A long-term retrospective series evaluating a subperineural “onion-peeling” dissection strategy in vestibular schwannoma surgery.

Liu and colleagues reviewed 146 consecutive vestibular schwannoma resections using a technique that preserves a thin perineural membrane as a protective buffer over the facial nerve. Most tumors were Koos III–IV, and 86.3% were removed through a retrosigmoid approach.

At a mean follow-up of 89.8 months, 95.2% of patients had House–Brackmann I–II facial function, while an extent of resection of at least 95% was achieved in 97.3%. Overall tumor recurrence was 3.4%, and postoperative CSF leakage occurred in 2.7%.

Why it matters

This series addresses one of the central trade-offs in vestibular schwannoma surgery: maximizing tumor removal while protecting facial nerve function. The subperineural plane offers a clear anatomical concept that is particularly valuable for operative teaching and discussion of onco-functional balance.

Reference

Liu JK, Sabra A, Levin-Carrion Y, et al.
Subperineural ‘onion-peeling’ dissection for maximizing extent of resection and facial nerve preservation for onco-functional balance in vestibular schwannoma surgery.
Journal of Neuro-Oncology. 2026;179:54. Published August 25, 2026.
DOI: 10.1007/s11060-026-05755-5
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