmann grade IV in three (37.5%) and grade III in five (62.5%) patients. There was no incidence of definitive hemitongue atrophy and no patient complaint of swallowing or speech difficulty. Conclusions. The modification of the conventional technique of Hypoglossal-Facial nerve anastomosis by means of sectioning one third of the hypoglossal nerve area does not lead to dysfunction of this nerve and the surgical results in terms of facial reanimation are satisfactory.     

End-to-side intrapetrous hypoglossal-facialanastomosis for reanimation of the face. Technical note

The aim of this paper was to report on further experience with a new technique for reanimation of the facial nerve. This procedure allows a straight end-to-side hypoglossal-facial anastomosis without interruption of the 12th cranial nerve or the need for graft interposition. It is technically demanding and time consuming but offers an effective, reliable, and extraordinarily quick means of reinnervating the facial muscles, including the orbicularis oculi muscle, thus avoiding the need for a gold weight in the eyelid or a fascial sling.     

Facial nerve schwannomas: different manifestations and outcomes

BACKGROUND: The purpose of this study was to provide data on the different clinical presentations of facial nerve schwannoma, the appropriate planning for the management of schwannoma of various origins, and the predictive outcomes of surgical management. METHODS: A retrospective study was conducted in a tertiary referral hospital. We reviewed 8 consecutive cases of facial nerve schwannoma diagnosed and managed between 1993 and 2001. RESULTS: Facial nerve schwannomas originated in the internal auditory canal (IAC) (2 cases), parotid gland (2 cases), intratemporal portion (3 cases), and stylomastoid foramen (1 case). Tumor of the stylomastoid foramen presented as an intra- and extratemporal mass. The initial presenting symptom of the 8 patients was facial nerve paralysis in 4 patients, hearing loss in 2, facial numbness in 1, and an infra-auricular mass in 1. Facial palsy occurred in 7 patients during the course of the disease. One patient with a mass in the parotid gland did not show facial palsy up to 1 year after presentation of the initial symptom (facial numbness). Facial nerve paralysis was most severe in intratemporal tumors and less severe in parotid tumors. The patients with IAC suffered from hearing loss and intermittent vertigo and showed decreased vestibular function. The patients with intratemporal tumors also complained of hearing loss. The tumors were completely removed by superficial parotidectomy for parotid tumors; the translabyrinthine approach for 1 IAC tumor and 1 intratemporal tumor; the middle fossa approach for the other IAC tumor; the transmastoid approach for mastoid tumors; and the infratemporal fossa approach for intratemporal and extratemporal tumors. End-to-end cable grafts for the facial nerve were performed in 5 out of 8 cases. In 2 cases, the facial nerve was preserved after the resection of the mass. One case showed complete loss of the peripheral branch of the facial nerve. CONCLUSIONS: Facial nerve schwannoma can present in various ways. By examining the site of origin and the presenting symptoms and signs, we were able to diagnose facial nerve schwannoma preoperatively. According to the operative management of the facial nerve, the postoperative outcome of facial function could be estimated. Our finding could be pivotal in the management of the facial nerve schwannoma.     

Cross-facial nerve grafting as an adjunct to hypoglossal-facial nerve crossover in reanimation of early facial paralysis: clinical and electrophysiological evaluation

Reanimation of a spontaneous and synchronous smile, and sufficient depressor mechanism of the lower lip presents a surgical challenge in facial paralysis. Hypoglossal-facial nerve crossover and cross-facial nerve grafting are the best options if the mimetic muscles around the mouth are still viable in patients in whom the facial nerve was sacrificed at the brainstem. Although good muscle tone and facial motion have been obtained by hypoglossal-facial nerve crossover, smile is dependent on conscious tongue movement. Cross-facial nerve grafting provides a voluntary and emotion-driven smile, but requires two coaptation sites, which leads to substantial axonal loss and a long regeneration time. This method was not successful in activating the depressor mechanism. The first stage is the classic "baby-sitting" procedure, in which the bulk of the mimetic muscles was maintained by the rapid reinnervation of the hypoglossal-facial nerve crossover during the regeneration period of the cross-facial nerve graft, and temporalis muscle transfer to the eyelids is performed. During the second stage, the cross-facial nerve graft that used the thickest zygomaticobuccal branch on the healthy side was coapted with the corresponding branches on the paralyzed side. The hypoglossal-facial nerve crossover continued to innervate the depressor muscles. Good spontaneous smile and sufficient depressor mechanism were achieved by cross-facial nerve grafting and hypoglossal-facial nerve crossover respectively, and these techniques are demonstrated by the authors clinically and electrophysiologically.     

