Return to: Facial Paralysis (surgery for facial nerve paralysis weakness)

Please also see: Sural Nerve Graft Harvest and Facial Reanimation and Cross Face Nerve Graft (Case Example)

Note: last updated before 2017

Dr. Douglas Henstrom University of Iowa Facial Plastic and Reconstructive Surgeon, Director of Facial Nerve Center
For appointment please call: 319-356-3600

GENERAL CONSIDERATIONS

Cross-face nerve grafting is indicated if the proximal ipsilateral facial nerve is not available but the distal stumps are available. Outcome of cross-nerve grafting depends on timing and technique and can provide the best facial reanimation scheme if performed on the right patient. The surgeon must select appropriate segmental branches of the contralateral facial nerve as donors, with the sural nerve serving as a cable graft. Many techniques have been described, such as a single segmental-to – main trunk anastomosis and multiple anastomoses from segmental branches to segmental branches. The grafts are tunneled above the supraorbital ridge for the orbicularis oculi, the upper lip for the zygomatic and buccal branches, and below the lower lip for the marginal mandibular branch. Facial muscle movement will not emerge until 9-12 months after the procedure (ie, the allotted time for axonal growth to cross the graft). This method is superior to other methods of facial reanimation because of its unique potential for restoring mimetic spontaneous smiling.

PREOPERATIVE PREPARATIONS

1. Evaluation 
   1. Pre-operative photography including dynamic i.e. smiling motions
   2. Pre-operative electromyography
   3. Consent for Surgery should include discussion of realistic goals, benefits, possible risks
2. Speak with Anesthesia team prior to case to ensure that no long-lasting paralytic is administered as you will be stimulating facial nerve branches

NURSING CONSIDERATIONS

1. Room Setup 
   1. Turn either 90 or 180 degrees to allow access to the chosen leg 
      1. Consider having sandbag available for propping of chosen leg
2. Instrumentation and Equipment 
   1. Parsons- McCabe nerve stimulator, start on 2 V to identify distal branches
3. Medications (specific to nursing)
   1. Plain epinephrine 1:100,000
4. Prep and Drape 
   1. Medium drape under leg along with stockinette rolled to just below the knee
   2. Green masking tape for hair
   3. Head drape with medium drape and towel
   4. Split drape for head only, place second medium drape over leg
5. Drains and Dressings 
   1. 1/4 inch Penrose drain to place under flap on non-paralyzed side
   2. Kerlix rolls and fluffs for modified mastoid dressing or Barton's dressing to place over dissected non-paralyzed side

ANESTHESIA CONSIDERATIONS

1. Use of an oral rae tube taped at midline helps facilitate the sublabial placement of the harvested sural nerve.
   1. Sterile tubing will be used to exchange after prepping and draping to allow the tubing to be on top of drapes and help facilitate head movement during surgery.
2. The need for nerve stimulation will necessitate not using any paralytics throughout the case.

OPERATIVE PROCEDURE

1. The patient is placed in the supine position, and the entire face is prepped out. The CONTRALATERAL (side without facial paralysis) face is injected with 10-15 cc of plain epinephrine 1:100,000 without lidocaine. 
2. An incision is made in the preauricular crease with a #15 blade and extended to temporal and cervical areas for access to distal branches of the nerve. 
   1. A skin flap is then elevated anteriorly in the subSMAS plane overlying the parotid fascia using the facelift scissors until the anteriormost aspect of the parotid gland is reached. 
   2. The facial nerve branches are then identified in the parotomasseteric fascia and stimulated using the Parsons-McCabe nerve simulator. 
      1. Multiple buccal branches are identified, including redundant branches that create a smile effect the functional side. 
      2. Each identified branch is isolated with vessel loops and carefully stimulated and face observed to identify specific muscle action of each nerve branch
         1. A proper branch, that provides smile without excess movement in the eye or nose, is then selected to be sacrificed to become a donor nerve to be used for innervation of the ipsilateral side with facial paralysis. 
3. A sural nerve graft is then harvested subcutaneously from the desired leg in the usual fashion using a tendon stripper. A 30 cm segment is more than sufficient for this procedure.
   1. Please also see: Sural Nerve Graft Harvest
   2. Leg incision is closed with buried monocryl sutures, steri-strips and ace wrap.
4. The nerve graft is then brought up to the site of the donor buccal branch. The distal end of the sural nerve will be coapted to the donor nerve, and the proximal end will be passed to the contralateral lip.
   1. Bilateral sublabial incisions are made.   
      1. The nerve is then passed by attaching it to a fascia passer with 3-0 silk through the sublabial incisions created in the upper lip on the ipsilateral side.
      2. The nerve is released from the fascia needle, and the fascia needle is then passed from the contralateral lip incision, across the face of the maxilla, and out the incision where the nerve is now located
      3. The nerve is once again attached to the fascia needle and pulled through the tunnel to the contralateral (paralyzed) side of the face.
      4. The end of the nerve is marked by suturing a 4-0 or 5-0 black nylon suture to the end with multiple knots, and buried.
      5. Sublabial incisions are closed with a 5-0 chromic.
   2. The operative microscope was then brought into the field. 
      1. After the nerve is then trimmed adequately, the donor nerve and sural nerve are brought into position.
      2. A blue background is placed at the neurorrhaphy site. 
      3. 10-0 nylon sutures are used in an interrupted fashion to complete the neurrorhaphy between donor and recipient nerve. Approximately three to four sutures are adequate for this neurorrhaphy. Tisseel is then used circumferentially at the neurrorhaphy site. 
5. A 1/4 inch penrose drain is then placed under the raised flap. 4-0 Monocryl sutures are used in an interrupted fashion for deep closure of the flap. The preauricular incision is then closed superficially in a running fashion using 5-0 Black Nylon.
6. A facelift-type compression dressing is then applied.

