Facial Plastic Surgery & Aesthetic Medicine

Volume X, Number X, 2020

ª American Academy of Facial Plastic and Reconstructive Surgery, Inc.
DOI: 10.1089/fpsam.2020.0082

Degree of Self-Reported Facial Impairment

Correlates with Social Impairment in Individuals
with Facial Paralysis and Synkinesis
Natalie A. Krane, MD,1 Dane Genther, MD,2 Kendall Weierich, BS,1 Haley Hanseler, BS,1
Sara W. Liu, MD,2 Alia Mowery, BA,1 and Myriam Loyo, MD1,*
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Abstract
Importance: Facial paralysis leads to both aesthetic and functional deficits placing patients at risk for
sociopsychological sequelae and social impairment.
Objective: To examine the effect of facial paralysis and synkinesis on social impairment and quality of life
(QOL).
Design, Setting, and Participants: This is a cross-sectional study at a tertiary care medical center. Adults with
a history of facial palsy were broadly categorized by self-reported degree of facial paralysis and synkinesis.
Main Outcomes and Measures: Clinical demographic information, self-reported degrees of facial paralysis
and synkinesis, and facial palsy-specific QOL as measured by the Facial Clinimetric Evaluation (FaCE) Scale
and the Synkinesis Assessment Questionnaire (SAQ) were collected. FaCE and SAQ scales were evaluated as
predictors of social impairment outcomes, as measured by the Brief Fear of Negative Evaluation-II (BFNE-II),
the Social Anxiety Questionnaire (SAQ-A30), and Social Avoidance and Distress (SAD) scales, in addition to
health utility scores from the Short-Form 6D (SF-6D).
Results: Fifty-six participants with facial palsy were included (30% male; average age: 56.4 [standard devi-
ation (SD): 15] years). Sixty-three percent of participants reported history of Bell’s palsy; 37% reported other
etiologies. Forty-seven percent of participants reported moderate or severe facial impairment and 46% of
participants reported involuntary facial movement. Participants with moderate or severe facial impairment
exhibited increased BFNE-II ( p = 0.03), SAQ-A30 ( p = 0.04), and SAD ( p < 0.01) scores and lower health val-
uation on SF-6D ( p = 0.04). FaCE scores moderately correlated with lower health valuation (r = 0.39, p < 0.01),
and moderately and inversely correlated with SAD (r = 0.33, p = 0.01) and BFNE-II (r = 0.35, p < 0.01)
scores. Furthermore, worsening FaCE scores predicted worsening SAQ ( p < 0.01), SAD ( p = 0.01), BFNE-II
( p < 0.01), and SF-6D ( p < 0.01) scores. Worse degrees of synkinesis correlated with higher BFNE-II scores
(r = 0.38, p < 0.01) and worsening SAQ scores predicted worsening FaCE ( p < 0.01) and BFNE-II ( p < 0.01)
scores. Females demonstrated significantly worse BFNE-II scores ( p = 0.04) when compared with men,
and female gender significantly predicted worse FaCE scores ( p < 0.01). Seventy-one percent of women
with self-reported moderate or severe facial impairment met criteria for social anxiety, as did 67% of
women with self-reported moderate or severe synkinesis.
Conclusions and Relevance: Individuals with self-reported moderate or severe facial impairment exhibit a
higher degree of social impairment and poorer health valuation than those with no or mild facial impair-
ment. Facial palsy-specific QOL moderately and inversely correlated with social impairment and moderately
correlated with health valuation. Our results indicate that FaCE scores may be used as a predictor of SAD,
BFNE-II, and SF-6D scores and that facial palsy QOL and its relationship with social impairment should be
considered when treating patients with a history of facial palsy.

1
Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA.
2
Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio, USA.
This study was presented as a podium presentation at the AAFPRS Annual Meeting in San Diego, CA, on October 3, 2019.

