Recognizing Emotional Expression as an Outcome Measure After Face Transplant

IMPORTANCE: Limited quantitative data exist on the restoration of nonverbal communication via facial emotional expression after face transplant. Objective and noninvasive methods for measuring outcomes and tracking rehabilitation after face transplant are lacking. OBJECTIVE: To measure emotional expression as an indicator of functional outcomes and rehabilitation after face transplant via objective, noninvasive, and nonobtrusive software-based video analysis. DESIGN, SETTING, AND PARTICIPANTS: This single-center case-control study analyzed videos with commercially available video analysis software capable of detecting emotional expression. The study participants were 6 patients who underwent face transplant at Brigham and Women’s Hospital between April 2009 and March 2014. They were matched by age, race/ethnicity, culture, and sex to 6 healthy controls with no prior facial surgical procedures. Participants were asked to perform either emotional expressions (direct evaluation) or standardized facial movements (indirect evaluation). Videos were obtained in a clinical setting, except for direct evaluation videos of 3 patients that were recorded at the patients’ residences. Data analysis was performed from June 2018 to November 2018. MAIN OUTCOMES AND MEASURES: The possibility of detecting the emotional expressions of happiness, sadness, anger, fear, surprise, and disgust was evaluated using intensity score values between 0 and 1, representing expressions that are absent or fully present, respectively. RESULTS: Six patients underwent face transplant (4 men; mean [SD] age, 42 [14] years). Four underwent full face transplants, and 2 underwent partial face transplants of the middle and lower two-thirds of the face. In healthy controls, happiness was the only emotion reliably recognized in both indirect (mean [SD] intensity score, 0.92 [0.05]) and direct (mean [SD] intensity score, 0.91 [0.04]) evaluation. Indirect evaluation showed that expression of happiness significantly improved 1 year after transplant (0.04 point per year; 95% CI, 0.02 to 0.06 point per year; P = .002). Expression of happiness was restored to a mean of 43% (range, 14% to 75%) of that of healthy controls after face transplant. The expression of sadness showed a significant change only during the first year after transplant (−0.53 point per year; 95% CI, −0.82 to −0.24 point per year; P = .005). All other emotions were detectable with no significant change after transplant. Nearly all emotions were detectable in long-term direct evaluation of 3 patients, with expression of happiness restored to a mean of 26% (range, 5% to 59%) of that of healthy controls. CONCLUSIONS AND RELEVANCE: Partial restoration of facial emotional expression is possible after face transplant. Video analysis software may provide useful clinical information and aid rehabilitation after face transplant.