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.

Oral Health-Related Quality of Life in Rare Disorders of Congenital Facial Weakness

Congenital facial weakness (CFW) encompasses a heterogenous set of rare disorders presenting with decreased facial movement from birth, secondary to impaired function of the facial musculature. The aim of the present study is to provide an analysis of subject-reported oral health-related quality of life (OHRQoL) in congenital facial weakness (CFW) disorders. Forty-four subjects with CFW and age- and sex- matched controls were enrolled in an Institutional Review Board (IRB)-approved study. Demographic data, medical and surgical history, comprehensive oral examination, and the Oral Health Impact Profile (OHIP-14) were obtained. Compared to unaffected controls, subjects with CFW had higher OHIP-14 scores overall (mean ± SD: 13.11 ± 8.11 vs. 4.46 ± 4.98, p < 0.0001) and within five of seven oral health domains, indicating decreased OHRQoL. Although subjects with Moebius syndrome (MBS) were noted to have higher OHIP-14 scores than those with Hereditary Congenital Facial Paresis (HCFP), there was no significant correlation in OHIP-14 score to age, sex, or specific diagnosis. An increase in OHIP-14 scores in subjects was detected in those who had undergone reanimation surgery. In conclusion, subjects with CFW had poorer OHRQoL compared to controls, and subjects with MBS had poorer OHRQoL than subjects with HCFP. This study provides better understanding of oral health care needs and quality of life in a CFW cohort and suggests that guidelines for dental treatment are required.

Comparison of Objective Facial Metrics on Both Sides of the Face Among Patients with Severe Bell's Palsy Treated with Mirror Effect Plus Protocol Rehabilitation Versus Controls

Objective: The extent to which the healthy hemiface dynamically contributes to facial synchronization during facial rehabilitation has been largely unstudied. This study compares the synchronization of both hemifaces in severe Bell's palsy patients who either received facial rehabilitation called "Mirror Effect Plus Protocol" (MEPP) or basic counseling. Methods: Baseline and 1-year postonset data from 39 patients (19 = MEPP and 20 = basic counseling) were retrospectively analyzed using Emotrics+, a software that generates facial metrics with artificial intelligence (AI) algorithms. Paired t-tests were used for intrasubject comparisons of hemifaces, and mixed model analysis were used to compare between groups. Results: For voluntary movements, a significant difference in favor of the MEPP group was only found for smiling (p = 0.025*). However, at 1-year postonset, the control group showed significant variability between hemifaces for most synkinesis measurements [nasolabial fold (p = 0.029*); eye area (p = 0.043*); palpebral fissure (p = 0.011*)]. Conclusion: In this study, a better synchronization of both hemifaces was found in the MEPP group. Interestingly, motor adaptation in movement amplitude of the healthy hemiface seemed to contribute to this synchronization in MEPP patients. Further studies are needed to standardize the procedure of AI measurements and to adapt it for clinical use.

Use of Convolutional Neural Networks to Evaluate Auricular Reconstruction Outcomes for Microtia

OBJECTIVES

The objective of this study is to determine whether machine learning may be used for objective assessment of aesthetic outcomes of auricular reconstructive surgery.

METHODS

Images of normal and reconstructed auricles were obtained from internet image search engines. Convolutional neural networks were constructed to identify auricles in 2D images in an auto-segmentation task and to evaluate whether an ear was normal versus reconstructed in a binary classification task. Images were then assigned a percent score for "normal" ear appearance based on confidence of the classification.

RESULTS

Images of 1115 ears (600 normal and 515 reconstructed) were obtained. The auto-segmentation task identified auricles with 95.30% accuracy compared to manually segmented auricles. The binary classification task achieved 89.22% accuracy in identifying reconstructed ears. When the confidence of the classification was used to assign percent scores to "normal" appearance, the reconstructed ears were classified to a range of 2% (least like normal ears) to 98% (most like normal ears).

CONCLUSION

Image-based analysis using machine learning can offer objective assessment without the bias of the patient or the surgeon. This methodology could be adapted to be used by surgeons to assess quality of operative outcome in clinical and research settings.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2413-2416, 2023.

Cross-species Blink Characterisation Tool for the Analysis of Emerging Interventions for Overcoming Facial Paralysis

The loss of the ability to blink is considered the most severe consequence of facial nerve paralysis. Surgical techniques and implantable technologies continue to be developed to reanimate the eye; however, few analyse the full movement of blink when evaluating success. Here, we describe a method of taking high-quality, and high-speed video recordings of the eye, to non-invasively extract meaningful data about the dynamic movement of blinking. This can then be used to assess the effectiveness of a new technology in mimicking the natural movement. The tool was validated on humans (N=2, authors) before testing on an ovine recording (N=1), to confirm the cross-species utility of the tool, for use during preclinical development of technologies. It was found to be accurate and comprehensive, able to give insights on blinking in both human and ovine cases.