*Address correspondence to: Myriam Loyo, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, Oregon Health
and Science University, 3303 SW Bond Avenue, Portland, OR 97239, USA, Email: loyo@ohsu.edu

1
 2 KRANE ET AL.
KEY POINTS
Question: What is the relationship between disease-specific
quality of life (QOL) and social impairment in subjects with a
history of facial palsy and varying degrees of facial function
and synkinesis?
Findings: Facial palsy-specific QOL moderately and inversely
correlates with social anxiety and social discomfort, moder-
ately correlates with health valuation, and may be used as a
predictor of social impairment.
Meaning: Consider the likelihood of social impairment and
comorbid social anxiety when treating patients with a history
of facial palsy.
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Introduction
Frances C. Macgregor, a renowned social scientist who
wrote extensively on the social implications of facial ap-
pearance and deformities, eloquently summarized the
plight of social interaction for those with facial disfigure-
ment: ‘‘While distressed each day by the reflection in
their own mirrors, as much if not more hurtful and dam-
aging to their self-image and self-esteem is seeing their
own flawed faces reflected in the reactive behavior of
the non-disfigured.’’1 It is, therefore, easy to understand
that the primary complaints and difficulties expressed
by facial palsy patients involve their interactions with
others.1,2 These struggles with social interaction lead to
psychological distress in the form of negative self-image,
low self-esteem, and social isolation.1,3 Furthermore,
40% of patients with facial paralysis exhibit symptoms
consistent with an anxiety or depressive mood disorder,
and 33% have significant levels of anxiety.4,5
These facts highlight the prevalence of psychological
comorbid conditions in individuals with facial palsy
and the necessity to recognize their impact on social
interaction—facial appearance and symmetry are para-
mount to the conveyance of emotion, development of
relationships, and professional success. Facial symme-
try is perceived as beautiful and a judgment of good
health6,7; conversely, asymmetry may be seen as un-
healthy, unattractive, and abnormal.8 It is well estab-
lished that those with facial paralysis are perceived as
less attractive, less trustworthy, more disabled, and
more distressed.9–14
Facial paralysis can be subcategorized into flaccid pa-
ralysis, hypertonic paralysis, or a combination of both.
Flaccid facial paralysis results in the generalized inability
to move the muscles of facial expression. Hypertonic pa-
ralysis manifests as involuntary facial movement and
tightening of facial musculature during intentional facial
movement. Both forms of facial palsy result in a failure
to showcase an intended emotion or affect and nega-
tively impact the ability to effectively communicate. For
example, when individuals with facial paralysis attempt
to smile, they may appear hostile to others and provoke
a negative response.15,16
Although psychological comorbidities and quality of
life (QOL) have been studied in the facial palsy popula-
tion, previous studies have not fully captured the effects
of facial palsy and synkinesis on social impairment.
This study’s objective was to evaluate the social dimen-
sion of QOL for individuals with varying degrees of fa-
cial dysfunction and involuntary movement particularly
as it relates to interactions in social settings and social
anxiety.
Materials and Methods
This study is an Institutional Review Board (IRB)-
approved cross-sectional study that evaluated adults
with facial palsy. Participants >18 years and with a diag-
nosis history of facial palsy from any etiology were
recruited from a search of the electronic medical record
between the years of 2013 and 2017 at Oregon Health
and Science University (OHSU) by searching relevant
International Classification of Diseases (ICD)-9 codes.
Study participants were called and, if in agreement
with participating, were asked to provide demographic
and basic information regarding their history of facial
palsy (Supplementary Data S1) and completed the fol-
lowing instruments through phone, e-mail, or mail:
Brief Fear of Negative Evaluation-II (BFNE-II), Social
Anxiety Questionnaire (SAQ-A30), Social Avoidance
and Distress Scale (SAD), Short-Form 6D (SF-6D),
Facial Clinimetric Evaluation (FaCE), and the Synkine-
sis Assessment Questionnaire (SAQ). Participants were
then categorized based on their self-perceived level of fa-
cial function and degree of involuntary movement: normal
or minimal facial impairment versus moderate or severe
impairment, and no or mild synkinesis versus moderate
or severe synkinesis. Photo documentation was not avail-
able given the design of the study.
Surveys
Social impairment surveys. The BFNE-II is a 12-item
survey that uses a 5-point Likert scale to measure fears
of negative evaluation by others, with scores ranging
from 12 to 60. A cutoff score of 25 is indicative of clin-
ically significant social anxiety.17 The SAQ-A30 is a
30-item survey using a 5-point Likert scale to measure
unease, stress, or nervousness in social situations, with
scores ranging from 30 to 150. A score of >89 in males
and >98 in females (or 90 in all patients) qualifies as so-
cial anxiety.18 The SAD scale, which is a 28-item true or
false survey, attempts to determine the level of anxiety
people feel in social situations and the extent to which
they avoid these situations.19 Scores range from 0 to 28
and cutoff scores vary between males and females. In
males, a low degree of social discomfort is a score <4,
 SOCIAL ANXIETY IN FACIAL PARALYSIS AND SYNKINESIS 3