Reanimation of early facial paralysis with hypoglossal/facial end-to-side neurorrhaphy: a new approach

The classic hypoglossal transfer to the facial nerve invariably results in profound functional deficits in speech, mastication, and swallowing, and causes synkinesis and involuntary movements in the facial muscles despite good reanimation. Techniques such as a hypoglossal/facial nerve interpositional jump graft and splitting the hypoglossal nerve cause poor functional results in facial reanimation and mild-to-moderate hemiglossal atrophy, respectively. Direct hypoglossal/facial nerve cross-over through end-to-side coaptation without tension was done in three fresh cadavers and four patients. The patients had facial paralysis for less than 7 months. Complete mobilization of the facial nerve trunk and its main branches beyond the pes anserinus from the stylomastoid foramen, division of the frontal branch, if necessary, and superior elevation of the hypoglossal nerve after dividing the descendens hypoglossi, thyrohyoidal branches, occipital artery, and retromandibular veins were performed. The end of the facial nerve was hooked up through both a quarter of a partial oblique neurotomy and a perineurial window at the side of the hypoglossal nerve. Temporalis muscle transfer to the eyelids and the first stage of cross-facial nerve transfer were performed simultaneously. None of the patients experienced hemiglossal atrophy, synkinesis, and involuntary movements of the facial muscles. Regarding facial reanimation, one patient had excellent, one patient good, and the others fair and poor results after a follow-up of at least 1 year.     

Outcomes of Direct Facial-to-Hypoglossal Neurorrhaphy with Parotid Release

Lesions of the temporal bone and cerebellopontine angle and their management can result in facial nerve paralysis. When the nerve deficit is not amenable to primary end-to-end repair or interpositional grafting, nerve transposition can be used to accomplish the goals of restoring facial tone, symmetry, and voluntary movement. The most widely used nerve transposition is the hypoglossal-facial nerve anastamosis, of which there are several technical variations. Previously we described a technique of single end-to-side anastamosis using intratemporal facial nerve mobilization and parotid release. This study further characterizes the results of this technique with a larger patient cohort and longer-term follow-up. The design of this study is a retrospective chart review and the setting is an academic tertiary care referral center. Twenty-one patients with facial nerve paralysis from proximal nerve injury at the cerebellopontine angle underwent facial-hypoglossal neurorraphy with parotid release. Outcomes were assessed using the Repaired Facial Nerve Recovery Scale, questionnaires, and patient photographs. Of the 21 patients, 18 were successfully reinnervated to a score of a B or C on the recovery scale, which equates to good oral and ocular sphincter closure with minimal mass movement. The mean duration of paralysis between injury and repair was 12.1 months (range 0 to 36 months) with a mean follow-up of 55 months. There were no cases of hemiglossal atrophy, paralysis, or subjective dysfunction. Direct facial-hypoglossal neurorrhaphy with parotid release achieved a functional reinnervation and good clinical outcome in the majority of patients, with minimal lingual morbidity. This technique is a viable option for facial reanimation and should be strongly considered as a surgical option for the paralyzed face.     

Facial electroneurography: clinical and experimental investigations

Facial electroneurography (ENoG) appears to be a reliable prognostic test for intratemporal facial nerve paralysis. ENoG is objective and allows a permanent record to be maintained. Nonetheless, occasional inconsistencies in clinical correlation may diminish the utility of ENoG. A qualitative study was undertaken to identify the possible reasons for the inaccuracy of ENoG in some patients. Four clinical groups and one experimental group were studied: (1) normal subjects, (2) patients with acute facial palsy, (3) patients with progressive facial palsy, (4) patients with temporal bone tumors and normal facial function, and (5) animals in which one facial nerve was crushed and repaired. The reliability of ENoG is dependent on careful interpretation of data obtained by optimal electrode placement and stimulus duration.     

