Donor nerve selection in free gracilis muscle transfer for facial reanimation. A systematic review and meta-analysis of clinical outcomes

K Can Bayezid; Marek Joukal; Erdem Karabulut; Jan Macek; Ludmila Moravcová; Libor Streit

doi:10.1016/j.bjps.2023.04.014

Donor nerve selection in free gracilis muscle transfer for facial reanimation. A systematic review and meta-analysis of clinical outcomes

J Plast Reconstr Aesthet Surg. 2023 Jul:82:31-47. doi: 10.1016/j.bjps.2023.04.014. Epub 2023 Apr 18.

Authors

K Can Bayezid¹, Marek Joukal², Erdem Karabulut³, Jan Macek¹, Ludmila Moravcová⁴, Libor Streit⁵

Affiliations

¹ Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
² Department of Anatomy, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
³ Department of Biostatistics, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
⁴ Masaryk University Campus Library, Masaryk University, Brno, Czech Republic.
⁵ Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic. Electronic address: libor.streit@med.muni.cz.

PMID: 37148809
DOI: 10.1016/j.bjps.2023.04.014

Abstract

Background: One of the critical factors in facial reanimation is selecting the donor nerve. The most favored neurotizers are the contralateral facial nerve with a cross-face nerve graft (CFNG) and motor nerve to the masseter (MNM). A relatively new dual innervation (DI) method has shown successful results. This study aimed to compare the clinical outcomes of different neurotization strategies for free gracilis muscle transfer (FGMT).

Methods: The Scopus and WoS databases were queried with 21 keywords. Three-stage article selection was performed for the systematic review. Articles presenting quantitative data for commissure excursion and facial symmetry were included in meta-analysis, using random-effects model. ROBINS-I tool and Newcastle-Ottawa scale were used to assess bias and study quality.

Results: One hundred forty-seven articles containing FGMT were systematically reviewed. Most studies indicated CFNG as the first choice. MNM was primarily indicated in bilateral palsy and in elderly. Clinical outcomes of DI studies were promising. 13 studies including 435 observations (179 CFNG, 182 MNM, 74 DI) were eligible for meta-analysis. The mean change in commissure excursion was 7.15 mm (95% CI: 4.57-9.72) for CFNG, 8.46 mm (95% CI: 6.86-10.06) for MNM, and 5.18 mm (95% CI: 4.01-6.34) for DI. In pairwise comparisons, a significant difference was found between MNM and DI (p = 0.0011), despite the superior outcomes described in DI studies. No statistically significant difference was found in resting and smile symmetry (p = 0.625, p = 0.780).

Conclusions: CFNG is the most preferred neurotizer, and MNM is a reliable second option. Outcomes of DI studies are promising, but more comparison studies are needed to draw conclusions. Our meta-analysis was limited by incompatibility of the assessment scales. Consensus on a standardized assessment system would add value to future studies.

Keywords: Dual innervated free gracilis flap; Facial palsy; Facial reanimation; Free gracilis muscle transfer.

Publication types

Meta-Analysis
Systematic Review
Review
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Facial Expression
Facial Paralysis* / surgery
Gracilis Muscle* / transplantation
Humans
Plastic Surgery Procedures*
Smiling / physiology