an intermediate degree is a score between 4 and 19, and a
high degree is a score >19. In females, a low degree of
social discomfort is a score of 0, an intermediate degree
is a score of 1–16, and a high degree is a score >16.
The higher the score, the greater the degree of social
discomfort.19
Health utility survey. SF-6D scores were calculated into
health state utility values by using a weighted algorithm
outlined by Brazier et al. and used with permission
from the Department of Health Economics and Decision
Science at the University of Sheffield, Sheffield, United
Kingdom.20 The algorithm estimates the value that the
general population assigns to any particular health state.
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els with backward stepwise selection; for each survey,
characteristics with a p-value of <0.2 were included in
the multivariate analysis. Self-reported level of function-
ality and presence of synkinesis were not included in
multivariate analyses to avoid collinearity with FaCE
and SAQ scores, which are validated measures of the
same parameters. All comparisons were two tailed with
statistical significance set at 0.05. Statistical analysis
was performed using SPSS version 24 (IBM SPSS,
Armonk, NY).
Results
Fifty-six subjects with a history of facial palsy, with an

average duration of 11.9 years (standard deviation [SD]:

Scores range from 0.3 to 1.0, with lower scores indicating
poorer valuation of a particular health state and 1.0 being
in perfect health.
Facial paralysis-specific QOL surveys. The FaCE Scale
is a validated patient-graded instrument to measure
impairment and disability in facial palsy and includes a
specific social function domain.21 Scores range from
0 to 100 (worst to best facial function). The SAQ is a
9-item self-assessment of involuntary movement (synki-
nesis) of the face, with higher scores representing more
synkinesis.22
13.3) since diagnosis, participated in the study. Demo-
graphic data and descriptive characteristics are outlined
in Table 1, including age, sex, etiology of palsy, treat-
ments underwent, and self-perceived degree of facial
impairment and involuntary movement. The univariate
relationships between participant characteristics, includ-
ing sex, level of functionality, cause of facial palsy, pres-
ence of synkinesis, severity of synkinesis, and scores on
survey instruments, were calculated (Table 2). There was
no significant difference in specific etiology of palsy
when evaluating self-perceived degree of functional
impairment or involuntary movement.

