Determining the outcomes of unilateral mid-facial reanimation: a proposed classification and systematic review
Jonathan I Leckenby, MD, PhD1,2, Victoria SM Driesman, BS3, Jessica Forman, BS, MD3, David Milek, MD1 and Adriaan Grobbelaar, MB ChB, FRCS(Plast)4, 1University of Rochester Medical Center, Rochester, NY, 2Great Ormond Street Hospital for Children, London, London, United Kingdom, 3University of Rochester, Rochester, NY, 4Inselspital, Bern, Switzerland
Background: Reanimation of the chronically unilateral paralyzed faced is a complex surgical niche that continues to evolve. Traditionally, the gold-standard treatment has been considered a two-stage free functional muscle transfer. However, there are a multitude of alternative procedures that have emerged that entail nerve grafting, nerve transfers, local muscle transfers, as well as FFMTs powered by a selection of nerve donors. The purpose of this study is to complete a systematic review of reanimation techniques and report their outcomes to provide a better understanding of the outcomes yielded by each modality of surgery.
Methods: A PubMed, EMBASE, Web of Science and Cochrane database search was completed in accordance with PRISMA guidelines. Peer-reviewed studies published between the first reported facial reanimation by Harii in 1976 and 2023. The inclusion criteria were: unilateral facial paralysis, more than 4 months duration of facial paralysis, pre- and post-surgical documentation of outcomes, and a minimum of a 1-year post-operative follow-up. Studies not written in English, cadaveric studies, and animal studies were excluded. Statistical analyses were completed for studies reporting House-Brackmann scores (n=XXX) and Terzis scores (n=XXX). All studies were converted to a 100-point modified scale to enable comparison of outcomes.
Results: Our initial search yielded 3419 studies of which 42 met the inclusion criteria for this study. A total of 1339 patients were included in our analysis. Patients were separated into three general classifications, which were further sub-divided (Figure 1): 1) nerve transfers (NT), 2) local muscle transfers (LMT), and 3) free functional muscle transfers (FFMT). 394 patients underwent NTs (Mean age 43.3 years, SD 7.6), no studies met the inclusion criteria for LCM, and 945 underwent FFMTs (Mean age 33.0, SD 9.7); patients undertaking FFMT were significantly younger (p=0.0021). Overall, all facial reanimation surgeries improved by a standard mean difference (SMD) of 5.76 with a 95% Confidence Interval (CI) of 4.44 – 7.08. When comparing each classification, there was no significant difference however, a single-stage FFMT using the masseteric nerve as the donor trended towards yielding the best result (Figure 2).
Conclusions: This study failed to demonstrate which reanimation procedure yielded the best outcome. This is most likely due to the heterogenous patient population. The presented classification may facilitate future comparative analysis between institutions; however, it is clear the community needs to adopt a standardized reporting metric.
FP Classification with legend.jpg
Picture1.png
Back to 2024 ePosters