Surgical Management of Facial Paralysis: Demographic and Socioeconomic Associations

Objective: To determine demographic and socioeconomic variables associated with whether surgery is performed for patients with facial paralysis (FP). Background: Management of FP may include elective surgery dependent on patient goals of care and physician experience. Methods: The 2016 State Inpatient Database and State Ambulatory Surgery Services Database for six states were queried to identify patients with FP. These patients were then stratified based on receiving surgery for FP. Demographic and socioeconomic information was collected. Multivariable logistic regression modeling was used to identify predictors of undergoing FP surgery, as well as the hospital setting in which surgery was performed. Results: Of 20,218 patients with FP, 515 underwent surgery. Black patients were significantly less likely to undergo surgery (p < 0.001), as were patients with Medicaid or self-pay insurance (p < 0.001). Those living in rural areas were also less likely to receive surgery (p = 0.001). Individuals receiving surgery in the inpatient setting were more likely to have private insurance, whereas those in the ambulatory setting were more likely to have Medicare (p < 0.001). Conclusion: Several variables are correlated with whether FP is managed surgically, including insurance status, race, and type of residential area.

The Valuation of Rhytidectomy in Different Economic Markets

This study demonstrates that the trend of how rhytidectomy is valued can be used to determine not only the pricing of this good but also how receptive developing economic markets are to the export of cosmetic facial plastic surgery. This study seeks to analyze and compare the value of rhytidectomy in an established market and an emerging market. A cross-sectional survey was administered through public online forums to 162 casual observers in the United States and 74 casual observers in India. Participants were shown pre- and postoperative photos of 10 patients who underwent cosmetic rhinoplasty and 2 patients who did not undergo surgery. Observers were asked to quantify the perceived change in attractiveness, change in age, and willingness to pay (WTP). There is a similar nonlinear trend between WTP and change in attractiveness in both the United States and India. Baseline values of rhytidectomy in the United States and India have a similar ratio of 2.122 compared with the ratio between both countries in the 2018 Big Mac index. The comparison of the trend in WTP in the United States and India shows that facial cosmetic surgery functions as a luxury good in both an established market and an emerging market. Our model successfully approximates the relationship between each country's purchasing power parity. Since the market behavior of rhytidectomy can be predicted based on purchasing power parity, there may be an untapped market for facial cosmetic surgery among populations with growing economies.

Assessment of Casual Observers' Willingness to Pay for Increased Attractiveness Through Rhinoplasty

Importance

Contingent valuation, or willingness to pay, is an established economic concept that has been applied in other areas of medicine and may be useful for understanding the economic forces that determine the cost of cosmetic procedures.

Objective

To determine the monetary value of changes in attractiveness achieved through rhinoplasty, as perceived by society.

Design, Setting, and Participants

Cross-sectional survey administered via public online forums to 228 casual observers.

Main Outcomes and Measures

Participants were shown preoperative and postoperative photographs of 12 patients who underwent cosmetic rhinoplasty and 4 patients who did not undergo any surgery. They were asked to rate (1) the change in overall attractiveness of the patients, and (2) the monetary value they would associate with these changes.

Results

Completed surveys were obtained from 228 casual observers; 144 were female (63.2%); median age, 25 years (median income bracket, $50 000-$75 000). Multilevel, mixed-effects, linear regression was used to characterize the association between monetary value and change in attractiveness. There was a significant association between the change in attractiveness from a rhinoplasty and its monetary value as perceived by society. The baseline value of a rhinoplasty without any change in attractiveness was $3769.98 (95% CI, $3541.59-$4007.10; P < .001). To increase 1 standard deviation in attractiveness was worth an additional $2353.77 (95% CI, $2197.57-$2512.81; P < .001), while increasing 2 standard deviations in attractiveness was worth an additional $5453.07 (95% CI, $5052.57-$5865.51; P < .001).

Conclusions and Relevance

There is a significant association between the societally perceived value of cosmetic rhinoplasty and the change in attractiveness after surgery. The average value of a rhinoplasty in our study approximates the actual average cost of cosmetic rhinoplasty, suggesting that willingness to pay may be a useful concept for studying the value of cosmetic procedures.

Level of Evidence

NA.

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.

Societal Identification of Facial Paralysis and Paralysis Location

Importance

When able to identify facial paralysis, members of society regard individuals with facial paralysis differently. They perceive a decrease in attractiveness, more negative affect, and lower quality of life. However, the ability of lay people in society to accurately identify the presence of facial paralysis has not yet been defined.

Objective

To determine societal members' ability to (1) identify paralysis in varying degrees of paralysis severity and (2) localize the defect on the face.

Design, Setting, and Participants

A prospective observational study conducted in an academic tertiary referral center using a group of 380 casual observers was carried out.

Main Outcomes and Measures

Surveys were designed containing smiling and repose images of normal faces and faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) as categorized by House-Brackmann (HB) grade. The photographs were then shown to casual observers in a web-based survey. After reviewing both normal faces and faces with varying degrees of paralysis, they then indicated (1) whether paralysis was present and (2) if so, where the paralysis was on the face.

