Extratemporal Facial and Radiotherapy
Nerve
Grafting
Harold C. Pillsbury, MD, Ugo Fisch, MD
\s=b\ Nineteen patients with extratemporal facial nerve grafting procedures and 13 patients with facial hypoglossal anastomosis were followed up with serial photographs for at least one year. The photographic analysis of the results demonstrates that radiotherapy had a detrimental influence on the return of facial movements after extratemporal facial
grafting. (Arch Otolaryngol 105:441-446, 1979)
nerve
Accepted for publication Nov 24,
1977. From the Ear, Nose, and Throat Department, University of Zurich, Kantonsspital, Zurich, Switzerland. Dr Pillsbury is now with the Section of Otolaryngology, Yale Medical Center, New Haven, Conn. Reprint requests to Ear, Nose, and Throat Department, University of Zurich, Kantonsspital, 8091 Zurich, Switzerland (Dr Fisch).
Since 1932,
when Ballance and Duel1 first described the restoration of facial function using facial nerve grafts, many advances in nerve graft¬ ing have occurred. The selection of suitable donor nerves as well as tech¬ niques of grafting have varied consid¬ erably.-4 The major indication for extratemporal facial nerve grafting has been the occurrence of neoplasia in the parotid gland involving the nerve. Conley,5 in 1961, and Miehlke et al,6 in 1972, related that the influence of radiotherapy on the outcome of facial nerve grafting was negligible. In 1963, Lathrop7 presented results indicating that postoperative radio¬ therapy had a markedly detrimental effect on return of facial function
Table 1 .—Distribution of Patients in Nerve
Follow-up, Patient
mo
1
18
MATERIAL AND METHODS
Forty-two patients have undergone ex¬ tratemporal facial nerve grafting proce-
Grafting*
Duration of
Underlying Disease Anaplastic carcinoma
Donor Nerve
Preoperative Palsy,
Greater auricular
mo
Radiotherapy Postop : 3,400 rads electrons, 2,600 rads cobalt
None 12
13
Acinic cell carcinoma Malignant melanoma Malignant mixed tumor
Sural Greater auricular Greater auricular Sural Sural Greater auricular
None
Postop: 5,150 rads cobalt Postop: 1,500 rads cobalt Preop: 6,000 rads cobalt Preop: 6,000 rads cobalt Postop: Unknown Postop 3,000 rads electrons, 3,000
12
Malignant
Sural
None
Postop 1,400 rads electrons, 900
24
Epidermoid carcinoma Adenoid cystic carcinoma High-grade mucoepidermoid
Sural Sural Sural
13 23
Postop: 6,000
None
Postop: 6,000
rads cobalt
Greater auricular Greater auricular Greater auricular
Postop: 6,000
rads cobalt
None 10
14 24 19 22 12
10
following grafting. In an effort to clarify the situation, McGuirt and McCabe8 performed a well-conceived study in cats using facial autografts and compared the results with and without radiotherapy. Their findings indicated that postoperative radio¬ therapy has no effect on the outcome of facial nerve autografts. Our experi¬ ence in a group of 19 patients has not coincided with these findings. We report the results of a postoperative photographic analysis of patients with and without radiotherapy following extratemporal facial nerve grafting.
24 12
Epidermoid carcinoma Epidermoid carcinoma Malignant mixed tumor
melanoma
None 40 None
rads cobalt
rads cobalt rads cobalt
None
carcinoma 12 13 14
12
31 12
Epidermoid carcinoma Hemangioma Infection, mastoid fistula,
iatrogenic palsy_ 15
16 17 19
24
Facial neurinoma Facial neurinoma Facial neurinoma Facial neurinoma
Greater Greater Greater Greater
14
Traumatic division secondary
Sural
69 47
to
gunshot
None None
auricular
auricular auricular auricular
None None
None 36 15
wounds
,;'Preop, preoperative; Postop, Postoperative.
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None None None
Fig 1.—Facial movements 12 months following extratemporal reconstruction of facial nerve using two grafts from sural nerve. Operation was performed because of adenoid cystic carcinoma having produced facial palsy of 23 months' preoperative duration. No ra¬ diotherapy was given in view of radicality of extirpation. Average evaluation of return of function was 74 points (patient 10, Table 4).
