Abstract
Background
Radical parotidectomy with facial nerve sacrifice produces major functional and aesthetic deficits. Immediate or single-stage facial nerve reconstruction and facial reanimation may restore symmetry, ocular protection, oral competence, and dynamic movement while avoiding the limitations of delayed intervention. This review synthesizes the available evidence on reconstructive strategies and outcomes in this setting.
Methods
A systematic review was performed of studies evaluating immediate, concurrent, or single-stage facial nerve reconstruction or facial reanimation at the time of radical parotidectomy or oncologic facial nerve sacrifice. PubMed, Embase, Scopus, and Web of Science were searched from database inception through April 2026. Eligible studies were original clinical series reporting postoperative functional outcomes, patient-reported outcomes, complications, or revision procedures. Data were synthesized descriptively because of heterogeneity in techniques and outcome reporting.
Results
Nineteen studies comprising 277 patients met inclusion criteria. Reconstructive strategies included cable or interpositional nerve grafting, concurrent masseteric nerve transfer, vascularized nerve grafting, temporalis-based dynamic reanimation, free functional muscle transfer, and composite flap-based reconstruction. Across studies, immediate reconstruction was associated with restoration of resting symmetry, oral competence, and ocular protection, while dynamic approaches more often reported smile recovery and oral commissure movement. Interpositional cable grafting resulted in a postoperative recovery in the House–Brackmann III range. Reported complication rates were acceptable, with low donor-site morbidity and uncommon flap loss. Limited radiotherapy-specific analyses suggested that postoperative radiotherapy did not uniformly preclude functional recovery after immediate reconstruction.
Conclusions
Immediate or single-stage facial nerve reconstruction and facial reanimation after radical parotidectomy appear feasible across a range of oncologic defects and are associated with reported postoperative restoration of facial tone, symmetry, oral competence, ocular protection, and, in selected series, dynamic facial movement. However, the current evidence is limited by retrospective design, small sample sizes, and heterogeneous outcome reporting. Larger comparative studies using standardized functional and patient-reported outcome measures are needed to better define the optimal reconstructive strategy.
Keywords: Radical parotidectomy, Immediate facial reconstruction, Facial nerve reconstruction, Facial reanimation, Facial nerve sacrifice
Introduction
Parotid malignancies are rare but surgically consequential tumors of the head and neck because of their intimate relationship to the facial nerve.1,2 When the nerve is not infiltrated, preservation is preferred whenever oncologically safe; however, when the nerve is involved by tumor, the affected segment may need to be resected as part of radical parotidectomy, and primary reconstruction or reanimation is considered the most effective means of restoring long-term facial function and appearance.1,3
The deficits that follow facial nerve sacrifice after radical parotidectomy extend well beyond loss of neural continuity alone. Patients may be left with immediate hemifacial paralysis, lagophthalmos with risk of exposure keratopathy, oral incompetence, impaired speech and eating, and substantial psychosocial distress related to facial asymmetry and loss of expression.4,5 These functional problems coexist with major soft-tissue and contour defects created by parotid ablation, skin resection, or more extensive oncologic extirpation, making reconstruction after radical parotidectomy a simultaneous problem of restoring both form and function.4, 5, 6
For this reason, immediate or single-stage facial nerve reconstruction and facial reanimation have become increasingly attractive. Reconstruction performed at the time of tumor ablation may shorten the duration of paralysis, preserve the opportunity for reinnervation before prolonged denervation-related muscle atrophy occurs, and restore static symmetry, ocular protection, and oral competence without requiring a delayed second-stage pathway that may be less feasible in patients requiring adjuvant therapy.7,8 Recent studies suggest that immediate reconstruction can provide meaningful recovery even when postoperative radiotherapy is required.8, 9, 10
Despite growing interest in immediate reconstruction, the literature remains difficult to apply in a unified way. Most published studies are small, single-center series centered on one technical approach, such as cable grafting, concurrent masseteric nerve transfer, temporalis-based reanimation, vascularized nerve grafts, or composite flap-based reconstruction.11, 12, 13, 14, 15 In contemporary practice, technique selection is further shaped by oncologic variables such as perineural invasion, proximal and distal stump availability, extent of soft-tissue loss, prior treatment, and anticipated adjuvant therapy, which makes direct comparison across studies challenging.3,11
Accordingly, this systematic review synthesized the available evidence on immediate or single-stage facial nerve reconstruction and facial reanimation performed during the same operation as radical parotidectomy or oncologic facial nerve sacrifice. The review encompassed facial nerve reconstruction, dynamic reanimation, and composite reconstructions with soft-tissue restoration, with the aim of summarizing reconstructive strategies, functional outcomes, and complications in this challenging oncologic setting.
Methods
Study design
This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.16 The review was designed to evaluate immediate or single-stage facial nerve reconstruction and facial reanimation performed in the setting of radical parotidectomy or oncologic facial nerve sacrifice, with emphasis on reconstructive strategies, functional outcomes, and postoperative complications.
Information sources and search strategy
A systematic search was performed in PubMed, Embase, Scopus, and Web of Science from database inception through April 2026. Database-specific subject headings and free-text keywords were used to capture studies involving parotidectomy, facial nerve sacrifice, immediate reconstruction, facial reanimation, nerve grafting, nerve transfer, temporalis-based reanimation, and free functional or flap-based reconstruction. Complete search strategies can be found in Supplementary Appendix S1. Reference lists of relevant studies were also reviewed to identify additional eligible articles.