Hypoglossal-facial nerve anastomosis in the rabbits using laser welding

The aim of this study is to compare laser nerve welding of hypoglossal-facial nerve to microsurgical suturing and a result of immediate and delayed repair, and to evaluate the effectiveness of laser nerve welding in reanimation of facial paralysis of the rabbit models. The first group of 5 rabbits underwent immediate hypoglossal-facial anastomosis (HFA) by microsurgical suturing and the second group of 5 rabbits by CO2 laser welding. The third group of 5 rabbits underwent delayed HFA by microsurgical suturing and the fourth group of 5 rabbits by laser nerve welding. The fifth group of 5 rabbits sustained intact hypoglossal and facial nerve as control. In all rabbits of the 4 different groups, cholera toxin subunit B (CTb) was injected in the epineurium distal to the anastomosis site on the postoperative sixth week and in normal hypoglossal nerve in the 5 rabbits of control group. Neurons labeled CTb of hypoglossal nuclei were positive immunohistochemically and the numbers were counted. In the immediate HFA groups, CTb positive neurons were 1416 +/- 118 in the laser welding group (n = 5) and 1429 +/- 90 in the microsurgical suturing group (n = 5). There was no significant difference (P = 0.75). In the delayed HFA groups, CTb positive neurons were 1503 +/- 66 in the laser welding group (n = 5) and 1207 +/- 68 in the microsurgical suturing group (n = 5). Difference was significant (P = 0.009). There was no significant difference between immediate and delayed anastomosis in the laser welding group (P = 0.208), but some significant difference was observed between immediate and delayed anastomosis in the microsurgical suturing group (P = 0.016). Injected CTb in intact hypoglossal neurons (n = 5) were labeled 1970 +/- 165. No dehiscence was seen on the laser welding site of nerve anastomosis in all the rabbits as re-exploration was done for injection of CTb. This study shows that regeneration of the anastomosed hypoglossal-facial nerve was affected similarly by either laser welding or microsurgical suturing in immediate repair; however, the welding was more effective especially in delayed repair.     

Lähmungen der mimischen Gesichtsmuskulatur

INTRODUCTION: For 100 years hypoglossal-facial nerve anastomosis (HFA) has been a common surgical procedure for reanimation of paralyzed mimic muscles of the face after axotomy of the facial nerve. However, the denervation and subsequent scarred degeneration of the target muscles of the hypoglossal nerve often results in unfavorable late effects for speech and swallowing. Therefore, the ansa cervicalis nervi hypoglossi-facial nerve anastomosis (ACHFA) can be an alternative to avoid such late effects. As a branch of the hypoglossal nerve the ansa cervicalis innervates the infrahyoidal muscles. Neck dissection surgery proved that resection of the ansa cervicalis causes no side effects for swallowing because of several nerve anastomoses to the cervical plexus. PATIENTS AND METHOD: We compared our clinical results of eight cases following a delayed ACHFA with our own experiences after HFA and results from the literature. RESULTS: We found a reanimation rate lower than usually seen after HFA only in the target muscles of the forehead. This may be caused by a reduced neuronal plasticity of the ansa cervicalis. However, in the target muscles of the other two facial nerve branches we observed the same good results one would expect after HFA. There were no late side effects for swallowing and speech though.     

Surgical rehabilitation of reversible facial palsy: facial--hypoglossal network system based on neural signal augmentation/neural supercharge concept.

