Corner Of Mouth Research Articles

Mouth Corner Lift with Botulinum Toxin Type A and Hyaluronic Acid Filler.

An upturned mouth corner is associated with brightness, optimism, and friendliness, whereas a downturned mouth corner not only conveys negative feelings such as sadness, depression, and tiredness, but also makes a person appear years older than they are. Surgical approaches to the correction of a downturned mouth corner can result in predictable and long-lasting results. However, because of their fear of postsurgical scars and long downtimes, many patients are reluctant to undergo surgery involving the mouth corner. As a consequence, minimally invasive procedures have become increasingly popular in recent years. Among these, botulinum toxin type A and injectable fillers play a significant role. The author uses botulinum toxin type A and hyaluronic acid filler injections as complementary procedures for lifting flat or downturned mouth corners in young patients. This method has produced reliable and consistent outcomes without severe complications such as necrosis or infection in over 100 patients, as reflected in high patient satisfaction. The combination of botulinum toxin type A and hyaluronic acid filler provides excellent results in young patients who desire an uplifted mouth corner and are reluctant to undergo surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Automatically detecting rigidly and nonrigidly deformed facial landmarks from coarseness to fineness

We propose a coarse-to-fine method automatically detecting facial landmarks for both rigid and nonrigid facial deformations. For an input 3-D face, first, we roughly detect the nose by employing 3-D local shape descriptors and further detect the tip of the nose with the tip features, e.g., the symmetry of the face. Second, we localize the eyes and mouth according to the distribution of human facial features and use a convolutional neural network to minimize the combined loss and to provide candidates for the corners of the eyes and mouth. Finally, for accurately detecting the landmarks of the eyes and mouth, we iteratively update the candidates by maximizing the similarity of the candidates and the landmarks based on the features of the candidate and its neighbors. Over Bosphorus and CASIA datasets, we evaluate the proposed method. Experiments show that compared with the state-of-the-art methods, our method detects the corners of eyes and mouth more accurately and robustly.

New Insights Into 3-Dimensional Anatomy of the Facial Mimetic Muscles Related to the Nasolabial Fold: An Iodine Staining Technique Based on Micro-Computed Tomography.

This study aimed to introduce a novel approach to study the facial mimetic muscles (FMMs) related to the nasolabial fold (NLF) and realize the visualization of complex 3-dimensional (3D) structures of the FMM. Micro-computed tomography (micro-CT) and iodine staining technique were used to obtain the 2-dimensional radiographs of the FMM. Materialise Mimics software was then used to reconstruct the 3D model of the FMM. The zygomaticus major muscle was not directly connected to the orbicularis oris muscle (OOM). The terminal fibers of the zygomaticus major muscle were located in the levator anguli oris. The surface of the FMM was covered with some unknown muscle fibers in the NLF. The terminal fibers of the zygolabialis ended in the middle of the ipsilateral OOM rather than the edge of the OOM. At the same anatomical level, the FMM fibers were so closely connected to each other that they were not separated by adipose tissue. A detailed 3D sequence of the muscle fibers in the modiolus at the corner of the mouth was determined. The muscle fibers in the modiolus were organized rather than disorganized. The terminal fibers of the levator anguli oris were located at the terminal fibers of the musculus depressor anguli oris at the corner of mouth. Although the micro-CT had many disadvantages, the micro-CT combined with iodine staining technique enabled the 3D anatomical study of the FMM related to NLF. We imported the 2-dimensional images obtained by micro-CT scanning into Mimics software, successfully reconstructed the FMM related to the NLF, and finally obtained images of complex 3D structures of the FMM related to the NLF. The shapes, positions, and 3D spatial relationships between the FMM related to the NLF were clearly visualized. The novel insights into the 3D anatomy of the FMM related to NLF may help understand the formation of the NLF. Finally, the results of this study may help improve rejuvenation surgery of the NLF in the near future.