Results

A total of 380 participants (267 [70.3%] women and 113 [29.7%] men with a mean [SD] age of 29 [12] years) successfully completed the survey, viewing 2860 facial photographs in aggregate. The accuracy rate of identifying paralysis increased from low-grade through high-grade paralysis. Facial paralysis was identified in 249 (34.6%) of 719 facial photographs with low-grade paralysis, 448 (63.2%) of 709 with medium-grade paralysis, and 696 (96.7%) of 720 with high-grade paralysis (χ2 = 912.6, P < .001); 6.2% (44/731) of normal faces were incorrectly identified as having paralysis (χ2 = 912.6, P < .001). Participants correctly localized paralysis in 157 (63.0%) of 249 low-grade photographs, 307 (68.5%) of 448 medium-grade photographs, and 554 (79.6%) of 696 high-grade photographs (χ2 = 32.5, P < .001). In general, participants tended to identify facial paralysis more accurately in smiling vs repose faces (48.6% vs 20.6%, 92.4% vs 33.7%, and 96.7% vs 96.6% in low-, medium-, and high-grade paralysis, respectively) (χ2 = 62.2, P < .001; χ2 = 262.6, P < .001; χ2 = 0.0, P = .96, respectively).

Conclusions and Relevance

The ability of individuals to identify the presence of facial paralysis increased as paralysis severity increased. Further, smiling increased accurate identification. However, even when individuals can identify paralysis, they are not necessarily able to accurately localize the paralysis on a face. This may speak to a phenomenon in which perception of a facial defect comes from a holistic interpretation of a face, rather than a clinically accurate specification of the defect location. These findings are important in the future counseling of patients.

Level of Evidence

NA.

Perception of Hair Transplant for Androgenetic Alopecia

Importance

Hair transplant is among the most common cosmetic services sought by men, with more than 11 000 procedures performed in 2014. Despite its growing popularity, the effect of hair transplant on societal perceptions of youth, attractiveness, or facets of workplace and social success is unknown.

Objectives

To determine whether hair transplant improves observer ratings of age, attractiveness, successfulness, and approachability in men treated for androgenetic alopecia and to quantify the effect of hair transplant on each of these domains.

Design, Setting, and Participants

A randomized controlled experiment was conducted from November 10 to December 6, 2015, using web-based surveys featuring photographs of men before and after hair transplant. One hundred twenty-two participants recruited through various social media platforms successfully completed the survey. Observers were shown 2 side-by-side images of each man and asked to compare the image on the left with the one on the right. Of 13 pairs of images displayed, 7 men had undergone a hair transplant procedure and 6 had served as controls. Observers evaluated each photograph using various metrics, including age, attractiveness, successfulness, and approachability. A multivariate analysis of variance was performed to understand the effect of hair transplant on observer perceptions. Planned posthypothesis testing was used to identify which variables changed significantly as a result of the transplant.

Main Outcomes and Measures

Observer ratings of age (in number of years younger) and attractiveness, successfulness, and approachability (on a scale of 0 to 100; scores higher than 50 indicate a positive change).

Results

Of the 122 participants in the survey, 58 were men (47.5%); mean (range) age was 27.1 (18-52) years. The initial multivariate analysis of variance revealed a statistically significant multivariate effect for transplant (Wilks λ = 0.9646; P < .001). Planned posthypothesis analyses were performed to examine individual differences across the 4 domains. Findings determined with t tests showed a significant positive effect of hair transplant on observers' perceptions of age (mean [SD] number of years younger, 3.6 [2.9] years; P < .001), attractiveness (mean [SD] score, 58.5 [17.5]; P < .001), successfulness (mean [SD] score, 57.1 [17.1]; P = .008), and approachability (mean [SD] score, 59.2 [18.1]; P = .02).

Conclusions and Relevance

Men were perceived as being younger and more attractive by casual observers after undergoing hair transplant. Participants also rated posttransplant faces as appearing more successful and approachable relative to their pretransplant counterparts. These aspects have been shown to play a substantial role in both workplace and social success, and these data demonstrate that hair transplant can improve ratings universally across all 4 domains.

Level of Evidence

NA.

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.

Identification of the CD32/FcgammaRIIc-Q13/STP13 polymorphism using an allele-specific restriction enzyme digestion assay

We have recently reported that in addition to FcgammaRIIIa (CD16), approximately 45% of normal individuals also express FcgammaRIIc (CD32) on their natural killer (NK) cells. We found this expression to be regulated by an allelic polymorphism localized in the first extracellular exon (EC1) of the FcgammaRIIC gene, corresponding to aa 13. This is determined by a single nucleotide substitution, which results in either a functional open reading frame (glutamine-Q) or a premature stop codon (STP). Identification of this polymorphism provided a good explanation for the lack of CD32 expression previously observed with NK cells in some normal individuals. Here, we describe a new method for detection of FcgammaRIIc allelism based on RT-PCR amplification followed by an allele-specific restriction enzyme digestion. This method is rapid, reliable and time saving, as compared to the currently available allele-specific oligo-nucleotide probe-based Southern Blotting.