Accepted 22 January 2013 Published online 1 June 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: /hed.23276

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1 ORIGINAL ARTICLE Effect of postoperative brachytherapy and external beam radiotherapy on functional outcomes of immediate facial nerve repair after radical parotidectomy Bernardo Hontanilla, MD, PhD,* Shan-Shan Qiu, MD, Diego Marre, MD Department of Plastic and Reconstructive Surgery, Clínica Universidad de Navarra, Navarra, Spain. Accepted 22 January 2013 Published online 1 June 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: /hed ABSTRACT: Background. There is much controversy regarding the effect of radiotherapy on facial nerve regeneration. However, the effect of brachytherapy has not been studied. Methods. Fifty-three patients underwent total parotidectomy of which 13 were radical with immediate facial nerve repair with sural nerve grafts. Six patients (group 1) did not receive adjuvant treatment whereas 7 patients (group 2) received postoperative brachytherapy plus radiotherapy. Functional outcomes were compared using Facial Clima. Results. Mean percentage of blink recovery was for group 1 and for group 2 (p ¼.37). Mean percentage of commissural excursion restoration was for group 1 and for group 2 (p ¼.17). Mean time from surgery to first movement was months for group 1 and months for group 2 (p ¼.15). Conclusion. Brachytherapy plus radiotherapy does not affect the functional outcomes of immediate facial nerve repair with nerve grafts. VC 2013 Wiley Periodicals, Inc. Head Neck 36: , 2014 KEY WORDS: facial paralysis, facial nerve reconstruction, parotidectomy, radiotherapy, brachytherapy *Corresponding author: B. Hontanilla, Department of Plastic and Reconstructive Surgery, Clinica Universidad de Navarra, Av. Pio XII 36, 31008, Pamplona, Spain. bhontanill@unav.es Additional Supporting Information may be found in the online version of this article. INTRODUCTION Primary adenocarcinomas of the parotid gland are rare and account for less than 5% of all head and neck malignant neoplasms. Ten percent to 35% of malignancies affecting the parotid gland are nonprimary tumors, most of them being intraparotid metastasis of a primary neoplasm or parotid lymphoma. 1 Treatment of parotid adenocarcinoma is based on 2 fundamental pillars: surgery and radiotherapy. The therapeutic plan depends basically on tumor stage and the presence of local invasion. In cases in which the facial nerve is not involved, complete tumor excision preserving such nerve is indicated together with cervical node dissection to control node metastases in advanced stages. However, when the facial nerve is not easily dissected from the tumor or if the tumor is adherent or infiltrative, a radical parotidectomy should be performed. On the other hand, adjuvant radiotherapy is indicated for patients with high-grade carcinomas, advanced stages (III and IV), positive resection margins, facial nerve invasion, and cervical node involvement. 2 Despite its oncological effectiveness, radiotherapy is highly toxic for the surrounding tissues, producing several side effects (especially with doses over 60 Gy) the most frequent being skin damage and mucositis, xerostomia, osteoradionecrosis, and permanent taste impairment. Recently, the use of brachytherapy has gained popularity in the treatment of head and neck cancer because it delivers a high dose of radiation to a limited volume while sparing surrounding normal tissues. Currently, surgery in combination with brachytherapy and external beam radiotherapy has proven to be an effective modality of treatment for advanced-stage parotid cancers. 3,4 With this approach, the tumor can be aggressively radiated with minimal secondary damage to adjacent normal tissues. Moreover, the rate of control of local disease improved with this combination, resulting in a 5-year survival rate of 69% for primary tumors of the parotid gland. 4 The incidence of facial palsy at presentation in parotid cancer lies between 9% and 25%. 1 Whenever the facial nerve is transected during parotidectomy, immediate repair using nerve grafts is highly recommended. 5 However, as mentioned earlier, in cases with facial nerve invasion, adjuvant radiotherapy must be administered in order to optimize treatment. During the last decades there has been much controversy on whether to perform nerve repair before or after irradiation with several studies showing contradictory results regarding the impact of the external beam radiation on the functional outcomes. Nevertheless, the effect of new radiation strategies, namely brachytherapy plus radiotherapy, has not been evaluated so far. The purpose of the present study was to compare the functional long-term results of immediate facial nerve repair in patients with parotid neoplasms treated with surgery alone versus surgery plus brachytherapy and radiotherapy. Through this study, we attempt to address not only the direct effect of brachytherapy in nerve HEAD & NECK DOI /HED JANUARY

