Impact of facial palsy impact on make-up habits: An observational cohort study

OBJECTIVE

The esthetic problems inherent to peripheral (PFP) are frequent causes of complaint. Make-up is advocated as a form of therapy and can alleviate symptoms of depression. The aim of the present study was to collect data on make-up habits in female PFP patients and assess links with esthetic and/or functional complaints.

MATERIAL AND METHODS

Two questionnaires were drawn up to compare make-up habits in female PFP patients and women in the general population. The first was sent out between September and December 2019, to 39 House-Brackmann grade III PFP patients (group A), and the second on-line questionnaire was sent to a control population of 1385 women (group B).

RESULTS

PFP patients used make-up more often than controls at weekends (χ2=16.38; P=0.0009) and while at home (χ2=8.21; P=0.042), and more often with foundation (χ2=17.21; P=0.0006) and lip make-up (χ2=59.31; P<0.0001). The greater their functional complaint, the less they made up their eyes. The greater their self-confidence and the more they felt attractive, the less they made up their lips.

CONCLUSION

The differences in make-up use found in the present study aimed to mask facial palsy and were related to the esthetic complaint, impacting social life.

Searching for Signs of Plastic Surgery on the Face: Tracking the Eyes of Where Observers Look

Background: Objective measurement of where observers direct their attention to faces when searching for signs of facial plastic surgery (FPS) is currently lacking. Objective: To compare where laypersons direct their attention on facial photographs using eye-tracking software when they are asked to (1) search for signs of aesthetic facial surgery or (2) allowed to gaze without direction (free-gaze). Methods: Naïve observers either free-gazed or examined faces for signs of FPS (FPS-prompted) for 10 s per face while their gaze was recorded by an eye-tracking system. Faces had no known history or signs/stigmata of FPS and were selected from the FACES and CFD databases with a diverse demographic distribution. Gaze times in nine facial subregions were analyzed using mixed-effects linear regression. Results: In FPS-prompted observers (n = 50, mean age 32.7 ± 11.3 years, 23/50 (46%) female), the nose, mouth, cheeks, and forehead experienced the most substantial increases (p < 0.001) and a high percentage of overall gaze time (17.9%, 12.5%, 12.0%, 9.6%, respectively) compared to free-gazing observers [n = 57, 35.5 ± 13.9 years, 31/57 (54%) female]. Conclusions: Observers direct attention differently on a face when searching for signs of plastic surgery with increased attention on the nose, mouth, cheeks, and forehead.

Electroacupuncture with intermittent wave stimulation as rehabilitation approach for chronic Bell's palsy: a randomized controlled trial

PURPOSE

To evaluate the effectiveness and safety of electroacupuncture (EA) using intermittent wave stimulation in enhancing facial symmetry and nerve function in chronic Bell's palsy patients.

METHODS

A 6-week assessor-blinded, randomized trial followed by an 18-week observational period was conducted. Sixty individuals with chronic Bell's palsy, showing no signs of recovery after 12 months, were equally divided to receive either 18 sessions of EA using intermittent wave stimulation or Transcutaneous Electrical Stimulation (TES), administered thrice weekly over 6 weeks. The primary outcome measure was the change in the total facial nerve index (TFNI) score from baseline to Week 6, with secondary outcomes including TFNI scores at Weeks 12 and 24, as well as the change in Sunnybrook Facial Grading System (SFG) score from baseline to Week 6, and SFG scores at Weeks 12 and 24.

RESULTS

The EA group showed a significant improvement, with a mean total facial nerve index score increase of 24.35 (4.77) by Week 6 compared with 14.21 (5.12) in the Transcutaneous Electrical Stimulation group (P<.001). This superiority persisted during the 24-week follow-up. While no significant difference was observed in the Sunnybrook Facial Grading System score change from baseline to Week 6, variations were noted at Weeks 12 and 24. No major adverse effects were reported.