Eligibility criteria
Studies were eligible if they included patients undergoing radical or total parotidectomy, or parotid-region oncologic resection with facial nerve sacrifice, followed by immediate, concurrent, or single-stage facial rehabilitation performed during the same operation as tumor ablation. Eligible interventions included facial nerve reconstruction (eg, interpositional or cable grafting and vascularized nerve grafting), dynamic facial reanimation (eg, nerve transfer, temporalis-based reanimation, and free functional muscle transfer), and composite reconstructions in which facial nerve reconstruction or reanimation was a defined component. Studies were required to report postoperative outcomes related to facial function, facial symmetry, ocular protection, oral competence, patient-reported outcomes, complications, or revision procedures. Cases without direct neural reconstruction were eligible if immediate dynamic reanimation was performed and postoperative functional outcomes were reported.
Retrospective and prospective clinical case series were eligible. Studies were excluded if they focused exclusively on delayed reconstruction, secondary facial reanimation, benign parotid disease, non-oncologic facial paralysis, or non-parotid populations in which the relevant oncologic subgroup could not be separately extracted. Studies limited to static-only procedures were excluded, as were reviews, technical notes, conference abstracts without full text, and single-case reports.
Study selection
All records were imported into Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia) for deduplication and screening. Title and abstract screening was performed independently by two reviewers, followed by independent full-text review of potentially eligible articles by the same two reviewers. Disagreements at either stage were resolved through discussion and consensus; when consensus could not be reached, a third reviewer served as the tiebreaker.
Data extraction
Data were extracted on study characteristics, patient and tumor characteristics, reconstructive technique, adjuvant treatment, functional outcomes, and complications. Study-level variables included author, year, country, study design, sample size, study period, and follow-up duration. Patient- and disease-level variables included age, sex, pathology, preoperative facial nerve status, extent of parotidectomy, concurrent neck dissection, recurrent or salvage setting, and use of postoperative radiotherapy. Reconstruction-specific variables included the type of facial nerve reconstruction or reanimation, donor nerve or motor source, use of vascularized versus nonvascularized grafts, soft-tissue flap reconstruction, static suspension procedures, and ocular adjuncts. Extracted outcomes included facial nerve recovery, dynamic smile or commissural movement, static symmetry, ocular outcomes, oral competence, complications, and revision procedures.
Data synthesis
A quantitative meta-analysis was not performed because of substantial heterogeneity in reconstructive strategy, defect characteristics, patient selection, radiation exposure, and functional outcome reporting. Instead, findings were synthesized descriptively. Included studies were grouped by reconstructive approach, including immediate cable or interpositional grafting, vascularized nerve grafting, combined nerve grafting with nerve transfer, temporalis-based dynamic reanimation, and free functional muscle or composite flap reconstruction.
Outcomes were summarized across four main domains: facial motor recovery, static facial symmetry and oral competence, ocular function, and complications or revision burden. When studies reported House-Brackmann grades, these were extracted directly as reported. Methodological quality was assessed using the JBI Critical Appraisal Checklist for Case Series as all included studies were ultimately uncontrolled clinical case series without a comparator group.17
Results
Study selection
The search identified 318 records (Embase, n = 102; Scopus, n = 92; PubMed, n = 68; Web of Science, n = 56). After removal of 168 duplicates (166 by Covidence and 2 manually), 150 records underwent title and abstract screening, of which 123 were excluded. Twenty-seven reports were sought for retrieval, 1 was not retrieved, and 26 full-text articles were assessed for eligibility. Seven full-text articles were excluded for the following reasons: foreign language (n = 5), wrong outcomes (n = 1), and wrong study design (n = 1). Nineteen studies comprising 277 patients met the eligibility criteria and were included in the qualitative synthesis. The study selection process is shown in Fig. 1.
Fig. 1.
PRISMA 2020 flow diagram of study selection.
Study characteristics
The 19 included studies were published between 1993 and 2026 and consisted predominantly of retrospective case series, with one prospective case series. Sample sizes ranged from 4 to 32 patients. Most studies evaluated highly selected cohorts undergoing immediate reconstruction after radical or total parotidectomy with facial nerve sacrifice. When reported, follow-up ranged from 2 months to 9.5 years. Study-level characteristics are summarized in Table 1. Methodological quality assessment is summarized in Supplementary Table S1.
Table 1.
Characteristics of included studies.
