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However, recurrence risk correlates with residual tumor volume, and long-term outcomes remain unknown. The authors report their facial nerve outcomes with planned maximal safe resection using a facial nerve-sparing subperineural \u201conion-peeling\u201d technique, and compare their outcomes to those of the hybrid STR-SRS approach.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A retrospective study was performed on 146 patients who underwent VS resection by a single surgeon using a subperineural \u201conion-peeling\u201d technique, leaving a thin layer of perineurium as an anatomic buffer overlying the facial nerve. Tumor size, operative approach, extent of resection (EOR: GTR 100%, NTR 95\u201399%, STR\u2009&lt;\u200995%), facial nerve outcomes by House-Brackmann (HB) grade, recovery time, recurrence, and postoperative SRS usage were analyzed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Most tumors were Koos grade III-IV (69.9%), followed by grade I-II (30.2%), removed via retrosigmoid (86.3%) or translabyrinthine (13.7%) approaches.\n                      <jats:italic>At last follow-up (mean follow-up =\u200989.8 months)<\/jats:italic>\n                      ,\n                      <jats:italic>95.2% of patients achieved HB I-II scores while obtaining an EOR\u2009\u2265\u200995% (GTR\/NTR) in 97.3% of patients.<\/jats:italic>\n                      There was no significant difference in rates of HB I-II outcomes whether EOR was GTR or NTR (97.8% vs. 92.5%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.196). HB I-II outcomes were achieved in 100% of Koos I-II and 93.1% of Koos III-IV tumors. There was a trend of decreased GTR and increased NTR with increasing Koos grade I to IV (GTR: 93.75%, 86.2%, 76.9%, 39.5%; NTR: 6.25%, 13.8%, 23.1%, 55.3%, respectively). Postoperative CSF leak rate was 2.7%. Tumor recurrence (3.4%) was lower with GTR than NTR (1.1% vs. 7.5%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.0646).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The subperineural \u201conion-peeling\u201d dissection technique provides a safe, nerve-sparing approach for maximal VS resection while preserving facial nerve function thus achieving excellent onco-functional outcomes. Compared to historical hybrid STR-SRS data, our approach demonstrated favorable facial nerve outcomes with higher EOR, lower tumor recurrence, and less radiation usage.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s11060-026-05755-5","type":"journal-article","created":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T06:43:11Z","timestamp":1787640191000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Subperineural \u2018onion-peeling\u2019 dissection for maximizing extent of resection and facial nerve preservation for onco-functional balance in vestibular schwannoma surgery"],"prefix":"10.1007","volume":"179","author":[{"given":"James K.","family":"Liu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmed","family":"Sabra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yaxel","family":"Levin-Carrion","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caryn J.","family":"Ha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sraavya","family":"Anne","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arevik","family":"Abramyan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vicente","family":"Rojas-Navas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin","family":"Wong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yu-Lan Mary","family":"Ying","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert W.","family":"Jyung","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,8,25]]},"reference":[{"key":"5755_CR1","doi-asserted-by":"publisher","first-page":"331","DOI":"10.1007\/978-3-031-23705-8_12","volume":"1405","author":"V Gerganov","year":"2023","unstructured":"Gerganov V, Petrov M, Sakelarova T (2023) Schwannomas of Brain and Spinal Cord. 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