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Research Original Investigation

Facial Reanimation Procedures Performed With Total Parotidectomy and Facial Nerve Sacrifice

Table 1. Included CPT Codes

No. of Occurrences

Type of Repair CPT Code Code Procedure

Nerve Nerve Nerve Nerve Nerve Nerve Nerve Sling

64716 Neuroplasty with transposition of cranial nerve VII branches

3

64864 Suture of facial nerve; extracranial 64868 Anastomosis; facial-hypoglossal

11

1

64885 Nerve graft (includes obtaining graft), head or neck; ≤4 cm in length 28 64886 Nerve graft (includes obtaining graft), head or neck; >4 cm in length 19 64910 Nerve repair with synthetic conduit (for both repairs) 64727 Internal neurolysis of facial nerve (left) 15840 Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) 15841 Graft for facial nerve paralysis; free muscle graft (including obtaining fascia) 15845 Graft for facial nerve paralysis; regional muscle transfer (eg, temporalis tendon) 67917 Correction of ectropion; extensive (eg, tarsal strip operations) 67912 Correction of lagopthalmus (eyelid weight insertion) 0 0 18 3 5 6 23 15756 Free muscle or myocutaneous flap with microvascular anastomosis 15757 Free skin flap with microvascular anastomosis 15758 Free fascial flap with microvascular anastomosis 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest (rib deleted), metatarsal, or great toe 21 14 10 4 67900 Repair of brow ptosis (direct approach) 5

Sling

Sling

Sling Sling Sling Flap Flap Flap Flap

Abbreviation: CPT , Current Procedural Terminology .

types, P = .30). Mean (SD) ages of the reanimation vs nonre animation groups were not significantly different (64.7 [16.2] vs 64.1 [15.1] years; P = .68). Forty-nine patients (17.2%; 95% CI, 13.0%-22.0%) under went free tissue reconstruction. Of those patients, 24 (49.0%; 95%CI, 36.0%-63.0%) had concurrent facial reanimation pro cedures performed. This proportion is significantly higher ( P = .003) thanamong thepopulationwhodidnot undergo free flap reconstruction, with documented concurrent facial ani mation in 65 of 236 patients (28.0%; 95% CI, 22.0%-34.0%). Discussion This investigation is the first, to our knowledge, to describe the incidence of concurrent facial nerve reanimation proce dures during parotidectomy with facial nerve sacrifice. This study also presents a novel use of the ACS-NSQIP database to explore the association between concurrent procedures in a cross-sectionalmanner. However, this study should be viewed as preliminary owing to the inherent bias and limitations of large databases and should be used to guide further study of facial reanimation procedures after facial nerve sacrifice. We found that fewer than one-third of patients had concurrent fa cial reanimation at the time of nerve sacrifice during paroti dectomy. Patientswhounderwent free flap reconstructionwere significantlymore likely to receive concurrent facial reanima tion than those who did not. Ideally, facial nerve reanimationprocedures shouldbe per formed at the time of the nerve sacrifice during ablative pro cedures. Potential nerve repair would be easiest at the time of nerve transection because subsequent surgery leads to com plications of scarring, repeated general anesthesia, difficulty

Results A total of 285 cases (176men [61.8%] and 109women [38.2%]; mean [SD] age, 64 [15] years) met inclusion criteria. Of these, 188 cases (66.0%) were coded as the principle procedure. Eighty-nine patients (31.2%; 95% CI, 26.0%-37.0%) under went at least 1 concurrent facial reanimation procedure. Of these 89 patients with concurrent facial nerve procedures, 41 (46.1%; 95% CI, 36.0%-56.0%) had nerve repairs, 31 (34.8%; 95%CI, 26.0%-45.0%) underwent sling repairs, and 17 (19.1%; 95% CI, 12.0%-29.0%) had both types of repairs. Whenwe compared all patients undergoing concurrent re animationwith those who did not, no differences were found in sex, race, presence of diabetes, functional health, andAmeri can Society of Anesthesiologists class. The nonreanimation group had a higher incidence of smoking (39 [19.9%] vs 7 [7.9%]; P = .009) compared with the concurrent reanimation group. Most patients were white, but a higher proportion of the reanimation group was white compared with the nonre animation group (75 [84.3%] vs 133 [67.9%]; P = .02). Otolar yngologists were the predominant primary surgeons in both groups, but the nonreanimation group included more gen eral surgeons as primary surgeon compared with the reani mation group (14 [7.1%] vs 0; P = .04) ( Table 2 ). Among those patients receiving concurrent reanimation, those receiving nerve-type procedures only were signifi cantly younger (mean [SD] age, 57.6 [16.0] years) compared with those treatedwith sling-type repairs only (mean [SD] age, 72.1 [13.8] years; P < .001) and those receiving both repairs (mean [SD] age, 67.4 [14.8] years; P = .03). Demographic vari ableswere otherwise not significantly different between those receivingdifferent types of reanimation (sling-typeonlyvs both

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

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