dures at the University of Zurich (by U. F.) between 1969 and 1975 using previously described grafting techniques."10 Those in whom a partial graft or cross-face graft were used as well as those with a follow-up of less than one year were rejected from this study. Nineteen patients were ob¬ served for at least one year with serial photographs taken after 12 months to ascertain the quality of facial function. Of this group, 12 required grafting following the extirpation of malignant tumors that invaded the facial nerve. The remaining seven patients had benign or traumatic lesions (Table 1). Each patient required a graft that extended to or beyond the bifur¬ cation of the facial nerve, with the greater auricular and sural nerves being used as donors. Radiotherapy consisting of cobalt alone or in combination with electrons was administered postoperatively in nine pa¬ tients (82%) and preoperatively in two patients (18%). Those receiving preopera-
tive radiotherapy were treatment failures referred from outlying institutions. All records of radiotherapy have been re¬ viewed, with specific doses shown in Ta¬ ble 1. An additional 13 patients unsuitable for facial nerve grafting underwent facial hypoglossal anastomoses (Table 2). This group consisted mainly of patients who had undergone resection of large acoustic neuromas by the neurosurgeon in whom the medial stump of the facial nerve was insufficient for grafting. These patients were observed for at least 12 months and were
subjected
to
a
photographic analysis
of results. Interestingly, one patient in this group, with epidermoid carcinoma of the middle ear, received postoperative radio¬
therapy.
The standard photographs taken for evaluation of results were similar to those used by Jongkees," except that an addi¬ tional pose depicting the patients ability to
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whistle was added. Because the face at rest is often nearly normal in patients with facial palsy, ten points were subtracted from the importance of this view and given to the photograph of the whistle. The different photographic views and maximal points possible for a perfect result are shown in Table 3. Each photograph was evaluated on a scale from 0 to 3, with 0 representing no motion or tonus, while 3 represented normal symmetry. The evalua¬ tion of each picture was expressed in thirds and multiplied by the total possible point allotment for the particular view, following which all computed values were added. The indépendant evaluations of all photographs by three otolaryngologists familiar with facial nerve problems were averaged and
compared.
RESULTS
Figures 1 to 4 demonstrate typical examples taken from the different
Fig 2.—Child was sent to us immediate¬ ly following removal of large hemangio¬ ma in parotid region performed else¬ where with resulting total loss of facial function. Repair was performed with graft from greater auricular nerve reaching from stylomastoid foramen to zygomatic and mandibular branches of facial nerve. Photographic evaluation 12 months following repair has been qualified in average with 74 points (patient 13, Table 4).
groups of
investigated patients.
Fa¬ without radiother¬ grafting apy produces on the average a return of function reaching 70% of normal face movements (Fig 1 and 2). This reduction is mainly due to the inabili¬ ty to raise the upper lip when smiling and to lift the brow, as well as to inevitable presence of some degree of
cial
nerve
synkinesis. Radiotherapy has prevented any return of function following facial nerve grafting in the case shown in Fig 3. However, the photographic
evaluation of facial movements reaches 25%. This is mainly on account of the symmetry of the face at rest. Hypoglossal facial anastomosis does restore facial movements. But even if the ability to express emotions is not considered, the photographic evalua¬ tion usually shows a lesser degree of
facial symmetry than the reconstruc¬ tion of the continuity of the facial nerve (55% vs 70%, Fig 4). The reasons for the inferior results of hypoglossal facial anastomosis are the less differ¬ entiated mobility of the lips when smiling and whistling (Fig 4) as well as the presence of larger mass move¬ ments.
The computations and averages for patients with and without radiothera¬ py
are
shown in Tables 4 and 5. Radio¬
therapy has reduced the average postoperative results from 70% to 25%
of normal movements. This difference has been proved to be of statistical significance at the < .001 level according to the Wilcoxson test. Therefore, it is not surprising that the only patient having had radiotherapy following hypoglossal facial anasto¬ mosis had an end result of 26%, where-
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the average return of function in the nonirradiated group of patients is 55% (Table 5). Age, sex, duration of preoperative palsy, site of donor graft, and the effect of preoperative or postopera¬ tive irradiation have not proved to have significant influence on the return of facial movements. The ages of patients with facial nerve grafting and radiotherapy were significantly different than those of patients with facial nerve grafting without radio¬ therapy because of the natural occur¬ rence of malignant tumors in older age groups. However, when patients of similar ages from both groups were compared, the results were still signif¬ icantly different. In a recent study on intratemporal nerve grafting, Rouleau and Fisch1'' found that results were less satisfacas
Fig 3.—Results 12 months following extratemporal facial grafting after total parotidectomy and neck dissection because of epidermoid carcinoma of left parotid gland. Postoperative irra¬ diation with 6,000 rads. Average photo¬ graphic evaluation was 25 points (patient 9, Table 4).
