Role of Body Dysmorphic Disorder in Patients With Postparalytic Facial Synkinesis

Effect of Underlying Mental Health Disorders on the Correlation Between Patient- and Surgeon-Graded Synkinesis Scores

Background: Little is known about how depression and appearance anxiety affect patient reporting of synkinesis severity. Learning/Study Objective: Measure prevalence of depression and appearance anxiety in facial synkinesis and correlations between subjective and surgeon-graded synkinesis severity. Design Type: Prospective cohort. Methods: Patients with synkinesis volunteered and completed: Synkinesis Assessment Questionnaire (SAQ), facial clinimetric evaluation (FaCE) scale, Center for Epidemiological Studies Depression Scale (CES-D), and Fear of Negative Appearance Evaluation Scale (FNAES). Standardized videos were scored by facial plastic surgeons using Sunnybrook Scale and eFaCE. Multivariate linear regression was used to compare patient- and surgeon-graded metrics. Results: One hundred patients participated, 91 were female. Mean age was 56.4 (12.3). Eight percent identified as Black and 87% White. The most common nerve injury etiology was idiopathic (47%). Mean synkinesis duration was 7.6 years (6.2). Twenty percent and 15% reported history of an anxiety or depressive disorder, respectively. Patient (SAQ, FaCE) and clinician (Sunnybrook, eFaCE) scores were correlated (Pearson's r 0.223-0.294, p < 0.05). Upon adjusting for CES-D/FNAES, correlations between most patient and clinician metrics became stronger. As CES-D and FNAES worsened, patient-clinician correlations weakened. Conclusions: Depression and appearance anxiety may affect patient reporting of synkinesis severity. Worse mental health scores may decorrelate patient and clinician synkinesis assessments.

Translation and validation of the German version of the FACE-Q paralysis module in adult patients with unilateral peripheral facial palsy

The aim was to develop and validate a German version of the FACE-Q paralysis module, a patient-reported outcome measure to assess health-related quality of life in adult patients with unilateral facial palsy. The FACE-Q craniofacial questionnaire, which includes the paralysis module, was translated. 213 patients with facial palsy completed the German FACE-Q paralysis along with the established FDI and FaCE questionnaires. Regression analyses were performed to examine the relationships between the different FACE-Q domains and patient and therapy characteristics. The FACE-Q scales had high internal consistency (Cronbach's alpha all > 0.6). High correlations were found between the FACE-Q and the FDI and FaCE (mean rho = 0.5), as well as within the FACE-Q (mean rho = 0.522). Unifactorial influences were found for all domains except Breathing (all p < 0.05). Multivariate independent predictors were found for some FACE-Q domains. Most influential predictors (> 8 subdomains): Patients who received physical therapy scored lower in ten subdomains than those who did not (all p < 0.05). Patients who had surgery scored lower in nine subdomains than patients without surgery (all p < 0.05). The German version of the FACE-Q Paralysis Module can now be used as a patient-reported outcome instrument in adult patients with facial nerve palsy.

Selective zygomaticus muscle activation by ball electrodes in synkinetically reinnervated patients after facial paralysis

Introduction

Although many different treatments were developed for facial palsy, only a few therapeutic options are available for facial synkinesis. Electrical stimulation of specific muscles via implants could be useful in restoring facial symmetry in synkinetic patients. A challenge in developing stimulation devices is finding the right stimulation location, type, and amplitude. This work assesses the ability to selectively stimulate the zygomaticus muscle (ZYG) in patients with oral-ocular synkinesis to elicit a visually detectable response of the ipsilateral corner of the mouth (COM), without causing a reaction of the orbicularis oculi muscle (OOM). We aimed to assess how close to the COM the stimulation should be delivered in order to be selective.

Methods

A total of 10 patients (eight females, two males) were enrolled. Facial function was graded according to the Sunnybrook facial grading system. Needle EMG was used to test the activities of the muscles, during volitional and "unintended" movements, and the degree of synkinesis of the ZYG and OOM. Two ball electrodes connected to an external stimulator were placed on the paretic ZYG, as close as possible to the COM.

Results

Independent of the waveform with which the stimulation was presented, a selective ZYG response was observed within 4.5 cm of the horizontal plane and 3 cm of the vertical plane of the COM. When the distance between the electrodes was kept to ≤2 cm, the amplitude necessary to trigger a response ranged between 3 and 6 mA when the stimulation was delivered with triangular pulses and between 2.5 and 3.5 mA for rectangular pulses. The required amplitude did not seem to be dependent on the applied phase duration (PD), as long as the PD was ≥5 ms.

Conclusion

Our results show that selective stimulation of the ZYG presenting synkinetic ZYG-OOM reinnervation can be achieved using a broad PD range (25-1,000 ms) and an average amplitude ≤6 mA, which may be further decreased to 3.5 mA if the stimulation is delivered via rectangular rather than triangular waves. The most comfortable and effective results were observed with PDs between 50 and 250 ms, suggesting that this range should be selected in future studies.

Clinical Trial Registration

[https://drks.de/search/de/trial/DRKS00019992], identifier (DRKS00019992).

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.

Multidisciplinary Care of Patients with Facial Palsy: Treatment of 1220 Patients in a German Facial Nerve Center

To determine treatment and outcome in a tertiary multidisciplinary facial nerve center, a retrospective observational study was performed of all patients referred between 2007 and 2018. Facial grading with the Stennert index, the Facial Clinimetric Evaluation (FaCE) scale, and the Facial Disability Index (FDI) were used for outcome evaluation; 1220 patients (58.4% female, median age: 50 years; chronic palsy: 42.8%) were included. Patients with acute and chronic facial palsy were treated in the center for a median of 3.6 months and 10.8 months, respectively. Dominant treatment in the acute phase was glucocorticoids ± acyclovir (47.2%), followed by a significant improvement of all outcome measures (p < 0.001). Facial EMG biofeedback training (21.3%) and botulinum toxin injections (11%) dominated the treatment in the chronic phase, all leading to highly significant improvements according to facial grading, FDI, and FaCE (p < 0.001). Upper eyelid weight (3.8%) and hypoglossal–facial-nerve jump suture (2.5%) were the leading surgical methods, followed by improvement of facial motor function (p < 0.001) and facial-specific quality of life (FDI, FaCE; p < 0.05). A standardized multidisciplinary team approach in a facial nerve center leads to improved facial and emotional function in patients with acute or chronic facial palsy.