Multidisciplinary Approach to Maximizing Facial Function in High-risk Recurrent Pleomorphic Adenoma Patients with Prior Facial Nerve Injury
Y. Edward Wen, BA and Shai M. Rozen, MD, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
Background
Parotid pleomorphic adenoma (PA) patients present significant diagnostic and surgical challenges rendering them high-risk for facial nerve injury. Recurrent PA (rPA) patients often present with history of facial nerve injury or previous reanimations making salvage of the facial nerve or previous reanimations significantly more complex. The study aim is to share our experience for this high-risk for facial nerve injury population.
Methods
Adult patients with rPA and history of facial nerve injury with ≥3 months of follow-up were analyzed for demographics, facial palsy history, previous head and neck surgeries, previous facial paralysis reconstruction, preoperative imaging, surgical approach, and postoperative outcomes.
Results
Four female patients were identified with an average age of 62 years. All patients underwent an initial protective dissection of the facial nerve or previous reanimation reconstruction by the facial nerve reconstructive team followed by the extirpative team. The average number of previous head and neck surgeries was 5, number of recurrences was 2, and follow-up was 20 months. Half had prior dynamic facial reanimation. Two patients underwent complete pre-extirpative dissection of the facial nerve resulting in neuropraxia which recovered completely after an average of 143 days (Figures 1-3). A third patient presented with two recurrences, both during and after reanimation with a dually-innervated free functional muscle transfer. The reconstruction was salvaged, and motion was achieved. A fourth patient presented with benign preoperative findings, but intraoperative findings confirmed malignancy, necessitating facial nerve sacrifice, followed by immediate intratemporal grafting of the facial nerve and masseteric nerve transfer. Motion appeared 139 days postoperatively.
Conclusion
A multi-disciplinary effort should be implemented in this high-risk for facial nerve injury population with the primary goal of protecting the facial nerve or any previous reanimation procedures, yet with preparedness to apply any reconstructive strategy based on intraoperative findings (Figure 4).
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