Table 2.—Distribution of Patients in Facial
Hypoglossal
Anastomosis
Duration of Patient 1
Follow-up, mo
12
Underlying Disease Epidermoid carcinoma
Preoperative Palsy, mo None
6,000 rads cobalt
parotid_
16 24
25 35 13
Laceration of facial nerve brain stem Acoustic neurinoma Cholesteatoma Temporal bone fracture Acoustic neurinoma
Radiotherapy Postoperative,
35
None None
42
None None
10
None
(neurofibromatosis) 12 19 84 10
Acoustic neurinoma
Acoustic neurinoma Acoustic neurinoma Acoustic neurinoma
None 18
None None
14
None
11
None None None
(neurofibromatosis) 12 13
20 19 12
Acoustic neurinoma Acoustic neurinoma Acoustic neurinoma
10
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Fig 4.—Results 12 months following hypoglossal facial anastomosis follow¬ ing removal of large intracranial acous¬ tic neurinoma. Duration of preoperative palsy was six months. Average photo¬ graphic evaluation was 49 points (patient 3, Table 5).
Table
3.—Photographie Scale* Point Values
Table 4.—Photographie Evaluation of Results of Facial Nerve Grafting Evaluator
Present Pose
Study
Face at rest Closure of eyes Ability to lift brow Ability to show all anterior teeth
20 30 10
(modified smile)
30 10 100
Whistle Total
Table 5.—Photographie Evaluation of Results of Hypoglossal-Facial Anastomosis
Jongkees 30 30 10
With
Patient_1
Radiotherapy (Group 1) 1
2 3 4
30
5 6 7
100
"Key to the photographic evaluation of results after extratemporal facial nerve grafting. Each pose was evaluated on a scale from 0 to 3 with 0 representing no motion or tonus, while 3 repre¬ sents normal symmetry. The evaluation of each pose was expressed in thirds and multiplied by the total possible point allotment for the particu¬ lar view. All computed values are then totalled. For Instance if the closure of the eyes was rated with 2, % of 30 points 20 points were attrib¬ uted for that pose.
2
8 9
13 10 17 51 33
23
17
17 27 20 17
20 13 17
30 17 57 37
3
Av
30 27 14
22
57 27 20 27 17 20
Group av_. Without Radiotherapy (Group 2) 10 11 12 13 14 15 16 17 18 19
=
Group
67 77
77 74 67 76 74 70 77 63
76
71 70 71 60 73 65 63 76 65
80 66 63 77 66 63 70 56 77 70
av
22 16 55 32 18 25 17 18 25
Evaluator
With
Patient_1 1
Without
61
3
53 50 64 56 37 70 46 64 60 50 64
4
5 6 7 8 9
10 11
70 63 77 66 70
.
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12 13
Group
30
2
71 70 74 71
3
Av
20
27
26
Radiotherapy (Group 3)
74
64
2
Radiotherapy
53 47
63 47
59 49
47
53 67 57 43 73 43 53 60 51 63
50 59 57 37 74 47 57 57 53 66 55
47 57 30
80 53 53 47
57 70
av .
a graft of less than 1 cm was used. The influence of the operative gap was studied for this report, but all grafts were longer than 2 cm. This could explain our inability to correlate graft length with results.
tory if
COMMENT
Despite previous reports claiming
that radiation has minimal influence on grafting results," the figures presented herein show that radiother¬ apy prevents considerably a return in function following reconstruction of the continuity of the facial nerve. In fact, the obtained average return in function after irradiation was only confined to restoration of symmetry of the face at rest (Fig 3). Facial nerve grafting even without radiotherapy is always followed by an average reduc¬ tion of static and dynamic symmetry of the face that has been evaluated photographically at 70% (Table 4, Fig 1 and 2). Age and duration of preoperative palsy have no effect on the results obtained with facial nerve grafting. One of the best results was obtained in a patient who had preoperative facial palsy for 23 months following excision of an adenoid cystic carcino¬ ma of the parotid gland (Fig 1). Although one case is not sufficient for statistical analysis, Table 5 indicates that radiotherapy may also have a detrimental effect if used following hypoglossal facial anastomosis. The results of hypoglossal facial anasto¬ mosis are inferior to those obtained following facial nerve grafting, but still produce an average static and dynamic symmetry of 55%. The main difference is due to the less differen¬ tiated movements in the orbicularis oris area. Synkinesis and mass movement of facial musculature were significantly reduced in the reported cases of ex¬ tratemporal facial nerve grafting
by sectioning unimportant
nerve
branches situated in the buccal area. This measure (directed nerve regener¬ ation1") improves regeneration in the superior and inferior third of the face and reduces the intermingling of regenerating nerve fibers in the middle third of the face, where it is most likely to occur. Although the
directed
regeneration has im¬ results for lip closure and proved lip movements, no useful symmetry could be restored in all our patients in the frontal muscle. The observed negative effect of radiotherapy on the results of extratemporal facial nerve grafting may be nerve
our
explained by a recent investigation by Spiess." Spiess, in an effort to explain the cause of postirradiation brachial plexus paresis, has exposed the sciatic nerve of rats to analogous radiation surface doses given to men (3,000 to 8,000 rads). The
nerves were
studied
electrophysiologically and microscopi¬ cally at intervals up to six months after treatment. Normal conducting speed of the isolated nerves with no apparent functional impairment was noted at late interval in all animals.