2 HONTANILLA ET AL. TABLE 1. Patient demographics. Group Age, y Sex Histology Repaired branches BT, Gy RT, Gy Follow-up, mo 1 33 M Dermatofibrosarcoma protuberans 5 No No F Kidney carcinoma metastasis 4 No No F Basal cell carcinoma 5 No No F Basal cell carcinoma 4 No No M Squamous cell carcinoma 5 No No F Squamous cell carcinoma 5 No No F Adenoid cystic carcinoma M Recidivant basal cell carcinoma M Adenocarcinoma M Adenoid cystic carcinoma F Adenoid cystic carcinoma M Recidivant basal cell carcinoma M Adenocarcinoma Mean 6 SD Abbreviations: BT, brachytherapy; RT, radiotherapy. regeneration but also the possible effect caused by the mechanical presence of a brachytherapy catheter close to a nerve coaptation. PATIENTS AND METHODS The medical records of patients with parotid gland neoplasms submitted to total parotidectomy at our institution between 2007 and 2010 were reviewed. A total of 53 cases were identified. Of this population, 13 patients underwent radical parotidectomy and immediate facial nerve repair with nerve grafts. Despite facial movement, weakness was observed in only 1 patient preoperatively, the facial nerve was grossly involved macroscopically in all cases. The other 40 patients underwent either partial or total parotidectomy sparing the facial nerve, most of them because of primary pleomorphic adenoma. Patients with facial nerve repair were divided according to the presence of adjuvant radiotherapy. Group 1 consisted of 6 patients receiving surgery alone, whereas group 2 was formed by the remaining 7 patients treated with surgery and brachytherapy (24 Gy) plus external beam irradiation (45 Gy). The number of repaired branches varied little between 4 or 5. Histological diagnosis counted both primary and nonprimary parotid gland tumors. Primary tumors were mostly found in the second group, whereas other types of cancers, such as malignant skin neoplasms infiltrating the parotid gland were more frequent in the first group (Table 1). Patients were encouraged to perform facial movements and self massages at home several times per day after the first month after surgery. We routinely do not recommend any other rehabilitative service such as electrical stimulation to avoid synkinesis. Tumor surveillance tumors was generally conducted at our institution by a multidisciplinary team, including radiotherapists; oncologists; and ear, nose, and throat specialists. As there were different kinds of tumors, every patient was followed periodically as each tumor required. Surgical details All patients underwent radical parotidectomy resulting in damage of 4 or 5 facial nerve branches. The tumor and the surrounding infiltrated tissues were resected en bloc transecting the facial nerve in all patients. In cases of injury to 4 branches, either the frontal or marginal branches were spared. Patients from group 1 and 2 patients from group 2 (recurrent basal cell carcinoma) underwent transection of facial nerve branches distal to the pes anserinus. In the rest of patients from group 2, the facial nerve was resected proximal to the pes anserinus. Also, in 2 patients from group 2, the facial nerve canal had to be opened by the ear, nose, and throat surgeons in order to reach a tumor-free proximal nerve stump. Depending on the level of transection, nerve coaptation was performed in 2 different ways. If transection was proximal to the pes anserinus, the distal end of the sural nerve was sutured to the proximal stump of the facial nerve. Depending on the number of sectioned branches, the graft was split in many fascicules, each of which was connected to the transected branches. In cases with transections distal to the pes anserinus, the sural nerve was previously divided in different segments as required and these were used to connect the proximal stumps with their corresponding distal stumps. This technique was performed under microscopy using nylon 10/0 for end-to-end epineural sutures. Radical neck dissection was performed in all patients included in the second group. Intraoperative biopsies