The psychological and psychosocial effects of facial paralysis: A review

Facial nerve function is essential for a multitude of processes in the face, including facial movement; expression; and functions, such as eating, smiling, and blinking. When facial nerve function is disrupted, facial paralysis may occur and various complications for the patient may result. Much research has been conducted on the physical diagnosis, management, and treatment of facial paralysis. However, there is a lack of knowledge of the psychological and social effects of the condition. Patients may be at an increased risk for anxiety and depression, as well as negative self and social perceptions. This review analyzes the current literature on the various adverse psychological and psychosocial effects of facial paralysis, factors that may play a role, and treatment options that may help improve patients' quality of life.

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.

Evidence-Based Medicine: Facial Reanimation

This article provides a brief historical overview of the assessment instruments that have been developed to categorize the severity of disease in patients with facial palsy. Important advances in the quality of these instruments are discussed. The modern-day instruments that are commonly required for evidence-based patient assessment are then presented, with emphasis on the level of evidence of the studies that describe these instruments.

Automated Spontaneity Assessment after Smile Reanimation: A Machine Learning Approach

BACKGROUND

Recreation of a spontaneous, emotional smile remains a paramount goal of smile reanimation surgery. However, optimal techniques to reliably restore spontaneity remain unknown. Dual automated machine-learning tools were used to develop an objective tool to analyze spontaneous smiling. The feasibility of this tool was tested in a sample of functional free muscle transfers.

METHODS

Validated humorous videos were used to elicit spontaneous smiles. Automated facial landmark recognition (Emotrics) and emotion detection software (Affdex) were used to analyze video clips of spontaneous smiling in nine normal subjects and 39 facial reanimation cases. Emotionality quotient was used to quantify the ability of spontaneous smiles to express joy.

RESULTS

The software could analyze spontaneous smiling in all subjects. Spontaneous smiles of normal subjects exhibited median 100 percent joy and 0 percent negative emotion (emotional quotient score, +100/0). Spontaneous smiles of facial palsy patients after smile reanimation, using cross-facial nerve graft, masseteric nerve, and dual innervation, yielded median emotional quotient scores of +82/0, 0/-48, and +10/-24 respectively (joy, p = 0.006; negative emotion, p = 0.034).

CONCLUSIONS

Computer vision software can objectively quantify spontaneous smiling outcomes. Of the retrospective sample of cases reviewed in this study, cross-facial nerve graft-innervated gracilis functional free muscle transfer achieved a greater degree of emotionality during spontaneous smiling than masseteric or dually innervated transfer. Quantification of spontaneous smiling from standard video clips could facilitate future, blinded, multicenter trials with sufficient long-term follow-up to definitively establish the rates of spontaneity from a range of reanimation procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Multiple Model Evaluation of the Masseteric-to-Facial Nerve Transfer for Reanimation of the Paralyzed Face and Quick Prognostic Prediction

Facial paralysis is negatively associated with functional, aesthetic, and psychosocial consequences. The masseteric-to-facial nerve transfer (MFNT) has many advantages in facial reanimation. The aim is to evaluate the effectiveness of our MFNT technique and define the potential factors predictive of outcome. The authors conducted a retrospective review of 20 consecutive patients who underwent MFNT using the temporofacial trunk of facial nerve. Videotapes and images were documented and evaluated according to Facial Nerve Grading Scale 2.0 (FNGS2.0) and Sunnybrook Facial Grading System (FGS). The quality-of-life was obtained using the Facial Clinimetric Evaluation (FaCE) Scale. Moreover, Facial Asymmetry Index (FAI), quantitative measurement of the width of palpebral fissure, deviation of the philtrum, and angles or excursions of the oral commissure were applied to explore the effect of the transfer metrically. Multivariable logistic regression models and Cox regression were prepared to predict the effect of MFNT by preoperative clinical features. The patients showed favorable outcomes graded by FNGS2.0, and experienced significantly improved scores in static and dynamic symmetry with slightly elevated scores in synkinesis evaluated by the Sunnybrook FGS. The score of FaCE Scale increased in all domains after reanimation. The quantitative indices indicated the symmetry restoration of the middle and lower face after MFNT. Regression analysis revealed that younger patients with severe facial paralysis are preferable to receive MFNT early for faster and better recovery, especially for traumatic causes. The findings demonstrate that MFNT is an effective technique for facial reanimation, and case screening based on clinical characteristics could be useful for surgical recommendation.