CONCLUSION

EA with intermittent wave stimulation notably enhanced facial symmetry in chronic Bell's palsy patients over Transcutaneous Electrical Stimulation by Week 6, maintaining this edge throughout the follow-up.

Selective Neurectomy for Treatment of Post-Facial Paralysis Synkinesis: A Systematic Review

BACKGROUND

 Synkinesis is commonly encountered after flaccid facial paralysis and can have a detrimental impact on a patient's life. First-line treatment of synkinesis is chemodenervation with botulinum toxin (Botox) and neuromuscular retraining. Surgical options include selective myectomy, selective neurectomy (SN), cross-facial nerve grafting, nerve substitution, and free gracilis muscle transfer. Data on surgical management of synkinesis using SN is limited.

EVIDENCE REVIEW

 PubMed, Embase, Cochrane CENTRAL, Cochrane Neuromuscular Register, Clinicaltrials.gov, and World Health Organization International Clinical Trials Registry Platform were searched using a comprehensive keyword strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All English-only texts published in the past 20 years were included. Two independent investigators reviewed 906 abstracts and 7 studies met inclusion criteria. Demographics, etiology of paralysis, time to surgery, and primary outcomes studied were collected.

FINDINGS

 A total of 250 patients were included across 7 studies. In 6 out of 7 studies, Botox was used prior to surgical intervention. Two studies showed significant reduction in Botox dosage postoperatively, while one study showed no difference. Other primary outcomes included the House-Brackmann Score, palpebral fissure width, electronic clinician-graded facial function scale (eFACE) score, Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Three studies showed significant improvement in the eFACE score, two studies showed significant improvement in the FaCE scale, while one study showed improvement in quality of life measured by the SAQ.

CONCLUSION

 SN can be considered as an adjunct to other management options including neuromuscular retraining, Botox, selective myectomy, and reanimation procedures. While there is great heterogeneity of study design in the studies included, many cohorts showed improvement in facial symmetry, facial function, and quality of life. There remains a great gap in knowledge in this subject matter and a need for large well-designed prospective studies comparing this technique to other management options.

Sternocleidomastoid Muscle Transfer for Treatment of Longstanding Facial Paralysis: Long-term Outcomes and Complications

BACKGROUND/AIM

The use of sternocleidomastoid muscle (SCM) flap for facial reanimation was established in the 1980s by the senior author of this paper. We aimed to analyze long-term outcome and complications of this procedure.

PATIENTS AND METHODS

We conducted a retrospective chart review of all patients undergoing SCM reanimation for longstanding facial palsy between January 2009 and December 2015. Patients with follow-up longer than 12 months (range=12-96) were included in the study. Facial muscle function was evaluated before and at each follow-up after the surgery with the House-Brackmann (HB) scale-facial nerve grading system and Facegram analysis. Donor site morbidity and overall complication rates were documented and analyzed.

RESULTS

Forty-two patients aged 18-66 years (mean age=37) with a mean duration of facial palsy of 5 years (range=2-48) met the inclusion criteria. The HB score 2 years after surgery improved significantly (p<0.05) in comparison to the pre-operative condition (3.6 vs. 4.7). Twelve months after surgery, oral commissure excursion improved by mean 8.95 mm. No flap necrosis occurred, nor compromise of neck and shoulder function despite an obvious contour defect in the SCM donor site. None of the patients presented head posture or movement issues.

CONCLUSION

The SCM flap transfer is a reliable and effective procedure to achieve moderate improvement of the oral commissure excursion using a local method with moderate donor site morbidity. It can be regarded as a valuable option for dynamic facial reanimation in case of longstanding facial palsy.

Perceptions of Patients with Facial Paralysis: Predicting Social Implications and Setting Goals

The goal of this article is to better understand the social impact of facial paralysis. Patients with facial paralysis may suffer from impaired social interactions, disruption of self-concept, psychological distress, and decreased overall quality of life. Vigilance in detecting patients suffering from mental health issues may result in providing early referral for psychological evaluation and psychosocial support resources complementing facial reanimation treatment.

