Emerging microsurgical techniques for facial nerve reconstruction in traumatic skull base fractures: a systematic review and comprehensive evidence analysis.

Traumatic brain injury affects 69 million people annually, with skull base fractures causing devastating facial nerve palsy. Despite representing only 4% of cases, these injuries result in severe functional and psychosocial complications including hearing loss and cranial nerve dysfunction, presenting significant reconstructive challenges. This systematic review followed PRISMA guidelines and examined facial reanimation surgery outcomes in skull base fracture patients through comprehensive database searches and quality appraisal. Study quality was assessed using Joanna Briggs Institute (JBI) critical appraisal tools for case reports and series, and the Newcastle-Ottawa scale for observational studies. Systematic searches across eight databases and registries yielded 3,682 records; 3,251 underwent screening after duplicate removal. Eighteen studies were included, documenting predominantly severe facial dysfunction, with 88.8% reporting House-Brackmann Grade VI paralysis. Surgical approaches varied considerably, including masseteric-facial nerve transfers, split hypoglossal-facial anastomosis, and complex free tissue transfers with dual innervation, reflecting evolving microsurgical techniques for functional restoration in post-traumatic skull base fracture patients. This systematic review demonstrated that facial reanimation surgery following skull base fractures improves functional outcomes, with optimal results achieved within 6–12 months post-injury. Masseteric and hypoglossal-facial nerve transfers showed favorable outcomes for severe paralysis. However, evidence remains limited, necessitating timely specialist referral, individualized surgical planning, and standardized multicenter studies to establish evidence-based guidelines.