Key Points
Question
What are the incidence and subtypes of facial nerve reanimation procedures performed concurrently with total parotidectomy and facial nerve sacrifice?
Findings
In this cross-sectional database analysis of 285 patients undergoing total parotidectomy with facial nerve sacrifice, only 89 (31.2%) underwent concurrent facial reanimation procedures of any type.
Meaning
Many patients undergoing total parotidectomy with facial nerve sacrifice are not receiving a concurrent facial reanimation procedure at the time of their resection; this may represent an opportunity for earlier intervention.
This cross-sectional database analysis assesses the incidence and types of facial nerve reanimation performed concurrently with total parotidectomy and facial nerve sacrifice among patients identified in the American College of Surgeons–National Surgical Quality Improvement Project database.
Abstract
Importance
Facial reanimation procedures share the same surgical field as a parotidectomy and are most easily accomplished at the time of facial nerve sacrifice. Early reanimation would also reduce the duration of paralysis and may lead to better functional outcomes.
Objective
To assess the incidence and types of facial nerve reanimation performed concurrently with total parotidectomy and facial nerve sacrifice using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database.
Design, Setting, and Participants
This cross-sectional study identified 285 patients who underwent total parotidectomy with facial nerve sacrifice (Current Procedural Terminology code 42425) and evaluated the various types of facial reanimation procedures performed concurrently. Patients were identified from the ACS-NSQIP database encompassing 603 community and academic hospitals and underwent treatment from January 1, 2010, through December 31, 2015. Data were analyzed from September 20, 2017, through February 21, 2018.
Main Outcomes and Measures
Comparison of demographics in nonreanimation and reanimation groups and subgroups of nerve- and sling-type reanimation procedures.
Results
Of 285 patients who underwent total parotidectomy with facial nerve sacrifice (61.8% men; mean [SD] age, 64 [15] years), 89 (31.2%; 95% CI, 26.0%-37.0%) underwent at least 1 concurrent facial reanimation procedure. Of the facial nerve procedures performed, 41 (46.1%; 95% CI, 36.0%-56.0%) were nerve-type repairs, 31 (34.8%; 95% CI, 26.0%-45.0%) were sling-type repairs, and 17 (19.1%; 95% CI, 12.0%-29.0%) included both types. Patients treated with nerve-type repairs only were significantly younger than those treated with sling-type repairs only (mean [SD] age, 57.6 [16.0] vs 72.1 [13.8] years; P < .001). Forty-nine patients underwent free tissue reconstruction. Of those, 24 patients (49.0%) had concurrent facial reanimation procedure(s) performed; this proportion was significantly more than those who did not undergo free tissue reconstruction (65 of 236 [28.0%]; P = .003).
Conclusions and Relevance
In patients undergoing total parotidectomy with facial nerve sacrifice, many are not receiving a concurrent facial reanimation procedure at the time of their tumor resection. Those patients who underwent free tissue reconstruction were significantly more likely to receive a concurrent facial reanimation procedure. These findings may reveal an opportunity for earlier facial reanimation in this patient population.
Level of Evidence
NA.
Introduction
Ablative surgical procedures of the parotid gland are among the most common causes of iatrogenic facial paralysis. Facial nerve invasion occurs in 7% to 20% of malignant parotid tumors and warrants nerve resection.1,2 Facial nerve reanimation should be performed as early as possible, even concurrently with head and neck ablative surgery. Postoperative radiotherapy and positive nerve margins have been shown to have no significant effect on the outcome of nerve reconstruction.3,4,5 In addition, early reanimation shortens the total duration of paralysis and may yield improved functional results.6,7
Patients with facial paralysis experience a diminished quality of life from functional and psychosocial standpoints. Disruption of emotional expression, impaired communication, and diminished social attractiveness affect overall quality of life.8,9,10,11 Functional issues include poor eye protection, nasal obstruction, difficulty with articulation, and oral incompetence. A myriad of surgical techniques has been developed to treat facial paralysis with the goal of restoring facial symmetry and movement.12 Multiple studies have established significant improvements in quality of life after treatment of facial paralysis.13
Intraoperative facial nerve management during parotidectomy largely hinges on nerve integrity. If the nerve is severed or resected at the time of ablative surgery, then postoperative paralysis can be expected. We sought to assess the incidence and types of facial nerve reanimation procedures performed concurrently with total parotidectomy and facial nerve sacrifice.