Statistical analysis Table 1. Demographic data

Participants were divided into two primary groups for
Characteristic n (%), N = 56
both facial impairment (no and minimal versus moder-
ate and severe impairment) and involuntary movement Age, mean (SD), years 56.37 (15.5)
(no and mild versus moderate and severe synkinesis) Male sex 17 (30.4)
Race
given the overall low number of participants in each White 53 (94.7)
subset. Participant mean and median scores on all self- Black 1 (1.8)
Hispanic 2 (3.5)
assessment instruments were calculated. The relation-
Cause of paralysis
ships between cause of facial palsy and degree of Bell’s palsy 35 (62.5)
functional impairment and severity of synkinesis were Infectious 6 (10.7)
assessed using chi-square tests. The relationship between Neoplastic 12 (21.4)
Iatrogenic 2 (3.6)
severity of facial impairment and synkinesis with social Traumatic 1 (1.8)
QOL questionnaires and healthy utility was evaluated More than one acute palsy event 5 (8.9)
as hereunder. Correlations between assessments of facial Treatments underwent
Steroids 32 (57.1)
palsy-specific QOL (FaCE) and synkinesis (SAQ) with Antivirals 18 (32.1)
social impairment (BFNE-II, SAQ-A30, and SAD) and Acupuncture 10 (17.9)
health state utility (SF-6D) were performed using Spear- Botulinum toxin 10 (17.9)
Physical therapy 16 (28.6)
man correlation analyses. The univariate relationships Surgery 7 (12.5)
between participant characteristics, including sex, level Electric stimulation 3 (5.4)
of functionality, cause of facial palsy, presence of synki- Perceived level of deficit
Full function 14 (25.0)
nesis, and severity of synkinesis, and score on survey Minimal impairment 16 (28.6)
instruments were determined using independent samples Moderate impairment 17 (30.4)
t-tests. Linear regression analyses were performed to Severe impairment 9 (16.1)
determine the relationship between the FaCE total score Involuntary movement present 26 (46.4)
Severity of involuntary movements
and SAQ with other social impairment surveys and Mild 12 (46.2)
the health state utility survey. Multivariate analyses of Moderate 9 (34.6)
Severe 5 (19.2)
the relationship between participant characteristics and
each survey were conducted using linear regression mod- SD, standard deviation.
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Table 2. Univariate analysis

Quality of life domains Social impairment scales Health valuation

FaCE total score SAQ SAQ-A30 SAD BFNE-II SF-6D

Mean (SD) p Mean (SD) p Mean (SD) p Mean (SD) p Mean (SD) p Mean (SD) p

Sex 0.004 0.291 0.051 0.125 0.041 0.075

Male 75.68 (21.6) 34.22 (24.1) 70.63 (21.8) 8.24 (8.1) 25.71 (8.6) 0.7924 (0.131)
Female 52.56 (27.9) 41.14 (19.6) 87.18 (29.9) 11.97 (8.3) 33.47 (14.1) 0.7133 (0.157)
Functionality <0.001 0.005 0.049 0.004 0.030 0.040
No or minimal impairment 75.39 (23.2) 31.52 (18.0) 75.21 (24.7) 7.90 (6.8) 27.60 (11.5) 0.7760 (0.153)
Moderate or severe 41.35 (21.7) 47.92 (21.2) 90.35 (31.0) 14.23 (8.8) 35.24 (13.9) 0.6926 (0.142)
impairment
Cause 0.010 0.258 0.523 0.524 0.874 0.096
Idiopathic or infectious 66.13 (27.0) 40.92 (23.6) 84.59 (27.7) 11.38 (8.3) 31.20 (13.1) 0.7629 (0.145)
Neoplastic, traumatic, 44.78 (24.5) 33.48 (12.8) 79.00 (310) 9.73 (8.8) 31.86 (13.2) 0.6876 (0.153)
or iatrogenic

4
Synkinesis 0.003 <0.001 0.383 0.565 0.126 0.579
None 69.78 (27.2) 26.67 (12.9) 79.14 (29.4) 10.23 (8.9) 28.60 (12.1) 0.7480 (0.164)
Present 47.82 (24.7) 54.85 (18.8) 85.96 (27.9) 11.54 (7.8) 34.04 (13.8) 0.7250 (0.141)
Severity of synkinesis 0.002 0.003 0.891 0.356 0.828 0.290
No or mild 66.03 (25.5) 34.53 (20.1) 82.05 (27.2) 10.24 (8.1) 30.86 (12.6) 0.7499 (0.152)
Moderate or severe 40.24 (27.5) 55.15 (16.5) 83.29 (33.6) 12.64 (9.1) 31.77 (14.9) 0.6996 (0.154)