Cosmetic appreciation and emotional processing in patients with a peripheral facial palsy: A systematic review

Background; The goal of this review is 1) to summarize the studies assessing PFP by casual observers, patients themselves and the cosmetic appreciation of the PFP and 2) to summarize the studies assessing whether there is a difference in emotional recognition/processing of facial emotions and/or cognitive tasks in patients with a PFP. Materials and Methods; A multi-database systematic literature search was performed using the following databases: Pubmed, Embase, Medline, and The Cochrane Library from the earliest date of each database up to December 2019. Population of interest consisted of patients with a PFP and studies that investigated cosmetic appreciation and/or emotional recognition and/or emotional processing in these patients. Two authors rated the methodological quality of the included studies independently using the 'Newcastle - Ottawa Quality Assessment Scale' for nonrandomised studies' (NOS). Two authors extracted the outcome data regarding cosmetic appreciation and/or emotional recognition/processing from the included studies. Results; Twelve hundred and thirty-two studies were found of which eleven studies met the inclusion criteria. Most studies were assessed to be of 'fair' to 'good' methodological quality. The Cohen's kappa (between author RL and SP) was 0.68. Two studies investigated emotional processing and/or emotional recognition. Nine studies investigated cosmetic appreciation in both patients and casual observers. Important findings of this systematic review are that there is a correlation between the perceived severity of the PFP of the patients and the ratings by casual observers. Secondly there seems to be a laterality difference in cosmetic appreciation and thirdly there might to be a decreased emotional recognition and processing in patients with a PFP. Conclusion; Emotional recognition and cosmetic appreciation in patients with a PFP is an under investigated area, in which further studies are needed to substantiate the findings in current literature.

Assessing anxiety, depression and quality of life in patients with peripheral facial palsy: a systematic review

OBJECTIVE

Peripheral facial palsy (PFP) is predominantly a unilateral disorder of the facial nerve, which can lead to psychological disorders that can result in decreased quality of life. The aim of this systematic review was to assess anxiety, depression and quality of life symptoms associated with PFP.

DATA SOURCES

We searched the Medline, PEDro, CINAHL and Google Scholar databases to conduct this systematic review while following Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. The search was performed by two independent reviewers, and differences between the two reviewers were resolved by consensus.

STUDY SELECTION

The search terms used were derived from the combination of the following MeSH terms: "facial paralysis", "bell palsy", "anxiety", "anxiety disorders", "depression", "depressive disorders", "quality of life" and not MeSH: "facial palsy", "hemifacial paralysis", "facial paresis", "Peripheral Facial Paralysis", using the combination of different Boolean operators (AND/OR).

DATA EXTRACTION

On November 1st (2019).

DATA SYNTHESIS

In total, 18 cross-sectional articles and two case-control studies were selected.

CONCLUSIONS

The cross-sectional articles showed low methodological quality, while the case-control studies showed acceptable methodological quality. Limited evidence suggests that patients with PFP might have increased levels of anxiety and depressive symptoms. A qualitative analysis also showed limited evidence that quality of life might be diminished in patients with PFP.

PROSPERO

CRD42020159843.

Physical Therapy for Iatrogenic Facial Paralysis: A Systematic Review

Importance

Facial paralysis (FP) after surgery has substantial functional, emotional, and financial consequences. Most iatrogenic FP is managed by watchful waiting, with the expectation of facial function recovery. A potential treatment is physical therapy (PT).

Objective

To investigate whether noninvasive PT compared with no PT or other intervention improves facial nerve outcomes in adults with iatrogenic FP.