of the proximal stumps were sent in order to ensure safe and total removal of the tumor. Immediate facial nerve reconstruction with interpositional nerve autografts was performed in all patients (Figure 1). The sural nerve used as the donor nerve in all cases because of its adequate length, which allowed repair of several branches, its readily accessibility, similar diameter to the facial nerve, and straightforward technique of harvesting. Proximal nerve coaptation was intratemporal in 2 cases, whereas all distal ones were extratemporal, as mentioned above. Six patients (group 1: 2 patients; group 2: 4 patients) had 4 branches sectioned and 7 patients (group 1: 4 patients; group 2: 3 patients) had 5 branches (Table 1). As standard radical parotidectomy was performed equally in all patients, the nerve defects were similar between both groups (3 4 cm). Thus, nerve grafts of 4 to 5 cm were routinely used without differences between the groups. 114 HEAD & NECK DOI /HED JANUARY 2014

3 FACIAL NERVE REPAIR AND POSTOPERATIVE BRACHYTHERAPY FIGURE 1. (A) Facial nerve branches sectioned after a total parotidectomy. (B) Nerve grafts interpositioned to restore the continuity of facial nerve. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Regarding soft tissue reconstruction, patients with deficient skin cover postresection were reconstructed using regional flap advancements and a free anterolateral thigh flap in 1 case (case 8). In the remaining patients, direct closure of the surgical wound without undue tension was possible. Complete facial paralysis was detected in all patients after surgery. Radiation protocols Patients in group 2 received adjuvant radiotherapy. According to the established guidelines of our institution, all of them received 24 Gy by 5 interstitial brachytherapy catheters and 45 Gy by external radiation, giving a total dose of 69 Gy (Table 1). Even though there were no formal contraindications to start brachytherapy on the first postoperative day, we preferred to wait 72 hours in order to allow patients to recover from surgery. The protocol consisted of 2 sessions per day during 3 consecutive days. Three weeks after the end of brachytherapy, external radiation was administered consisting of 25 daily consecutive sessions with a dose of 1.8 Gy per session. Adjuvant radiotherapy was indicated in all malignant parotid gland tumors with the aim of improving overall survival and reduce local recurrence. 6 In adenoid cystic carcinoma, local recurrence was frequent because of the infiltrative growth pattern and perineural spread associated with them. 7 As for nonmelanoma skin tumors (basal and squamous cell carcinoma), brachytherapy was administered because of its beneficial effects in specific situations such as recurrence in which free-disease survival is improved and local recurrence reduced. 8 Evaluation of facial movement Although there are many grading systems for evaluation of facial palsy, in the present study, we used a 3D automatic capture system of facial movements called Facial Clima described by our group in This is an automatic optical motion system that involves placing special reflecting dots on the patient s face (a total of 18 dots) and video recording with 3 infrared-light cameras. Patients are asked to perform several facial movements, such as smile, mouth puckering, eyes closure, and forehead elevation. With these 4 movements, several vectors are obtained and analyzed. The most relevant movements include palpebral movement and commissure excursion. The data is automatically processed resulting in information on areas, velocities, and distances between the 18 dots. This system provides an adequate tool to assess the outcome of facial palsy rehabilitation surgeries. In this study, the test was performed at the immediate postoperative period, 6 and 12 months later. In addition, standard photographs and videos were obtained from all patients at revision. In order to objectively compare the degree of movement recovery between the groups, for each patient, a percentage of recovery was calculated considering the nonparalyzed side as the reference. This was done to avoid heterogeneous comparisons because smiles may vary greatly between individuals. For example, a patient with a strong full smile will have greater commissural excursion than another one with a "weak" lateral smile, without meaning that the latter has some form of paralysis. Hence, by calculating each individual s recovery according to his or her normal side, an objective measurement can be obtained, minimizing the possible bias from comparing the absolute values. Statistical analysis Categorical variables were compared using Fisher exact test, while quantitative variables were analyzed using Mann Whitney U test. Significance was set at p >.05. SPSS v17.0 (SPSS, Chicago, IL) was used to perform all statistical tests. RESULTS Mean age of the whole sample was years old, with years for group 1 and years for group 2. The male:female ratio was 2:4 in group 1 and 4:3 in group 2. Follow-up ranged from 17 to 54 HEAD & NECK DOI /HED JANUARY

