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Original Investigation |

Weighting of Facial Grading Variables to Disfigurement in Facial Palsy

Caroline A. Banks, MD1; Nate Jowett, MD1; Charles R. Hadlock, PhD2; Tessa A. Hadlock, MD1
[+] Author Affiliations
1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Harvard Medical School/Massachusetts Eye and Ear Infirmary, Boston
2Department of Mathematical Sciences, Bentley University, Waltham, Massachusetts
JAMA Facial Plast Surg. 2016;18(4):292-298. doi:10.1001/jamafacial.2016.0226.
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Importance  A universal, health care professional–graded scale for facial assessment would be a useful tool for reporting, comparing, and assessing facial function among patients with facial paralysis.

Objectives  To correlate scores of an assessment tool, the eFACE scale, with expert-rated facial disfigurement and to determine the relative contributions of facial features to facial palsy–related disfigurement.

Design, Setting, and Participants  The eFACE scale yields 15 individual variable scores, in addition to subscores for static, dynamic, and synkinesis elements, and a total score that is based on 100-point scales. Two hundred patients with varying degrees of unilateral facial palsy underwent independent eFACE assessment and assignment of a disfigurement score by 2 facial nerve surgeons. The mean scores were determined, and multivariate regression analysis was performed to fit eFACE subset scores (static, dynamic, and synkinesis) to disfigurement ratings. A hybrid regression model was then used to weight each of the 15 eFACE variables, using stepwise regression to control for the effect of the other variables. Scoring was performed during an 8-week period from March 16 to May 8, 2015.

Main Outcome and Measure  Use of the 100-point eFACE variables, together with a 100-point visual analog scale of disfigurement, with 0 representing the most extreme disfigurement possible from a facial nerve disorder and 100 representing no discernible facial disfigurement.

Results  In the 200 patients included in analysis (126 [63.0% female]; mean [SD] age, 46.5 [16.4] years]), predicted disfigurement scores based on eFACE subset scores demonstrated excellent agreement with surgeon-graded disfigurement severity (r2 = 0.79). Variable weighting demonstrated that the 6 key contributors to overall disfigurement were (in order of importance) nasolabial fold depth at rest (normalized coefficient [NC], 0.18; P < .001), oral commissure position at rest (NC, 0.15; P < .001), lower lip asymmetry while pronouncing the long /ē/ (NC, 0.09; P < .001), palpebral fissure width at rest (NC, 0.09; P < .001), nasolabial fold orientation with smiling (NC, 0.08; P = .001), and palpebral fissure width during attempts at full eye closure (NC, 0.06; P = .03).

Conclusions and Relevance  A mathematical association between eFACE-measured facial features and overall expert-graded disfigurement in facial paralysis has been established. For those using the eFACE grading scale, predictions of the specific effects of various interventions on expert-rated disfigurement are now possible and may guide therapy.

Level of Evidence  NA.

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Figure 1.
The eFACE Scale

Graphical user interface eFACE input screen, demonstrating 15 variables grouped into 3 categories: static (4 variables), dynamic (7), and synkinesis (4).

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Figure 2.
Score Distributions

Histograms demonstrating the distribution of expert-rated disfigurement severity scores (A) and eFACE static (B), eFACE dynamic (C), and eFACE synkinesis (D) subset scores. For disfigurement scoring, “0” represents the most extreme disfigurement possible from a facial nerve disorder, and “100” represents no discernible disfigurement. For eFACE scoring, “0” represents the most extreme facial asymmetry possible, and “100” represent complete symmetry with the contralateral.

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Figure 3.
eFACE Model Predicted vs Expert-Graded Disfigurement Scores

A plot of predicted disfigurement scores based on the developed mathematical model for which inputs are expert-rated eFACE subset scores vs actual expert-rated disfigurement scores demonstrates high correlation (r2 = 0.79; P < .05 for all 3 variables). The equation governing the model is as follows: predicted disfigurement = −38.895 + [0.488 (static eFACE score)] + [0.761 (dynamic eFACE score)] + [0.119 (synkinesis eFACE score)]. For disfigurement scoring, “0” represents the most extreme disfigurement possible from a facial nerve disorder, and “100” represents no discernible disfigurement.

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Figure 4.
Weighted Scores of Individual eFACE Variables to Disfigurement

A hybrid regression model was used to determine the relative contribution of each eFACE variable to expert-graded disfigurement. NLF indicates nasolabial fold.

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