Evidence Review

Patients with noniatrogenic FP, facial reanimation surgery, and invasive adjunctive treatments (acupuncture or botulinum toxin injection) were excluded. A systematic review was conducted for records discussing iatrogenic FP and PT; a search for these records was performed using Ovid MEDLINE (1946-2019), Embase (1947-2019), Scopus (1823-2019), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform (2004-2019), and ClinicalTrials.gov (1997-2019). The references of all the included articles were also assessed for eligible studies. All human participant, English-language study designs with at least 2 cases were included. Quality assessment was performed using the Methodological Index for Non-randomized Studies (MINORS) and the revised Cochrane Risk of Bias 2 (RoB 2) tool for randomized controlled trials. All search strategies were completed on May 16, 2019, and again on October 1, 2019.

Findings

Fifteen studies (7 of which were retrospective cohort studies) and 313 patients with iatrogenic FP were included in the systematic review. Most iatrogenic FP (166 patients [53%]) was associated with parotidectomy; traditional PT (ie, facial massage) was the most common intervention (196 patients [63%]). The use of various facial grading systems and inconsistent reporting of outcomes prevented direct comparison of PT types.

Conclusions and Relevance

Because of heterogeneity in reported outcomes of facial nerve recovery, definitive conclusions were unable to be made regarding the association between PT and outcomes of iatrogenic FP. Physical therapy probably has benefit and is associated with no harm in patients with iatrogenic FP.

Dermal Filler Treatment Improves Psychosocial Well-Being in Facial Paralysis Patients

Background: In the care of the facial paralysis (FP) patient, outcomes have historically focused on facial function rather than the psychosocial burden of the disease state. Yet, FP patients often describe the impact of their disease on domains of psychosocial health. These patient concerns have motivated clinicians to formally recognize and treat nonfunctional sequelae of the disease. Dermal filler therapy (DFT) is a minimally invasive reversible procedure that can be used to treat facial asymmetry and improve psychosocial well-being in FP patients. However, there are no data describing outcomes of DFT in FP-related facial asymmetry. Therefore, we sought to formally characterize FP patients' facial symmetry and psychosocial well-being before and after DFT. Methods: FP patients presenting for DFT at a tertiary academic medical center were prospectively interviewed. Patients completed the validated FACE-Q for Appearance-Related Psychosocial Distress instrument. Self-reported facial symmetry scores were recorded. Patients were evaluated before and 2 weeks after DFT. Statistical analysis was performed on R software using paired sample t-tests. Results: Twenty FP patients completed DFT treatment and two surveys. The cohort was predominantly female (n = 19, 95%) with an average age of 54 years. After a single treatment of DFT averaging 2.3 mL, patients had significant improvement in facial symmetry and psychosocial well-being. Patients felt particular improvement in self-confidence and emotional expression (p < 0.0001 for all stated comparisons). Conclusion: FP of varying etiologies is associated with significant functional, psychosocial, and quality-of-life impairments. This is the first prospective study to demonstrate statistically significant improvements in facial symmetry and psychosocial well-being after a single office-based treatment of dermal filler. In addition, our study's emphasis on psychosocial health instruments reflects an increased awareness of this important domain in the care of the FP patient.

Association of Facial Paralysis With Perceptions of Personality and Physical Traits

IMPORTANCE

Facial paralysis has a significant effect on affect display, with the most notable deficit being patients' the inability to smile in the same way as those without paralysis. These impairments may result in undesirable judgements of personal qualities, thus leading to a significant social penalty in those who have the condition.

OBJECTIVE

To quantify the association of facial paralysis with the way smiling patients are perceived by others with respect to personality traits, attractiveness, and femininity or masculinity and to evaluate the potential association of facial palsy-related patient-reported outcome measures with how patients are perceived by others.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study used 20 images of smiling patients with facial paralysis evaluated between January 1, 2014, and December 31, 2016. Using photograph editing software, the photographs were edited to create a simulated nonparalysis smiling facial appearance. A total of 40 photographs were split into 4 groups of 10 photographs, each with 5 altered and 5 unaltered photographs. The surveys were designed such that altered and unaltered photographs of the same patient were not placed in the same survey to avoid recall bias. Anonymous raters used a 7-point Likert scale to rate their perception of each patient's personality traits (ie, aggressiveness, likeability, and trustworthiness), attractiveness, and femininity or masculinity based on photographs in their assigned survey. Raters were blinded to study intent. Scores from the Facial Clinimetric Evaluation questionnaire were included to assess self-perception. Data were analyzed from November 11, 2019, to February 20, 2020.