Regression Regression Regression Regression Regression Regression

coefficients coefficients coefficients coefficients coefficients coefficients
(95% CI) p (95% CI) p (95% CI) p (95% CI) p (95% CI) p (95% CI) p

FaCE total score — — 0.334 0.001 0.234 0.093 0.099 0.012 0.161 0.009 0.002 0.003
( 0.530 to ( 0.508 to ( 0.175 to ( 0.280 to (0.001 to
0.138) 0.040) 0.022) 0.042) 0.003)
SAQ 0.588 0.001 — — 0.360 0.068 0.098 0.072 0.245 0.004 0.001 0.433
( 0.933 to ( 0.027 to ( 0.009 to (0.083 to ( 0.003 to
0.243) 0.747) 0.205) 0.407) 0.001)

BFNE-II, Brief Fear of Negative Evaluation-II; CI, confidence interval; FaCE, Facial Clinimetric Evaluation; SAD, Social Avoidance and Distress; SAQ, Synkinesis Assessment Questionnaire; SAQ-A30, Social
Anxiety Questionnaire; SF-6D, Short-Form 6D.
 SOCIAL ANXIETY IN FACIAL PARALYSIS AND SYNKINESIS 5

As expected, subjects who reported moderate or severe
facial impairment were found to have worse FaCE scores
when compared with no or minimal impairment, and par-
ticipants who reported moderate or severe synkinesis
were found to have worse FaCE scores when compared
with no or mild synkinesis (Table 2). In addition, partic-
ipants who reported involuntary movement had worse
SAQ and FaCE scores when compared with those who
reported no involuntary movement, and those with mod-
erate or severe synkinesis were found to have worse
SAQ scores when compared with no or mild synkinesis
(Table 2). Worse FaCE total scores were also seen in par-
ticipants with neoplastic, traumatic, or iatrogenic etiolo-
gies of facial palsy when compared with those who
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[SD: 25], p = 0.04), and SAD (14.23 [SD: 8.8] vs. 7.90
[SD: 6.8], p < 0.01) scales and reported lower valuation
of health on SF-6D (0.69 [SD: 0.14] vs. 0.77 [SD: 0.15],
p = 0.04) (Fig. 1).
FaCE scores moderately and inversely correlated with
BFNE-II and SAD scores, and moderately correlated
with lower health valuation scores on SF-6D (Fig. 2).
FaCE scores did not significantly correlate with SAQ-
A30 scores (r = 0.22, p = 0.09). FaCE social function
scores moderately and inversely correlated with SAQ-
A30 (r = 0.34, p = 0.01), BFNE-II, and SAD scores,
and moderately correlated with lower health valuation
scores on SF-6D (Fig. 2). Worse degrees of synkinesis
moderately correlated with higher BFNE-II scores

reported a history of Bell’s palsy or an infectious etiol-
ogy (Table 2). Worsening FaCE scores predicted worsen-
ing SAQ, SAD, BFNE-II, and SF-6D scores, whereas
worsening SAQ scores predicted worsening FaCE and
BFNE-II scores (Table 2).
Subjects with self-perceived moderate or severe fa-
cial impairment were then compared with those who
reported no or mild impairment. Participants with mod-
erate or severe impairment demonstrated increased
scores on the BFNE-II (35.24 [SD: 14] vs. 27.6 [SD:
12], p = 0.03), SAQ-A30 (90.35 [SD: 31] vs. 75.21
(r = 0.38, p < 0.01), but were not found to correlate with
SAD, SAQ-A30, or SF-6D. On multivariate analyses,
FaCE score was found to predict outcomes on both the
SAQ and SF-6D scales; SAQ was found to predict out-
comes on both BFNE-II and FaCE scales (Table 3).
Incidence of social impairment in this patient cohort as
it relates to sex and self-reported degree of facial impair-
ment and synkinesis was calculated using previously de-
fined cutoff values for each survey described in materials
and methods (shown in Supplementary Table S1). High
rates of social anxiety determined by BFNE-II were