Releasing the Smile: Depressor Anguli Oris Excision in the Context of Managing Nonflaccid Facial Palsy

BACKGROUND

Nonflaccid facial palsy is a debilitating entity characterized by hypertonicity, synkinesis, and hypomobility. Patients with nonflaccid facial palsy often have smile asymmetry and restriction because of disruption of normal vector forces on the modiolus. Excision of the depressor anguli oris can lead to improved oral commissure excursion, smile angle, dental show, and symmetry.

METHODS

All depressor anguli oris resection cases between January 8, 2018, and December 26, 2019, were reviewed. Patients with postoperative photographs were included in this cohort study. Preoperative and postoperative photographs were analyzed using the Emotrics software program, and changes in oral commissure excursion, smile angle, and dental show were tracked. Clinician-graded facial palsy assessments and patient-reported outcome measures were compared preoperatively and postoperatively using the Electronic Facial Paralysis Assessment and Facial Clinimetric Evaluation Scale, respectively.

RESULTS

Forty-three patients were included in this study; 79 percent of patients underwent isolated depressor anguli oris resection. Depressor anguli oris resection led to a statistically significant increase in oral commissure median excursion, smile angle, and dental show [3.02 mm (p = 0.015), 1.70 degrees (p = 0.002), and 2.36 mm (p < 0.001), respectively]. Median Electronic Facial Paralysis Assessment and Facial Clinimetric Evaluation Scale instrument scores also improved [6.0 (p = 0.001) and 7.5 (p = 0.013), respectively]. Depressor anguli oris resection also led to more symmetric smiles. No correlation was seen between duration of follow-up and change in metrics.

CONCLUSION

Depressor anguli oris resection is a minimal-risk procedure that frequently results in improved smile dynamics, smile symmetry, and quality of life in patients with nonflaccid facial palsy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Temporalis Tendon Transfer Versus Gracilis Free Muscle Transfer: When and Why?

Temporalis tendon transfer (T3) and gracilis free muscle transfer (GFMT) are popular techniques in lower facial rehabilitation when reinnervation techniques are unavailable. T3 involves a single-stage outpatient procedure resulting in immediate improvement in resting symmetry and a volitional smile. GFMT allows a spontaneous smile, customized vectors, and increased excursion but requires longer surgical time, a delay before movement, and specialized equipment. Ultimately, shared decision making between the clinician and patient should focus on the patient's goals and unique medical condition.

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.

Aesthetic crown lengthening and lip repositioning surgery: Pre- and post-operative assessment of smile attractiveness

AIM

To assess the effect of aesthetic crown lengthening (ACL) and lip repositioning surgery (LRS) on perception of smile attractiveness.

MATERIALS AND METHODS

Preoperative and 6-month postoperative smile photographs of ACL- or LRS-treated patients were evaluated by 100 raters (five gender-balanced groups of ten per procedure) of diverse background (dental students, general dentists, periodontists and laypersons with and without any aesthetic concerns about their own smile). Smile attractiveness was rated by visual analogue scale (VAS). Multivariate mixed-effect models were applied to determine the effect of procedure, rater (age, gender and group) and case (gingival display and GD) on smile attractiveness rating.

RESULTS

Average preoperative and postoperative VAS scores for ACL patients were 3.8 ± 2.0 and 6.2 ± 1.9, respectively. Corresponding LRS patient values were 4.8 ± 2.0 and 6.4 ± 1.9. Treatment, baseline GD and rater age were significant determinants (p < .001) of smile attractiveness for both procedures. Rater gender was not significant. Rater group was significant (p < .032) only for ACL. Procedure (p < .001), baseline VAS (p < .001), change in GD (p ≤ .002) and rater age (p ≤ .017) were significant determinants of smile attractiveness change from preoperative to postoperative.

CONCLUSIONS

ACL and LRS are two periodontal plastic surgery procedures that deliver significant smile attractiveness improvements, in the eyes of both laypersons and dental professionals.

Pediatric facial reanimation: An algorithmic approach and systematic review

Facial palsy has a broad clinical presentation and the effects on psychosocial interaction and facial functions can be devastating. Pediatric facial palsy, in particular, introduces unique familial and technical considerations as anatomy, future growth potential, and patient participation influence treatment planning. Though some etiologies of pediatric facial palsy are self-limiting, congenital and long-standing facial palsies pose difficult challenges that require a combination of surgical, adjunctive, and rehabilitative techniques to achieve facial reanimation. Given the spectrum of ages and symptom severity, as well as the various surgical options available for facial palsy, a tailored approach needs to be developed for each child to restore facial balance and function. Here, we review the etiologies, workup, and treatment of pediatric facial palsy and present our novel algorithmic approach to treatment.

