Psychological and social factors in reconstructive surgery for hemi-facial palsy
Introduction
The psychological literature on the subject of facial disfigurement has consistently shown that those with facial disfigurement do experience psychological and social problems. However, there is no inevitable relationship between the degree of disfigurement and the degree of subjective distress.2 Whilst there is nothing new about stigmatising cultural and social responses to facial disfigurement,3 and those with facial disfigurement continue to report social problems,1 there are also factors that mediate individual responses such as personal resilience, strong family and social support and the development of effective coping strategies.4
Within the context of social stressors and individual differences, there is also the possibility that some types of disfigurement may be more intrinsically stressful than others. In addition, to differences between individuals, there may be factors that influence psychological outcome such as the site of the disfigurement and its aetiology.
There is evidence in the literature that those with facial palsy experience marked psychological and social problems. Normal face-to-face communication can be interrupted by altered or diminished facial expression.5 Nonverbal facial clues to emotion can be misinterpreted. The aesthetic impact of the disfigurement caused by facial palsy is exacerbated by impaired facial movement and, therefore, the individual may try to restrict expressive facial movements to minimise the disfigurement. This can be interpreted as hostile by others, provoking aggressive responses, and can increase social anxiety and avoidance. In addition, the individual may become self-conscious when eating or drinking because of functional problems.
However, research in this field is not extensive and the numbers examined have tended to be small. Hirschenfang et al.6 assessed 25 patients with facial palsy and found social difficulties, problems in initiating friendships, weakening of the family unit and difficulties in employment. Neely et al.7 assessed 11 patients with post-operative acoustic neuroma where the main concern was a generalised loss of expression and inability to smile and express feelings. They reported social and employment problems and reduced self-confidence. Kiese-Himmel et al.8 assessed 20 patients with spontaneously arising facial paralysis and compared them to 14 subjects with post-operative paralysis. They found that the latter group were significantly more disturbed and reported greater psychosocial problems than those whose condition arose spontaneously, suggesting that the cause of the condition is significant. However, as with the other studies, it is difficult to draw definitive conclusions from such small numbers
As has been noted elsewhere in psychological studies of disfigurement, psychological distress rather than functional impairment has been found to be the most significant predictor of social disability in patients with hemi-facial palsy.9 However, these authors also found that psychological distress was a moderator of the relationship between impairment and physical disability and a mediator of the relationship between impairment and social disability for individuals with facial neuromotor disorders. There is some evidence in the literature of a link between psychological and physical factors in facial palsy patients. Suguria et al.1 evaluated 23 patients with facial palsy and found high levels of psychological stress following the onset of the condition. This decreased over subsequent testing as the palsy improved.
Two-stage microsurgical reconstruction is not an easy option for the patient. What motivates those with facial palsy to seek reconstructive surgery? Does reconstructive surgery improve the psychological well-being of patients with facial palsy by improving the faces of those whose condition has not spontaneously improved? Does such surgery mimic the effect of spontaneous recovery found by Suguria10 or does this depend on nonsurgical factors as has been found elsewhere in the literature on facial disfigurement? If facial palsy is a particularly stressful condition, does any improvement through surgical intervention bring particular psychological rewards irrespective of other psychosocial factors?
This paper describes a study carried out in order to examine these issues. This is a retrospective study in which adults who have undergone reconstructive surgery were assessed in order to identify the pre-operative psychosocial impact of facial palsy, motivation for reconstructive surgery, and to identify factors which influence satisfaction with surgical outcome.
Section snippets
Materials and method
One hundred and six adults who had undergone vascularised free muscle graft reconstruction to correct hemi-facial palsy were assessed. All operations had been carried out by the same surgeon. The participants were drawn from a hospital database of 150 patients who had undergone such surgery. All were at least 12 months post-operative. Patients with learning difficulties were excluded, but these only comprised six participants. Of those initially contacted (N=144), 138 agreed to participate in
Results
Of the 106 participants assessed, 67% (N=71) had late acquired facial palsy. The largest single cause of late acquired palsy was acoustic neuroma 53.4% (N=39). The remainder were the result of a range of diverse conditions such as Bell's Palsy and other tumour removal. A small minority was a result of trauma (8.2%). The remainder 33% (N=35) of the participants had suffered from facial palsy since birth and had thus grown up with the condition.
The mean age of the total group was 43.67 years
Discussion
All the participants in this study have suffered from hemi-facial palsy and have undergone two-stage reconstructive surgery carried out by the same experienced surgeon. Their motivation for surgery was primarily related to psychosocial issues. Functional problems were less important as motivating factors for most of those seeking surgery.
The process of surgery was stressful in that they had to cope with two operations, with an increase in facial abnormality prior to the second procedure. Not
References (13)
Folklore surrounding facial deformity and the origins of facial prejudice
Br J Plast Surg
(1981)- et al.
Psychological distress: linking impairment with disability in facial neuromotor disorders
Otolaryngol head Neck Surg
(1998) - et al.
The social psychology of facial appearance
(1988) - et al.
The Emmanual Miller Memorial Lecture 1992, the theory and practice of resilience
J Child Psychol Psychiat
(1994) - et al.
Emotional experience and perception in the absence of facial feedback
J Int Neuropsychol Soc
(2002)
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☆This paper was presented at the 2004 summer meeting of the British Association of Plastic Surgery in Dublin, Eire. It was funded by a grant awarded by the Esmee Fairbairn Foundation.