Anatomical and radiological evaluation of modiolus anguli oris in facial anatomy

Aim: Modiolus is a dense, mobile fibromuscular structure lateral to the mouth corner. It is of great importance in aesthetic and reconstructive surgery. The aim of this study was to enlighten the structural changes in modiolus with demographic variables such as age and gender in living individuals.Methods: This retrospective cohort study was conducted on MR images of healthy individuals. Age and sex-related changes in modiolus level and volume were retrospectively analyzed in 64 patients [37M; 27F; mean age 48.2(16.3)] who underwent head and neck magnetic resonance imaging. ROC analysis was performed to determine the cut off values for age of modiolus. Correlation analysis (Pearson and point biserial correlation) was used to determine whether there was a significant correlation between age and volume. Significance of the differences between the volumes of right and left modiolus of the same individual were evaluated by dependent t tests.Results: The mean volume of the modiolus was calculated as 0.51(0.26) mm3. The volumes of right and left modioli decreased by aging. Ninety-one percent of the patients with modioli located inferior to horizontal line were over 49 years old. Right and left modioli relocated inferior to horizontal line with age. Modiolus volume was prominently less in women and the downward displacement of modiolus in women was 3.3 times higher than in men. Gender and age had significant effects on modiolus level. The right and left modiolus volumes were similar (P=0.975).Conclusion: Surgeon’s knowledge on modiolus and its relations will provide benefit, not only for the procedures such as face lifting and botulinum toxin injection, but also for the surgeries of facial paralysis and trauma patients.

Effects of Facial Threading on Female Skin Texture: A Prospective Trial with Physiological Parameters and Sense Assessment.

Background Facial threading is a common tradition in Taiwan, Southeast Asia (called “Bande Abru”), Middle East (called “Khite”), and Egypt (called “Fatlah”). In addition to the ability to remove facial vellus hairs, facial threading can make the skin fairer and shinier. However, there has been a lack of hard evidence regarding the effects of facial threading on the skin. Objective To examine the effects of facial threading on skin physiology as well as visual and touch senses by using scientific instruments. Methods A total of 80 participants were allocated to receive facial threading, application of powder only, exfoliation, and shaving. Prior to and following the assigned treatment, a noninvasive skin condition detection device was used to measure skin coarseness, hydration, melanin, and erythema index. Sense assessment and image analysis were also performed. Results This study showed that facial threading was found to improve the facial skin roughness indices with significant decreases by 30.4%, 35.9%, and 16.7%, respectively, for the participants' forehead, cheek, and mouth corner skin. No significant adverse changes in moisture levels and skin pigment indices were detected. In addition, there was improvement in subjects' touch sense of their skin and feelings about skin color. Conclusions Traditional facial threading can remove facial vellus hairs and lower skin roughness levels, thereby improving the skin texture. However, pricking sensation appeared during the facial threading process, which might cause concerns about irritation.

Application of face image detection based on deep learning in privacy security of intelligent cloud platform

The application of deep learning-based face detection in the privacy and security of intelligent cloud platforms is studied, in order to resolve the risk of private photo leakage on such platforms. Five key feature points of human faces (two eyes, two noses and two corners of mouth) are sought using the multitask cascaded convolution network (MTCNN). The algorithm utilizes the intrinsic links among Proposal Network (P-Net), Refine Network (R-Net) and Output Network (O-Net) to improve their face detection performances substantially. Since many existing data encryption methods, such as DES, RSA and AES, are applicable only to test data instead of digital images, the encryption of eigenvalues is achieved with a combination of chaotic logic diagrams and RC4 stream ciphers. Meanwhile, the MTCNN-generated face coordinates and user passwords are hash-converted and double-encrypted using hash table. The results show that the face detection accuracy of MTCNN reaches 95.04%, and that the image encryption method is suitable for network transmission. The chaotic logic diagrams increase the security of S-box initialization in the RC4 algorithm. The hash structure accelerates the file reading, whereas the hash conversion improves the security of critical data. In conclusion, the proposed encryption scheme is computationally fast and highly secure.

Digital planning workflow for partial maxillectomy using an osteotomy template and immediate rehabilitation of maxillary Brown II defects with prosthesis.