Free Functional Gracilis Flaps for Facial Reanimation in Elderly Patients

Importance: The free functional gracilis flap (FFGF) is a versatile procedure in reanimating the paralyzed face, yet its application in seniors is limited by perceptions of morbidity and inefficacy. Objective: The study objective was to compare the morbidity and effectiveness of FFGF reanimation among senior and younger patients. Design, Setting, and Participants: A retrospective chart review was performed on 20 consecutive patients aged 60 years and above (seniors) and 35 patients aged 40 years and below (juniors) who underwent FFGF for facial reanimation. Among this group, 16 senior and 22 junior patients with available long-term follow-up data were analyzed for functional outcomes. Main Outcomes and Measures: The length of postoperative stay and postoperative complications were compared with assess immediate results. A second analysis for functional outcomes was assessed by resting and smile facial asymmetry index (FAI), as well as maxillary dental display to compare facial tone and lip excursion. Results: The average age of seniors was 67 ± 5 years and that of juniors was 27 ± 10 years. Mean lengths of postoperative stay were 4 ± 2 versus 3 ± 1 days in seniors versus Juniors, respectively (p = 0.16). There were no intraoperative complications and postoperative complications in one (5%) senior and four (11%) juniors (p = 0.64). There was functional muscle recovery in all cases, with more pronounced correction of both resting (Δ3.0 mm vs. Δ2.4 mm, p = 0.66) and dynamic (Δ5.2 mm vs. Δ4.2 mm, p = 0.37) FAI in seniors than in juniors. Among patients who underwent a multivector FGFF, there was an additional three versus one visualized maxillary teeth (p = 0.03) in seniors versus juniors, respectively. Conclusions and Relevance: The FFGF is effective for facial reanimation among seniors and can be performed with minimal morbidity. Age alone should not preclude the application of the FFGF in seniors with a preference for more dynamic options.

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.

The Social Perception of Microtia and Auricular Reconstruction

OBJECTIVES

To examine the social perception of microtia and quantify the effect of reconstruction on socially perceived attributes.

METHODS

Parental consent was obtained for peri-reconstruction photographs in a patient with unilateral grade 3 microtia without an underlying craniofacial syndrome. With computer simulation, the normal, preoperative microtia, and postoperative reconstruction ear were isolated and blended into the oblique and lateral views of that volunteer's face to isolate ear morphology as a variable against a constant facial baseline. These photographs were embedded into Web-based surveys with visual analogue scales to capture social perception data and then were sourced to general population adults.

RESULTS

Survey respondents totaled 631. On average, the face with the microtia ear was perceived to be less friendly (P = .015), less healthy (P = .022), and less successful (P = .005) than the same face with the "normal" ear. There were no statistically significant differences in socially perceived attributes between the face with the normal ear and the face with the reconstructed ear.

CONCLUSION

This is the first study to examine the social perception consequences of microtia and microtia reconstruction in children. These findings may explain the significant psychosocial distress experienced by these patients by exploring the social perception of specific attributes perceived. Lastly, this study may better inform microtia patients and their physicians on the impact of auricular reconstruction on third party's perception of social attributes.

LEVEL OF EVIDENCE

N/A Laryngoscope, 131:195-200, 2021.

Measuring Outcomes of Mohs Defect Reconstruction Using Eye-Tracking Technology

Importance

Objectively measuring how Mohs defect reconstruction changes casual observer attention has important implications for patients and facial plastic surgeons.

Objective

To use eye-tracking technology to objectively measure the ability of Mohs facial defect reconstruction to normalize facial attention.

Design, Setting, and Participants

This observational outcomes study was conducted at an academic tertiary referral center from January to June 2016. An eye-tracking system was used to record how 82 casual observers directed attention to photographs of 32 patients with Mohs facial defects of varying sizes and locations before and after reconstruction as well as 16 control faces with no facial defects. Statistical analysis was performed from November 2018 to January 2019.

Main Outcomes and Measures

First, the attentional distraction caused by facial defects was quantified in milliseconds of gaze time using eye tracking. Second, the eye-tracking data were analyzed using mixed-effects linear regression to assess the association of facial defect reconstruction with normalized facial attention.

Results

The 82 casual observers (63 women and 19 men; mean [SD] age, 34 [12] years) viewed control faces in a similar and consistent fashion, with most attention (65%; 95% CI, 62%-69%) directed at the central triangle, which includes the eyes, nose, and mouth. The eyes were the most visually important feature, capturing a mean of 60% (95% CI, 57%-64%) of fixation time within the central triangle and 39% (95% CI, 36%-43%) of total observer attention. The presence of Mohs defects was associated with statistically significant alterations in this pattern of normal facial attention. The larger the defect and the more centrally a defect was located, the more attentional distraction was observed, as measured by increased attention on the defect and decreased attention on the eyes, ranging from 729 (95% CI, 526-931) milliseconds for small peripheral defects to 3693 (95% CI, 3490-3896) milliseconds for large central defects. Reconstructive surgery was associated with improved gaze deviations for all faces and with normalized attention directed to the eyes for all faces except for those with large central defects.

