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Original Investigation Research

Powering the Gracilis for Facial Reanimation

Figure 3. Meta-analysis of Studies Assessing Facial Symmetry

Favors Cross Facial Nerve

Favors Masseteric Nerve

At rest A

Weight, %

Study

SMD (95% CI)

Bhama et al, 11 2014

0.07 (–0.38 to 0.51)

69.25

Lindsay et al, 25 2014

–0.59 (–1.51 to 0.32)

30.75

Overall a

–0.14 (–0.73 to 0.46)

100

–2

–1

SMD (95% CI) 0

1

2

Favors Cross Facial Nerve

Favors Masseteric Nerve

Smiling B

Weight, %

Study

SMD (95% CI)

Lindsay et al, 25 2014 Bhama et al, 11 2014

–0.13 (–0.58 to 0.32)

80.81

–0.61 (–1.53 to 0.31)

19.19

SMD indicates standardized mean difference. Studies of smile (A) at rest and (B) while smiling after reanimation with gracilis powered by cross-facial nerve graft vs masseteric nerve.

Overall a

–0.22 (–0.62 to 0.18)

100

–2

–1

SMD (95% CI) 0

1

2

fromtheFACEgram. Thoughwewereunable toperformameta analysis onstudies reporting results onsmile spontaneityowing toheterogeneity in reportedoutcomemeasures, 100%of the 10 patients included in this systematic reviewachieved spontane itywithmassetericnerveplusCFNG,whereas fewer thanhalf of the46patientswhounderwentmassetericnervealoneachieved spontaneity.Roughlyonequarterofpatientsunderwent thinning of the flap postoperatively in the 2 studies 24,27 that reported re vision rates. Given that our study includedcase series and retro spective cohort studies, this constitutes level 3a evidence. 32 The 3 major categories of outcome measures reported in the included studies were excursion, symmetry, and sponta neity. Unfortunately, despite calls to standardize reporting of results after facial reanimation surgery, there continue to be disparate outcomemeasures reported in the literature. Otolo gists faced a similar problem in the reporting of hearing out comes after surgery, limiting the ability to perform meta analyses on published data. They addressed that barrier by creating aminimumreporting standard, put forth by theHear ing Committee of the American Academy of Otolaryngology– Head and Neck Surgery, and recommended that researchers publish results inwhatever format they desired, as long as the minimum standard was included. 33 This reporting standard was subsequently endorsed by other major peer-reviewed journals, 34 but not without generating some controversy from the American Academy of Audiology, for example. 35 This was followed by the proposal of a reporting standard formiddle ear implants, 36 suggesting that researchers are benefiting from a minimum reporting standard. A reporting standard has also beenmentioned as amethod to improve the transparency and quality of published research. 37 An analogous standard could be developed for reporting outcomes of facial reanimation sur gery, to allow for better collaboration andmeta-analysis of fu ture studies. This reporting standard could include agreed-on measures of these 3 categories—excursion, symmetry, and spontaneity.

achieved spontaneity with the masseteric nerve. In 2 case series 7,13 including 4 and 6 patientswithmasseteric nerve plus CFNG, 4of 4 (100%) and6of 6patients (100%) achieveda spon taneous smile. Additional Outcome Measures Four studies examined other outcome measures. These mea sures included secondary revision rates for thinning of the gracilis for flap bulkiness (2 studies 24,27 ); the FaCE scale, 31 a validated patient-reported outcome measure focused on fa cial impairment and disability (1 study 14 ); and the compound motor action potential (CMAP), an electromyographic mea sure that allows for quantitative assessment ofmuscle strength (1 study 12 ). Though several studies excluded patients who un derwent secondary revisionof thegracilis flap, the2 studies 23,27 that did report cited a rate ranging from 23% to 29%. Postop erative thinning of the flap, while decreasing excursion, may help improve symmetry in patients with excessive pull. Of the 7 studies 7,11,13,23,24,27,28 that reported flap survival, 213 of 218 flaps survived (97.7%). One study 27 reported 2 infections in 14 flaps, 1 in the face, and 1 in the donor site. Discussion Thissystematicreviewandmeta-analysis included295adultsun dergoing freegracilismuscle transfer for facial reanimation from 10studiesdone around theworld. It is encouraging that all stud ies included in this systematic reviewandmeta-analysiswereof high quality. Unfortunately, the meta-analysis was limited ow ing to the heterogeneity of reporting, whichprecluded our abil ity tomake definitive conclusions regarding the optimal choice ofdonornerve.However, ourmeta-analysisof 3studieswith108 patients showed that excursionmaybe superiorwithmasseteric nerve comparedwithCFNG. Symmetrywas not found tobedif ferent between the2groups in the2 studies reporting angledata

(Reprinted) JAMA Otolaryngology–Head & Neck Surgery May 2020 Volume 146, Number 5 433

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