Facial Reanimation by Means of the Hypoglossal Nerve

To the Editor: In the introduction to the interesting article titled “Facial Reanimation by Means of the Hypoglossal Nerve: Anatomic Comparison of Different Techniques” (4), the authors state: “Since 1904, when Korte (10) performed the first facial reanimation surgery (Fig. 1A), multiple techniques have been described with the same purpose, the most widely used to date being the classical hypoglossal-facial nerve anastomosis” (4). The authors provide the following reference: “Korte W: A case of nerve transfer from the facial nerve to the hypoglossal nerve. Dtsch Med Wochenschr 29:293, 1903” (4). This statement and reference, however, contain inaccuracies, which incite us to provide a few historical remarks on the early history of hypoglossal-to-facial nerve crossover anastomosis. The first facial nerve crossover operations were performed in the last decade of the 19th century. In 1895, Charles Ballance (1856–1936) (Fig. C1), from England, was the first to perform a facial-to-spinal accessory nerve crossover anastomosis (16,17). Ballance's operation was first documented in Saint Thomas's Hospital Reports of the year 1895, which was published in 1897 (18). Ballance et al. (3) reported the long-term results of this operation in the British Medical Journal on May 2, 1903, in their landmark article, “Remarks on the Operative Treatment of Chronic Facial Palsy of Peripheral Origin” (3). In this article, Ballance discussed six spinal accessory-to-facial nerve crossover operations that were performed between 1895 and 1902. In the same article, Ballance also reported his first hypoglossal-to-facial nerve crossover anastomosis (3). Of this operation, which he had performed on January 9, 1903, he stated: “this latter operation of facio-hypoglossal anastomosis is the one which we would recommend in the future in preference to that of facio-accessory union. We considered whether it might not be practicable to select for anastomosis with the distal supplying muscles whose cortical centre is nearer to the face centre than in the case of the shoulder. The hypoglossal nerve and the cortical tongue centre fulfil these requirements. As will be seen from the accompanying diagrams” (Fig. C2) (3, p 1012).FIGURE C2: Diagram of hypoglossal-to-facial nerve crossover anastomosis (from Ballance CA, Ballance HA, Steward P: Remarks on the operative treatment of chronic facial palsy of peripheral origin. Br Med J May 2:1009–1013, 1903 [3]).FIGURE C1: Charles Ballance (A) and Werner Körte (B).Ballance was, however, not the first to actually perform a hypoglossal-to-facial nerve crossover anastomosis. On December 20, 1901, the German surgeon Werner Körte (1853–1937) (Fig. C1) had already performed this operation. He reported it for the first time on December 8, 1902, at the meeting of the “Freie Vereinigung der Chirurgen Berlins” (8). The results of the operation were published on April 23, 1903, in the Deutsche Medicinische Wochenschrift in an article titled “Ein Fall von Nervenpfropfung: des Nervus facialis auf den Nervus hypoglossus” (8). It is striking that, after this operation, Körte, in contrast to Ballance, favored the spinal accessory nerve, because he considered the loss of tongue function more impairing than dysfunction of the shoulder muscles (8). The German neurologist Martin Bernhardt (1844– 1915), who was involved in the postoperative treatment of Körte's patient, did not agree, however, with Körte's preference of the spinal accessory nerve. In a private letter to Ballance, in May 1903, he wrote: “I believe, however, that there are associated movements of the tongue which escape observation, as the tongue is confined within the mouth, but they in no way trouble the patient nor are they noticed by those around her. From all that I have observed, I entirely agree with you (Ballance) that in grafting the facial for the relief of facial palsy, it is, better, notwithstanding the opinion of Körte, to choose the hypoglossal rather than the spinal accessory” (1, p 1288). The discussion of which donor nerve to use in facial nerve crossover anastomosis would continue for years (2,7,14,15). Currently, the hypoglossal nerve is the commonly used donor nerve in facial nerve crossover anastomosis surgery (4,6,9,11,13,19). From the beginning of hypoglossal-to-facial nerve crossover anastomosis surgery, there was also a difference of opinion about whether end-to-end or end-to-side nerve repair should be performed (7). For a long time, the end-to-end anastomosis was considered the preferred technique. In this method, which is now referred to as the classical technique (4–6,10,15), the hypoglossal nerve is completely transected and sutured to the facial nerve. This, however, inevitably results in paralysis and atrophy of one tongue half, which in turn affects speech, mastication, and swallowing, particularly when the facial mimic function is less than normal. Apparently, both Körte and Ballance were aware of these adverse effects of a complete division of the hypoglossal nerve, as they did not employ the classical technique, but instead performed an end-to-side anastomosis (3,8). The first to actually report about the classical technique seems to be James Henderson Nicoll (1863–1921) from Scotland. Nicoll, being aware of Körte's and Ballance's cases, operated on a patient on July 30, 1903. He reported this operation in the Lancet of October 3, 1903, in an article titled “Remarks on a Case of ‘Facio-hypoglossal Anastomosis’ (the Körte-Ballance operation)” (12). To overcome the hemiparalysis of the tongue, Nicoll discussed some possible modifications of his technique, which he, like Drs. Campero and Socolovsky (4), tested on a cadaver (12). For example, he described the grafting of the peripheral stump of the divided hypoglossal nerve end-to-side to the contralateral hypoglossal nerve (12). Other modifications were developed in subsequent years (2,4,6,14). At the end of his career, in 1932, Ballance concluded that the classical hypoglossal-to-facial nerve end-to-end anastomosis should be the preferred technique instead of the proposed modifications, even though the classical technique has its adverse consequences. He wrote: “We have performed end-to-side hypoglossal-facial anastomosis, and the experience has persuaded us that it is a mistake to attempt the great problem of curing facial palsy and, at the same time, to endeavour to preserve the function of the tongue unimpaired. We think, too, objectives in surgery, as in war, mean, as a rule, partial success or failure. The curing of facial palsy justifies the sacrifice of the movements of half of the tongue. The end-to-side anastomosis may militate against a more perfect restoration of the facial movements. The only operation, therefore, that should be carried out is the end-to-end anastomosis. On this earth of ours what great good has ever been or can be gained except by sacrifice? It is, in every era, and in every zone, the law of life” (2, p 6). Today, 75 years later, the ideal technique has yet to be found. Although the treatment of patients with irreversible facial paralysis has improved greatly over the past decades, we are still searching for the best way to reanimate the paralysed facial muscles. Studies such as the one by Drs. Campero and Socolovsky (4) are essential in this quest, which has already lasted more than a century. Robert C. van de Graaf Frank F.A. IJpma Jean-Philippe A.