MAIN OUTCOMES AND MEASURES

Ratings of personality traits, attractiveness, and femininity or masculinity. Social function domain scores and overall scores were analyzed from the Facial Clinimetric Evaluation questionnaire.

RESULTS

This study included photographs of 20 patients with facial paralysis (mean [range] age, 54 [28-69] years; 15 [75%] women). A total of 122 respondents completed the survey (71 [61%] women). Most respondents were between the ages of 25 and 34 years (79 participants [65%]). Overall, smiling photos of patients with facial paralysis were perceived as significantly less likeable (difference, -0.29; 95% CI, -0.43 to -0.14), trustworthy (difference, -0.25; 95% CI, -0.39 to -0.11), attractive (difference, -0.47; 95% CI, -0.62 to -0.32), and feminine or masculine (difference, -0.21; 95% CI, -0.38 to -0.03) compared with their simulated preparalysis photographs. When analyzed by sex, smiling women with facial paralysis experienced lower ratings for likeability (difference, -0.34; 95% CI, -0.53 to -0.16), trustworthiness (difference, -0.24; 95% CI, -0.43 to -0.06), attractiveness (difference, -0.74; 95% CI, -0.94 to -0.55), and femininity (difference, -0.35; 95% CI, -0.58 to -0.13). However, smiling men with facial paralysis only received significantly lower ratings for likeability (difference, -0.24; 95% CI, -0.47 to -0.01) and trustworthiness (difference, -0.30; 95% CI, -0.53 to -0.07). As patients' self-reported social function and total Facial Clinimetric Evaluation scores increased, there was an increase in perceived trustworthiness (rs[480] = 0.11; P = .02) and attractiveness (rs[478] = 0.10; P = .04) scores by raters.

CONCLUSIONS AND RELEVANCE

In this study, photographs of patients with facial paralysis received lower ratings for several personality and physical traits compared with digitally edited images with no facial paralysis. These findings suggest a social penalty associated with facial paralysis.

Degree of Self-Reported Facial Impairment Correlates with Social Impairment in Individuals with Facial Paralysis and Synkinesis