However, on microscopic examination,
axonal degeneration and damage in the myelin sheaths (mainly fibrosis of the capillary endothelium) were ob¬ served as early as two months follow¬ ing doses as low as 5,000 rads. Later changes included complete nerve fiber degeneration at six months with doses of more than 6,000 rads. Although the observed neuronal damage and angiomesenchymal change did not af¬ fect the function of a normal nerve, the situation may be different in the presence of regenerating nerve fibers. If irradiation produces fibrosis of capillaries in the nerve sheath proxi¬ mally and distally to the grafted site, there is a good chance that adequate anastomotic healing will not occur. Animal experiments showing the op¬ posite2" only stress the differences existing in regenerating potential, differentiation of movements, and size between animals and men. In¬ deed, following extratemporal facial grafting, the regenerating nerve fi¬ bers need four to six months to reach the facial muscles in humans vs four to six weeks in guinea pigs and cats. Therefore, the angiomesenchymal changes induced by preoperative or early postoperative irradiation have much more time to affect the delicate process of neuronal repair in men than under a similar condition in animals. In view of the observed detrimental effect of radiotherapy on the results of extensive facial nerve grafting, we
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have begun to use fascia lata slings and muscle transfer to restore the symmetry of the face in patients in whom after extensive extratemporal excision of the main trunk and branches of the facial nerve postoper¬ ative radiotherapy is anticipated. These reconstructive measures cut down the operative time and produce better end results than the most precise attempt of reconstructing the continuity of the facial nerve followed
by radiotherapy. Postoperative irradiation has been found to have an unquestionable
detrimental effect on the results obtained by facial nerve grafting procedures in the extratemporal re¬ gion. In view of the poor results to be expected when facial nerve grafting is associated with postoperative radio¬ therapy, the use of alternative mea¬ sures (such as fascia lata sling and muscle transfers) are proposed in lieu of facial nerve grafting or facial hypo¬ glossal anastomosis for patients in whom radiotherapy is anticipated. References C, Duel AB: The operative treatpalsy by the introduction of nerve grafts into the Fallopian canal and by the infratemporal method. Arch Otolaryngol 25:1-70, 1. Ballance
ment of facial
1932. 2. McCabe BF: Facial nerve grafting. Plast Reconstr Surg 45:70-75, 1970. 3. Sade J: Facial nerve reconstruction and its prognosis. Ann Otol Rhinol Laryngol 84:695-703, 1975. 4. Kettel K: Repair of intratemporal lesions of the facial nerve due to trauma. Ann Otol Rhinol Laryngol 72:756-775, 1963. 5. Conley JJ: Facial nerve grafting. Arch Otolaryngol 73:322-327, 1961. 6. Miehlke A, Stennart E, Schuster R, et al: Ueber die Regeneration peripherer Nerven nach Einwirkung ionisierender Strahlen. ORL 34:88\x=req-\ 100, 1972. 7. Lathrop FD: Management of the facial nerve during operations on the parotid gland. Ann Otol Rhinol Laryngol 72:780-801, 1963. 8. McGuirt WF, McCabe BF: Effect of radiation therapy on facial nerve cable autografts. Laryngoscope 87:415-428, 1977. 9. Fisch U: Operations on the facial nerve in its labyrinthine and meatal course, in Miehlke A (ed): Surgery of the Facial Nerve. Munich, Urban & Schwarzenberg, 1973, pp 175-205. 10. Fisch U: Facial nerve grafting. Otolaryngol Clin North Am 7:517-529, 1974. 11. Jongkees LBW: Decompression of the facial nerve. Arch Otolaryngol 85:473-479, 1967. 12. Rouleau M, Fisch U: Results of intratemporal facial nerve grafting. Arch Otolaryngol, to be
published. 13. Spiess
H: Schadigungen an peripheren Nervensystem durch ionisierende Strahlen. Neurol. Series No. 10, New York, Springer-Verlag, 1972.
