Revision Surgery of Microvascular Decompression for Hemifacial Spasm: 2-Dimensional Operative Video

Although microvascular decompression is highly effective for treating hemifacial spasm, cases of ineffectiveness and recurrence can still occur. Ineffectiveness is primarily due to missed neurovascular compression (NVC), whereas recurrence is most often caused by adhesion of Teflon pledgets (Chestmedical Co., Ltd., Shanghai, China), both of which may necessitate revision surgery.¹^,² However, adhesions in the surgical area make revision surgeries more difficult. This video presentation includes 2 cases of revision surgery for hemifacial spasm (Video 1). In the first case, symptom recurrence was due to pledget adhesion, with no NVC observed during surgery. After removing the pledget and carefully repositioning it to avoid any direct contact with the facial nerve root exit zone (REZ), the spasms were completely relieved. The second case involved a missed NVC, where the pledget was improperly placed between the artery and the cisternal portion of the facial nerve during the initial surgery, overlooking compression at the REZ, an error more common in less experienced centers. Subsequent decompression of the REZ resulted in full symptom relief. Our experience highlights the importance of thorough decompression of the REZ while ensuring the pledget does not come into direct contact with the REZ to prevent long-term adhesions and recurrent hemifacial spasm.