Importance: Facial paralysis leads to both aesthetic and functional deficits placing patients at risk for sociopsychological sequelae and social impairment. Objective: To examine the effect of facial paralysis and synkinesis on social impairment and quality of life (QOL). Design, Setting, and Participants: This is a cross-sectional study at a tertiary care medical center. Adults with a history of facial palsy were broadly categorized by self-reported degree of facial paralysis and synkinesis. Main Outcomes and Measures: Clinical demographic information, self-reported degrees of facial paralysis and synkinesis, and facial palsy-specific QOL as measured by the Facial Clinimetric Evaluation (FaCE) Scale and the Synkinesis Assessment Questionnaire (SAQ) were collected. FaCE and SAQ scales were evaluated as predictors of social impairment outcomes, as measured by the Brief Fear of Negative Evaluation-II (BFNE-II), the Social Anxiety Questionnaire (SAQ-A30), and Social Avoidance and Distress (SAD) scales, in addition to health utility scores from the Short-Form 6D (SF-6D). Results: Fifty-six participants with facial palsy were included (30% male; average age: 56.4 [standard deviation (SD): 15] years). Sixty-three percent of participants reported history of Bell's palsy; 37% reported other etiologies. Forty-seven percent of participants reported moderate or severe facial impairment and 46% of participants reported involuntary facial movement. Participants with moderate or severe facial impairment exhibited increased BFNE-II (p = 0.03), SAQ-A30 (p = 0.04), and SAD (p < 0.01) scores and lower health valuation on SF-6D (p = 0.04). FaCE scores moderately correlated with lower health valuation (r = 0.39, p < 0.01), and moderately and inversely correlated with SAD (r = -0.33, p = 0.01) and BFNE-II (r = -0.35, p < 0.01) scores. Furthermore, worsening FaCE scores predicted worsening SAQ (p < 0.01), SAD (p = 0.01), BFNE-II (p < 0.01), and SF-6D (p < 0.01) scores. Worse degrees of synkinesis correlated with higher BFNE-II scores (r = 0.38, p < 0.01) and worsening SAQ scores predicted worsening FaCE (p < 0.01) and BFNE-II (p < 0.01) scores. Females demonstrated significantly worse BFNE-II scores (p = 0.04) when compared with men, and female gender significantly predicted worse FaCE scores (p < 0.01). Seventy-one percent of women with self-reported moderate or severe facial impairment met criteria for social anxiety, as did 67% of women with self-reported moderate or severe synkinesis. Conclusions and Relevance: Individuals with self-reported moderate or severe facial impairment exhibit a higher degree of social impairment and poorer health valuation than those with no or mild facial impairment. Facial palsy-specific QOL moderately and inversely correlated with social impairment and moderately correlated with health valuation. Our results indicate that FaCE scores may be used as a predictor of SAD, BFNE-II, and SF-6D scores and that facial palsy QOL and its relationship with social impairment should be considered when treating patients with a history of facial palsy.

A closer look at the paralyzed face; a narrative review of the neurobiological basis for functional and aesthetic appreciation between patients with a left and a right peripheral facial palsy

BACKGROUND

The facial nerve or n. facialis (NVII) is the seventh cranial nerve and it is responsible for the innervation of the mimic muscles, the gustatory organ, and the secretomotor function to the salivary, lacrimal, nasal and palatine glands. Clinical presentation of Facial Palsy (FP) is characterized by unilateral facial asymmetry and may present with a change in taste, decreased saliva production, and dysarthria. A facial palsy has a notable effect on the facial appreciation by both the patient and the environment and also affects quality of life and emotional processing. There appear to be differences in the appreciation of people with a left and right facial palsy.

PURPOSE OF THIS REVIEW

The purpose of the review is to give an overview of the anatomy of the facial nerve, neuro-anatomy of face processing, and hemispheric specialization and lateralization. Further,an overview is given of the clinical studies that translated the neuro-anatomical and neurobiological basis of these concepts into clinical studies. What this review adds: This review emphasizes the neurobiological evidence of differences in face processing between the left and right cerebral hemisphere, wherein it seems that the right hemisphere is superior in emotional processing. Several theories are proposed; 1) a familiarity hypothesis and 2) a left-right hemispheric specialization hypothesis. In clinical studies, promising evidence might indicate that, in patients with FP, there is indeed a difference in how left and right FP are perceived. This might give differences in decreased quality of life and finally in occurrence of depression. Further research must aim to substantiate these findings and determine the need for altering the standard therapeutic advice given to patients.

Make-Up Therapy for Patients With Facial Nerve Palsy

Objectives:

To investigate the effectiveness of make-up therapy for patients with facial nerve palsy.

Methods:

Seven female patients with facial nerve palsy who received specialist make-up therapy were enrolled. The objective of the make-up therapy was to obtain a symmetrical facial appearance.

Results:

Overall score for the Facial Clinimetric Evaluation (FaCE) scale was significantly improved after make-up therapy. There was a tendency for symptoms of depression to be improved among patients after make-up therapy.

Conclusion:

Make-up therapy to improve the symmetry of facial appearance could afford a noninvasive and low-cost treatment for patients with facial nerve palsy, especially in terms of patient quality of life and psychological condition.

