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Research Original Investigation

Facial Reanimation Procedures Performed With Total Parotidectomy and Facial Nerve Sacrifice

rifice of the facial nerve (eg, lower division)may have their sur gery billed as excision of parotid tumor with dissection and preservation of facial nerve ( CPT code 42415). Although these patientsmight benefit fromanimation procedures, their cases would not be captured by this study because of the inherent limitations of retrospective databases. Furthermore, not all cases are amenable to nerve-type procedures owing to the sta tus of the proximal or distal facial nerve branches. The ACS NSQIP database does not provide specific information on the extent of nerve resection to allow determination of whether individual patients are candidates for nerve-type proce dures. The breakdown on types of reanimation procedures in the data serve as a description, but no further conclusions can be drawn regarding nerve sacrifice and choice of reconstruction. The ACS-NSQIP does not link planned subsequent proce dures, so we are unable to reliably record subsequent reani mation procedures that are not performed concurrently with facial nerve sacrifice. At least some of the patients likely un derwent some type of reanimation procedure under local an esthetic after surgery or a planned second procedure in the im mediate postoperative period. Thus, the percentage of patients undergoing facial rehabilitation at some point during their care is likely larger than what we reported. The data presented herein simplydescribe thosepatients receiving concurrent pro cedures during the same surgical procedure as facial nerve sacrifice. The ACS-NSQIP is not a population-based data set; there fore, our findings arenot representativeof the incidenceof con current reanimation procedures in the general population. However, the ACS-NSQIP captures 32% of surgical proce dures performednationally and therefore provides a useful es timate of the frequency with which concurrent reanimation procedures are being performed using a large data set. Conclusions In patients undergoing total parotidectomy with facial nerve sacrifice, most are not receiving a concurrent facial reanima tion procedure at the time of tumor ablation. Those patients undergoing a free flapprocedurewere significantlymore likely to receive a concurrent facial reanimation procedure. These findings are limited by available data but may reveal an opportunity to intervene earlier with facial nerve rehabilita tion in this patient population. Further investigation is warranted.

those receiving and not receiving concurrent reanimation.We hypothesize that this difference is owing to an association be tween smoking status and overall patient health rather than a true causative factor in deciding to performconcurrent reani mation procedures. Facial paralysis is known to cause morbidity to patients in the form of functional losses, societal isolation, and depres sion. Early reanimation can minimize the morbidity experi enced by patients with paralysis by decreasing the duration of total facial paralysis. This study provides preliminary data for understanding the incidence of facial nerve rehabilitation oc curring concurrently with surgical ablation. The data from the ACS-NSQIP database provide a rough estimate of the number and types of concurrent facial reanimation procedures occur ring during parotidectomy with facial nerve sacrifice. Further multi-institutional studies are needed to investigate the inci dence of reanimation procedures among a wider variety of ab lativeprocedures and to establish the cost-effectiveness of con current reanimation vs delayed reanimation procedures. Limitations The conclusions of this study are limited by the inherent flaws with cross-sectional analysis of a large national patient data base. First, the variables collected by the database limit our analysis because of selection bias. The database was not spe cifically designed to detect the incidence of concurrent facial nerve reanimationprocedures, although itwasdesigned tocap ture all concurrent procedures performedwithin the same sur gical procedure. The variables collecteddonot allowus to iden tify all headandneck cases inwhich facial nerve sacrificemight have occurred. However, we sought to isolate a subset of pa tients inwhich facial nerve sacrificedefinitelyoccurred through their CPT code (42425 [parotidectomy with facial nerve sac rifice]) and evaluate what percentage of this group received a concurrent reanimation procedure. This group is not repre sentative of all instances of facial nerve sacrifice (such as dur ing neuro-otologic surgery or skull base resections); the rate of reanimationmay differ in other subgroups of patients who undergo facial nerve sacrifice. Unfortunately, the limitations of the CPT system do not allow for determination of whether facial nerve sacrificewas performed during temporal bone re section or lateral skull base surgery. In addition, the CPT code for facial nerve sacrificewith pa rotidectomy does not specify the extent of facial nerve sacri fice. A subset of patientsmay have undergone distal nerve sac rifice that does not necessitate reanimation procedures. Similarly, patientswhoundergoparotidectomywithpartial sac

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ARTICLE INFORMATION Accepted for Publication: July 1, 2018. Published Online: September 20, 2018. doi:10.1001/jamafacial.2018.1057

Surg . 1986;8(3):177-184. doi:10.1002/hed. 2890080309

Drafting of the manuscript: Lu. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Villwock. Supervision: Kriet, Bur. Conflict of Interest Disclosures: None reported. REFERENCES 1 . Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2807 patients. Head Neck

2 . Zbären P, Schüpbach J, Nuyens M, Stauffer E, Greiner R, Häusler R. Carcinoma of the parotid gland. Am J Surg . 2003;186(1):57-62. doi:10.1016/ S0002-9610(03)00105-3 3 . Reddy PG, Arden RL, Mathog RH. Facial nerve rehabilitation after radical parotidectomy. Laryngoscope . 1999;109(6):894-899. doi:10.1097/ 00005537-199906000-00010

Author Contributions: Dr Lu had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Lu, Bur. Acquisition, analysis, or interpretation of data: All authors.

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

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