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

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.