Conclusions and Relevance

Mohs defects are associated with altered facial perception, diverting attention from valuable features such as the eyes. Reconstructive surgery was associated with normalized attentional distraction for many patients with cutaneous Mohs defects. These data are important to patients who want to know how reconstructive surgery could change the way people look at their face. The data also point to the possibility of outcomes prediction based on facial defect size and location before reconstruction. Eye tracking is a valuable research tool for outcomes assessment that lays the foundation for understanding how reconstructive surgery may change perception and normalize facial deformity.

Comparison of Objective Outcomes in Dynamic Lower Facial Reanimation With Temporalis Tendon and Gracilis Free Muscle Transfer

Importance

Facial paralysis affects patients' physical, social, and psychological function. Dynamic smile reanimation can mitigate these effects, but there are limited data to guide the surgeon in selecting the best reanimation procedure for each patient.

Objective

To compare quantitative changes in oral commissure symmetry and smile excursion following temporalis tendon transfer (T3) and gracilis free muscle transfer.

Design, Setting, and Participants

Retrospective case series of 28 adults with unilateral facial paralysis seeking dynamic lower facial reanimation at a tertiary academic medical center between July 1, 2010, and July 30, 2014. Data were analyzed from May 1, 2016, to June 30, 2016.

Interventions

Minimally invasive T3 (n = 14) compared with gracilis free muscle transfer (n = 14).

Main Outcomes and Measures

Measured symmetry of the oral commissure between the healthy and paralyzed sides in the horizontal, vertical, and angular dimension and excursion of the paralyzed commissure following reanimation compared with the healthy commissure.

Results

Of the 28 patients, 19 (68%) were women; mean (SD) age was 51.7 (17) years. Commissure symmetry during smile improved significantly for the T3 patients in the vertical and angular dimensions, and the gracilis free muscle transfer patients had significant improvement in the vertical and horizontal dimensions. Commissure excursion significantly improved in both groups following surgery, with a larger improvement seen in the gracilis free muscle transfer group (11.3 mm; 95% CI, 7.0 to 15.5 mm) compared with the T3 group (4.8 mm; 95% CI, 0.2 to 9.3 mm), with a mean difference of 6.5 mm (95% CI, 0.7 to 12.4 mm; Cohen d, 0.86). Postoperative smile excursion of the paralyzed side was within 1.0 mm of the healthy side in the gracilis free muscle transfer group (95% CI, -2.1 to 4.0 mm).

Conclusions and Relevance

Temporalis tendon transfer and gracilis free muscle transfer both improve oral commissure symmetry and excursion in facial paralysis. The improvement in smile excursion appears to be larger in patients treated with gracilis free muscle transfer and, on average, the excursion approximates the contralateral healthy side.

The Multivector Gracilis Free Functional Muscle Flap for Facial Reanimation

Importance

A multivector functional muscle flap that closely simulates the biomechanical effects of facial muscle groups is essential for complete smile restoration after facial paralysis.

Objective

To determine the feasibility of a multivector gracilis muscle flap design for reanimation after facial paralysis and to analyze the effect on the smile display zone.

Design, Setting, and Participants

Prospective analysis of patients who underwent a double paddle multivector gracilis flap for complete facial paralysis between June 2015 and December 2016 was carried out in a tertiary hospital.

Interventions

The gracilis muscle was harvested as a double paddle flap and inserted along 2 vectors for facial reanimation.

Main Outcomes and Measures

The primary outcome measures were: (1) dental display (the number of maxillary teeth displayed on paralyzed vs normal sides), (2) exposed maxillary gingival scaffold width, (3) interlabial gap at midline and canine, (4) facial asymmetry index (FAI), and (5) dynamic periorbital wrinkling.

Results

There were 10 women and 2 men between ages 20 and 64 years (mean [SD], 46 [15] years). Five flaps were reinnervated with facial and masseteric nerves, 5 with masseteric nerve only, and 2 with crossfacial nerve only. There was functional muscle recovery in all cases. On average there was additional 3.1 maxillary teeth exposed posttreatment when smiling (5.5 vs 8.6; CI, 7.9 to 16.6; P < .001). The mean exposed maxillary gingival scaffold width improved from 31.5 mm to 43.7 mm (95% CI, 1.9 to 4.3; P < .001). There was no significant difference in interlabial exposure at midline (7.1 mm vs 7.7 mm; CI, -1.5 to 2.7; P = .56) but a 56.4% improvement at the level of the canines (3.9 vs 6.1; CI, 0.1 to 4.3; P = .04). The mean FAI when smiling was reduced from 9.1 mm to 4.5 mm (CI, -8.0 to -1.2; P = .01). Dynamic wrinkling of the periorbital area with smiling was noted in 4 patients.

