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Original Investigation Research

Facial Reanimation Procedures Performed With Total Parotidectomy and Facial Nerve Sacrifice

A blative surgical procedures of the parotid gland are among themost common causes of iatrogenic facial pa ralysis. Facial nerve invasion occurs in 7% to 20% of malignant parotid tumors andwarrants nerve resection. 1,2 Fa cial nerve reanimation should be performed as early as pos sible, even concurrently with head and neck ablative surgery. Postoperative radiotherapy and positive nerve margins have been shown to have no significant effect on the outcome of nerve reconstruction. 3-5 In addition, early reanimation short ens the total durationof paralysis andmayyield improved func tional results. 6,7 Patientswith facial paralysis experience adiminishedqual ity of life from functional and psychosocial standpoints. Dis ruption of emotional expression, impaired communication, and diminished social attractiveness affect overall quality of life. 8-11 Functional issues include poor eye protection, nasal ob struction, difficulty with articulation, and oral incompe tence. Amyriad of surgical techniques has been developed to treat facial paralysis with the goal of restoring facial symme try and movement. 12 Multiple studies have established sig nificant improvements in quality of life after treatment of fa cial paralysis. 13 Intraoperative facial nerve management during paroti dectomy largely hinges on nerve integrity. If the nerve is sev ered or resected at the time of ablative surgery, then postop erative paralysis can be expected. We sought to assess the incidence and types of facial nerve reanimationprocedures per formed concurrentlywith total parotidectomy and facial nerve sacrifice. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) provides a large data base of patients in which all concurrent surgical procedures are documented in addition to patient characteristics and 30 daypostoperative outcomes fromJanuary 1, 2010, throughDe cember 31, 2015.We reviewed theACS-NSQIPdatabase to iden tify encounters for which parotidectomy with facial nerve sacrifice was included as a procedure (principal, concurrent, or other). Cases with Current Procedural Terminology ( CPT ) code 42425 were included. Deidentified patient information is freely available to all institutionalmemberswho complywith the ACS-NSQIP data use agreement. The data use agreement implements the protections afforded by the Health Insur ance Portability and Accountability Act (HIPAA) of 1996. This study was exempted from approval and informed consent by the institutional reviewboardof theUniversityof KansasMedi cal Center, Kansas City. Patient encounters were identifiedwithin the participant use data files of the ACS-NSQIP, which in 2015 included 603 community and academic hospitals throughout the United States, with 273 HIPAA-compliant variables for each case. Trainednurses collect data at participating institutions through systematic sampling of operations performed. Each variable in the database is specifically defined, and data collectors are periodically audited to ensure standardization and accuracy

of the content. To ensure a 30-day follow-up period, patients are contactedby letter or telephone survey after discharge. The list and definitions of variables collected in the database can be found at the ACS-NSQIP website (https://www.facs.org/ quality-programs/acs-nsqip). The primary comparison of interest was the proportion of patients who underwent parotidectomy with nerve sacrifice and received 1 or more facial reanimation procedure(s) dur ing the same operation. Among the patients queriedwith CPT code 42425, all procedure categories (primary, concurrent, and other) were queried for facial reanimation procedures, includ ing CPT codes 64716, 64864, 64868, 64885, 64886, 64910, 65727, 15840, 15841, 15845, 67917, 67912, and 67900 ( Table 1 ). Patients receiving these reanimation procedures were sepa rated into the following 3 categories: nerve-type repairs, non nerve or sling-type repairs, and both types.We designated CPT codes 64716, 64864, 64868, 64885, 64886, 64910, and 65727 as nerve-type repairs and CPT codes 65727, 15840, 15841, 15845, 67917, 67912, and 67900 as sling-type repairs. Nerve type repairs were those involving nerve repair or nerve trans fer to reanimate native facial musculature. Sling-type proce dures predominantly encompassed static procedures and regional muscle transfers. Although regional muscle trans fers, such as the orthodromic temporalis tendon transfer, may also provide dynamic movement, their principal function is as a facial sling. Inaddition, thosepatientswhounderwent con current free tissue transfer were identified using CPT codes 15756, 15757, 15758, and 20969. Datawere analyzed fromSeptember 20, 2017, throughFeb ruary 21, 2018. Categorical and continuous variableswere com pared using Pearson χ 2 and Mann-Whitney tests, respec tively. Where appropriate, data were given 95% CIs using the modified Wald method. Statistical tests were run using SPSS software for Windows (version 21.0; IBM Corp). Demo graphic data compared included sex, race, age, surgical sub specialty, diabetes status, smoking status, functional health status before surgery, and American Society of Anesthesiolo gists class. Racewas reclassified aswhite, black, andother. Dia betes was reclassified into present or absent. Two-tailed significance was set at α = .01 to limit type I errors due to multiplicity. Key Points Question What are the incidence and subtypes of facial nerve reanimation procedures performed concurrently with total parotidectomy and facial nerve sacrifice? Findings In this cross-sectional database analysis of 285 patients undergoing total parotidectomy with facial nerve sacrifice, only 89 (31.2%) underwent concurrent facial reanimation procedures of any type. Meaning Many patients undergoing total parotidectomy with facial nerve sacrifice are not receiving a concurrent facial reanimation procedure at the time of their resection; this may represent an opportunity for earlier intervention.

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(Reprinted) JAMA Facial Plastic Surgery January/February 2019 Volume 21, Number 1

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