Methods
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) provides a large database of patients in which all concurrent surgical procedures are documented in addition to patient characteristics and 30-day postoperative outcomes from January 1, 2010, through December 31, 2015. We reviewed the ACS-NSQIP database to identify encounters for which parotidectomy with facial nerve sacrifice was included as a procedure (principal, concurrent, or other). Cases with Current Procedural Terminology (CPT) code 42425 were included. Deidentified patient information is freely available to all institutional members who comply with the ACS-NSQIP data use agreement. The data use agreement implements the protections afforded by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This study was exempted from approval and informed consent by the institutional review board of the University of Kansas Medical Center, Kansas City.
Patient encounters were identified within the participant use data files of the ACS-NSQIP, which in 2015 included 603 community and academic hospitals throughout the United States, with 273 HIPAA-compliant variables for each case. Trained nurses collect data at participating institutions through systematic sampling of operations performed. Each variable in the database is specifically defined, and data collectors are periodically audited to ensure standardization and accuracy of the content. To ensure a 30-day follow-up period, patients are contacted by letter or telephone survey after discharge. The list and definitions of variables collected in the database can be found at the ACS-NSQIP website (https://www.facs.org/quality-programs/acs-nsqip).
The primary comparison of interest was the proportion of patients who underwent parotidectomy with nerve sacrifice and received 1 or more facial reanimation procedure(s) during the same operation. Among the patients queried with CPT code 42425, all procedure categories (primary, concurrent, and other) were queried for facial reanimation procedures, including CPT codes 64716, 64864, 64868, 64885, 64886, 64910, 65727, 15840, 15841, 15845, 67917, 67912, and 67900 (Table 1). Patients receiving these reanimation procedures were separated into the following 3 categories: nerve-type repairs, nonnerve or sling-type repairs, and both types. We designated CPT codes 64716, 64864, 64868, 64885, 64886, 64910, and 65727 as nerve-type repairs and CPT codes 65727, 15840, 15841, 15845, 67917, 67912, and 67900 as sling-type repairs. Nerve-type repairs were those involving nerve repair or nerve transfer to reanimate native facial musculature. Sling-type procedures predominantly encompassed static procedures and regional muscle transfers. Although regional muscle transfers, such as the orthodromic temporalis tendon transfer, may also provide dynamic movement, their principal function is as a facial sling. In addition, those patients who underwent concurrent free tissue transfer were identified using CPT codes 15756, 15757, 15758, and 20969.
Table 1. Included CPT Codes.
| Type of Repair | CPT Code | Code Procedure | No. of Occurrences |
|---|---|---|---|
| Nerve | 64716 | Neuroplasty with transposition of cranial nerve VII branches | 3 |
| Nerve | 64864 | Suture of facial nerve; extracranial | 11 |
| Nerve | 64868 | Anastomosis; facial-hypoglossal | 1 |
| Nerve | 64885 | Nerve graft (includes obtaining graft), head or neck; ≤4 cm in length | 28 |
| Nerve | 64886 | Nerve graft (includes obtaining graft), head or neck; >4 cm in length | 19 |
| Nerve | 64910 | Nerve repair with synthetic conduit (for both repairs) | 0 |
| Nerve | 64727 | Internal neurolysis of facial nerve (left) | 0 |
| Sling | 15840 | Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) | 18 |
| Sling | 15841 | Graft for facial nerve paralysis; free muscle graft (including obtaining fascia) | 3 |
| Sling | 15845 | Graft for facial nerve paralysis; regional muscle transfer (eg, temporalis tendon) | 5 |
| Sling | 67917 | Correction of ectropion; extensive (eg, tarsal strip operations) | 6 |
| Sling | 67912 | Correction of lagopthalmus (eyelid weight insertion) | 23 |
| Sling | 67900 | Repair of brow ptosis (direct approach) | 5 |
| Flap | 15756 | Free muscle or myocutaneous flap with microvascular anastomosis | 21 |
| Flap | 15757 | Free skin flap with microvascular anastomosis | 14 |
| Flap | 15758 | Free fascial flap with microvascular anastomosis | 10 |
| Flap | 20969 | Free osteocutaneous flap with microvascular anastomosis; other than iliac crest (rib deleted), metatarsal, or great toe | 4 |
Abbreviation: CPT, Current Procedural Terminology.
