Extratemporal Facial Nerve Interconnections and Trunk's Variability: A Systematic Review with Meta-Analysis

Abstract

Background: The present systematic review with meta-analysis is a significant contribution to the understanding of the morphological variability of the facial nerve (FN) extratemporal segment, i.e., the facial trunk (FT) variability, its division, and terminal branching patterns. The study also provides a comprehensive overview of the clinical significance of the FN extracranial division.

Methods: Four online databases were utilized to conduct the systematic review according to evidence-based anatomy guidelines. A meta-analysis of the studies included was carried out using R programming software. The combined prevalence of the FN variants was calculated, along with subgroup and cumulative analysis.

Results: From the systematic review, 29 studies were retrieved as eligible for our initial purpose. However, 19 studies followed the same classification system and were selected for the meta-analysis, with a total sample of 2453 nerves. The most common pattern of the FN morphology was the FT bifurcation (typical pattern), with a pooled prevalence of 94.1% and a single interconnection (IC) between the temporofacial and cervicofacial branches (23.1% pooled prevalence). Two ICs between these branches were the rarest pattern (8.9% pooled prevalence).

Conclusions: Our findings underscore the extensive morphological variability of the FN extratemporal anatomy, which has led to confusion among researchers. While several classification systems have been developed, none accurately represent the typical and variant anatomy. Our meta-analysis provided a small range between 8.9-23.1% for the rarest and most common pattern; thus, diversity is the rule. Therefore, it is not safe to conclude the typical morphology of FN extratemporal anatomy for its whole distribution before the FT's division (proximally) and its terminal branches (distally). Nevertheless, the bifurcation of the FT can be considered the typical morphology, and it is far more constant than the distal branching pattern. These findings have significant implications for surgical procedures, particularly parotidectomy, where surgeons must exercise utmost caution due to the potential clinical implications of FN injury.

Keywords: branching pattern; evidence-based anatomy; facial nerve; interconnections; variation.

Figure 1

PRISMA 2020 flow diagram [16].

Figure 2

Bifurcation: Forest plot evaluating the prevalence, cumulative meta-analysis assessing the small-study effect, and funnel plot assessing the small-study effect [2,6,8,9,10,11,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47].

Figure 3

Trifurcation: Forest plot evaluating the prevalence, Cumulative meta-analysis assessing the small-study effect, and funnel plot assessing the small-study effect [2,6,8,9,10,11,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47].

Figure 4

Type III morphology: Forest plot evaluating the prevalence, cumulative meta-analysis for assessing the small-study effect, funnel plot for assessing the small-study effect [2,6,8,9,10,11,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47].

Figure 5

Type IV morphology: Forest plot evaluating the prevalence, cumulative meta-analysis for assessing the small-study effect, funnel plot for assessing the small-study effect [2,6,8,9,10,11,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47].

Figure 6

Type II morphology: Forest plot evaluating the prevalence, cumulative meta-analysis for assessing the small-study effect, funnel plot for assessing the small-study effect [2,6,8,9,10,11,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47].

Figure 7

Type I morphology: Forest plot evaluating the prevalence, cumulative meta-analysis for assessing the small-study effect, funnel plot for assessing the small-study effect [2,6,8,9,10,11,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47].

Figure 8

Type V morphology: Forest plot evaluating the prevalence, cumulative meta-analysis for assessing the small-study effect, funnel plot for assessing the small-study effect [2,6,8,9,10,11,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47].

Figure 9

Type VI morphology: Forest plot evaluating the prevalence, cumulative meta-analysis for the assessment of the small-study effect, funnel plot for the evaluation of the small-study effect [2,6,8,9,10,11,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47].