Nerve
Grafting
Harold C. Pillsbury, MD, Ugo Fisch, MD
\s=b\ Nineteen patients with extratemporal facial nerve grafting procedures and 13 patients with facial hypoglossal anastomosis were followed up with serial photographs for at least one year. The photographic analysis of the results demonstrates that radiotherapy had a detrimental influence on the return of facial movements after extratemporal facial
grafting. (Arch Otolaryngol 105:441-446, 1979)
nerve
Accepted for publication Nov 24,
1977. From the Ear, Nose, and Throat Department, University of Zurich, Kantonsspital, Zurich, Switzerland. Dr Pillsbury is now with the Section of Otolaryngology, Yale Medical Center, New Haven, Conn. Reprint requests to Ear, Nose, and Throat Department, University of Zurich, Kantonsspital, 8091 Zurich, Switzerland (Dr Fisch).
Since 1932,
when Ballance and Duel1 first described the restoration of facial function using facial nerve grafts, many advances in nerve graft¬ ing have occurred. The selection of suitable donor nerves as well as tech¬ niques of grafting have varied consid¬ erably.-4 The major indication for extratemporal facial nerve grafting has been the occurrence of neoplasia in the parotid gland involving the nerve. Conley,5 in 1961, and Miehlke et al,6 in 1972, related that the influence of radiotherapy on the outcome of facial nerve grafting was negligible. In 1963, Lathrop7 presented results indicating that postoperative radio¬ therapy had a markedly detrimental effect on return of facial function
Table 1 .—Distribution of Patients in Nerve
Follow-up, Patient
mo
1
18
MATERIAL AND METHODS
Forty-two patients have undergone ex¬ tratemporal facial nerve grafting proce-
Grafting*
Duration of
Underlying Disease Anaplastic carcinoma
Donor Nerve
Preoperative Palsy,
Greater auricular
mo
Radiotherapy Postop : 3,400 rads electrons, 2,600 rads cobalt
None 12
13
Acinic cell carcinoma Malignant melanoma Malignant mixed tumor
Sural Greater auricular Greater auricular Sural Sural Greater auricular
None
Postop: 5,150 rads cobalt Postop: 1,500 rads cobalt Preop: 6,000 rads cobalt Preop: 6,000 rads cobalt Postop: Unknown Postop 3,000 rads electrons, 3,000
12
Malignant
Sural
None
Postop 1,400 rads electrons, 900
24
Epidermoid carcinoma Adenoid cystic carcinoma High-grade mucoepidermoid
Sural Sural Sural
13 23
Postop: 6,000
None
Postop: 6,000
rads cobalt
Greater auricular Greater auricular Greater auricular
Postop: 6,000
rads cobalt
None 10
14 24 19 22 12
10
following grafting. In an effort to clarify the situation, McGuirt and McCabe8 performed a well-conceived study in cats using facial autografts and compared the results with and without radiotherapy. Their findings indicated that postoperative radio¬ therapy has no effect on the outcome of facial nerve autografts. Our experi¬ ence in a group of 19 patients has not coincided with these findings. We report the results of a postoperative photographic analysis of patients with and without radiotherapy following extratemporal facial nerve grafting.
24 12
Epidermoid carcinoma Epidermoid carcinoma Malignant mixed tumor
melanoma
None 40 None
rads cobalt
rads cobalt rads cobalt
None
carcinoma 12 13 14
12
31 12
Epidermoid carcinoma Hemangioma Infection, mastoid fistula,
iatrogenic palsy_ 15
16 17 19
24
Facial neurinoma Facial neurinoma Facial neurinoma Facial neurinoma
Greater Greater Greater Greater
14
Traumatic division secondary
Sural
69 47
to
gunshot
None None
auricular
auricular auricular auricular
None None
None 36 15
wounds
,;'Preop, preoperative; Postop, Postoperative.
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None None None
Fig 1.—Facial movements 12 months following extratemporal reconstruction of facial nerve using two grafts from sural nerve. Operation was performed because of adenoid cystic carcinoma having produced facial palsy of 23 months' preoperative duration. No ra¬ diotherapy was given in view of radicality of extirpation. Average evaluation of return of function was 74 points (patient 10, Table 4).