Facial Rehabilitation as Noninvasive Treatment for Chronic Facial Nerve Paralysis

OBJECTIVES

This study aims to evaluate the effectiveness of facial rehabilitation (FR) in patients with chronic facial nerve paralysis (FNP) and describe factors that predict improved facial nerve function after FR in this patient population.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Around 241 patients were referred to a university hospital facial rehabilitation (FR) program for FNP between 1995 and 2016. Seventy-six patients met criteria, defined as diagnosis of FNP ≥12 months prior to initiation of FR.

INTERVENTIONS

Each received at least two sessions of directed FR by a single therapist. Techniques employed: neuromuscular retraining, stretching/massage, and active exercise.

MAIN OUTCOMES

Variables affecting outcomes were analyzed to determine association with success of FR as measured by improvement in Facial Grading System (FGS) scale.

RESULTS

Onset of FNP to initiation of FR ranged 12 to 384 months (mean latency = 64.7 months). All patients, age 20 to 89, showed improvement in FGS after FR (mean, 16.54 points, SD 9.35). Positive predictors of FGS improvement after therapy (p-values < 0.05): increased the number of therapy sessions, right side of face being treated for FNP, lower starting FGS score. When controlling for these important variables, time from diagnosis to initiation of therapy was not significantly associated with improvement in FGS score.

CONCLUSION

Facial rehabilitation was associated with improved FGS score regardless of patient age, gender, or latency to facial rehabilitation. As a noninvasive treatment option with positive outcomes, it should be offered to patients with facial nerve paralysis regardless of chronicity.

Comparing Patient, Casual Observer, and Expert Perception of Permanent Unilateral Facial Paralysis

Importance

Differences in perception of facial paralysis among patients, casual observers, and experts may have implications for outcomes research and patient care.

Objective

To compare multiple domains of casual observer and expert perception with the actual experience of patients with permanent unilateral facial paralysis.

Design, Setting, and Participants

This investigation was a prospective cohort study conducted at an academic tertiary referral center. Patients with permanent unilateral facial paralysis (House-Brackmann grades IV to VI) were randomly selected from The Johns Hopkins University Division of Facial Plastic and Reconstructive Surgery clinic. A diverse group of casual observers and experts were recruited to rate their perception of each patient with facial paralysis. The study dates were July 2014 to July 2015.

Main Outcomes and Measures

Patients rated their paralysis severity, attractiveness, quality of life, and affect using established metrics. Casual observers and experts viewed standardized facial videos of each patient and then used the same metrics to rate each patient's paralysis severity, attractiveness, quality of life, and affect.

Results

The analysis yielded 40 patient observations, 6400 casual observer observations, and 200 expert observations for each outcome metric in the study. Compared with the patients' self-perception, casual observers and experts rated patients with facial paralysis more negatively in all measured domains. A multivariable mixed-effects regression showed that observers perceived patients as having greater paralysis severity (8.49 [95% CI, -0.65 to 17.64] of 100 points; SE, 4.67), being less attractive (-7.71 [95% CI, -14.92 to -0.50] of 100 points; SE, 3.68), and having a worse quality of life (-7.76 [95% CI, -14.18 to -1.34] of 100 points; SE, 3.28) compared with the patients' perceptions. Logistic regression demonstrated that observers were less likely to rate patients' affect as positive (odds ratio, 0.28 [95% CI, 0.14-0.58]; SE, 0.10) compared with the patients' self-rating. The raw data and regression analyses also showed that patients, casual observers, and experts perceived faces with higher House-Brackmann grades more negatively in all measured domains of facial perception.

Conclusions and Relevance

This study found that casual observers and experts generally perceive patients with facial paralysis more negatively than patients perceive themselves. These findings have implications for patients and facial plastic surgeons alike. They also emphasize the importance of assessing outcomes from all 3 perspectives. This pilot study lays the groundwork for developing new tools to assess the social perception of facial deformity that could lead to advancement in facial paralysis outcomes research and improved care for patients with facial paralysis.

Level of Evidence

NA.