| Study | Year | Country | Study design | Sample size, n | Immediate reconstructive approach | Follow-up duration |
|---|---|---|---|---|---|---|
| Vaughan et al. | 1993 | United Kingdom | Retrospective case series | 14 | Immediate extratemporal facial nerve grafting, usually with cutaneous radial nerve autograft | Follow-up in 10/14; duration NR |
| Motomura et al. | 2011 | Japan | Retrospective case series | 10 | Immediate sural nerve grafting with muscle-flap recipient-bed preparation | Mean 39 months (range, 8–76) |
| Revenaugh et al. | 2012 | United States | Retrospective case series | 5 | Single-stage ALT flap, OTTT, and cable grafting when feasible | Mean 10.2 months (range, 5–15) |
| Biglioli et al. | 2013 | Italy | Retrospective case series | 4 | Lateral thoracic wall reconstruction with thoracodorsal nerve graft and costal grafts when needed | Mean 28.2 months (range, 18–86) |
| Biglioli et al. | 2014 | Italy | Retrospective case series | 7 | Immediate thoracodorsal interpositional nerve grafting after radical parotidectomy | NR |
| Hontanilla et al. | 2014 | Spain | Retrospective case series | 13 | Immediate sural nerve interposition grafting after radical parotidectomy | Mean 35.7 months (range, 17–54) |
| Renkonen et al. | 2015 | Finland | Retrospective case series | 31 | Immediate nonvascularized peripheral nerve grafting after radical parotidectomy | 24 had >2-y follow-up; 23 had adequate functional assessment |
| Owusu et al. | 2016 | United States | Retrospective case series | 9 | Concurrent masseteric transfer and cable grafting | Follow-up completed March 14, 2016; exact duration NR |
| Ciolek et al. | 2018 | United States | Retrospective case series | 17 | Immediate comprehensive reconstruction with ALT flap, OTTT, lower lip suspension, and cable grafting when feasible | Mean 19 months |
| Rashid et al. | 2019 | Pakistan | Prospective case series | 22 | Immediate interpositional grafting with sural or greater auricular nerve after total parotidectomy with facial nerve sacrifice | 4–8 months |
| Li et al. | 2021 | France / United States | Retrospective case series | 25 | Immediate SD-LDVxN flap reconstruction after total parotidectomy with facial nerve sacrifice | Mean 5 years (range, 3 mo–7 y) |
| Mangialardi et al. | 2021 | France | Retrospective case series | 29 | Immediate SDVN flap reconstruction for extensive composite parotid-region defects | Mean 38.7 months (range, 8–114) |
| Yao et al. | 2023 | United States | Retrospective case series | 10 | Immediate PAP-gracilis flap reconstruction | Mean 11.1 months (range, 8.1–19.5) |
| Ji et al. | 2024 | South Korea | Retrospective case series | 13 | Selective reinnervation or OTTT | Median 14 months (mean 17.2; range, 8–30) |
| Brennan et al. | 2024 | United Kingdom | Retrospective case series | 5 | Immediate lengthening temporalis myoplasty (Labbé procedure) | Mean 5.2 months (range, 2–12) |
| Econ et al. | 2025 | Japan | Retrospective case series | 7 | Immediate single-stage FVL-FMT | Mean 41 months (range, 12–78) |
| Grewal et al. | 2026 | United States | Retrospective case series | 32 | Immediate MABC cable graft reconstruction | Minimum 18 months |
| Onoda et al. | 2026 | Japan | Retrospective case series | 9 | Immediate vascularized nerve grafting based on the lateral femoral circumflex system | Minimum 12 months |
| Bolognesi et al. | 2026 | Italy | Retrospective case series | 15 | Multimodal immediate facial reanimation with masseteric-to-facial neurorrhaphy or temporalis tendon transposition plus static adjuncts | 8–12 months postoperative functional assessment |
Abbreviations: ALT, anterolateral thigh; FVL-FMT, free vastus lateralis functional muscle transfer; MABC, medial antebrachial cutaneous; NR, not reported; OTTT, orthodromic temporalis tendon transfer; PAP, profunda artery perforator; SD-LDVxN, scapulodorsal vascularized latissimus dorsi nerve flap; SDVN, scapulodorsal vascularized nerve.
Patient, tumor, and reconstructive characteristics
Included cohorts comprised primary salivary malignancies, metastatic cutaneous squamous cell carcinoma, carcinoma ex pleomorphic adenoma, adenoid cystic carcinoma, high-grade adenocarcinoma, leiomyosarcoma, soft-tissue sarcoma, recurrent pleomorphic adenoma, and recurrent or salvage disease. Previously irradiated and salvage settings were represented in some series.9,10 Patient age varied widely, although many cohorts involved middle-aged or older adults; one series focused on an elderly cohort treated with immediate lengthening temporalis myoplasty.18 Preoperative facial weakness, when reported, was associated with advanced disease, recurrence, or direct nerve involvement, while neck dissection and postoperative radiotherapy were common in many cohorts.5,6,8, 9, 10,18, 19, 20
Reconstructive strategies were heterogeneous. Immediate interpositional or cable nerve grafting was the most common approach, using sural, greater auricular, medial antebrachial cutaneous, superficial radial, thoracodorsal, and vascularized motor nerve grafts. Several studies used vascularized nerve grafting, including scapulodorsal vascularized nerve flaps and grafts based on the lateral femoral circumflex vascular system.12,13,21 Dynamic strategies included orthodromic temporalis tendon transfer, lengthening temporalis myoplasty, selective reinnervation, concurrent masseteric nerve transfer, and free functional muscle transfer using gracilis- or vastus lateralis-based constructs.4,7,14,18,22 In more complex defects, neural reconstruction was combined with simultaneous restoration of volume and contour using ALT, PAP-gracilis, scapulodorsal, latissimus dorsi, or vastus lateralis-based flaps, often with adjunctive fascia lata suspension, lip suspension, brow lift, eyelid procedures, or temporary tarsorrhaphy.4, 5, 6,11,13,18,22 These patient, tumor, treatment, and reconstructive characteristics are detailed in Tables 2 and 3.
Table 2.
Patient, tumor, and treatment characteristics.