To obtain symmetric appearance in facial palsy patients, it is important to retain any remaining potential of the compromised facial mimetic muscles. The purpose of the present study was to introduce surgical rehabilitation based on neural signal augmentation/neural supercharge concept for the treatment of reversible facial palsy patients. With construction of facial-hypoglossal network system using end-to-side neurorrhaphy technique, both facial and hypoglossal motor signals are provided to the compromised facial mimetic muscles. It is hypothesised that the remaining potential of incompletely or completely paralysed muscles without atrophy is activated by a neural 'supercharge' effect. To date, nine patients presented with reversible facial palsy have been treated by surgical rehabilitation with facial-hypoglossal network system in our institutes. Facial mimetic muscle function evaluated by the House-Brackmann grading system was improved from grade IV-VI to II-III in this series. The postoperative ENMG findings showed double innervation of the mimetic muscles supplied by the facial and hypoglossal donor motor sources. Hemiglossal dysfunction and mimetic muscle synkinesis associated with tongue motion were never seen with an average follow-up period of 21 months after surgery. This reconstructive concept offers a significant advantage for the treatment of the facial palsy patients with persistent incomplete type and reversible complete type without distinct mimetic muscle atrophy.     

Side-to-end hypoglossal-facial anastomosis via transposition of the intratemporal facial nerve

Summary The technique of facial nerve repair with side-to-end hypoglossal-facial anastomosis is presented and evaluated in five patients who were operated on for facial nerve paralysis after acoustic schwannoma surgery, or had cranial base trauma. The end-to-end hypoglossal-facial anastomosis is accompanied by hemilingual paralysis, with difficulty in swallowing, chewing and speaking. In this new technique, the facial nerve is mobilised in the temporal bone, transected at the second genu and transposed to the hypoglossal nerve where a tensionless side-to-end anastomosis is performed. The hypoglossal nerve is transected in oblique fashion to about one third of its circumference. We were able to achieve a tensionless anastomosis in all patients. The idea is to bring about re-innervation of the previously denervated tissue via a collateral sprouting of axons of the donor nerve through the site of coaptation without sacrificing the innervation of the donor nerve’s original targets. With side-to-end hypoglossal-facial anastomosis, two patients attained a House- Brackmann grade of III (one of them with independent movement of eyelids and mouth); one achieved grade IV, another grade V and grade VI. No patient had hemilingual atrophy nor any problems associated with swallowing or chewing.     

Direct Facial-to-Hypoglossal Neurorrhaphy with Parotid Release.

Objective: Facial nerve paralysis or compromise can be caused by lesions of the temporal bone and cerebellopontine angle and their treatment. When the facial nerve is transected or severely compromised and primary end-to-end repair is not possible, hypoglossal-facial nerve anastomosis remains the most popular method for accomplishing three main goals: restoring facial tone, restoring facial symmetry, and facilitating return of voluntary facial movement. Our objectives are to evaluate the surgical feasibility and long-term outcomes of our technique of direct facial-to-hypoglossal neurorrhaphy with a parotid-release maneuver. Design: Prospective cohort. Setting: Academic tertiary care referral center. Patients: Ten patients with facial paralysis from proximal nerve injury underwent the facial-hypoglossal neurorrhaphy with a parotid-release maneuver. Main outcome measures: The Repaired Facial Nerve Recovery Scale, questionnaires, and photographs. Results: Facial-hypoglossal neurorrhaphy with parotid release was technically feasible in all cases, and anastomosis was performed distal to the origin of the ansa hypoglossi. All patients had good return of facial nerve function. Nine patients had scores of C or better, indicating strong eyelid and oral sphincter closure and mass motion. There was no hemilingual atrophy and no subjective tongue dysfunction. Conclusions: The parotid-release maneuver mobilizes additional length to the facial nerve, facilitating a tensionless communication distal to the ansa hypoglossi. The technique is a viable option for facial reanimation, and our patients achieved good clinical outcomes with continual improvement.     

Surgical anatomy for direct hypoglossal-facial nerve side-to-end "anastomosis".