There is increasing evidence of benefits for the rehabilitation of Brown II defects with prosthesis in surgery. However, the current literature is sparse for maxillary tumour resection using osteotomy templates. To assess the accuracy of maxillectomy using a custom fabricated osteotomy template and to evaluate the prosthesis for surgical accuracy, appearance and functioning (speech, swallowing and occlusal force). Ten patients with Brown II defects caused by tumour resection were treated with precise partial maxillectomy using an osteotomy template. The immediate rehabilitation of the Brown II defect was completed with a prefabricated prosthesis. The post-operative three-dimensional images and the pre-operative virtual images were superimposed, and average deviation and maximum deviation were calculated. Speech intelligibility, swallowing, appearance and University of Washington Quality of Life Questionnaire (UW-QoL) were examined at 1, 3 and 6months after surgery. Occlusal force was examined post-operatively at 6months. The maximum deviation between the actual and virtual surgery was 5.12±0.44mm, with an average of 1.02±0.17mm. Speech intelligibility, swallowing and UW-QoL improved significantly (P<.05) after wearing the prosthesis. The recovery index of the occlusal force on the affected side was 20.19%-32.28%. The skewed degree of the mouth corner, the difference in the height of the left and right lips, the maximum deviation distance and the change area volume decreased significantly (P<.05). The precise rehabilitation of maxillary Brown II defects can be achieved using a prosthesis fabricated with an osteotomy template. The prosthesis restored appearance and functional capabilities (such as speech and occlusal force).

High-efficiency Combination Treatment of Submental Neck Fullness.

Background:Fat accumulation, skin laxity, and muscle contraction cause aging cervical fullness. Combining botulinum toxin to treat muscle contraction, and technique-oriented microfocused ultrasound for skin laxity, can improve cervical fullness without requiring lipolysis. Gel-assisted depth adjustment (GADA) is a depth-targeting, image-guided approach using an appropriate gel volume to precisely heat tissue layers during real-time visualization.Methods:A 41-year-old woman presented with moderate submental neck fullness and saggy cheeks. An appropriate gel volume was applied as determined by the targeted tissue layer’s distance from the skin. The submental and submandibular areas received 112 lines of 0.9 J/cm2 microfocused ultrasound with visualization (MFU-V) from a 4.5-mm transducer and 0.3 J/cm2 from a 3-mm transducer to treat the SMAS and dermosubcutis, respectively. For concomitant jowling, these transducers delivered 111 MFU-V lines to the lower cheek. Six units of incobotulinumtoxinA was injected in 1 point at the mandible to modulate hyperactive mentalis muscles. The platysma received 10U of incobotulinumtoxinA per cheek, whereas downturned mouth corners received 4U of incobotulinumtoxinA.Results:One-month posttreatment, submentum improvements included changes of the vertical pogonion position, more mandible angularity, and a straighter mandibular line. Anterior chin projection was more pronounced and the pogonion had more inferior displacement, creating a younger appearance in the chin-neck complex. Patients followed-up for 3 months also demonstrated these changes.Conclusions:Delivering MFU-V using the GADA technique effectively tightens submental and submandibular soft tissues. When combined with incobotulinumtoxinA, muscles in the chin and perioral area are relaxed. Thus, GADA yields significant clinical improvement and patient satisfaction.

Scleromyxedema Problem in Odontological Practice

Scleromyxedema is a skin disorder, which is considered very rare. Its symptoms are mucin accumulation in the patients’ skin, which is also called mucinosis. It causes papular and sclerodermoid bumps. Also, people affected by this disease have increased production of fibroblasts in the absence of a thyroid disorder. Another symptom includes monoclonal gammopathy, which is shown as abnormal protein existence in the person’s blood. This disease has no standard treatment. All patients should have their life quality improved by any means possible. These ses are extremely challenging for most of the treatments, that are being made by a dentist, because the patient is unable to open his mouth wide enough, so that standard dental manipulations can be made. A 60-year-old patient was presented with Scleromyxedema to our clinic. He was unable to open his mouth by more than 1,7 centimeters, which is considered a very narrow mouth opening. Patients face muscles were rigid, especially – musculus orbicularis oris and musculus masseter. Any attempts to open the mouth by more than 1,7 centimeters resulted with ruptures in patients mouth corners. Intra-oral Examination revealed 2 teeth left in the lower jaw, and no teeth in the upper jaw. Patient was in need of masticatory function rehabilitation, phonetics and aesthetics improvement. Such case requires special procedures and specific adaptation, compared to a standard edentulous patients’ treatment. In this case report, we review all the intra oral procedures, which should be modified accordingly to this rare case. Clinicians should be informed of such rare diseases and should be able to diagnose and treat them accordingly.