Fig. 1. Comparison of social anxiety (BFNE-II, SAQ-A30), social discomfort (SAD), and health valuation (SF-
6D) survey results between subjects with self-perceived no or mild facial impairment and those with
moderate or severe facial impairment. BFNE-II, Brief Fear of Negative Evaluation-II; SAD, Social Avoidance
and Distress; SAQ-A30, Social Anxiety Questionnaire; SF-6D, Short-Form 6D.
 6 KRANE ET AL.
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Fig. 2. FaCE total and social function scores as correlated with SAD, BFNE-II, and SF-6D scores. FaCE, Facial
Clinimetric Evaluation.

seen in participants with a history of facial palsy (24/28
[63%] of women and 9/17 [53%] of men), especially
those with moderate or severe facial impairment (15/21
[71%] of women and 4/4 [100%] of men) (Supplemen-
tary Table S1). Ninety-five percent of women with a his-
tory of facial palsy had an intermediate or high degree of
social discomfort using the SAD scale, as compared with
49% of men (Supplementary Table S1). The proportion
of subjects with a high degree of social discomfort in-
creased with worsening degree of facial impairment, for
example, 10 of 22 (45%) women and 2 of 4 (50%) men
with moderate-to-severe facial impairment versus 3 of
17 (18%) women and 0 of 13 (0%) men with no or mild
facial impairment. When compared with males, female
participants demonstrated significantly worse BFNE-II
and FaCE total scores (Table 2). Gender was included
in the multivariate analysis, female gender significantly
predicted worse FaCE scores (Table 3).
Discussion
Patients with facial palsy have greater levels of anxiety,
depression, lower mood scores, and reduced emotional
well-being16,23 than healthy individuals. In addition,
worsening severity of facial palsy is associated with in-
creased depression and worse QOL,3,24–27 whereas the
degree of facial palsy has been shown to be a main pre-
dicting factor for QOL.28 Our data revealed that >50%
of the research subjects met criteria for social anxiety.
In addition, self-reported worsening degrees of facial
impairment demonstrated an increasing degree of social
 SOCIAL ANXIETY IN FACIAL PARALYSIS AND SYNKINESIS 7