Data were analyzed from September 20, 2017, through February 21, 2018. Categorical and continuous variables were compared using Pearson χ2 and Mann-Whitney tests, respectively. Where appropriate, data were given 95% CIs using the modified Wald method. Statistical tests were run using SPSS software for Windows (version 21.0; IBM Corp). Demographic data compared included sex, race, age, surgical subspecialty, diabetes status, smoking status, functional health status before surgery, and American Society of Anesthesiologists class. Race was reclassified as white, black, and other. Diabetes was reclassified into present or absent. Two-tailed significance was set at α = .01 to limit type I errors due to multiplicity.
Results
A total of 285 cases (176 men [61.8%] and 109 women [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%) underwent 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.
When we compared all patients undergoing concurrent reanimation with those who did not, no differences were found in sex, race, presence of diabetes, functional health, and American 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 nonreanimation group (75 [84.3%] vs 133 [67.9%]; P = .02). Otolaryngologists were the predominant primary surgeons in both groups, but the nonreanimation group included more general surgeons as primary surgeon compared with the reanimation group (14 [7.1%] vs 0; P = .04) (Table 2).
Table 2. Categorical Demographic Dataa.
| Characteristic | Reanimation Group by Repair Type | P Value | Nonreanimation Group (n = 196) | P Value | |||
|---|---|---|---|---|---|---|---|
| Nerve (n = 41) | Sling (n = 31) | Both (n = 17) | All (n = 89) | ||||
| Sex, No. (%) | |||||||
| Male | 20 (48.8) | 22 (71.0) | 12 (70.6) | 54 (60.7) | .10 | 122 (62.2) | .79 |
| Female | 21 (51.2) | 9 (29.0) | 5 (29.4) | 35 (39.3) | 74 (37.8) | ||
| Race, No. (%) | |||||||
| White | 31 (75.6) | 28 (90.3) | 16 (94.1) | 75 (84.3) | .13 | 133 (67.9) | .02 |
| Black | 1 (2.4) | 0 | 1 (5.9) | 2 (2.2) | 10 (5.1) | ||
| Other | 9 (22.0) | 3 (9.7) | 0 | 12 (13.5) | 53 (27.0) | ||
| Surgeon specialty, No. (%) | |||||||
| ENT | 40 (97.6) | 30 (96.8) | 17 (100) | 87 (97.8) | .55 | 175 (89.3) | .04 |
| Neurosurgery | 0 | 1 (3.2) | 0 | 1 (1.1) | 1 (0.5) | ||
| Plastics | 1 (2.4) | 0 | 0 | 1 (1.1) | 6 (3.1) | ||
| General surgery | 0 | 0 | 0 | 0 | 14 (7.1) | ||
| Diabetes present, No. (%) | |||||||
| Yes | 4 (9.8) | 3 (9.7) | 0 | 7 (7.9) | .80 | 33 (16.8) | .18 |
| No | 37 (90.2) | 28 (90.3) | 17 (100) | 82 (92.1) | 163 (83.2) | ||
| Smoking status | |||||||
| Yes | 3 (7.3) | 2 (6.4) | 2 (11.8) | 7 (7.9) | .80 | 39 (19.9) | .009 |
| No | 38 (92.7) | 29 (93.5) | 15 (88.2) | 82 (92.1) | 157 (80.1) | ||
| Functional health | |||||||
| Independent | 40 (97.6) | 31 (100) | 16 (94.1) | 87 (97.8) | .24 | 192 (98.0) | .54 |
| Partially dependent | 1 (2.4) | 0 | 1 (5.9) | 2 (2.2) | 4 (2.0) | ||
| ASA classb | |||||||
| I | 1 (2.4) | 1 (3.2) | 0 | 2 (2.2) | .57 | 13 (6.6) | .21 |
| II | 15 (36.6) | 5 (16.1) | 6 (35.3) | 26 (29.2) | 64 (32.7) | ||
| III | 24 (58.5) | 24 (77.4) | 11 (64.7) | 59 (66.3) | 107 (54.6) | ||
| IV | 1 (2.4) | 1 (3.2) | 0 | 2 (2.2) | 11 (5.6) | ||
Abbreviations: ASA, American Society of Anesthesiologists class; ENT, ear, nose, and throat.
