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Original Investigation |

Association of Facial Paralysis–Related Disability With Patient- and Observer-Perceived Quality of Life

Jennifer B. Goines, BS1; Lisa E. Ishii, MD, MHS2; Jacob K. Dey, BS2; Maria Phillis, JD2; Patrick J. Byrne, MD2; Kofi D. O. Boahene, MD2; Masaru Ishii, MD, PhD3
[+] Author Affiliations
1Medical student, Morehouse School of Medicine, Atlanta, Georgia
2Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
3Division of Rhinology, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
JAMA Facial Plast Surg. 2016;18(5):363-369. doi:10.1001/jamafacial.2016.0483.
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Importance  The interaction between patient- and observer-perceived quality of life (QOL) and facial paralysis–related disability and the resulting effect of these interactions on social perception are incompletely understood.

Objective  To measure the associations between observer-perceived disability and QOL and patient-perceived disability and QOL in patients with facial paralysis.

Design, Setting, and Participants  This prospective study in an academic tertiary referral center included 84 naive observers who viewed static and dynamic images of faces with unilateral, House-Brackmann grades IV to VI facial paralysis (n = 16) and demographically matched images of nonparalyzed control individuals (n = 4). Data were collected from June 1 to August 1, 2014, and analyzed from August 2 to December 1, 2014.

Main Outcomes and Measures  Observers rated the patient and control images in 6 clinically relevant domains. The patients self-reported their disability and QOL using validated tools, such as the Facial Clinimetric Evaluation Scale. Quality of life, severity of paralysis, and disability were measured on a 100-point visual analog scale.

Results  The 84 observers (59 women [70%] and 25 men [30%]) ranged in age from 20 to 68 years (mean [SD] age, 35.2 [11.9]). Structural equation modeling showed that for each 1-point decrease in a patient’s Facial Clinimetric Evaluation Scale score, the patient’s visual analog scale QOL improved by 0.36 (SE, 0.03; 95% CI, 0.31-0.42) points. Similarly, from an observer perspective, as the perceived disability (−0.29 [SE, 0.04; 95% CI, −0.36 to −0.22]) and severity (−0.21 [SE, 0.03; 95% CI, −0.28 to −0.14]) decreased, the perceived QOL improved. Furthermore, attractive faces were viewed as having better QOL (disability, severity, and attractiveness regression coefficients, −0.29 [SE, 0.04; 95% CI, −0.36 to −0.22], −0.21 [SE, 0.03; 95% CI, −0.28 to −0.14], and 0.32 [SE, 0.03; 95% CI, 0.26 to 0.39], respectively). An inverse association was found between a paralyzed patient’s self-reported QOL rating and the observers’ perceived QOL. This association was complex and was mediated through perceived severity and disability. Observers judged the severity of paralyzed faces to be 3.61 (SE, 1.80; 95% CI, 0.09-7.14) points more severe when viewing dynamic rather than static images.

Conclusions and Relevance  Observers were more likely to rate QOL lower owing to disability than were the patients with paralysis. This finding may be explained by previous literature reporting that disabled people adjust their values to accommodate their disability, thereby limiting the negative effect on their QOL. Given the importance of QOL on social interaction, the dissonance between observers and patients in this area has important implications for the socialization of patients with facial paralysis.

Level of Evidence  NA.

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Figure 1.
Examples of Facial Paralysis Images Used as Static Study Stimuli

Faces on the left depict static repose; faces on the right, static smile. House-Brackmann scale for facial paralysis ranges from grades I to VI, with VI indicating total paralysis.

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Figure 2.
Conceptual Path Diagram

The diagram illustrates dominant interactions among the variables in the structural equation model for facial paralysis–related disability. QOL indicates quality of life.

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