4 HONTANILLA ET AL. TABLE 2. Mann Whitney U test between the groups for age, sex, and follow-up. Group Age, y, Male:female ratio Follow-up, : : p value Mann Whitney U test shows no significant differences between the groups for age, sex, and follow-up (p >.05). Fisher exact test shows no significant differences between male:female ratio. months showing a mean of months for all 13 cases, with months for group 1 and months for group 2. There were no significant differences between the groups for any of these variables (Table 2). Most patients (12 of 13 patients; 92.3%) presented normal facial motion before radical parotidectomy. Only 1 female patient of the second group showed partial facial palsy that affected the lower third of her face, which was evident at the preoperative assessment. Regarding recovery, 10 patients recovered more than 90% of the eyelid movement and the remaining 3 recovered more than 80%. Mean percentage of blink recovery was for group 1 and for group 2 (p ¼.37). The difference between commissure excursion of the reconstructed face and the healthy face ranged from 3 to 5 mm, with most patients (11 of 13; 84.6%) achieving more than 75% of recovery. Mean percentage of commissural excursion restoration was for group 1 and for group 2 (p ¼.17; Table 3). All patients showed symmetrical and synchronous movement on follow-up (Figure 2 and Supplemental video, online only). It is important to underscore that, so far, we have not seen a drop in facial nerve function in the irradiated group secondary to scarring. Time from surgery to first movement reported by patients ranged from 4 to 7 months with a mean of The mean for group 1 and 2 was 5.7 and 6.3 months, respectively, with no significant differences (p ¼.15; Table 3). Ancillary procedures were performed to gain symmetry in 5 cases, and consisted mainly in infiltration of botulinum toxin type A. Good results and high patient satisfaction were observed after such procedures. Mild facial synkinesis developed in 4 cases and the solution was managed with botulinum toxin type A. To date, no recurrences have been detected in either of the 2 groups. DISCUSSION Facial paralysis secondary to nerve transection can be approached in different ways and treated with different procedures depending on a series of factors, one of the most important is time of evolution. In this sense, transection because of tumoral invasion in parotid carcinomas represents a unique situation for the reconstructive surgeon, because the damaged fibers are readily identified and adequately exposed, permitting immediate repair. Previous studies have shown that such approach provides very good functional and esthetic results. 5 Our protocol in these cases follows this premise as we attempt facial nerve repair whenever possible, no matter the number of affected branches, the age of the patient, the preoperative facial nerve function, and the indication (or not) of postoperative radiotherapy. Throughout our experience, we have observed good functional and esthetic results with this therapeutic approach. The influence of radiotherapy in facial nerve repair has been previously studied by several authors with contradictory results. Conley 10 in 1961 and Miehlke et al 11 in 1972 reported that irradiation did not have a negligible effect on facial nerve grafts. In contrast, Lathrop 12 in his series of 7 patients, found no satisfactory return of facial nerve function in the cases treated with postoperative radiotherapy. Later on, McGuirt and McCabe 13 conducted an experimental study on cats, performing facial nerve autografts and then submitting a group of animals to 6000 rads. After a follow-up period of 2 to 6 months, histological study revealed that the number of regenerated axons was less in the radiated specimens, which represented 80% of the control group. In spite of having a fewer number of regenerated axons, movement restoration was similar between the groups. In another study by Pillsbury