Percentages have been rounded and may not total 100.
I indicates healthy patient; IV, severe systemic disease. One case in the data set was labeled ASA class not assigned.
Among those patients receiving concurrent reanimation, those receiving nerve-type procedures only were significantly younger (mean [SD] age, 57.6 [16.0] years) compared with those treated with 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 variables were otherwise not significantly different between those receiving different types of reanimation (sling-type only vs both types, P = .30). Mean (SD) ages of the reanimation vs nonreanimation 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%) underwent free tissue reconstruction. Of those patients, 24 (49.0%; 95% CI, 36.0%-63.0%) had concurrent facial reanimation procedures performed. This proportion is significantly higher (P = .003) than among the population who did not undergo free flap reconstruction, with documented concurrent facial animation 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 procedures 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-sectional manner. 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 facial reanimation at the time of nerve sacrifice during parotidectomy. Patients who underwent free flap reconstruction were significantly more likely to receive concurrent facial reanimation than those who did not.
Ideally, facial nerve reanimation procedures should be performed at the time of the nerve sacrifice during ablative procedures. Potential nerve repair would be easiest at the time of nerve transection because subsequent surgery leads to complications of scarring, repeated general anesthesia, difficulty identifying nerve endings, and potential compromise of microvascular flap when performed.14 Wallerian degeneration also sets in within 72 hours and eliminates the option of nerve stimulation to identify functional movement of distal nerve branches. Static procedures and regional muscle transfers (eg, temporalis tendon and masseter muscle transfer) also share the same surgical field as parotidectomy and are amenable to concurrent repair. Free flap reconstruction of radical parotidectomy defects have been described in combination with static and dynamic facial rehabilitation to achieve dynamic movement and improvement in patient disfigurement scales.15,16,17,18 Early eyelid loading has been shown to prevent the sequelae of paralytic lagophthalmos and does not show an increased rate of complication.19,20,21 Some evidence exists in the literature on the utility of immediate facial reanimation procedures at the time of facial nerve sacrifice. In a retrospective study, Yawn et al6 found that acute hypoglossal-facial anastomosis repair was associated with a 4.97-fold greater odds of achieving a House-Brackmann grade of 3 or less. Ultimately, the decision to perform concurrent reanimation may vary on a case-by-case basis but should include consideration of patient factors, such as extent of nerve sacrifice, risk of prolonged anesthetic time, and disease prognosis.
The availability of a reconstructive surgeon comfortable with facial reanimation procedures is another consideration. Those patients receiving free tissue reconstruction were significantly more likely to receive a facial rehabilitation procedure, and a 2-team approach is often used in these reconstructive cases. The team performing free tissue reconstruction may also routinely perform facial nerve rehabilitation and have an increased comfort level with these procedures. Availability of a reconstructive surgeon familiar with facial rehabilitation may dictate whether the patient undergoes concurrent rehabilitation. Otolaryngologists performed most of the concurrent reanimation procedures during parotidectomy with facial nerve sacrifice. This situation may be associated with otolaryngologists’ comfort in areas of ablative parotidectomy surgery as well as facial reanimation. In addition, at most institutions, otolaryngologists perform reconstruction after oncologic surgery of the head and neck.
Those patients receiving nerve-type repairs only were younger than those receiving sling-type procedures. Unmeasured patient factors such as extent of disease, risk of prolonged general anesthetic, and patient prognosis, may contribute to intraoperative decision making. We found a statistically significant difference in smoking status between those receiving and not receiving concurrent reanimation. We hypothesize that this difference is owing to an association between smoking status and overall patient health rather than a true causative factor in deciding to perform concurrent reanimation procedures.
