title: Societal Value of Surgery for Facial Reanimation.
abstract: OBJECTIVE
  Patients with facial paralysis are perceived negatively by society in a number of domains. Society's perception of the health utility of varying degrees of facial paralysis and the value society places on reconstructive surgery for facial reanimation need to be quantified.
  
  
  OBJECTIVE
  To measure health state utility of varying degrees of facial paralysis, willingness to pay (WTP) for a repair, and the subsequent value of facial reanimation surgery as perceived by society.
  
  
  METHODS
  This prospective observational study conducted in an academic tertiary referral center evaluated a group of 348 casual observers who viewed images of faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) categorized by House-Brackmann grade. Structural equation modeling was performed to understand associations among health utility metrics, WTP, and facial perception domains. Data were collected from July 16 to September 26, 2015.
  
  
  METHODS
  Observer-rated (1) quality of life (QOL) using established health utility metrics (standard gamble, time trade-off, and a visual analog scale) and (2) their WTP for surgical repair.
  
  
  RESULTS
  Among the 348 observers (248 women [71.3%]; 100 men [28.7%]; mean [SD] age, 29.3 [11.6] years), mixed-effects linear regression showed that WTP increased nonlinearly with increasing severity of paralysis. Participants were willing to pay $3487 (95% CI, $2362-$4961) to repair low-grade paralysis, $8571 (95% CI, $6401-$11 234) for medium-grade paralysis, and $20 431 (95% CI, $16 273-$25 317) for high-grade paralysis. The dominant factor affecting the participants' WTP was perceived QOL. Modeling showed that perceived QOL decreased with paralysis severity (regression coefficient, -0.004; 95% CI, -0.005 to -0.004; P < .001) and increased with attractiveness (regression coefficient, 0.002; 95% CI, 0.002 to 0.003; P < .001). Mean (SD) health utility scores calculated by the standard gamble metric for low- and high-grade paralysis were 0.98 (0.09) and 0.77 (0.25), respectively. Time trade-off and visual analog scale measures were highly correlated. We calculated mean (SD) WTP per quality-adjusted life-year, which ranged from $10 167 ($14 565) to $17 008 ($38 288) for low- to high-grade paralysis, respectively.
  
  
  CONCLUSIONS
  Society perceives the repair of facial paralysis to be a high-value intervention. Societal WTP increases and perceived health state utility decreases with increasing House-Brackmann grade. This study demonstrates the usefulness of WTP as an objective measure to inform dimensions of disease severity and signal the value society places on proper facial function.
  
  
  METHODS
  NA.
authors.affiliation: Medical student, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Peiyi
authors.initials: P
authors.lastname: Su
authors.affiliation: Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Lisa E
authors.initials: LE
authors.lastname: Ishii
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Andrew
authors.initials: A
authors.lastname: Joseph
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Jason
authors.initials: J
authors.lastname: Nellis
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Jacob
authors.initials: J
authors.lastname: Dey
authors.affiliation: Medical student, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Kristin
authors.initials: K
authors.lastname: Bater
authors.affiliation: Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Byrne
authors.affiliation: Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Kofi D O
authors.initials: KD
authors.lastname: Boahene
authors.affiliation: Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Masaru
authors.initials: M
authors.lastname: Ishii
mesh_terms: D000328:Adult; D005158:Facial Paralysis / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D009042:Motivation; D011446:Prospective Studies; D019651:Plastic Surgery Procedures / Q000191:economics*; D012720:Severity of Illness Index; D012938:Social Perception