Facial nerve surgery in the 19th and early 20th centuries: The evolution from crossover anastomosis to direct nerve repair.

The historical aspects of facial nerve (FN) anatomy and of Bell's palsy have long been favorite topics of otologic historians. Little attention has been paid, however, to the evolution of FN surgery, a subject with a remarkably rich and engaging history. In the early 13th century, Roland, an Italian surgeon, used a red hot iron to coapt severed nerve endings. In the 17th century, Ferrara, another Italian, sutured injured nerves with tortoise tendon dipped in hot red wine. It was not until the late 19th century that peripheral nerve suture became a subject of serious scientific study. Although it is ironic, the course of events suggests that the evolution of FN repair was greatly stimulated by the development of the modern mastoid operation. Whereas the simple mastoid operation practiced by Wilde (1853) and others carried little risk of FN injury, more adventuresome procedures such as radical mastoidectomy (Kessel, 1885) carried a much greater risk. The abundance of iatrogenic palsies during this era undoubtedly did much to motivate surgeons to seek a better means of restoring facial animation. Most surgeons would be surprised to learn that crossover anastomoses predated direct nerve repair by nearly half a century. In 1879, the German surgeon Drobnik performed the first facial-spinal accessory anastomosis. Over the next two decades, numerous articles were written (most notably by Sir Charles Balance and Harvey Cushing) on crossovers between the FN and cranial nerves IX, X, XI, and XII. Although a few tentative attempts at reapproximating severed FNs took place in the first two decades of this century, it was not until 1925 that an actual suture repair of an intratemporal injury was undertaken. This feat was first accomplished by the famous hand surgeon Sterling Bunnell and shortly thereafter by the otolaryngologist Robert Martin. The evolution of FN surgery in the days predating the operating microscope is a rich tapestry of colorful personalities and clashing egos, which saw promising advances relegated to obscurity and some previously obscure techniques become progressively more promising.