Conclusions and Relevance

The gracilis flap can be reliably designed as a functional double paddle muscle flap for a multivector facial reanimation. The multivector gracilis flap design is effective in improving all components of the smile display zone and has the potential for producing periorbital-wrinkling characteristic of a Duchenne smile.

Level of Evidence

4.

Outcome Tracking in Facial Palsy

Outcome tracking in facial palsy is multimodal, consisting of patient-reported outcome measures, clinician-graded scoring systems, objective assessment tools, and novel tools for layperson and spontaneity assessment. Patient-reported outcome measures are critical to understanding burden of disease in facial palsy and effects of interventions from the patient perspective. Clinician-graded scoring systems are inherently subjective and no 1 single system satisfies all needs. Objective assessment tools quantify facial movements but can be laborious. Recent advances in facial recognition technology have enabled automated facial measurements. Novel assessment tools analyze attributes such as spontaneous smile, emotional expressivity, disfigurement, and attractiveness as determined by laypersons.

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.

Association Among Facial Paralysis, Depression, and Quality of Life in Facial Plastic Surgery Patients

Importance

Though anecdotally linked, few studies have investigated the impact of facial paralysis on depression and quality of life (QOL).

Objective

To measure the association between depression, QOL, and facial paralysis in patients seeking treatment at a facial plastic surgery clinic.

Design, Setting, Participants

Data were prospectively collected for patients with all-cause facial paralysis and control patients initially presenting to a facial plastic surgery clinic from 2013 to 2015. The control group included a heterogeneous patient population presenting to facial plastic surgery clinic for evaluation. Patients who had prior facial reanimation surgery or missing demographic and psychometric data were excluded from analysis.

Main Outcomes and Measures

Demographics, facial paralysis etiology, facial paralysis severity (graded on the House-Brackmann scale), Beck depression inventory, and QOL scores in both groups were examined. Potential confounders, including self-reported attractiveness and mood, were collected and analyzed. Self-reported scores were measured using a 0 to 100 visual analog scale.

Results

There was a total of 263 patients (mean age, 48.8 years; 66.9% were female) were analyzed. There were 175 control patients and 88 patients with facial paralysis. Sex distributions were not significantly different between the facial paralysis and control groups. Patients with facial paralysis had significantly higher depression, lower self-reported attractiveness, lower mood, and lower QOL scores. Overall, 37 patients with facial paralysis (42.1%) screened positive for depression, with the greatest likelihood in patients with House-Brackmann grade 3 or greater (odds ratio, 10.8; 95% CI, 5.13-22.75) compared with 13 control patients (8.1%) (P < .001). In multivariate regression, facial paralysis and female sex were significantly associated with higher depression scores (constant, 2.08 [95% CI, 0.77-3.39]; facial paralysis effect, 5.98 [95% CI, 4.38-7.58]; female effect, 1.95 [95% CI, 0.65-3.25]). Facial paralysis was associated with lower QOL scores (constant, 81.62 [95% CI, 78.98-84.25]; facial paralysis effect, -16.06 [95% CI, -20.50 to -11.62]).

Conclusions and Relevance

For treatment-seeking patients, facial paralysis was significantly associated with increased depression and worse QOL scores. In addition, female sex was significantly associated with increased depression scores. Moreover, patients with a greater severity of facial paralysis were more likely to screen positive for depression. Clinicians initially evaluating patients should consider the psychological impact of facial paralysis to optimize care.

Level of Evidence

2.

Societal Value of Surgery for Facial Reanimation

Importance

Patients with facial paralysis are perceived negatively by society in a number of domains. Society's perception of the health utility of varying degrees of facial paralysis and the value society places on reconstructive surgery for facial reanimation need to be quantified.

Objective

To measure health state utility of varying degrees of facial paralysis, willingness to pay (WTP) for a repair, and the subsequent value of facial reanimation surgery as perceived by society.

Design, Setting, and Participants

This prospective observational study conducted in an academic tertiary referral center evaluated a group of 348 casual observers who viewed images of faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) categorized by House-Brackmann grade. Structural equation modeling was performed to understand associations among health utility metrics, WTP, and facial perception domains. Data were collected from July 16 to September 26, 2015.

Main Outcomes and Measures

Observer-rated (1) quality of life (QOL) using established health utility metrics (standard gamble, time trade-off, and a visual analog scale) and (2) their WTP for surgical repair.

