Management of facial nerve during parotid recurrent pleomorphic adenoma revision surgery

Revision surgery remains the standard treatment for parotid recurrent pleomorphic adenoma (RPA). Despite recent advancements in surgical techniques, the management of the facial nerve (FN) during parotid RPA surgery still poses a challenge. This retrospective study collected demographic data, clinical characteristics, and details of the surgical procedure, with a particular focus on FN management of parotid RPA patients between 2020 and 2024. Sixty-six patients who underwent parotid RPA surgeries were included; the FN was successfully preserved in 39 (59%). A significant difference in recurrence frequency was observed between patients with and without FN preservation (P = 0.006). Among the 27 patients who underwent intraoperative FN sacrifice, eight received direct coaptation, 12 underwent great auricular nerve grafting, three were treated with nerve transfer, and four received dual innervation. Postoperative recovery was favourable (HBGS ≤ III) in 19 of these patients. Based on these findings, an algorithm for FN management during parotid RPA revision surgery is proposed. Preservation of the FN should be prioritized during parotid RPA revision surgery. In cases of FN sacrifice, immediate repair is recommended. The proposed algorithm offers a structured approach to FN management in various surgical scenarios during parotid RPA revision procedures.