Immediate compared with late repair of extracranial branches of the facial nerve: a comparative study
Introduction
Injuries to the facial nerve, whatever the cause, have disastrous functional and aesthetic consequences, and are challenging for clinicians, particularly in cases of distal extracranial trauma. These patients may present with an acute traumatic or iatrogenic injury to the nerve that necessitates immediate coaptation. Depending on the defect, site of injury, and patient’s age, this gives the best possible outcome, but is the ideal, and is not always the case.
Patients are often referred to us (a tertiary centre for facial nerve injuries) with known or suspected injuries to the facial nerve. These will have been noted clinically or intraoperatively, while patients who have had elective operations (such as facelifts) will have been under observation for several months before the problem is identified. Definitive diagnosis is based on clinical assessment as well as on electromyographic (EMG) studies. The limiting factor here is the nerve-muscle interface, which degenerates within 18–24 months after neurotmesis.1 It is therefore essential to re-establish corticoneuromuscular pathways within this period (the “late” phase) but this is difficult, as the surgeon must traverse extensive perineural scarring to identify small-calibre nerves within the supermicrosurgical range (0.3–0.8 mm) and some as small as 0.1 mm.
In this article we compare the gold standard of practice, immediate (or early) repair, with late repair (between 6 and 18 months after onset when the motor endplate starts to degenerate). It challenges the notion that most injuries (however caused) in the late phase of recovery are best managed conservatively.
Section snippets
Patients and methods
We prospectively studied 18 patients who had extracranial injuries to the facial nerve/branch. They were all treated between June 2016 and March 2018 at Queen Victoria Hospital, East Grinstead, a tertiary care centre. Eight had immediate nerve coaptation and 10 late repair (coaptation between 6 and 18 months after injury) comprising direct coaptation, neurolysis, or nerve transfer after clinical analysis. No patient in the late group was referred in the intermediate period (between 3 weeks and
Results
The group consisted of 11 men and 7 women, mean (range) age 58 (23–83) years. The demographics between the two groups were well-matched. Postoperatively, apart from one patient who had a haematoma, there were no other complications. The mean (range) hospital stay was 1.5 (1–10) days.
A total of 25 facial nerve branches were operated on: 1.5 nerve branches were repaired/patient in the immediate repair group, and 1.1 nerve branches explored and repaired/patient in the late repair group. All
Discussion
Immediate repair of injuries to the facial nerve is the gold-standard for reanimation.5 In clinical practice, however, it is not often done, as has been shown in a recent study in which only 19% of 285 patients had their damaged/sacrificed nerves repaired.9 This is often because there is a lack of expertise in reanimation among oncologists, and patients are usually referred to tertiary facial reanimation centres for further management.10 By this time, however, degeneration of the muscle
Conflict of interest
We can confirm that none of the authors herein have any financial or personal relationships with other people or organisations that could inappropriately influence or bias their work. These include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent application/registrations, grants, or other funding.
Ethics statement/confirmation of patients’ permission
Not applicable as the gold standard of care, facial nerve repair, was done as soon as possible, be it an early or late presentation. Photographic consent was obtained in all cases in accordance with QVH policy.
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