Additional suspension method in mouth corner lift to treat descended mouth corner

Aging affects the perioral region, resulting in folding, wrinkles, and drooping of the corners of the mouth. This might cause esthetic and functional problems. Here, we demonstrate a new suspension technique to lift the descending corners of the mouth. Two case reports are presented. A wraparound mouth corner lift is combined with an additional suspension method. A suspension suture is fixated at the commissure and subcutaneous layer in the nasolabial fold just lateral of the alar base to provide an extra lift of the corners. Ptosis of the corners of the mouth can be corrected naturally with the additional suspension technique. Further investigations are necessary to provide insight into the long-term results.

Pathogenic Variants in GPC4 Cause Keipert Syndrome

Glypicans are a family of cell-surface heparan sulfate proteoglycans that regulate growth-factor signaling during development and are thought to play a role in the regulation of morphogenesis. Whole-exome sequencing of the Australian family that defined Keipert syndrome (nasodigitoacoustic syndrome) identified a hemizygous truncating variant in the gene encoding glypican 4 (GPC4). This variant, located in the final exon of GPC4, results in premature termination of the protein 51 amino acid residues prior to the stop codon, and in concomitant loss of functionally important N-linked glycosylation (Asn514) and glycosylphosphatidylinositol (GPI) anchor (Ser529) sites. We subsequently identified seven affected males from five additional kindreds with novel and predicted pathogenic variants in GPC4. Segregation analysis and X-inactivation studies in carrier females provided supportive evidence that the GPC4 variants caused the condition. Furthermore, functional studies of recombinant protein suggested that the truncated proteins p.Gln506∗ and p.Glu496∗ were less stable than the wild type. Clinical features of Keipert syndrome included a prominent forehead, a flat midface, hypertelorism, a broad nose, downturned corners of mouth, and digital abnormalities, whereas cognitive impairment and deafness were variable features. Studies of Gpc4 knockout mice showed evidence of the two primary features of Keipert syndrome: craniofacial abnormalities and digital abnormalities. Phylogenetic analysis demonstrated that GPC4 is most closely related to GPC6, which is associated with a bone dysplasia that has a phenotypic overlap with Keipert syndrome. Overall, we have shown that pathogenic variants in GPC4 cause a loss of function that results in Keipert syndrome, making GPC4 the third human glypican to be linked to a genetic syndrome.

Semiology of hyperkinetic seizures of frontal versus temporal lobe origin.

Hyperkinetic seizures are usually associated with frontal lobe epilepsy. However, some patients have hyperkinetic seizures of temporal lobe origin. The semiological differences in hyperkinetic seizures between frontal and temporal lobe epilepsy have not been well studied. Here, we retrospectively assessed ictal semiology in order to distinguish between hyperkinetic seizures of frontal lobe origin and those of temporal lobe origin. We retrospectively reviewed data on patients who had undergone surgery for hyperkinetic seizures of temporal or frontal lobe origin and achieved favourable seizure outcomes (Engel Class I) with a minimum postoperative follow-up of 24 months. We reviewed seizure histories, imaging reports, video-EEG monitoring data, operative records, and pathological findings. We analysed and compared the hyperkinetic semiology of video-recorded seizures of temporal lobe origin and those of frontal lobe origin. Forty hyperkinetic seizures in eight patients (seven adult patients and one 12-year-old patient) with temporal lobe epilepsy and 45 hyperkinetic seizures in nine patients (eight adult patients and one 16-year-old patient) with frontal lobe epilepsy were analysed. Emotional facial expressions (such as fear, laughing, or anger), bilateral forceful elbow flexion, bilateral forceful grasping, facial flushing, and bilateral facial contraction were observed significantly more frequently in seizures of frontal lobe origin. Oroalimentary automatisms, seizures during wakefulness, salivation, and bilateral drop of the corners of the mouth were observed significantly more frequently in seizures of temporal lobe origin. Observation of a number of signs during hyperkinetic manifestations may help to predict whether a seizure originates from the frontal lobe or the temporal lobe.

Development of Infant Reaching Strategies to Tactile Targets on the Face.

Infant development of reaching to tactile targets on the skin has been studied little, despite its daily use during adaptive behaviors such as removing foreign stimuli or scratching an itch. We longitudinally examined the development of infant reaching strategies (from just under 2 to 11 months) approximately every other week with a vibrotactile stimulus applied to eight different locations on the face (left/right/center temple, left/right ear, left/right mouth corners, and chin). Successful reaching for the stimulus uses tactile input and proprioception to localize the target and move the hand to it. We studied the developmental progression of reaching and grasping strategies. As infants became older the likelihood of using the hand to reach to the target – versus touching the target with another body part or surface such as the upper arm or chair – increased. For trials where infants reached to the target with the hand, infants also refined their hand postures with age. As infants became older, they made fewer contacts with a closed fist or the dorsal part of the hand and more touches/grasps with the fingers or palm. Results suggest that during the first year infants become able to act more precisely on tactile targets on the face.