and Fisch, 14 from a total of 19 cases repaired with interpositional grafts, 9 received postoperative irradiation. The authors evaluated their results with photographs taken 1 year after surgery and concluded that postoperative radiotherapy had a detrimental influence on the return of facial function. They also suggest that alternative methods of facial rehabilitation should be used in cases in which radiotherapy has been administered and recommend performing facial reanimation once irradiation has been completed. A few years later, in 1987, Gullane and Havas 15 studied the effect of postoperative irradiation in 6 patients with radical parotidectomy and immediate nerve repair with cable grafts. The total doses of radiation administered were 20 Gy in 4 weeks (5 Gy per week), starting 6 weeks after the surgery. They reported good to excellent function in 4 cases despite postoperative irradiation and fair recovery or total failure in the remaining 2 patients. In light of their results, these authors recommend a maximum dose of 5000 rads and delaying the start of radiotherapy until 6 weeks after surgery. However, a major drawback of this study is that the outcomes were not measured with any functional scale, which makes their conclusions difficult to interpret. On this same issue, Brown et al 16 have also recommended a delay of 5 weeks between surgery and irradiation. In their study, they included 52 patients with facial nerve repair but only 28 of them received postoperative radiotherapy 5 weeks after their surgery. The average doses of radiation were 60.3 Gy, without specifying the duration of TABLE 3. Comparisons of functional recovery and time to notice first contraction. Group % Blink recovery, % Commissure excursion recovery, First contraction, p value Mann Whitney U test shows no significant differences for any of the variables analyzed (p >.05). 116 HEAD & NECK DOI /HED JANUARY 2014

5 FACIAL NERVE REPAIR AND POSTOPERATIVE BRACHYTHERAPY FIGURE 2. A 58-year-old patient with a total parotidectomy with immediate reconstruction of 5 facial nerve branches. Brachytherapy and external radiotherapy was administered. Patient in the immediate postoperative period at rest (A) and when smiling (B). One-year postoperative at rest (C) and when smiling (D). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Video 1, online only. One-year postoperative video of the patient shown in Figure 2. therapy. After a follow-up of more than 10 years, they concluded that radiotherapy was not a deleterious factor in the nerve regeneration Gidley et al 17 studied 39 patients of which 34 received postoperative radiotherapy versus 5 that did not. The median postoperative radiotherapy dose was 60 Gy (range, Gy; mean, 59.9 Gy). These authors conclude that postoperative radiotherapy does not affect facial function after nerve repair. It is important to note that all these previous studies compared the results after external irradiation but HEAD & NECK DOI /HED JANUARY

6 HONTANILLA ET AL. not brachytherapy. Overall, looking at the evidence currently available on the effect of radiotherapy over nerve regeneration and return of function after immediate facial nerve repair after surgical transection, 2 facts are certainly striking, namely the limited number of publications and the contradictory results reported. In our practice, we have observed that radiation does not affect the functional recovery of patients submitted to immediate repair with cable grafts. The results reported in this study support the above. Despite the relatively small sample, both groups (irradiated and nonirradiated) were homogeneous regarding age, male:female ratio, time of evolution, and number of repaired branches. Being the groups were comparable, no significant differences were observed on the functional recovery of neither blinking nor commissural excursion. Furthermore, time from surgery to notice of first contraction (reported by the patients) ranged between 4 and 6 months, with no significant differences between the groups. Considering these results and the surgical advantages of immediate over delayed repair, such as ease of dissection and nerve stumps identification, we strongly believe that the benefits of immediate repair cannot be overemphasized. An important aspect of the present study is the number of branches reconstructed, which varied very little among the whole sample and between the groups (4 or 5). In previous studies, this number varied from 2 to 5, and in others it was not reported. In our opinion, this