dures at the University of Zurich (by U. F.) between 1969 and 1975 using previously described grafting techniques."10 Those in whom a partial graft or cross-face graft were used as well as those with a follow-up of less than one year were rejected from this study. Nineteen patients were ob¬ served for at least one year with serial photographs taken after 12 months to ascertain the quality of facial function. Of this group, 12 required grafting following the extirpation of malignant tumors that invaded the facial nerve. The remaining seven patients had benign or traumatic lesions (Table 1). Each patient required a graft that extended to or beyond the bifur¬ cation of the facial nerve, with the greater auricular and sural nerves being used as donors. Radiotherapy consisting of cobalt alone or in combination with electrons was administered postoperatively in nine pa¬ tients (82%) and preoperatively in two patients (18%). Those receiving preopera-
tive radiotherapy were treatment failures referred from outlying institutions. All records of radiotherapy have been re¬ viewed, with specific doses shown in Ta¬ ble 1. An additional 13 patients unsuitable for facial nerve grafting underwent facial hypoglossal anastomoses (Table 2). This group consisted mainly of patients who had undergone resection of large acoustic neuromas by the neurosurgeon in whom the medial stump of the facial nerve was insufficient for grafting. These patients were observed for at least 12 months and were
subjected
to
a
photographic analysis
of results. Interestingly, one patient in this group, with epidermoid carcinoma of the middle ear, received postoperative radio¬
therapy.
The standard photographs taken for evaluation of results were similar to those used by Jongkees," except that an addi¬ tional pose depicting the patients ability to
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whistle was added. Because the face at rest is often nearly normal in patients with facial palsy, ten points were subtracted from the importance of this view and given to the photograph of the whistle. The different photographic views and maximal points possible for a perfect result are shown in Table 3. Each photograph was evaluated on a scale from 0 to 3, with 0 representing no motion or tonus, while 3 represented normal symmetry. The evalua¬ tion of each picture was expressed in thirds and multiplied by the total possible point allotment for the particular view, following which all computed values were added. The indépendant evaluations of all photographs by three otolaryngologists familiar with facial nerve problems were averaged and
compared.
RESULTS
Figures 1 to 4 demonstrate typical examples taken from the different
Fig 2.—Child was sent to us immediate¬ ly following removal of large hemangio¬ ma in parotid region performed else¬ where with resulting total loss of facial function. Repair was performed with graft from greater auricular nerve reaching from stylomastoid foramen to zygomatic and mandibular branches of facial nerve. Photographic evaluation 12 months following repair has been qualified in average with 74 points (patient 13, Table 4).
groups of
investigated patients.
Fa¬ without radiother¬ grafting apy produces on the average a return of function reaching 70% of normal face movements (Fig 1 and 2). This reduction is mainly due to the inabili¬ ty to raise the upper lip when smiling and to lift the brow, as well as to inevitable presence of some degree of
cial
nerve
synkinesis. Radiotherapy has prevented any return of function following facial nerve grafting in the case shown in Fig 3. However, the photographic
evaluation of facial movements reaches 25%. This is mainly on account of the symmetry of the face at rest. Hypoglossal facial anastomosis does restore facial movements. But even if the ability to express emotions is not considered, the photographic evalua¬ tion usually shows a lesser degree of
facial symmetry than the reconstruc¬ tion of the continuity of the facial nerve (55% vs 70%, Fig 4). The reasons for the inferior results of hypoglossal facial anastomosis are the less differ¬ entiated mobility of the lips when smiling and whistling (Fig 4) as well as the presence of larger mass move¬ ments.
The computations and averages for patients with and without radiothera¬ py
are
shown in Tables 4 and 5. Radio¬
therapy has reduced the average postoperative results from 70% to 25%
of normal movements. This difference has been proved to be of statistical significance at the < .001 level according to the Wilcoxson test. Therefore, it is not surprising that the only patient having had radiotherapy following hypoglossal facial anasto¬ mosis had an end result of 26%, where-
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the average return of function in the nonirradiated group of patients is 55% (Table 5). Age, sex, duration of preoperative palsy, site of donor graft, and the effect of preoperative or postopera¬ tive irradiation have not proved to have significant influence on the return of facial movements. The ages of patients with facial nerve grafting and radiotherapy were significantly different than those of patients with facial nerve grafting without radio¬ therapy because of the natural occur¬ rence of malignant tumors in older age groups. However, when patients of similar ages from both groups were compared, the results were still signif¬ icantly different. In a recent study on intratemporal nerve grafting, Rouleau and Fisch1'' found that results were less satisfacas
Fig 3.—Results 12 months following extratemporal facial grafting after total parotidectomy and neck dissection because of epidermoid carcinoma of left parotid gland. Postoperative irra¬ diation with 6,000 rads. Average photo¬ graphic evaluation was 25 points (patient 9, Table 4).
