Changes in Articulatory Control Pre- and Post-Facial Transplant: A Case Report

Neuromotor Speech Recovery Across Different Behavioral Speech Modifications in Individuals Following Facial Transplantation

Despite signs of facial nerve recovery within a few months following face transplantation, speech deficits persist for years. Behavioral speech modifications (e.g., slower-than-normal speaking rate and increased loudness) have shown promising potential to enhance speech intelligibility in populations with dysarthric speech. However, such evidence-based practice approach is lacking in clinical management of speech in individuals with facial transplantation. Because facial transplantation involves complex craniofacial reconstruction and facial nerve coaptation, it is unknown to what extent individuals with face transplant are capable of adapting their motor system to task-specific articulatory demands. The purpose of this study was to identify the underlying articulatory mechanisms employed by individuals with face transplantation in response to speech modification cues at early and late stages of neuromotor recovery. In addition, we aimed to identify speech modifications that conferred improved speech clarity. Participants were seven individuals who underwent full or partial facial vascularized composite allografts that included lips and muscles of facial animation and were in early (~2 months) or late (~42 months) stages of recovery. Participants produced repetitions of the sentence “Buy Bobby a puppy” in normal, fast, loud, and slow speech modifications. Articulatory movement traces were recorded using a 3D optical motion capture system. Kinematic measures of average speed (mm/s) and range of movement (mm³) were extracted from the lower lip (± jaw) marker. Two speech language pathologists rated speech clarity for each speaker using a visual analog scale (VAS) approach. Results demonstrated that facial motor capacity increased from early to late stages of recovery. While individuals in the early group exhibited restricted capabilities to adjust their motor system based on the articulatory demands of each speech modification, individuals in the late group demonstrated faster speed and larger-than-normal range of movement for loud speech, and slower speed and larger-than-normal range of movement for slow speech. In addition, subjects in both groups showed overreliance on jaw rather than lip articulatory function across all speech modifications, perhaps as a compensatory strategy to optimize articulatory stability and maximize speech function. Finally, improved speech clarity was associated with loud speech in both stages of recovery.

Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review

Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field.

Recognizing Emotional Expression as an Outcome Measure After Face Transplant

IMPORTANCE

Limited quantitative data exist on the restoration of nonverbal communication via facial emotional expression after face transplant. Objective and noninvasive methods for measuring outcomes and tracking rehabilitation after face transplant are lacking.

OBJECTIVE

To measure emotional expression as an indicator of functional outcomes and rehabilitation after face transplant via objective, noninvasive, and nonobtrusive software-based video analysis.

DESIGN, SETTING, AND PARTICIPANTS

This single-center case-control study analyzed videos with commercially available video analysis software capable of detecting emotional expression. The study participants were 6 patients who underwent face transplant at Brigham and Women's Hospital between April 2009 and March 2014. They were matched by age, race/ethnicity, culture, and sex to 6 healthy controls with no prior facial surgical procedures. Participants were asked to perform either emotional expressions (direct evaluation) or standardized facial movements (indirect evaluation). Videos were obtained in a clinical setting, except for direct evaluation videos of 3 patients that were recorded at the patients' residences. Data analysis was performed from June 2018 to November 2018.

MAIN OUTCOMES AND MEASURES

The possibility of detecting the emotional expressions of happiness, sadness, anger, fear, surprise, and disgust was evaluated using intensity score values between 0 and 1, representing expressions that are absent or fully present, respectively.

RESULTS

Six patients underwent face transplant (4 men; mean [SD] age, 42 [14] years). Four underwent full face transplants, and 2 underwent partial face transplants of the middle and lower two-thirds of the face. In healthy controls, happiness was the only emotion reliably recognized in both indirect (mean [SD] intensity score, 0.92 [0.05]) and direct (mean [SD] intensity score, 0.91 [0.04]) evaluation. Indirect evaluation showed that expression of happiness significantly improved 1 year after transplant (0.04 point per year; 95% CI, 0.02 to 0.06 point per year; P = .002). Expression of happiness was restored to a mean of 43% (range, 14% to 75%) of that of healthy controls after face transplant. The expression of sadness showed a significant change only during the first year after transplant (-0.53 point per year; 95% CI, -0.82 to -0.24 point per year; P = .005). All other emotions were detectable with no significant change after transplant. Nearly all emotions were detectable in long-term direct evaluation of 3 patients, with expression of happiness restored to a mean of 26% (range, 5% to 59%) of that of healthy controls.

CONCLUSIONS AND RELEVANCE

Partial restoration of facial emotional expression is possible after face transplant. Video analysis software may provide useful clinical information and aid rehabilitation after face transplant.