| Study | Year | Age, years | Sex, male/female | Predominant pathology or tumor profile | Preoperative facial function | Neck dissection | Adjuvant treatment |
|---|---|---|---|---|---|---|---|
| Vaughan et al. | 1993 | Mean 51.6 (range, 14–82) | 9/5 | Mixed malignant/recurrent salivary-parotid cohort including melanoma, SCC, recurrent MEC, NHL, ACC, recurrent pleomorphic adenoma, CXPA, acinic cell carcinoma | Weakness: 5/14 | 7/14 (RND 5, FND 2) | RT: 10/14; prior RT: 2/14 |
| Motomura et al. | 2011 | Mean 57.5 (range, 20–74) | 8/2 | ACC 3, adenocarcinoma 3, MEC 3, malignant peripheral nerve sheath tumor 1 | Complete palsy: 2/10; incomplete palsy: 1/10 | NR | RT: 7/10 (mean dose 55 Gy) |
| Revenaugh et al. | 2012 | Mean 67.4 (range, 48–82) | 5/0 | High-grade adenocarcinoma 2, cutaneous SCC 2, recurrent dermatofibrosarcoma protuberans 1; all T4 tumors | NR | NR | RT: 4/5; cetuximab: 1/5 |
| Biglioli et al. | 2013 | Mean 72.5 (range, 67–78) | 2/2 | CXPA, high-grade MEC, high-grade adenocarcinoma, leiomyosarcoma | HB II: 2/4; HB III: 2/4 | Modified radical 3/4; selective 1/4 | RT: 4/4 |
| Biglioli et al. | 2014 | Mean 60.8 (range, 34–78) | 3/4 | 6 parotid malignancies, 1 multiply recurrent pleomorphic adenoma | HB II: 2/7; HB III: 3/7; HB IV: 2/7 | 5/7 | RT: 6/7 |
| Hontanilla et al. | 2014 | Mean 53.1 ± 11.9 | 7/6 | Mixed malignant parotid-region cohort including ACC, adenocarcinoma, recurrent BCC, SCC, renal metastasis, dermatofibrosarcoma protuberans | Partial palsy: 1/13; none: 12/13 | 7/13 | Brachytherapy + EBRT: 7/13 |
| Renkonen et al. | 2015 | Mean 54.7 (range, 30–82); median 54 | 18/13 | 30 carcinomas, 1 recurrent pleomorphic adenoma | Motor dysfunction: 6/31 | 16/31 | RT: 23/31; chemo: 4/31 |
| Owusu et al. | 2016 | Mean 62.6 (range, 51–73) | 3/6 | Malignant radical parotidectomy cohort including CXPA, acinic cell carcinoma, high-grade MEC, salivary duct carcinoma, adenocarcinoma, ACC, metastatic SCC, paraganglioma | Weakness: 7/9; none: 2/9 | NR | RT: 5/9 |
| Ciolek et al. | 2018 | Mean 60.5 | 8/9 | Radical parotidectomy cohort; metastatic SCC most common | NR | 17/17 | RT: 16/17 |
| Rashid et al. | 2019 | Mean 47 (range, 25–64) | 7/15 | ACC 9, non-invasive CXPA 7, MEC 6 | Palsy: 8/22 | NR | RT: 19/22 |
| Li et al. | 2021 | Median 48 | 11/14 | Complex parotid-region oncologic defects after at least total parotidectomy with FN sacrifice | NR | NR | RT: 20/25 |
| Mangialardi et al. | 2021 | Mean 45.2 (range, 7–67) | 13/16 | Parotid primary 20/29, skin primary 4/29, soft-tissue sarcoma 4/29 | Palsy: 3/29 (HB III, <3 mo); dysesthesia: 1/29 | NR | RT: 23/29; prior RT: 3/29 |
| Yao et al. | 2023 | Mean 71.3 (range, 52–83) | 6/4 | SCC 5, salivary adenocarcinoma 2, basaloid SCC 1, pleomorphic adenoma 1, sarcoma/osteosarcoma 1 | Weakness/paralysis: 10/10 | NR | RT: 10/10; chemo: 8/10; prior RT/re-irradiation: 1/10 |
| Ji et al. | 2024 | Median 54 | 9/4 | 10 malignant and 3 benign/recurrent tumors requiring radical parotidectomy with FN sacrifice | HB I–V | Selective | RT alone 5/13; CRT 3/13; chemo alone 1/13 |
| Brennan et al. | 2024 | Mean 83 (range, 73–87) | 3/2 | MEC 3, adenocarcinoma 1, SCC 1; pT2 in 1 and pT4 in 4 | Severe palsy: 5/5 (HB V 4, HB VI 1) | 5/5 (levels II–IV) | RT: 5/5; chemo: 1/5 |
| Econ et al. | 2025 | Mean 49 (range, 13–79) | 4/3 | Stage IVA parotid cancer; adenocarcinoma 3, acinic cell carcinoma 2, CXPA 1, sarcomatoid carcinoma 1 | Palsy: 3/7 | All | RT: 4/7; chemo: 2/7 |
| Grewal et al. | 2026 | By subgroup; overall late 60s–early 70s | 25/7 | SCC in all patients | HB V–VI in subset; exact distribution NR | Typically performed | Prior RT in salvage group: 8/32; postoperative RT: 24/32 |
| Onoda et al. | 2026 | NR | NR | Total parotidectomy with unilateral FN resection | NR | NR | NR |
| Bolognesi et al. | 2026 | Mean 64.5 ± 14.3 | 7/8 | 11/15 malignant, 4/15 benign; SCC 5, pleomorphic adenoma 3, acinic cell carcinoma 2, and 1 each renal clear-cell metastasis, BCC, melanoma, carcinosarcoma, salivary duct carcinoma, FN schwannoma | NR | NR | NR |
Abbreviations: ACC, adenoid cystic carcinoma; BCC, basal cell carcinoma; CRT, chemoradiotherapy; CXPA, carcinoma ex pleomorphic adenoma; EBRT, external beam radiotherapy; FND, functional neck dissection; HB, House–Brackmann; MEC, mucoepidermoid carcinoma; NHL, non-Hodgkin lymphoma; NR, not reported; RND, radical neck dissection; RT, radiotherapy; SCC, squamous cell carcinoma.
Table 3.
