Surgical treatment of first branchial cleft anomalies using retrograde facial nerve dissection technique

Abstract

Purpose: First branchial cleft anomalies (FBCAs) are infrequent congenital malformations. In FBCAs removal surgery, due to the previous infection history and the anatomical proximity of the FBCAs tract to the facial nerve, postoperative recurrence and facial paralysis are not uncommon. This study aimed to assess the clinical feasibility and outcomes of FBCAs resection using the retrograde facial nerve dissection technique.

Methods: This retrospective study included 19 patients (mean age, 6.3 ± 4.4 years) who underwent FBCAs excision via retrograde facial nerve dissection between 2017 and 2023. Data on demographics, operative details, histopathology, postoperative complications, and follow-up survey were reviewed.

Results: Preoperative infection history was present in 94.7% of patients; 42.1% had prior incision and drainage and 15.8% had previous excision attempts. Complete resection was achieved in all cases without facial nerve palsy. No recurrence was observed during the follow-up periods (median, 23.9 ± 9.8 months). Postoperative pain and paresthesia showed clinical improvement, while cosmetic satisfaction was relatively limited.

Conclusion: In FBCAs patients, the close proximity of the facial nerve and the adhesion between the tract and facial nerve pose significant challenges. Using retrograde facial nerve dissection is believed to enable complete removal and reduce postoperative facial nerve paralysis.

Keywords: Children; Facial nerve; First branchial cleft anomalies; Retrograde dissection; Surgical treatment.

Fig. 1

Surgical incision of left FBCAs’ resection. Based on the preauricular incision, the upper temporal extension was made to facilitate the identification of the peripheral facial nerve outside the parotid gland and the lower extension was made along the ear lobule to improve the cosmetic result. A Additional incisions (dotted line) may be used in the form of a vertical limb. B Additional incision (dotted line) descends toward the neck in a lazy S-shape

Fig. 2

Variable surgical incision depending on the location of the lesion in different patients. If removal of infected skin is required, an elliptical incision around the skin lesion can be made

Fig. 3

Intraoperative surgical field view of the patients with FBCAs. A Preoperative photograph of a 3-year-old female patient with skin defects (white arrow). B Intraoperative surgical field view of the same patient, showing the skin defects being excised (white arrow) and the FBCAs tract (black arrow head) passing under the facial nerve trunk (asterisk). C Preoperative photograph of a 5-year-old female patient. A skin defect (white arrow) is observed (white arrow). D Intraoperative surgical field view of the same patient, showing the FBCAs tract (black arrow head) passing under the facial nerve trunk (asterisk)

Fig. 4

Intraoperative surgical field view of left FBCA resection surgery. A The surgical field demonstrates the identification of peripheral branches of the facial nerve, including the zygomatic branch innervating the zygomaticus major muscle (black arrowhead), the zygomatic branch innervating the orbicularis oculi muscle (black arrow), and the temporal branch (white arrow), through peripheral exploration and retrograde dissection. The left first branchial cleft cyst (asterisk) is shown during excision. B The surgical field after complete excision of the lesion, including the tract, with complete preservation of the peripheral branches of the facial nerve

Fig. 5

Changes over time in patients’ average scores of symptoms and cosmetic satisfaction. A Patients’ mean postoperative pain scores. B Patients’ mean postoperative paresthesia scores. C Patients’ mean postoperative cosmetic satisfaction scores