Table 2.—Distribution of Patients in Facial
Hypoglossal
Anastomosis
Duration of Patient 1
Follow-up, mo
12
Underlying Disease Epidermoid carcinoma
Preoperative Palsy, mo None
6,000 rads cobalt
parotid_
16 24
25 35 13
Laceration of facial nerve brain stem Acoustic neurinoma Cholesteatoma Temporal bone fracture Acoustic neurinoma
Radiotherapy Postoperative,
35
None None
42
None None
10
None
(neurofibromatosis) 12 19 84 10
Acoustic neurinoma
Acoustic neurinoma Acoustic neurinoma Acoustic neurinoma
None 18
None None
14
None
11
None None None
(neurofibromatosis) 12 13
20 19 12
Acoustic neurinoma Acoustic neurinoma Acoustic neurinoma
10
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Fig 4.—Results 12 months following hypoglossal facial anastomosis follow¬ ing removal of large intracranial acous¬ tic neurinoma. Duration of preoperative palsy was six months. Average photo¬ graphic evaluation was 49 points (patient 3, Table 5).
Table
3.—Photographie Scale* Point Values
Table 4.—Photographie Evaluation of Results of Facial Nerve Grafting Evaluator
Present Pose
Study
Face at rest Closure of eyes Ability to lift brow Ability to show all anterior teeth
20 30 10
(modified smile)
30 10 100
Whistle Total
Table 5.—Photographie Evaluation of Results of Hypoglossal-Facial Anastomosis
Jongkees 30 30 10
With
Patient_1
Radiotherapy (Group 1) 1
2 3 4
30
5 6 7
100
"Key to the photographic evaluation of results after extratemporal facial nerve grafting. Each pose was evaluated on a scale from 0 to 3 with 0 representing no motion or tonus, while 3 repre¬ sents normal symmetry. The evaluation of each pose was expressed in thirds and multiplied by the total possible point allotment for the particu¬ lar view. All computed values are then totalled. For Instance if the closure of the eyes was rated with 2, % of 30 points 20 points were attrib¬ uted for that pose.
2
8 9
13 10 17 51 33
23
17
17 27 20 17
20 13 17
30 17 57 37
3
Av
30 27 14
22
57 27 20 27 17 20
Group av_. Without Radiotherapy (Group 2) 10 11 12 13 14 15 16 17 18 19
=
Group
67 77
77 74 67 76 74 70 77 63
76
71 70 71 60 73 65 63 76 65
80 66 63 77 66 63 70 56 77 70
av
22 16 55 32 18 25 17 18 25
Evaluator
With
Patient_1 1
Without
61
3
53 50 64 56 37 70 46 64 60 50 64
4
5 6 7 8 9
10 11
70 63 77 66 70
.
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12 13
Group
30
2
71 70 74 71
3
Av
20
27
26
Radiotherapy (Group 3)
74
64
2
Radiotherapy
53 47
63 47
59 49
47
53 67 57 43 73 43 53 60 51 63
50 59 57 37 74 47 57 57 53 66 55
47 57 30
80 53 53 47
57 70
av .
a graft of less than 1 cm was used. The influence of the operative gap was studied for this report, but all grafts were longer than 2 cm. This could explain our inability to correlate graft length with results.
tory if
COMMENT
Despite previous reports claiming
that radiation has minimal influence on grafting results," the figures presented herein show that radiother¬ apy prevents considerably a return in function following reconstruction of the continuity of the facial nerve. In fact, the obtained average return in function after irradiation was only confined to restoration of symmetry of the face at rest (Fig 3). Facial nerve grafting even without radiotherapy is always followed by an average reduc¬ tion of static and dynamic symmetry of the face that has been evaluated photographically at 70% (Table 4, Fig 1 and 2). Age and duration of preoperative palsy have no effect on the results obtained with facial nerve grafting. One of the best results was obtained in a patient who had preoperative facial palsy for 23 months following excision of an adenoid cystic carcino¬ ma of the parotid gland (Fig 1). Although one case is not sufficient for statistical analysis, Table 5 indicates that radiotherapy may also have a detrimental effect if used following hypoglossal facial anastomosis. The results of hypoglossal facial anasto¬ mosis are inferior to those obtained following facial nerve grafting, but still produce an average static and dynamic symmetry of 55%. The main difference is due to the less differen¬ tiated movements in the orbicularis oris area. Synkinesis and mass movement of facial musculature were significantly reduced in the reported cases of ex¬ tratemporal facial nerve grafting
by sectioning unimportant
nerve
branches situated in the buccal area. This measure (directed nerve regener¬ ation1") improves regeneration in the superior and inferior third of the face and reduces the intermingling of regenerating nerve fibers in the middle third of the face, where it is most likely to occur. Although the
directed
regeneration has im¬ results for lip closure and proved lip movements, no useful symmetry could be restored in all our patients in the frontal muscle. The observed negative effect of radiotherapy on the results of extratemporal facial nerve grafting may be nerve
our
explained by a recent investigation by Spiess." Spiess, in an effort to explain the cause of postirradiation brachial plexus paresis, has exposed the sciatic nerve of rats to analogous radiation surface doses given to men (3,000 to 8,000 rads). The
nerves were
studied
electrophysiologically and microscopi¬ cally at intervals up to six months after treatment. Normal conducting speed of the isolated nerves with no apparent functional impairment was noted at late interval in all animals.
