Psychological and social factors in reconstructive surgery for hemi-facial palsy

Summary

This paper examines the psychological and social impact of reconstructive surgery for hemi-facial palsy and considers psychosocial factors which may be associated with patient satisfaction. It reports a retrospective study in which 106 adults were assessed using primarily qualitative methods. All participants had undergone two-stage reconstruction using vascularised free muscle grafts, with all procedures having been carried out by the same surgeon. The participants were all at least 12 months post-surgery. They were assessed using demographic questionnaires, the hospital anxiety and depression scale (HADS) and the facial paralysis evaluation measure (FPEM). In addition, all participants were interviewed using a semi-structured format, the interviews were recorded verbatim and the transcripts were analysed using thematic analysis.

Of the total study group, 67% had acquired facial palsy. The mean age of the total group was 44.7 years and 67.9% were female. As a group they were rather less depressed than the normal population with similar levels of anxiety to population norms. The primary motivation for surgery was appearance rather than function. Using interview data in addition to the FPEM, satisfaction with the process and outcome of surgery was assessed. Thirty five percent were very satisfied with both process and outcome, 34% were satisfied with the outcome but found the treatment process stressful, 15.1% were not entirely satisfied with process or outcome but felt surgery had been worthwhile as there had been some improvement. The remainder were very dissatisfied with both process and outcome and regretted having undergone surgery.

There was no significant association between dissatisfaction and anxiety, the cause of the acquired palsy, longevity prior to surgery, gender nor whether the condition was acquired or congenital. There was a significant relationship with depression, in that those who were suffering from depression were more likely to be dissatisfied with surgery. Participants were asked in interview about social pressures and comments or remarks made by others about their condition. The majority (89.6%) of the total study group reported intrusive questions by acquaintances and strangers, with more than half of these being distressed by such questions. Following surgery, there was a significant reduction in the incidence of these questions. There was no relationship between distress in response to these questions prior to surgery and dissatisfaction with surgery. However, 27.4% also reported aggressive hurtful comments before surgery with a minimal improvement in incidence following surgery. These participants also reported consistent patterns of social avoidance and social isolation before and after surgery, and were more likely to be depressed than the rest of the study group. They were significantly more likely to be dissatisfied with surgery (p=.016).

It is recommended that patients are screened and counseled prior to surgery to identify such problems and referred for psychological treatment in order to ensure they gain maximum benefit from reconstructive surgery.

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.