Results

Among the 348 observers (248 women [71.3%]; 100 men [28.7%]; mean [SD] age, 29.3 [11.6] years), mixed-effects linear regression showed that WTP increased nonlinearly with increasing severity of paralysis. Participants were willing to pay $3487 (95% CI, $2362-$4961) to repair low-grade paralysis, $8571 (95% CI, $6401-$11 234) for medium-grade paralysis, and $20 431 (95% CI, $16 273-$25 317) for high-grade paralysis. The dominant factor affecting the participants' WTP was perceived QOL. Modeling showed that perceived QOL decreased with paralysis severity (regression coefficient, -0.004; 95% CI, -0.005 to -0.004; P < .001) and increased with attractiveness (regression coefficient, 0.002; 95% CI, 0.002 to 0.003; P < .001). Mean (SD) health utility scores calculated by the standard gamble metric for low- and high-grade paralysis were 0.98 (0.09) and 0.77 (0.25), respectively. Time trade-off and visual analog scale measures were highly correlated. We calculated mean (SD) WTP per quality-adjusted life-year, which ranged from $10 167 ($14 565) to $17 008 ($38 288) for low- to high-grade paralysis, respectively.

Conclusions and Relevance

Society perceives the repair of facial paralysis to be a high-value intervention. Societal WTP increases and perceived health state utility decreases with increasing House-Brackmann grade. This study demonstrates the usefulness of WTP as an objective measure to inform dimensions of disease severity and signal the value society places on proper facial function.

Level of Evidence

NA.

Outcome of a graduated minimally invasive facial reanimation in patients with facial paralysis

Peripheral paralysis of the facial nerve is the most frequent of all cranial nerve disorders. Despite advances in facial surgery, the functional and aesthetic reconstruction of a paralyzed face remains a challenge. Graduated minimally invasive facial reanimation is based on a modular principle. According to the patients' needs, precondition, and expectations, the following modules can be performed: temporalis muscle transposition and facelift, nasal valve suspension, endoscopic brow lift, and eyelid reconstruction. Applying a concept of a graduated minimally invasive facial reanimation may help minimize surgical trauma and reduce morbidity. Twenty patients underwent a graduated minimally invasive facial reanimation. A retrospective chart review was performed with a follow-up examination between 1 and 8 months after surgery. The FACEgram software was used to calculate pre- and postoperative eyelid closure, the level of brows, nasal, and philtral symmetry as well as oral commissure position at rest and oral commissure excursion with smile. As a patient-oriented outcome parameter, the Glasgow Benefit Inventory questionnaire was applied. There was a statistically significant improvement in the postoperative score of eyelid closure, brow asymmetry, nasal asymmetry, philtral asymmetry as well as oral commissure symmetry at rest (p < 0.05). Smile evaluation revealed no significant change of oral commissure excursion. The mean Glasgow Benefit Inventory score indicated substantial improvement in patients' overall quality of life. If a primary facial nerve repair or microneurovascular tissue transfer cannot be applied, graduated minimally invasive facial reanimation is a promising option to restore facial function and symmetry at rest.

Reconstruction of facial nerve after radical parotidectomy

CONCLUSION

Most patients benefitted from immediate facial nerve grafting after radical parotidectomy. Even weak movement is valuable and can be augmented with secondary static operations. Post-operative radiotherapy does not seem to affect the final outcome of facial function.

OBJECTIVES

During radical parotidectomy, the sacrifice of the facial nerve results in severe disfigurement of the face. Data on the principles and outcome of facial nerve reconstruction and reanimation after radical parotidectomy are limited and no consensus exists on the best practice.

METHOD

This study retrospectively reviewed all patients having undergone radical parotidectomy and immediate facial nerve reconstruction with a free, non-vascularized nerve graft at the Helsinki University Hospital, Helsinki, Finland during the years 1990-2010. There were 31 patients (18 male; mean age = 54.7 years; range = 30-82) and 23 of them had a sufficient follow-up time.

RESULTS

Facial nerve function recovery was seen in 18 (78%) of the 23 patients with a minimum of 2-year follow-up and adequate reporting available. Only slight facial movement was observed in five (22%), moderate or good movement in nine (39%), and excellent movement in four (17%) patients. Twenty-two (74%) patients received post-operative radiotherapy and 16 (70%) of them had some recovery of facial nerve function. Nineteen (61%) patients needed secondary static reanimation of the face.

Medidas faciais em indivíduos adultos sem queixas orofaciais: compatibilidade entre medidas antropométricas e percepção facial