POSTOPERATIVE CARE

1. Can typically remove Penrose drain on POD#1
2. Can discontinue pressure dressing on POD#1 or 2

DICTATION TEMPLATE

Informed and written consent was obtained. The patient was then transferred to the OR and placed in the supine position. A timeout was performed and the correct patient and procedure were confirmed. The *** face was injected with # cc of epinephrine 1:100,000, and the face was then prepped and draped in the usual sterile fashion. An incision was planned out in the preauricular crease with temporal and cervical extension, and made with a #15 blade, approximately 14 cm in length. A thick skin flap elevation was carried out, directly off of the parotid gland, using the facelift scissors until the anteriormost aspect of the parotid gland was reached. The parotid gland was identified and carefully freed from surrounding tissues. At this point, the facial nerve branches at the junction of the parotid gland and masseteric fascia were identified and stimulated using the Parsons-McCabe nerve simulator. A segmental parotidectomy was performed in order to accomplish thorough facial nerve dissection. Multiple buccal branches were identified, including redundant branches that created a smile on the healthy side. Each branch and its effect on facial movement was carefully noted. A single buccal branch was selected for donor.

A sural nerve graft was harvested subcutaneously from the right leg in the usual fashion using a tendon stripper. A horizontal incision was made with a #15 blade lateral to the lateral malleolus and carried down to the level of the fascia. A mosquito was used to identify the sural nerve and this was isolated using a vessel loop. The nerve was severed distally and then a nerve stripper was placed over the nerve and used to dissect the nerve free from surrounding tissues more proximally to adequate length. Approximately a *** cm segment was dissected out. A small incision was made more proximally to the right calf down onto the nerve stripper, and the nerve was then sharply released at this proximal location. It was then delivered through the inferior-most incision. The leg incisions were then closed using 4-0 Monocryl in a running subcuticular fashion with Steri-Strips. The donor nerve was then brought up to the right face and reversed so that the distal nerve was approximated to donor facial nerve branches. The nerve was passed using a fascia passer through the sublabial incisions created in the upper lip, and passed over to the contralateral (paralyzed) side of the face in a gingivobuccal incision. A small pocket was made there.

The donor branch of the facial nerve was sharply transected and carefully prepared for microscopic neurorrhaphy. After the nerve had been trimmed adequately, the donor nerve and sural nerve were brought into position. The operative microscope was then brought into the field. A blue background was placed at the neurorrhaphy site. 10-0 nylon sutures were used in an interrupted fashion for epineural repair, using the microscope to complete the neurrorhaphy between donor and recipient nerve. Next, Tisseel was used to seal the anastomosis. Then the tip of the nerve graft was marked with a 4-0 black nylon suture tied to the end with at least 6 knots, and tucked into the gingivobuccal pocket. The sublabial incisions were then closed using 5-0 chromic suture in an interrupted fashion.

Attention was then directed toward the approximately 80 square cm facial wound, where a multilayered advancement flap closure was begun. Posterior skin flaps were raised to advance toward the wound for tensionless closure. The SMAS was plicated where necessary for tensionless closure. The right preauricular incision was then closed using 4-0 monocryl placed in the subcutaneous tissues to reapproximate the dermis, and finally 5-0 nylon in running segments to reapproximate the skin edges, after a Penrose drain had been placed. Bacitracin antibiotic ointment and a facelift-type compression dressing were then applied. The patient was turned over to the Anesthesia team for emergence from general anesthesia. The patient tolerated this procedure well without any immediate complications and was transferred to the recovery room in stable condition.

REFERENCES

Lee EI, Hurvitz KA, Evans GR, Wirth GA. Cross-facial nerve graft: past and present. J Plast Reconstr Aesthet Surg. 2008;61(3):250-6.

Hadlock TA, Cheney ML. Single-Incision endoscopic sural nerve harvest for cross face nerve grafting. J Reconstr Microsurg. 2008 Oct;24(7):519-23