Long-Term Implications of Combined Cross-Facial Nerve Graft and Nerve Transfer in Facial Paralysis

Assessing the long-term implications of combining cross-facial nerve graft (CFNG) and masseteric-to-facial nerve transfer on long-term outcomes in patients with subacute facial paralysis.Patients with subacute facial palsy who underwent a masseteric-to-facial nerve transfer with CFNG from 2013 to 2020 were reviewed. A minimum of 2-year follow-up was required with 18 patients meeting inclusion criteria. Midface and periorbital measurements on standardized photos of patients in repose, closed, and open smile were analyzed preoperatively, 3 months, 1 year, and 3 years postoperatively as available. Emotrics software (Massachusetts Eye and Ear Infirmary, Boston, MA) and ImageJ (Rasband, W.S., U.S, National Institutes of Health, Bethesda, MD) were used for measurements. Longitudinal comparisons at each timepoint were analyzed using Wilcoxon two-sample testing.In repose, 1-year measurements including Commissure-Position, Smile-Angle, and Upper-Lip-Height-Deviation, were nonsignificant, whereas significance was noted at 3 years postoperatively (p = 0.042, 0.031, 0.042, respectively). Midface dynamic smile measurements on the palsy side and with symmetry showed significant differences from preoperative measurements at 1 and 3 years postoperatively. Periorbital measurements, including Marginal-Reflex-Distance-1, Marginal-Reflex-Distance-2, and Palpebral-Fissure-Height in repose, showed no significant changes at 1 year but were significant at 3 years (p = 0.004, 0.011, and 0.002, respectively), while during animation were significant at 1 and 3 years postoperatively.Combining CFNG with nerve transfer demonstrated progressive long-term improvement in resting tone and symmetry around the midface and periorbital region. Expected improvements were observed during animation over time.