OBJETIVO: verificar a compatibilidade entre os achados de medidas faciais mensuradas pelo paquímetro e a percepção das características faciais realizada subjetivamente por um avaliador experiente. MÉTODOS: foram avaliados 24 sujeitos do sexo feminino e 24 do sexo masculino, pareados por sexo e idade, sem queixas morfológicas e funcionais do sistema estomatognático. Foram avaliados os aspectos de simetria entre os terços médio e inferior, altura e largura da face, e canto externo dos olhos direito e esquerdo às comissuras do lábio direita e esquerda, respectivamente. Cada medida foi realizada três vezes por paquímetro digital para consideração da média entre estes valores, considerando-se assimétricas comparações com diferenças superiores à 4 milímetros. A largura da face foi obtida por meio do paquímetro digital adaptado com prolongamento de 10 centímetros. Já a avaliação da percepção das características faciais foi realizada por um avaliador cegado quanto às medidas obtidas, devendo assinalar simetrias e assimetrias nestes mesmos aspectos avaliativos. RESULTADOS: por meio do teste de concordância de Kappa e Qui-quadrado, pode-se verificar uma boa compatibilidade entre as avaliações realizadas, demonstrando-se a fidedignidade entre os métodos utilizados. Além disso, verificou-se que existe uma relação entre a simetria dos terços da face e a atribuição da tipologia facial na avaliação perceptiva, observando-se simetria em faces médias e curtas e ausência de um padrão determinante para faces longas. CONCLUSÃO: a caracterização da simetria facial por paquímetro apresenta uma boa compatibilidade com a percepção subjetiva de um avaliador experiente.

Functional outcomes of face transplantation

In this study we provide a compilation of functional impairments before and improvements after face transplantation (FT) of five FT recipients of our institution and all FTs reported in current literature. Functional outcome included the ability to smell, breath, eat, speak, grimace and facial sensation. Before FT, all our patients revealed compromised ability to breath, eat, speak, grimace and experience facial sensation. The ability to smell was compromised in two of our five patients. Two patients were dependent on tracheostomy and one on gastrostomy tubes. After FT, all abilities were significantly improved and all patients were independent from artificial air airways and feeding tubes. Including data given in current literature about the other 24 FT recipients in the world, the abilities to smell, eat and feel were enhanced in 100% of cases, while the abilities of breathing, speaking and facial expressions were ameliorated in 93%, 71% and 76% of cases, respectively. All patients that required gastrostomy and 91% of patients depending on tracheostomy were decannulated after FT. Unfortunately, outcomes remain unreported in all other cases and therefore we are unable to comment on improvements.

Seeing is believing: objectively evaluating the impact of facial reanimation surgery on social perception

OBJECTIVES/HYPOTHESIS

Objectively measure the ability of facial reanimation surgery to normalize the appearance of facial paralysis using eye-tracking technology.

STUDY DESIGN

Prospective randomized controlled experiment.

METHODS

An eye-tracker system was used to record the eye-movement patterns, called scanpaths, of 86 naïve observers gazing at pictures of paralyzed faces (House-Brackmann IV-VI), smiling and in repose; before and after facial reanimation surgery; as well as normal, nonparalyzed faces. Observers gazed at each face for 10 seconds. Fixation durations for all predefined facial areas of interest were analyzed using mixed-effects linear regression.

RESULTS

Observers spent the majority of time (6.6 of 10 seconds) gazing in the central triangle region (eyes, nose, and mouth) of normal faces and paralyzed faces. There were significant deviations in fixation within the central triangle of paralyzed faces as compared to normal faces. Total fixation on the eyes remained conserved. However, total nose fixation decreased and mouth fixation increased on paralyzed faces. Facial reanimation surgery normalized many of the hemifacial gaze asymmetries caused by unilateral facial paralysis, and restored a normal distribution of gaze between the functional and paralyzed sides of the face and mouth.

CONCLUSION

There were objective differences in the way observers directed their attention to facial features when viewing normal and paralyzed faces. After facial reanimation surgery, the attentional distraction caused by facial feature irregularities was reduced. These findings are important additions to the emerging body of objective evidence indicating the effectiveness of reanimation surgery; they also suggest opportunities to optimize reconstruction.

LEVEL OF EVIDENCE

N/A.

Geometric facial gender scoring: objectivity of perception

Gender score is the cognitive judgement of the degree of masculinity or femininity of a face which is considered to be a continuum. Gender scores have long been used in psychological studies to understand the complex psychosocial relationships between people. Perceptual scores for gender and attractiveness have been employed for quality assessment and planning of cosmetic facial surgery. Various neurological disorders have been linked to the facial structure in general and the facial gender perception in particular. While, subjective gender scoring by human raters has been a tool of choice for psychological studies for many years, the process is both time and resource consuming. In this study, we investigate the geometric features used by the human cognitive system in perceiving the degree of masculinity/femininity of a 3D face. We then propose a mathematical model that can mimic the human gender perception. For our experiments, we obtained 3D face scans of 64 subjects using the 3dMDface scanner. The textureless 3D face scans of the subjects were then observed in different poses and assigned a gender score by 75 raters of a similar background. Our results suggest that the human cognitive system employs a combination of Euclidean and geodesic distances between biologically significant landmarks of the face for gender scoring. We propose a mathematical model that is able to automatically assign an objective gender score to a 3D face with a correlation of up to 0.895 with the human subjective scores.