However, on microscopic examination,
axonal degeneration and damage in the myelin sheaths (mainly fibrosis of the capillary endothelium) were ob¬ served as early as two months follow¬ ing doses as low as 5,000 rads. Later changes included complete nerve fiber degeneration at six months with doses of more than 6,000 rads. Although the observed neuronal damage and angiomesenchymal change did not af¬ fect the function of a normal nerve, the situation may be different in the presence of regenerating nerve fibers. If irradiation produces fibrosis of capillaries in the nerve sheath proxi¬ mally and distally to the grafted site, there is a good chance that adequate anastomotic healing will not occur. Animal experiments showing the op¬ posite2" only stress the differences existing in regenerating potential, differentiation of movements, and size between animals and men. In¬ deed, following extratemporal facial grafting, the regenerating nerve fi¬ bers need four to six months to reach the facial muscles in humans vs four to six weeks in guinea pigs and cats. Therefore, the angiomesenchymal changes induced by preoperative or early postoperative irradiation have much more time to affect the delicate process of neuronal repair in men than under a similar condition in animals. In view of the observed detrimental effect of radiotherapy on the results of extensive facial nerve grafting, we
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have begun to use fascia lata slings and muscle transfer to restore the symmetry of the face in patients in whom after extensive extratemporal excision of the main trunk and branches of the facial nerve postoper¬ ative radiotherapy is anticipated. These reconstructive measures cut down the operative time and produce better end results than the most precise attempt of reconstructing the continuity of the facial nerve followed
by radiotherapy. Postoperative irradiation has been found to have an unquestionable
detrimental effect on the results obtained by facial nerve grafting procedures in the extratemporal re¬ gion. In view of the poor results to be expected when facial nerve grafting is associated with postoperative radio¬ therapy, the use of alternative mea¬ sures (such as fascia lata sling and muscle transfers) are proposed in lieu of facial nerve grafting or facial hypo¬ glossal anastomosis for patients in whom radiotherapy is anticipated. References C, Duel AB: The operative treatpalsy by the introduction of nerve grafts into the Fallopian canal and by the infratemporal method. Arch Otolaryngol 25:1-70, 1. Ballance
ment of facial
1932. 2. McCabe BF: Facial nerve grafting. Plast Reconstr Surg 45:70-75, 1970. 3. Sade J: Facial nerve reconstruction and its prognosis. Ann Otol Rhinol Laryngol 84:695-703, 1975. 4. Kettel K: Repair of intratemporal lesions of the facial nerve due to trauma. Ann Otol Rhinol Laryngol 72:756-775, 1963. 5. Conley JJ: Facial nerve grafting. Arch Otolaryngol 73:322-327, 1961. 6. Miehlke A, Stennart E, Schuster R, et al: Ueber die Regeneration peripherer Nerven nach Einwirkung ionisierender Strahlen. ORL 34:88\x=req-\ 100, 1972. 7. Lathrop FD: Management of the facial nerve during operations on the parotid gland. Ann Otol Rhinol Laryngol 72:780-801, 1963. 8. McGuirt WF, McCabe BF: Effect of radiation therapy on facial nerve cable autografts. Laryngoscope 87:415-428, 1977. 9. Fisch U: Operations on the facial nerve in its labyrinthine and meatal course, in Miehlke A (ed): Surgery of the Facial Nerve. Munich, Urban & Schwarzenberg, 1973, pp 175-205. 10. Fisch U: Facial nerve grafting. Otolaryngol Clin North Am 7:517-529, 1974. 11. Jongkees LBW: Decompression of the facial nerve. Arch Otolaryngol 85:473-479, 1967. 12. Rouleau M, Fisch U: Results of intratemporal facial nerve grafting. Arch Otolaryngol, to be
published. 13. Spiess
H: Schadigungen an peripheren Nervensystem durch ionisierende Strahlen. Neurol. Series No. 10, New York, Springer-Verlag, 1972.