Reconstructive characteristics.
| Study | Year | Reanimation strategy | Donor nerve or motor source | Flap choice | Static or adjunctive procedures |
|---|---|---|---|---|---|
| Vaughan et al. | 1993 | Immediate extratemporal FN graft reconstruction | Superficial radial nerve 10/14; greater auricular nerve 4/14 | Primary closure 8/14; radial forearm flap 6/14 | Temporary tarsorrhaphy in all; early facial exercises; home electrical stimulation |
| Motomura et al. | 2011 | Immediate FN grafting with recipient-bed preparation | Sural nerve in all; facial-hypoglossal supercharging in latest 6 | SCM + SMAS/platysma flap 6/10; pectoralis major flap 4/10 | End-to-side facial-hypoglossal neurorrhaphy 6/10 |
| Revenaugh et al. | 2012 | Single-stage ALT flap + OTTT + cable grafting when feasible | MNVL 3/5; great auricular nerve 1/5 | ALT in all (fasciocutaneous 3, buried 2) | OTTT in all; lower lip/orbicularis sling 4/5; gold weight, ectropion repair, brow lift |
| Biglioli et al. | 2013 | Immediate branch reconstruction with simultaneous soft-tissue and skeletal reconstruction | Thoracodorsal nerve graft | LD perforator cutaneous free flap; costal grafts 2/4 | Physiotherapy in all; intermaxillary fixation/mandibular rehabilitation in costal-graft cases |
| Biglioli et al. | 2014 | Immediate trunk-to-branch interpositional grafting | Thoracodorsal nerve graft | De-epithelialized LD perforator flap 4/7; rib graft 2/7 | Fibrin glue; physiotherapy in all |
| Hontanilla et al. | 2014 | Immediate sural interpositional grafting | Sural nerve grafts | Direct closure in most; regional flap advancement; free ALT flap 1/13 | Home exercises and self-massage; no routine electrical stimulation |
| Renkonen et al. | 2015 | Immediate FN grafting after radical parotidectomy | Sural 24/31; greater auricular 7/31 | No major flap-based reconstruction reported | End-to-end neurorrhaphy in 30/31; secondary static procedures often required |
| Owusu et al. | 2016 | Concurrent masseteric transfer + cable grafting | Masseteric nerve + medial antebrachial cutaneous nerve graft | No major flap-based reconstruction reported | Vein graft entubulation; no standardized static adjunct reported |
| Ciolek et al. | 2018 | Comprehensive immediate reconstruction with ALT flap, OTTT, lower lip suspension, and cable grafting | MNVL cable graft; masseteric nerve used in 3; no graft in 1 | ALT in all, with fascia lata and MNVL from same donor site | OTTT, lower lip suspension, ALT fascia suspension |
| Rashid et al. | 2019 | Immediate interpositional grafting | Sural 12/22; greater auricular 10/22 | Primary closure 15/22; local flap 2/22; free flap 5/22 | Palmaris sling 5/22; facial exercises, elastic chin belt, TENS in all |
| Li et al. | 2021 | Immediate SD-LDVxN reconstruction | Vascularized latissimus dorsi motor nerve | Chimeric scapulodorsal flap with optional muscle and/or lateral scapular bone | NR |
| Mangialardi et al. | 2021 | Immediate SDVN reconstruction after extensive oncologic resection | Vascularized thoracodorsal motor nerve graft; mean 4.5 distal anastomoses | Defect-tailored SDVN flap | Vascularized/innervated LD tendon for dynamic commissure in 4; fibula added in 1 |
| Yao et al. | 2023 | Immediate PAP-gracilis reconstruction with free functional gracilis transfer | Facial stump 3, spinal accessory 3, masseteric 3, hypoglossal 1; grafting in 3/10 | Separate PAP + gracilis 7/10; chimeric PAP-gracilis 3/10 | Static sling effect in non-dynamic cases; direct brow lift in 1 |
| Ji et al. | 2024 | Selective reinnervation or OTTT | Masseteric nerve; proximal facial stump via graft; ansa cervicalis when available | SCM flap 4/13; temporalis flap 1/13; radial forearm flap 3/13; ALT flap 4/13 | Tendon/fascia extension for OTTT; abdominal fat obliteration + gold weight in 1 |
| Brennan et al. | 2024 | Immediate Labbé version 2 temporalis myoplasty | Temporalis muscle/tendon | No flap-based reconstruction | Temporary lateral tarsorrhaphy and brow lift in all; lateral canthopexy later in 2 |
| Econ et al. | 2025 | Immediate single-stage FVL-FMT with FN reconstruction | Descending VL motor branch as graft; oblique branch for type 2 flap | Vastus lateralis myocutaneous flap; type 1 in 6/7, type 2 in 1/7 | No standardized static adjuncts; discharge facial massage/exercise |
| Grewal et al. | 2026 | Immediate cable grafting after radical parotidectomy | MABC nerve with 3–5 distal branches | No flap-based reconstruction | Multiple epineural coaptations; optional end-to-side donor-site sensory repair |
| Onoda et al. | 2026 | Immediate vascularized nerve grafting | Vascularized motor nerve graft based on lateral femoral circumflex system | No flap-based reconstruction | NR |
| Bolognesi et al. | 2026 | Algorithmic immediate reanimation: masseteric-to-facial neurorrhaphy or temporalis tendon transposition | Masseteric nerve; supercharged cross-face sural graft in selected cases | No flap-based reconstruction | Upper eyelid lipofilling, lateral tarsorrhaphy, fascia lata midface suspension, contralateral DLI neurectomy |
Abbreviations: ALT, anterolateral thigh; FN, facial nerve; LD, latissimus dorsi; MABC, medial antebrachial cutaneous; MNVL, motor nerve to vastus lateralis; OTTT, orthodromic temporalis tendon transfer; PAP, profunda artery perforator; SCM, sternocleidomastoid; SD-LDVxN, scapulodorsal vascularized latissimus dorsi nerve flap; SDVN, scapulodorsal vascularized nerve; SMAS, superficial musculoaponeurotic system; TENS, transcutaneous electrical nerve stimulation; VL, vastus lateralis.