New record of the Crenimugil crenilabis (Forsskål, 1775) (Mugiliformes: Mugilidae) from Korea, as revealed by mitochondrial DNA barcoding

Crenimugil crenilabis (Forsskål 1775) is a fish species newly identified with molecular analysis and reported in Korea for the first time. A single specimen of C. crenilabis was collected from a tidal pool on the southern coast of Jeju Island, Korea in August 2018. This species is characterized by several rows of papillae on both lips, no notch in the mouth corner, the presence of 36 lateral-line scales, and 24 vertebrae. The present specimen is morphologically similar to another seven mugilid species reported in Korea, but mitochondrial DNA COI gene analysis revealed that it is almost identical to C. crenilabis, sharing 98.9–99.3% identity, compared with 75.9–90.3% identity with other species. It’s newly proposed Korean names are ‘Dol-gi-ip-sung-eo-sok’ for the genus and ‘Dol-gi-ip-sung-eo’ for the species.

Pain perception and efficacy of local analgesia using 2% lignocaine, buffered lignocaine, and 4% articaine in pediatric dental procedures.

BackgroundThe purpose of this study was to compare the pain perception and anesthetic efficacy of 2% lignocaine with 1:200,000 epinephrine, buffered lignocaine, and 4% articaine with 1:200,000 epinephrine for the inferior alveolar nerve block.MethodsThis was a double-blind crossover study involving 48 children aged 5–10 years, who received three inferior alveolar nerve block injections in three appointments scheduled one week apart from the next. Pain on injection was assessed using the Wong-Baker Faces pain scale and the sound eye motor scale (SEM). Efficacy of anesthesia was assessed by subjective (tingling or numbness of the lip, tongue, and corner of mouth) and objective signs (pain on probing).ResultsPain perception on injection assessed with Wong-Baker scale was significantly different between buffered lignocaine and lignocaine (P < 0.001) and between buffered lignocaine and articaine (P = 0.041). The onset of anesthesia was lowest for buffered lignocaine, with a statistically significant difference between buffered lignocaine and lignocaine (P < 0.001). Moreover, the efficacy of local analgesia assessed using objective signs was significantly different between buffered lignocaine and lignocaine (P < 0.001) and between lignocaine and articaine.ConclusionBuffered lignocaine was the least painful and the most efficacious anesthetic agent during the inferior alveolar nerve block injection in 5–10-year-old patients.

Effect of Low-Level LASER Therapy on Wound Recovery and Sequelae After Orthognathic Surgery: A Randomized Controlled Trial

Introduction: Despite the application of low-level laser therapy (LLLT) in diverse dental procedures, its postoperative effects especially on wound recovery after orthognathic surgery have not been well explored. Therefore, the current study aimed to investigate the effects of 660 nm LLLT on postoperative consequences of orthognathic surgery through a randomized controlled trial. Material and Methods: In this split-mouth, triple-blind randomized controlled trial, 12 patients who needed bimaxillary orthognathic surgery were recruited. After the surgery, one side of their face was irradiated with a diode low-level laser device of 660 nm during 1, 2, 4, and 7 days after the surgery, and the other side of their face was considered as placebo. Later, LLLT outcomes were assessed in terms of swelling, pain, and wound recovery after the surgery. For estimating the swelling, distances between tragicus to corner of mouth, tragicus to pogonion, and gonion to cantus were measured; for pain evaluation, the visual analog scale was used. Recovery of wounds was assessed via two ways of probing wounds depth and appraising their clinical features. Results: Although both LLLT and placebo sides presented a constant reduction of swelling over three postoperative months, the swelling in LLLT sides was significantly lower than placebos during the second and fourth days after the surgery. Regarding the pain, there were no significant differences on either sides of the face, 4 days after the surgery. Wounds probing indicated better recoveries at LLLT sides for both upper and lower jaws, whereas the results of clinical features did not show any significant differences between LLLT and placebo sides. Conclusion: LLLT can effectively accelerate the wound recovery after an orthognathic surgery. Also, it is helpful for postoperative sequelae of orthognathic surgery including swelling and pain.