information is not only absolutely relevant but also determinant for the analysis of postoperative nerve regeneration because it allows one to assess the extent of paralysis that has been produced from transection (which should be correlated with postoperative physical examination and appropriate tests) and to determine whether the return of function is because of regeneration of the reconstructed fibers or because of residual innervation from nonsectioned branches once edema and damage from surgical manipulation of such branches has resolved. In all our cases, a complete paralysis was produced secondary to the oncological resection and, thus, we attribute the return of function to reinnervation of the repaired branches via the interpositional grafts performed. As described elsewhere, with brachytherapy, it is possible to administer a high dose of radiation to a limited amount of tissue, preserving the surrounding normal structures. Several studies have shown the reliability and oncological effectiveness of brachytherapy in the management of head and neck cancer According to the protocol followed in our center for the treatment of parotid tumors, adjuvant radiation was administered by interstitial brachytherapy catheters and external beam radiotherapy, at doses of 24 and 54 Gy, respectively. Following previous guidelines, brachytherapy was initiated 72 hours after surgery, with 2 sessions daily during 3 consecutive days. 4 Despite previous recommendations of delaying the start of radiotherapy 5 to 6 weeks after surgery in hope of reducing the degree of axonal degeneration fibrosis and capillary damage, 15 we have observed adequate recovery with the current protocol. A major difference between prior studies and ours is the modality of radiation, namely the administration of brachytherapy. In fact, to our knowledge, this is the first study evaluating the functional recovery of patients submitted to facial nerve repair and postoperative brachytherapy. In this sense, and considering the progressively expanding use of this radiation protocol in head and neck cancers and specifically for those affecting the parotid gland, we believe that our study provides valuable information regarding the effect of brachytherapy on functional recovery after reconstruction of the facial nerve. Another issue that deserves discussion is the method used in the evaluation of our postoperative outcomes. Traditionally, the most commonly used is the House- Brackmann scale, which assesses facial motion qualitatively in 6 grades, from normal symmetrical function in all areas (I) to no movement, loss of tone, no synkinesis, contracture, or spasm (VI). 21 In our study, we have used a quantitative automatic system called the Facial Clima, 9 which, in our opinion, is superior to the abovementioned scale for a number of reasons. First, with the House- Brackmann scale, the results are evaluated by physical examination, which can be subjective. In contrast, with the Facial Clima, objective numeric measurements of distances and velocities between 2 points are obtained. Second, the House Brackmann scale is difficult to apply in cases in which several facial nerve branches have been damaged because it grades general and not segmental facial function (ie, upper third, middle third, and lower third). The Facial Clima, in turn, provides detailed information of each segment separately. At this point, it is important to underscore that, as stated previously, the Facial Clima analyzes several other movements apart from the ones studied here, however, we decided to evaluate commissural displacement and blinking for 3 reasons: (1) to avoid giving extenuating information of angles, velocities of contraction, and area; (2) commissural displacement and blinking are the most relevant movements analyzed by the system; and (3) the zygomatic and palpebral branches were severed in all patients, while the frontal or marginal were spared in some; hence, the movements that can be homogeneously compared between the groups are smiling and blinking. Finally, symmetry of motion can be assessed with the Facial Clima and not with the House Brackmann scale, because the former provides information on the moment that a given movement begins. Regarding the number of patients included in our study, we are aware that a larger sample size would serve to confirm that immediate facial nerve repair with grafts can be safely performed in patients who will receive postoperative brachytherapy. However, judging by our clinical observations and the