Functional outcomes
Functional outcomes were reported heterogeneously. House-Brackmann outcomes were reported in 10 studies.4,7,9,12,18,19,22, 23, 24, 25 All 19 studies reported some degree of postoperative facial functional outcome after immediate reconstruction. In large grafting series, recovery was observed in 18 of 23 evaluable patients in one study and postoperative House-Brackmann grade III was achieved in 25 of 32 patients in another, including similar outcomes in irradiated salvage and adjuvant radiotherapy settings; a prospective interpositional grafting series reported House-Brackmann grades II-III in 11 of 22 patients.8,9,19 Smaller studies using thoracodorsal nerve grafting, recipient-bed preparation, and vascularized nerve flap reconstruction also reported functional recovery within a similar range.12,23,25
Dynamic facial movement or smile-related outcomes were reported in 8 studies.4, 5, 6, 7,11,14,18,22 Oral commissure motion returned within 2–7 months after concurrent masseteric nerve transfer and cable grafting, selective reinnervation improved 9 of 10 patients to modified House-Brackmann grade III and Terzis grade 4–5, and algorithm-based masseteric-to-facial neurorrhaphy showed favorable eFACE smile outcomes.7,11,14 Volitional gracilis activation was observed in 6 of 10 PAP-gracilis cases, while orthodromic temporalis tendon transfer-based series consistently reported favorable dynamic smile restoration and oral competence.4, 5, 6
Ocular outcomes were specifically reported in 9 studies.6,10,11,13,18,20,22, 23, 24 ALT- and temporalis-based reconstructions achieved resting symmetry, oral competence, dynamic corner-of-mouth movement, and full eye closure in small series, while a large vascularized nerve flap series reported satisfactory volumetric restoration in 93% of cases.4,6,13 Ocular outcomes were more variably reported, but studies incorporating tarsorrhaphy, eyelid lipofilling, or upper-face support generally described acceptable corneal protection and eyelid closure.11,18,20
Complications, secondary procedures, and radiotherapy
Among the 11 studies explicitly reporting donor-site outcomes, donor-site morbidity was generally low, and several smaller or intermediate-sized series reported no donor-site complications.4, 5, 6,9,12,13,20, 21, 22, 23, 24 Reported complications included donor-site seroma, wound infection, hematoma, delayed donor-site healing, Frey syndrome, and tendon dehiscence.4,5,8,21 No PAP or gracilis flap loss was reported in the PAP-gracilis series, and one vascularized nerve graft series reported only a single case of Frey syndrome with no donor-site or vascular complications.5,21 In contrast, one larger nonvascularized grafting series reported Frey syndrome in 3 of 31 patients and a high secondary procedure burden, with 19 of 31 patients ultimately requiring revision, most commonly eyelid procedures.8 Another recipient-bed preparation series explicitly reported no Frey syndrome.25 Complications and revision burden are summarized in Table 4.
Table 4.
Functional outcomes and postoperative complications.
| Study | Year | Facial nerve outcomes | Other functional outcomes | Complications or revisions |
|---|---|---|---|---|
| Vaughan et al. | 1993 | Recovery onset 2–12 months in followed patients; symmetry excellent 6, good 4; eye closure excellent/good 7, poor 2, NA 1; smile excellent/good 7, poor 3 | Restoration of tone with variable blink and smile recovery | No significant donor-site disability; no significant perioperative grafting complications |
| Motomura et al. | 2011 | HB II 2, III 7, IV 1, unassessable 1; mean Sunnybrook 50 | Synkinesis score 0 in 3, 1 in 2, unassessable in 1 of latest 6 cases | No contour deformity; no Frey syndrome |
| Revenaugh et al. | 2012 | Dynamic corner-of-mouth movement in all; neural grading NR | Midfacial symmetry at rest, oral competence, full eye closure in all | No flap loss; no donor-site complications; 1 urinary retention/cardiac event; 2 cosmetic revisions; 1 later tarsorrhaphy for recurrence |
| Biglioli et al. | 2013 | Partial recovery in all by 6–14 months HB I 1, II 2, III 1 | Consistent eyelid closure in all; mild synkinesia in all; good aesthetics | No flap loss; no recipient-site complications; no donor-site complications; no costal graft resorption/infection |
| Biglioli et al. | 2014 | First contraction at 5–14 months final HB I 2, II 2, III 3 | Almost complete symmetry at rest in all; eyelid closure in all | No donor-site morbidity; no perioperative nerve-grafting complications; 1 surgical field infection |
| Hontanilla et al. | 2014 | Blink recovery and commissural excursion similar between RT and non-RT groups | First movement 5.7 vs 6.3 months symmetrical and synchronous motion in all | Mild synkinesis 4/13; symmetry procedures 5/13; no recurrences |
| Renkonen et al. | 2015 | Recovery in 18/23 evaluable patients: slight 5, moderate/good 9, excellent 4; no recovery 5 | Some recovery in 13/17 evaluable irradiated patients | Postoperative complications in 9/31, including Frey syndrome in 3/31; 19/31 required secondary procedures |
| Owusu et al. | 2016 | Oral commissure motion returned by 2–7 months with good excursion and minimal synkinesis | Improved resting symmetry | NR |