A Case of Inconspicuous Recurrent Herpes Labialis Mimicking Unilateral Angular Cheilitis Unilateral Angular Cheilitis

Recurrent herpes labialis (RHL) is a common manifestation of herpes simplex virus (HSV) reactivation in immunocompetent individuals, whereas angular cheilitis is an inflammatory lesion occurring on one or both lip commissures and is induced by local and/or systemic conditions. We describe a case of RHL eruption on the corner of the mouth, easily mistaken as angular cheilitis. Case Report: A 21-year-old male presented to our dental hospital with a 3 day history of a painful, unilateral lesion on the left corner of his mouth. The lesion featured an erythematous base with a yellowish crust that extended outward. We diagnosed the lesion as RHL. We prescribed chlorhexidine solution and topical acyclovir to be applied onto the lesion. At 2 weeks follow-up, the lesion was resolved. An RHL lesion that erupts on the corner of the mouth may initially resemble angular cheilitis. However, the typical clinical presentation, history of recurrence, and the absence of predisposing factors for other lesions suggested an infection caused by HSV. Conclusion: RHL which occurred at one side of the mouth corner can be similar with unilateral AC. But, detailed history taking and clinical observation led to correct diagnosis and management.

Ideal Length of Oral Endotracheal Tube for Critically Ill Intubated Patients in an Asian Population: Comparison to Current Western Standards.

BackgroundEndotracheal (ET) intubation is used to maintain the airway patency of patients during mechanical ventilation and is inserted at a particular depth into the trachea through the nose, mouth, or through an incision in the neck. The aim of our study was to validate the ideal length of an oral endotracheal tube (ETT) in the Asian population compared to Western standards.MethodsPatient records with an oral ETT inserted between April 2011 and June 2015 in the Intensive Care Unit (ICU) of a hospital were retrospectively analyzed. The key variables included demographics, height, and ideal body weight of the patient, length of the oral ETT, and chest X-rays. Statistical analyses were performed using R software (https://cran.r-project.org/).ResultsThere were 876 incidences of oral cuffed ETT insertions in 708 adult patients ≥ 18 years of age. The median ETT depth in all the ethnic groups (Chinese, Malay, Indians, and others) was 22 cm. The median depth of oral ETTs was 22 cm in males and 21 cm in females as compared to Western standards (males: P < 0.0001; females: P = 0.93). In ICU patients intubated with an ETT at an acceptable distance from the carina (2 - 5 cm), the median ETT depth was different in males (P < 0.0001) but was similar in females (P = 0.87).ConclusionWe suggest that males and females in the Asian population, especially in South East Asia, should have their ETTs secured at the corner of mouth by at least 1 cm less in comparison to the Western population (22 cm in males and 20 cm in females).

Facial expression video analysis for depression detection in Chinese patients

Emotional state analysis of facial expression is an important research content of emotion recognition. At the same time, in the medical field, the auxiliary early screening tools for depression are also urgently needed by clinics. Whether there are differences in facial expression changes between depressive patients and normal people in the same situation, and whether the characteristics can be obtained and recognized from the video images of depressive patients, so as to help doctors detect and diagnose potential depressive patients early are the contents of this study. In this paper, we introduce the videos collection process of depression patients and control group at Shandong Mental Health Center in China. The key facial features are extracted from the collected facial videos by person specific active appearance model. On the basis of locating facial features, we classified depression with the movement changes of eyes, eyebrows and corners of mouth by support vector machine. The results show that these features are effective for automatic classification of depression patients.

Viewpoint: Establishing rapport: the GP without a smile.

The Royal College of Paediatrics and Child Health gives a seemingly simple piece of advice: ‘Doctors should treat children with a big smile.’ 1 After all, a smile is a cornerstone of good non-verbal communication and it is arguably the most important tool we have for establishing rapport with a patient. However, if a smile really is so important for a doctor–patient interaction, where does this leave the GP who cannot smile? I found this out the hard way. Last summer, I woke up one morning with excruciating ear pain and looked in the mirror to be confronted by a face that I barely recognised. My left cheek hung heavy and motionless, dragging the corner of my mouth down with it. My …