Postoperative Hypoglossal Nerve Palsy in Breast Reconstruction Surgery

Background/Objectives: Hypoglossal nerve palsy is a rare but disabling complication of general anesthesia, typically associated with tracheal intubation and head and neck surgery. This study evaluated the incidence, clinical characteristics, and potential mechanisms of postoperative tongue deviation after breast reconstruction and other surgeries performed under general anesthesia with orotracheal intubation. Methods: We retrospectively reviewed 240,646 consecutive general anesthetic procedures with orotracheal intubation performed at two tertiary hospitals between September 2011 and October 2025. Eighteen patients who developed new-onset postoperative tongue deviation were identified, and demographic features, surgical department, breast reconstruction status, anesthetic details, patient positioning, laterality of deviation, symptom duration, and recovery outcomes were analyzed. Results: Postoperative tongue deviation was documented in 18 patients, corresponding to an overall incidence of approximately 0.01%, most frequently after breast reconstruction (7/18, 38.9%), followed by vascular (27.8%), head and neck tumor (16.7%), neurosurgical (11.1%), and hepatobiliary-pancreatic surgery (5.6%). All seven breast-reconstruction cases occurred at the breast-cancer center hospital, corresponding to 0.31% of 2256 breast reconstructions. The median age was 58.0 years; 66.7% patients were female. Most patients (77.8%) achieved complete recovery, whereas 16.7% had residual deviation. Conclusions: Postoperative hypoglossal nerve palsy with tongue deviation is an exceptionally rare event after general anesthesia. In our two-center cohort, it was observed most frequently among patients undergoing breast reconstruction at one participating center; this pattern is confounded by institution-specific anesthetic and positioning practices and should not be interpreted as evidence that the procedure itself carries inherent risk. The findings are hypothesis-generating and suggest that prolonged operating time, repeated intraoperative position changes, and specific head-fixation and tube-fixation practices warrant prospective investigation. Meticulous head-neck alignment, careful tube fixation, and a structured postoperative cranial-nerve check (tongue-protrusion and voice-quality assessment in the recovery room and on postoperative day 1) may aid the early detection of this complication.