xRead - May 2023

Original Investigation Research

Powering the Gracilis for Facial Reanimation

used to assess study quality, graded independently by 2 authors (P.M.V. and J.J.C.).

Figure 1. Flow Diagram of Studies Through Systematic Review

116 Abstracts identified through computerized and manual search on November 8, 2018

Statistical Analysis Descriptive statisticswere used for studies included in the sys tematic review that were unable to be summarized in meta analysis owing toheterogeneityof outcomemeasures. Random effectsmeta-analyseswere performed toquantifymean excur sionandsymmetrywithsmilingandat restwiththeMNvsCFNG instudies thatusedtheFACEgram. Theeffect sizewas calculated usingthestandardizedmeandifferences incentimeters.All analy ses were performed in Stata statistical software (version 14.1, StataCorp) andMicrosoft Excel (version 15.2, Microsoft). Results The search strategy resulted in 130 unique citations. After ap plying inclusion and exclusion criteria, 10 studies were in cluded in our systematic review (Figure 1). The Table describes the characteristics of the included studies. Eight were retrospective cohort studies, and 2 were case series. The studies came from all over the world, includ ing Italy, Germany, Spain, Taiwan, South Korea, Japan, Bos ton, Massachusetts, and Baltimore, Maryland. Eight studies scored 8 of 9 on the Newcastle-Ottawa scale, and 2 studies scored 7 of 9 on the scale, indicating all studies were of good quality. All studies lost a point in the comparability category because there were no controls and the studies were all retro spective, and 2 studies 13,24 lost another point in the selection category due to including both flaccid and nonflaccid paraly sis patients in their study. Follow-up time ranged from 6 months for patients reanimated with MN, and 12 months for CFNG, to over 40months. One study 23 did not explicitly state length of follow-up. Six studies 7,12,23,25,26,28 were rated as hav ing an unclear risk of bias, 2 studies 11,27 had a low risk of bias, and 1 study 24 had a high risk of bias. The only study 24 with a high risk of bias was rated as such because the outcome as sessment was unblinded and relied entirely on assessment from the surgeon. Because the data used in themeta-analysis came from studies with either low or unclear risk of bias, we do not believe the risk of bias is sufficient to affect the inter pretation of the results (eTable 2 in the Supplement). Excursion and Symmetry All 10 studies examined excursion and symmetry as an out comemeasure. Reportedmeasures included the distance from themidline lower lip to the oral commissure as calculatedwith FACEgram 17 software (4 studies 11,25-27 ); Terzis and Noah grade, 29 a combined aesthetic and functional scale ranging from 1 (poor) to 5 (excellent) based on standard photographic analysis by an observer (4 studies 7,24,26,28 ); FACIAL CLIMA, 10 an automated measurement software program based on in frared photographic analysis (1 study 12 ); distance between the tragionandoral commissureon lateral photography (1 study 10 ); and the Sunnybrook Facial Grading System, 30 a validated scor ing systemused to evaluate symmetry at rest andwithmove ment, as well as synkinesis (1 study 25 ).

116 Abstracts screened

74 Abstracts excluded 23 Review articles

12 Duplicate publications 5 Cadaver studies 4 Revision surgery 3 Bilateral facial paralysis 1 Double paddle gracilis 1 Not English language 13 Did not use gracilis 12 Pediatric studies

42 Full texts screened

33 Full texts excluded 12 Pediatric studies

3 Full text not available 3 Did not separate pediatric and adult data 1 Case report 7 Did not report objective outcome measures 4 Revision surgery

1 Duplicate publication 1 Incomplete paralysis 1 Not original research study

9 Studies included in review, search repeated December 23, 2019

14 Additional full texts screened

13 Full texts excluded 4 Did not separate pediatric and adult data

2 Duplicate data 2 Nonhuman studies

1 Not original research study 1 Case report

10 Studies included in review

3 Studies included in meta-analysis

Because 4 studies 11,25-27 reported outcomes using the FACEgram, we chose to use thismeasure formeta-analysis. Of the 4 studies reporting results, only FACEgram results for MN and CFNG were reported. Unfortunately, 1 study 26 reported combined results for patientswhounderwent eitherMNorMN combined with the CFNG, and was thus excluded from the meta-analysis. Thus, meta-analysis of MN (n = 56) vs CFNG (n = 52) showed no heterogeneity between the 3 studies 11,25,27 ( I 2 = 0%), and excursionwas greaterwith themasseteric nerve (0.55 mm; 95% CI, 0.17-0.94) ( Figure 2 ). Angles of symmetry were only reported in 2 of these studies, 11,25 and thus a meta analysis was performed for these 2 studies with MN (n = 51) vs CFNG (n = 47). Heterogeneitywas low( I 2 = 37.5%at rest, 0% with smiling). Angles of symmetry at rest (−0.14; 95%CI, −0.73 to 0.46) and with smiling (−0.22; 95% CI, −0.62 to 0.18) were better with MN, though the differences were not statistically significant ( Figure 3 ).

(Reprinted) JAMA Otolaryngology–Head & Neck Surgery May 2020 Volume 146, Number 5 431

jamaotolaryngology.com

© 2020 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ on 02/08/2023