statistical analyses conducted, we have observed promising results not only in nerve regeneration but in functional recovery. In our opinion, everything points at the fact that probably the brachytherapy has little effect on facial nerve regeneration after immediate repair with grafts. In fact, as mentioned previously, some authors have already reported that radiotherapy has no effect on the recovery of the reconstructed nerve. In spite of the small sample size of the current study, the observational data obtained indicates that brachytherapy may not affect the functional outcomes. In summary, we believe that, in light of the results obtained, it is fair to conclude that the administration of brachytherapy during the immediate postoperative period followed by external beam radiotherapy does not affect the functional outcomes of facial nerve repair with 118 HEAD & NECK DOI /HED JANUARY 2014

7 FACIAL NERVE REPAIR AND POSTOPERATIVE BRACHYTHERAPY interpositional grafts. As far as we know, this is the first study addressing the effect of brachytherapy on facial nerve regeneration and, despite the fact that larger studies are needed to confirm our observations, it provides valuable information to strongly consider immediate repair in cases in which the facial nerve is severed during cancer resection, no matter the indication (or not) of postoperative radiation. REFERENCES 1. Morinière S, Perie S, Lacau St Guily J. Primary and non-primary parotid malignancies: comparison of treatment modalities and outcomes. Eur Arch Otorhinolaryngol 2007;264: Nagliati M, Bolner A, Vanoni V, et al. Surgery and radiotherapy in the treatment of malignant parotid tumors: a retrospective multicenter study. Tumori 2009;95: Shibuya H. Current status and perspectives of brachytherapy for head and neck cancer. Int J Clin Oncol 2009;14: Mazeron JJ, Ardiet JM, Haie Meder C, et al. GEC-ESTRO recommendations for brachytherapy for head and neck squamous cell carcinomas. Radiother Oncol 2009;91: Volk GF, Pantel M, Streppel M, Guntinas Lichius O. Reconstruction of complex peripheral facial nerve defects by a combined approach using facial nerve interpositional graft and hypoglossal-facial jump nerve suture. Laryngoscope 2011;121: Duberge T, Benezery K, Resbeut M, et al. [Adenoid cystic carcinoma of the head and neck: a retrospective series of 169 cases]. [Article in French] Cancer Radiother 2012;16: Jeannon JP, Calman F, Gleeson M, et al. Management of advanced parotid cancer. A systematic review. Eur J Surg Oncol 2009;35: Sedda AF, Rossi G, Cipriani C, Carrozzo AM, Donati P. Dermatological high-dose-rate brachytherapy for the treatment of basal and squamous cell carcinoma. Clin Exp Dermatol 2008;33: Hontanilla B, Auba C. Automatic three-dimensional quantitative analysis for evaluation of facial movement. J Plast Reconstr Aesthet Surg 2008;61: Conley JJ. Facial nerve grafting. Arch Otolaryngol 1961;73: Miehlke A, Stennert E, Schuster R, Sch atzle W, Haubrich J. [Regeneration of peripheral nerve after effect of ionizing radiation]. [Article in German] ORL J Otorhinolaryngol Relat Spec 1972;34: Lathrop FD. Management of the facial nerve during operations on the parotid gland. Ann Otol Rhinol Laryngol 1963;72: McGuirt WF, McCabe BF. Effect of radiation therapy on facial nerve cable autografts. Laryngoscope 1977;87: Pillsbury HC, Fisch U. Extratemporal facial nerve grafting and radiotherapy. Arch Otolaryngol 1979;105: Gullane PJ, Havas TJ. Facial nerve grafts: effects of postoperative irradiation. J Otolaryngol 1987;16: Brown PD, Eshleman JS, Foote RL, Strome SE. An analysis of facial nerve function in irradiated and unirradiated facial nerve grafts. Int J Radiat Oncol Biol Phys 2000;48: Gidley PW, Herrera SJ, Hanasono MM, et al. The impact of radiotherapy on facial nerve repair. Laryngoscope 2010;120: Beitler JJ, Smith RV, Silver CE, et al. Close or positive margins after surgical resection for the head and neck cancer patient: the addition of brachytherapy improves local control. Int J Radiat Oncol Biol Phys 1998; 40: Kupferman ME, Morrison WH, Santillan AA, et al. The role of interstitial brachytherapy with salvage surgery for the management of recurrent head and neck cancers. Cancer 2007;109: Schiefke F, Hildebrandt G, Pohlmann S, Heinicke F, Hemprich A, Frerich B. Combination of surgical resection and HDR-brachytherapy in patients with recurrent or advanced head and neck carcinomas. J Craniomaxillofac Surg 2008;36: House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93: HEAD & NECK DOI /HED JANUARY