Reanimating the Face: The Case for Early Nerve Repair in Skull Base Surgery

By: Wynne Parry | March 25, 2026 | 8 min. read |

University of Miami Miller School surgeons argue that facial nerve reinnervation should begin at the time of tumor resection, an approach that can dramatically improve recovery after complex skull base surgery.

A clinician in a white coat consults with an adult patient seated in an exam room, with medical equipment and cabinets visible in the background.

When a large tumor invades the infratemporal fossa and the facial nerve must be cut, surgeons focus on the resection. Restoring the nerve typically comes later, or not at all. University of Miami Miller School of Medicine facial nerve specialist Liliana Ein, M.D., wants surgical teams to prioritize fixing the nerve.

“A lot of times people will just cut the nerve and then deal with it later, or they just leave the patients with flaccid paralysis,” said Dr. Ein, an assistant professor of clinical otolaryngology at the Miller School and head of the UHealth — University of Miami Health System’s Facial Nerve Program.

Dr. Liliana Ein A speaker addresses an audience from a podium at a professional conference, with a large screen on the lectern displaying “NASBS 2026 35th Annual Meeting” and conference branding. — Dr. Liliana Ein

During her presentation at the North American Skull Base Society conference, Dr. Ein emphasized the importance of reinnervation at the time of resection to ensure patients regain as much function as possible.

“If you lose that window, it’s a lot harder to reanimate patients,” she said, noting that in severe cases, there are additional options to help patients regain function.

Dr. Ein and colleague Larissa Sweeny, M.D., presented as part of a session on challenging scenarios in infratemporal fossa reconstruction. A microvascular reconstruction specialist, Dr. Sweeny addressed free tissue transfers, another critical component of restoring the mid-face after surgery. She emphasized the importance of flexibility when working within this complex anatomical region.

Dr. Larissa Sweeny stands at a lectern during a conference presentation, with a microphone, monitor, and a podium display reading “NASBS 2026 35th Annual Meeting” visible in the foreground. — Dr. Larissa Sweeny

“Each defect is dependent on the tumor,” said Dr. Sweeny, an associate professor of otolaryngology at the Miller School. “The surgeon needs to be able to visualize the three-dimensional space being reconstructed and adapt accordingly.”

Prioritizing the Smile

The two collaborate primarily on parotid tumor resections, which can require surgeons to cut the facial nerve. In some cases, the nerve is readily repaired. But, in others, when the tumor involves the infratemporal fossa, resection creates a bigger, more complicated defect, including an up to 10-centimeter gap in the nerve and too many distal nerve endings to graft.

In this scenario, Dr. Ein typically employs a combination of approaches, prioritizing reinnervating the eyelid for blinking with long cable grafts and restoring the smile with a masseteric nerve transfer. She may also use static maneuvers, such as lifts with fascia lata grafts to address drooping.

In these more severe cases, the free tissue transfers can supply the donor nerve to span the gaps. When selecting a donor site, Dr. Sweeny said she must consider the volume of tissue lost, which is impacted by the location of the defect and extent of the resection, and the distance to the nearest viable vessels. If the buttresses of the face are resected, then bone is often needed to restore and support the soft tissues, according to her.

In her presentation, Dr. Ein discussed an even more complicated case. The patient, a woman, had an aggressive parotid tumor that had invaded not only the facial nerve but the smile musculature itself, while extending all the way back into her skull base.

“I couldn’t reinnervate her smile muscles, because there was no nerve or muscle left,” she said.

At the time of resection, Dr. Ein grafted from the main nerve trunk to the patient’s eye to recover some blink function and rerouted ansa cervicalis fibers to her lower lip. The smile work came later, after the patient finished radiation treatment. In the first stage, Dr. Ein harvested the sural nerve from the patient’s ankle and routed it across her face, connecting one end to the intact smile nerve and then banking it in the paralyzed cheek.

Tissue Transfer from the Thigh

In the second stage, performed six months later, Dr. Sweeny and Dr. Ein harvested the gracilis muscle from the patient’s inner thigh.

“The gracilis is the ideal donor site for this reconstruction,” Dr. Sweeny said. “It allows for the closest match to the native tissue lost.”

She then dissected an artery and vein in the patient’s neck for the graft and performed the microvascular anastomosis, procedures made more challenging when a patient has received radiation. That’s because radiation causes fibrosis and scarring of the soft tissues. It can also damage the vessel walls, making them more fragile, according to Dr. Sweeny.

This procedure, gracilis free functional muscle transfer driven by cross facial nerve graft, has a success rate of 84 percent. Eleven months after the gracilis surgery, the patient is smiling spontaneously, Dr. Ein said. That smile was the culmination of a process that began with the tumor surgery.

She also discussed a case in which reinnervation at the time of resection allowed a patient to regain much of his function, without any further surgeries. But, as the more severe case demonstrates, this isn’t always possible.

“If reinnervation can’t be done fully or is neglected at the time of surgery, then we have to resort to other methods, including static fascia lata grafts and free muscle transfers, as we did in this young lady’s case,” Dr. Ein said.