| Ciolek et al. | 2018 | Neural recovery in 8/16 grafted patients; HB III in 5/8 | Good symmetry in 16/17; oral competence and dynamic smile in all | Donor-site seroma 3; wound infection 2; partial OTTT dehiscence 1; no chronic leg weakness |
| Rashid et al. | 2019 | HB II 3/22, III 8/22, IV 7/22, V 4/22 | Recovery began at 2–7 months | Uneventful healing; no major complications reported |
| Li et al. | 2021 | Mean HB 2.5; eFACE static 83.1, dynamic 67.5, smile 77.7 | Reinnervation time 9 months (range, 3–15) | No donor-site complications; no flap complications; no local recurrence |
| Mangialardi et al. | 2021 | In functional subset of 8: first movement 3–12 months HB IV 6, III 2; eFACE static 68–91, dynamic 66–80 | Total eye closure in all subset patients; satisfactory volume restoration in 93% | No flap necrosis; no hematoma; no wound infection; seroma 4; no donor-site complications |
| Yao et al. | 2023 | Volitional gracilis activation in 6/10; Terzis scores: 3,1,1,4,1,1,3,5,5,2 | Static sling support adequate in remaining 4; normal speaking/eating without leakage | Hematoma 1; delayed donor-site wound healing 2; no PAP loss; no gracilis loss; PAP wound dehiscence 1; no donor-site deformity |
| Ji et al. | 2024 | 9/10 selective reinnervation patients improved to modified HB III and Terzis 4–5; OTTT patients had moderate outcomes | Emotrics symmetry favorable; mean FDI total 131.5 | Major reconstructive complications: NR; disease progression in 6 |
| Brennan et al. | 2024 | One HB grade improvement in all; Sunnybrook 3.8 to 34.8 | Improved symmetry at 2 weeks; acceptable static and dynamic function | Earlobe necrosis 1; lower lid ectropion 2; no anaesthetic complications |
| Econ et al. | 2025 | Modified HB III 3, IV 2, V 2; Yanagihara 4–30 | Normal ocular function in 3; acceptable resting tone in 6/7; minimal synkinesis in all | No ocular complications; no feeding problems; temporary donor-leg weakness 1 |
| Grewal et al. | 2026 | HB III in 25/32 overall; group-specific outcomes similar | Most regained function by 9–12 mo, exact timing partly NR | No donor-site complications; later temporalis transfer in 1 |
| Onoda et al. | 2026 | Mean Sunnybrook 39.1 (range, 23–65) | No contour depression | Frey syndrome 1; no donor-site complications; no vascular complications |
| Bolognesi et al. | 2026 | eFACE showed good static and dynamic symmetry; smile excursion highest in masseteric group | Eye closure scores lower than smile/static symmetry; dynamic smile by ∼4–6 months | NR |
Abbreviations: eFACE, electronic Facial Clinimetric Evaluation; FDI, Facial Disability Index; HB, House–Brackmann; NA, not applicable; NR, not reported; OR, operating room; OTTT, orthodromic temporalis tendon transfer; PAP, profunda artery perforator; RT, radiotherapy.
Three studies also examined the effect of radiotherapy. 8, 9, 10 Immediate sural nerve grafting showed no significant differences in blink recovery, commissural excursion, or time to first movement between patients treated with surgery alone and those receiving postoperative brachytherapy and external beam radiotherapy.10 Similar conclusions were reported in a larger long-term grafting series and in an MABC graft series including both previously irradiated salvage cases and patients receiving postoperative adjuvant radiotherapy.8,9 Taken together, these findings suggest that immediate reconstruction remains feasible and potentially beneficial even in irradiated or salvage settings.
Discussion
Immediate facial nerve reconstruction at the time of radical parotidectomy appears feasible across a broad spectrum of oncologic defects. The available literature suggests that successful reconstruction in this setting extends beyond restoration of neural continuity alone. Earlier series focused primarily on interpositional grafting and regional reanimation, whereas more contemporary studies increasingly combine neural reconstruction with dynamic reanimation, soft-tissue restoration, contour correction, and periocular support. This shift is conceptually important because radical parotidectomy rarely creates an isolated nerve defect. Instead, it more often results in a composite deficit involving facial movement, resting symmetry, periocular competence, oral competence, and soft-tissue volume.
Facial nerve management remains fundamentally oncologic, but the decision to preserve or sacrifice the nerve is not always straightforward. Pretreatment facial weakness has long been regarded as a marker of neural invasion and poor prognosis, yet this relationship is imperfect.3,26,27 Park et al. reported that some resected nerves in patients with pretreatment facial weakness showed no histopathologic neural invasion, whereas Carlson et al. demonstrated that occult proximal spread may involve the intratemporal facial nerve despite preserved preoperative function and that positive proximal margins are associated with worse locoregional control.26,27 Thielker et al. similarly noted that some patients with normal preoperative facial function nevertheless required radical surgery because tumor infiltration was identified intraoperatively.3 For reconstructive planning, these findings underscore that preoperative facial function alone does not reliably define the extent of neural disease or the feasibility of preservation, and that intraoperative findings often determine whether immediate grafting, nerve transfer, or non-neural reanimation strategies are required.