Facial paralysis is known to cause morbidity to patients in the form of functional losses, societal isolation, and depression. Early reanimation can minimize the morbidity experienced 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 occurring 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 occurring during parotidectomy with facial nerve sacrifice. Further multi-institutional studies are needed to investigate the incidence of reanimation procedures among a wider variety of ablative procedures and to establish the cost-effectiveness of concurrent 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 database. First, the variables collected by the database limit our analysis because of selection bias. The database was not specifically designed to detect the incidence of concurrent facial nerve reanimation procedures, although it was designed to capture all concurrent procedures performed within the same surgical procedure. The variables collected do not allow us to identify all head and neck cases in which facial nerve sacrifice might have occurred. However, we sought to isolate a subset of patients in which facial nerve sacrifice definitely occurred through their CPT code (42425 [parotidectomy with facial nerve sacrifice]) and evaluate what percentage of this group received a concurrent reanimation procedure. This group is not representative of all instances of facial nerve sacrifice (such as during neuro-otologic surgery or skull base resections); the rate of reanimation may 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 sacrifice was performed during temporal bone resection or lateral skull base surgery.
In addition, the CPT code for facial nerve sacrifice with parotidectomy does not specify the extent of facial nerve sacrifice. A subset of patients may have undergone distal nerve sacrifice that does not necessitate reanimation procedures. Similarly, patients who undergo parotidectomy with partial sacrifice of the facial nerve (eg, lower division) may have their surgery billed as excision of parotid tumor with dissection and preservation of facial nerve (CPT code 42415). Although these patients might benefit from animation 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 status 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 procedures. 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 procedures, so we are unable to reliably record subsequent reanimation procedures that are not performed concurrently with facial nerve sacrifice. At least some of the patients likely underwent some type of reanimation procedure under local anesthetic after surgery or a planned second procedure in the immediate 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 simply describe those patients receiving concurrent procedures during the same surgical procedure as facial nerve sacrifice.
The ACS-NSQIP is not a population-based data set; therefore, our findings are not representative of the incidence of concurrent reanimation procedures in the general population. However, the ACS-NSQIP captures 32% of surgical procedures performed nationally and therefore provides a useful estimate 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 reanimation procedure at the time of tumor ablation. Those patients undergoing a free flap procedure were significantly more 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 rehabilitation in this patient population. Further investigation is warranted.
References
- 1.Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2807 patients. Head Neck Surg. 1986;8(3):177-184. doi: 10.1002/hed.2890080309 [DOI] [PubMed] [Google Scholar]
- 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 [DOI] [PubMed] [Google Scholar]
- 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 [DOI] [PubMed] [Google Scholar]
- 4.Hontanilla B, Qiu SS, Marré D. Effect of postoperative brachytherapy and external beam radiotherapy on functional outcomes of immediate facial nerve repair after radical parotidectomy. Head Neck. 2014;36(1):113-119. doi: 10.1002/hed.23276 [DOI] [PubMed] [Google Scholar]