OBJECT: In this study the authors investigated the histomorphometric background and microsurgical anatomy associated with surgically created direct hypoglossal-facial nerve side-to-end communication or nerve "anastomosis." METHODS: Histomorphometric analyses of the facial and hypoglossal nerves were performed using 24 cadaveric specimens and three surgically obtained specimens of severed facial nerve. Both the hypoglossal nerve at the level of the atlas and the facial nerve just distal to the external genu were monofascicular. The number of myelinated axons in the facial nerve (7228 +/- 950) was 73.2% of those in the normal hypoglossal nerve (9778 +/- 1516). Myelinated fibers in injured facial nerves were remarkably decreased in number. The cross-sectioned area of the normal facial nerve (0.948 mm2) accounted for 61.5% of the area of the hypoglossal nerve (1.541 mm2), whereas that of the injured facial nerve (0.66 mm2) was less than 50% of the area of the hypoglossal nerve. Surgical dissection and morphometric measurements were performed using 18 sides of 11 adult cadaver heads. The length of the facial nerve from the pes anserinus to the external genu ranged from 22 to 42 mm (mean 30.5 +/- 4.4 mm). The distance from the pes anserinus to the nearest point on the hypoglossal nerve ranged from 14 to 22 mm (mean 17.3 +/- 2.5 mm). The former was always longer than the latter; the excess ranged from 6 to 20 mm (mean 13.1 +/- 3.4 mm). Surgical anatomy and procedures used to accomplish the nerve connection are described. CONCLUSIONS: The size of a half-cut end of the hypoglossal nerve matches a cut end of the injured facial nerve very well. By using the technique described, a length of facial nerve sufficient to achieve a tensionless communication can consistently be obtained.     

Preliminary observations after facial rehabilitation with the ansa hypoglossi pedicle transfer

Facial paralysis is a very disabling condition, both functionally and cosmetically. Despite the different methods of facial reanimation that have been described, there is no single method that will restore normal facial tone and motion. Of the methods available, primary neurorrhaphy is probably the most effective. The recovery period, however, is prolonged and, as a result, muscle tone and bulk may be lost. The hypoglossal-facial anastomosis is also a very reliable and effective technique but requires necessary interruption of both major cranial nerve trunks. Transfer of a neuromuscular pedicle (based on the ansa hypoglossi) has been offered as a method of facial reanimation that involves neither prolonged recovery nor interruption of the major cranial nerve functions. The application of this technique for reinnervation of a paralyzed larynx was first described by Tucker in 1970, and the technique was applied to facial muscle (in animal models) in 1977. The effectiveness of this technique--and its application in the management of facial paralysis in the human patient--remains controversial. We report our experience with a series of six patients who underwent neuromuscular pedicle transfer in conjunction with other more conventional methods of facial reanimation. The function of the pedicle and its contribution to the overall facial rehabilitation were assessed clinically and electromyographically. Factors influencing the success of the procedure and clinical and experimental evidence to support its application are discussed. While our experience with this technique is limited, it would appear that the neuromuscular pedicle transfer may play a useful adjunctive role in reanimation of the face in selective cases of facial paralysis.     

Facial nerve reconstruction--after the operation of C-P angle tumor

Nineteen patients who undergo facial nerve reconstruction after the operation of cerebellopontine angle tumor from 1964 to 1981 were investigated. Eighteen cases were of acoustic neurinoma, and one was of low grade astrocytoma. Spinal accessory-facial nerve anastomosis was performed in thirteen cases. Cross facial nerve graft was done in three cases. Hypoglossal-facial nerve anastomosis, phrenico-facial nerve anastomosis, and intracranial direct anastomosis were done in one case each. In spinal accessory-facial nerve anastomosis cases, good result was obtained only in 30%, but using microsurgical technique since 1972, its rate went up to 50%. In cross facial nerve anastomosis cases in which two sural nerve grafts were used and the zygomatic and the buccal branches of the right and left connected each other, only one of three revealed good result. The cases of hypoglossal and intracranial direct facial anstomosis resulted in good recovery. As our conclusion, it is difficult to obtain the powerful reinnervation by means of the spinal accessory facial nerve anatomosis and the cross facial nerve graft. Therefore, the best method to be chosen in facial nerve reconstruction seems intracranial direct anastomosis. If the method is impossible, hypoglossal-facial nerve anastomosis should be chosen as the second best. The cross facial nerve graft seems to be leaving much room for technical improvement.