Immediate reconstruction retains value even when complete functional recovery is uncommon. Several graft-dominant series reported only partial recovery in a substantial proportion of patients and a considerable burden of secondary procedures, particularly eyelid procedures and static revisions.8, 9, 10,19 However, even partial recovery may still be clinically meaningful by restoring resting tone, improving symmetry, and enhancing oral competence, while also creating a better substrate for later refinement. Supporting this idea, Thielker et al. (2021) showed that long-term facial dysfunction remains common after primary parotid cancer surgery and suggested that facial reanimation may still be underutilized.28 Earlier reconstructive literature reached a similar conclusion. Sobol et al. (1990) emphasized the value of early facial reanimation after extirpative parotid and temporal bone surgery in reducing functional, cosmetic, and psychological morbidity.29 Taken together, these findings suggest that immediate reconstruction may not restore normal facial function in every patient, but it may still meaningfully improve the postoperative baseline.
A further observation from this review is that multimodal strategies may offer advantages over grafting alone in selected patients. Studies incorporating concurrent masseteric nerve transfer, selective reinnervation, orthodromic temporalis tendon transfer, or free functional muscle transfer generally reported more favorable smile outcomes and stronger oral competence than graft-only approaches.4,5,7,11,14,18 This observation should be interpreted cautiously, however, because these data are derived from small, noncomparative series with substantial selection bias and heterogeneity in defect severity, stump availability, salvage status, and adjuvant treatment. In long defects, irradiated fields, or salvage settings, interpositional grafting may restore continuity without producing strong or coordinated facial excursion. In such settings, addition of a reliable motor source or tendon-based reanimation may help address deficits in dynamic movement, oral competence, and symmetry within the same operation.
Patients undergoing radical parotidectomy with immediate facial nerve reconstruction have been shown to achieve broadly comparable overall quality of life to more limited parotidectomy cohorts, although deficits in speech, eye symptoms, and eating-related function may persist.30 This pattern is consistent with the included reconstructive series, in which resting symmetry, oral competence, and overall facial balance were often improved, whereas periocular symptoms and oral-phase function remained more difficult to normalize.
Soft-tissue restoration deserves particular emphasis. In several included studies, flap-based reconstruction appeared to provide more than simple volume replacement. It restored contour, improved the recipient bed, separated the skin flap from deeper structures, and likely improved the durability of reconstruction in patients receiving adjuvant treatment.5,6,13,24 This may also have implications for late parotid bed morbidity, although the available evidence in the radical oncologic setting remains limited. Roh (2023), in a conservative parotidectomy cohort, showed that Frey syndrome was significantly more common when exposed parotid tissue and fascia were left unclosed than when the bed was closed, and that sialocele was likewise more frequent in the non-closure group.31 Although this evidence is indirect and derives from a different surgical population rather than radical parotidectomy with immediate facial reanimation, it supports the broader principle that barrier restoration at the parotid bed may have functional consequences beyond appearance alone. In the radical setting, soft-tissue reconstruction should therefore be considered an integral component of functional rehabilitation rather than a secondary aesthetic measure.
The effect of radiotherapy warrants careful interpretation. Although anticipated postoperative radiotherapy is often viewed as a factor that may weaken the rationale for immediate nerve repair because of concerns regarding wound healing and long-term facial recovery, the available reconstructive literature does not support abandoning immediate reconstruction on this basis alone. Useful recovery has been reported after immediate grafting in both adjuvant and previously irradiated salvage settings, even though postoperative radiotherapy has also been identified as an independent risk factor for permanent facial dysfunction.8, 9, 10, 28, 30
This review must also be interpreted in light of significant limitations. Nearly all included studies were retrospective case series. Exclusion of five non-English full-text studies may have introduced language bias, which is particularly relevant in this rare and highly specialized field, where important reconstructive innovations may be reported by non-English-speaking centers. Functional outcomes were assessed with heterogeneous instruments, at variable postoperative intervals, and with inconsistent reporting of revision burden. The methodological appraisal showed that case identification and clinical reporting were generally adequate, but consecutive inclusion and complete inclusion were frequently unclear, particularly in older retrospective series. Because the evidence consists almost entirely of small, heterogeneous, uncontrolled case series, this review remains primarily descriptive and cannot support meaningful comparisons between reconstructive techniques or treatment strategies. This also complicates attempts to isolate the effect of reconstructive strategy from tumor extent, preoperative facial function, salvage status, prior treatment, and adjuvant therapy.
Conclusions
Immediate facial nerve reconstruction and facial reanimation at the time of radical parotidectomy appear feasible across a broad range of oncologic defects and are associated with at least partial functional benefit in many reported series. The available literature increasingly supports reconstructive strategies that address the full functional and structural consequences of radical parotidectomy rather than focusing on nerve continuity alone. Reconstructive planning should prioritize ocular protection, resting symmetry, oral competence, dynamic reanimation when feasible, and durable soft-tissue coverage. Better comparative studies with standardized functional and patient-reported outcome reporting are needed to refine procedure selection and optimize reconstruction in this setting.
Author contributions
Charbel Saad: Conceptualization; Methodology; Data curation; Formal analysis; Writing—original draft; Writing—review & editing.
Thadeu Rangel: Methodology; Data curation; Writing—review & editing; Supervision.
Juan Pablo Menendez: Writing—review & editing; Supervision.
Gregory Nicolas: Conceptualization; Methodology; Writing—review & editing; Supervision.
Funding
The authors did not receive support from any organization for the submitted work.
Ethical approval
Not applicable. This study is a systematic review of published literature and did not involve human participants, animals, or identifiable private data.
Declaration of competing interest
The authors declare no relevant financial or non-financial conflicts of interest.
Acknowledgements
None.
Footnotes
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jpra.2026.06.015.
Appendix. Supplementary materials
Data availability
All data extracted and analyzed in this systematic review are derived from publicly available, published studies.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data extracted and analyzed in this systematic review are derived from publicly available, published studies.