- 5.Wax MK, Kaylie DM. Does a positive neural margin affect outcome in facial nerve grafting? Head Neck. 2007;29(6):546-549. doi: 10.1002/hed.20562 [DOI] [PubMed] [Google Scholar]
- 6.Yawn RJ, Wright HV, Francis DO, Stephan S, Bennett ML. Facial nerve repair after operative injury: impact of timing on hypoglossal-facial nerve graft outcomes. Am J Otolaryngol. 2016;37(6):493-496. doi: 10.1016/j.amjoto.2016.05.001 [DOI] [PubMed] [Google Scholar]
- 7.Albathi M, Oyer S, Ishii LE, Byrne P, Ishii M, Boahene KO. Early nerve grafting for facial paralysis after cerebellopontine angle tumor resection with preserved facial nerve continuity. JAMA Facial Plast Surg. 2016;18(1):54-60. doi: 10.1001/jamafacial.2015.1558 [DOI] [PubMed] [Google Scholar]
- 8.Coulson SE, O’Dwyer NJ, Adams RD, Croxson GR. Expression of emotion and quality of life after facial nerve paralysis. Otol Neurotol. 2004;25(6):1014-1019. doi: 10.1097/00129492-200411000-00026 [DOI] [PubMed] [Google Scholar]
- 9.Ishii L, Godoy A, Encarnacion CO, Byrne PJ, Boahene KD, Ishii M. Not just another face in the crowd: society’s perceptions of facial paralysis. Laryngoscope. 2012;122(3):533-538. doi: 10.1002/lary.22481 [DOI] [PubMed] [Google Scholar]
- 10.Leong SC, Lesser TH. A national survey of facial paralysis on the quality of life of patients with acoustic neuroma. Otol Neurotol. 2015;36(3):503-509. doi: 10.1097/MAO.0000000000000428 [DOI] [PubMed] [Google Scholar]
- 11.Kleiss IJ, Hohman MH, Susarla SM, Marres HA, Hadlock TA. Health-related quality of life in 794 patients with a peripheral facial palsy using the FaCE Scale: a retrospective cohort study. Clin Otolaryngol. 2015;40(6):651-656. doi: 10.1111/coa.12434 [DOI] [PubMed] [Google Scholar]
- 12.Sahovaler A, Yeh D, Yoo J. Primary facial reanimation in head and neck cancer. Oral Oncol. 2017;74:171-180. doi: 10.1016/j.oraloncology.2017.08.013 [DOI] [PubMed] [Google Scholar]
- 13.Guntinas-Lichius O, Straesser A, Streppel M. Quality of life after facial nerve repair. Laryngoscope. 2007;117(3):421-426. doi: 10.1097/MLG.0b013e31802d83df [DOI] [PubMed] [Google Scholar]
- 14.Owusu JA, Truong L, Kim JC. Facial nerve reconstruction with concurrent masseteric nerve transfer and cable grafting. JAMA Facial Plast Surg. 2016;18(5):335-339. doi: 10.1001/jamafacial.2016.0345 [DOI] [PubMed] [Google Scholar]
- 15.Yla-Kotola T, Goldstein DP, Hofer SO, et al. Facial nerve reconstruction and facial disfigurement after radical parotidectomy. J Reconstr Microsurg. 2015;31(4):313-318. doi: 10.1055/s-0035-1544227 [DOI] [PubMed] [Google Scholar]
- 16.Chong LS, Eviston TJ, Ashford B, Ebrahami A, Clark JR. Single innervated segmented vastus lateralis for midfacial reanimation during radical parotidectomy. Head Neck. 2017;39(3):602-604. doi: 10.1002/hed.24668 [DOI] [PubMed] [Google Scholar]
- 17.Cristóbal L, Linder S, Lopez B, Mani M, Rodríguez-Lorenzo A. Free anterolateral thigh flap and masseter nerve transfer for reconstruction of extensive periauricular defects: surgical technique and clinical outcomes. Microsurgery. 2017;37(6):479-486. doi: 10.1002/micr.30086 [DOI] [PubMed] [Google Scholar]
- 18.Revenaugh PC, Knott PD, Scharpf J, Fritz MA. Simultaneous anterolateral thigh flap and temporalis tendon transfer to optimize facial form and function after radical parotidectomy. Arch Facial Plast Surg. 2012;14(2):104-109. doi: 10.1001/archfacial.2011.1263 [DOI] [PubMed] [Google Scholar]
- 19.Snyder MC, Johnson PJ, Moore GF, Ogren FP. Early versus late gold weight implantation for rehabilitation of the paralyzed eyelid. Laryngoscope. 2001;111(12):2109-2113. doi: 10.1097/00005537-200112000-00005 [DOI] [PubMed] [Google Scholar]
- 20.Linder TE, Pike VE, Linstrom CJ. Early eyelid rehabilitation in facial nerve paralysis. Laryngoscope. 1996;106(9, pt 1):1115-1118. doi: 10.1097/00005537-199609000-00014 [DOI] [PubMed] [Google Scholar]
- 21.Joseph SS, Joseph AW, Smith JI, Niziol LM, Musch DC, Nelson CC. Evaluation of patients with facial palsy and ophthalmic sequelae: a 23-year retrospective review. Ophthalmic Epidemiol. 2017;24(5):341-345. doi: 10.1080/09286586.2017.1294186 [DOI] [PubMed] [Google Scholar]