Table 3. Multivariate analysis and inversely correlate with social impairment mea-
Outcome Predictor Regression coefficient
sures, including BFNE-II, SAD, and the SAQ-A30. The
variable variable (95% CI) p FaCE Scale was also found to moderately correlate
with lower health valuation scores using SF-6D. Based
FaCE total Sex 16.287 0.016
score Male ( 29.426 to 3.149) on our results, FaCE scores may be used as a predictor
Female of SAD, BFNE-II, and SF-6D scores. In the future,
Cause 26.446 <0.001
Idiopathic or ( 39.633 to 13.259)
FaCE may be useful to screen for social impairment
infectious and identify individuals who can benefit from further
Neoplastic, traumatic social support or mental health interventions as a part
or iatrogenic
SAQ 0.606 ( 0.900 to 0.311) <0.001 of their treatment plan.
SAQ FaCE total score 0.334 ( 0.530 to 0.138) 0.001 A previous study found that higher age, viral etiology
SAQ-A30 SAQ 0.360 ( 0.027 to 0.747) 0.068
SAD FaCE total score 0.077 ( 0.157 to 0.003) 0.059
of palsy, overweight status, history of anxiety or chronic
BFNE-II Sex 6.633 ( 0.663 to 13.930) 0.074 pain, previous treatment for facial palsy, and previous
Male radiation therapy were all associated with lower QOL;
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Female
SAQ 0.224 (0.063 to 0.384) 0.007
SF-6D FaCE total score 0.002 (0.001 to 0.003) 0.007
Variables included in the MVA had a p < 0.2 on univariate analysis,
which included sex, FaCE total score, and SAQ for SAQ-A30; sex, FaCE
total score, and SAQ for SAD; sex, FaCE total score, and SAQ for
BFNE-II; sex, cause, and FaCE total score for SF-6D; sex, cause, and
SAQ for FaCE total score; FaCE total score for SAQ.
MVA, multivariate analysis.
impairment and a lower valuation of health. This strength-
ens previous data showing high rates of psychological
distress and anxiety in patients with facial paralysis,4,5
and solidifies the relationship between severity of palsy
and worsening social impairment. This highlights the
need to consider psychosocial comorbidities when treat-
ing patients with facial palsy.
Social impairment is significantly worse in women.
Previous studies of social anxiety have shown that
women are more likely to have social anxiety disorder
than men and report more severe symptoms and higher
levels of social fears.29 Social constructs and societal ex-
pectations of women, including the cultural emphasis on
physical appearance and complicated aspects of gender
roles, may play a role in this sex difference. Previous
data demonstrated that female facial palsy patients have
higher depression scores,3 a finding now supplemented
by our data, which demonstrated that women have signif-
icantly worse social anxiety scores and facial palsy-
specific QOL when compared with men, and that female
gender significantly predicted worse FaCE scores.
Psychological issues secondary to facial palsy may be
underestimated or unrecognized by surgeons.16 This is an
important consideration in both the pre- and postopera-
tive settings, as addressing these psychological prob-
lems before surgery promotes greater satisfaction and
self-esteem in patients postoperatively,30 and a person’s
psychological adjustment to facial disfigurement is a
large part of his or her overall recovery.5 In addition, so-
cial anxiety or discomfort may impact a patient’s willing-
ness to seek and pursue treatment.
The FaCE Scale is widely used in facial nerve centers
internationally. FaCE scores were found to moderately
whereas longer duration of palsy, malignant etiology,
and congenital etiology were associated with higher
QOL.28 Conversely, in our study, we demonstrated Bell’s
palsy and infectious etiologies for facial palsy were asso-
ciated with higher facial palsy QOL, whereas those with
history of tumor, trauma, or iatrogenic etiologies had a
lower QOL. The aforementioned study adjusted for con-
founding variables with a substantially larger cohort than
ours. In addition, many of their patients were presenting
for treatment/management, whereas many of our Bell’s
palsy participants were volunteers and not actively seek-
ing treatment. These factors may explain the difference
in findings.
Limitations
Assessments of facial function were based upon patient-
reported degrees of functional impairment and involun-
tary movement. Clinician assessment and photographic
analysis were not performed. This is a cross-sectional
study and cannot establish causation. In addition, our
sample size does not fully account for heterogeneity of
causes and degrees of palsy, which warrant further study.
Conclusion
Individuals with a history of facial palsy and self-reported
moderate or severe facial impairment demonstrated a
higher degree of social anxiety, social discomfort, and
a poorer valuation of health when comparing with
those with self-reported no or mild impairment. In addi-
tion, worse degrees of synkinesis were associated with a
higher degree of social anxiety. Facial palsy-specific
QOL as measured by the FaCE Scale moderately and in-
versely correlated with social anxiety and social discom-
fort, and moderately correlated with health valuation.
Our results indicate that FaCE scores may be used as a
predictor of social impairment and health valuation, by
way of SAD, BFNE-II, and SF-6D scores, and that facial
palsy QOL and its relationship with social impairment
should be considered when treating patients with a his-
tory of facial palsy.
 8 KRANE ET AL.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received.
Supplementary Material
Supplementary Data S1
Supplementary Table S1
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operations; some sociologic and psychiatric considerations. Psychosom
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