Spontaneous Smile Research Articles

Lengthening temporalis myoplasty and facial paralysis from birth

Congenital facial paralysis (FP) is present from birth. It can produce major esthetic and functional disorders. It can be from two different etiologies: developmental and acquired. There is no curative treatment for congenital FP and the aim for the plastic surgeon is to restore a smile as symmetrical and as dynamic as possible. For this, two opposite techniques can be used: muscular free flaps and locoregional flaps whose lengthening temporalis myoplasty. We report our series of 34 congenital FP patients who were operated by lengthening temporalis myoplasty (LTM). We divided the patients into three categories: acquired FP (11 cases), isolated developmental FP (13 cases), and syndromic developmental FP (10 cases). The evaluation of the smile is based on the quality of the commissural course compared to the healthy side and the spontaneity of it. In the acquired FP group, 100% obtained a spontaneous smile with a postoperative delay of 9.5 months, 12 of the 13 cases of isolated developmental FP (92.7%) after 7.3 months postoperatively, and finally, in the 10 cases of syndromic FP, nine (90%) had a spontaneous smile after 9.7 months. Muscular free flaps continue to be the gold standard for the reanimation of smile on the FP. To our knowledge, no articles comparing smile restoration using free flap and smile restoration using LTM exist. A comparison of the success rates from different studies shows that both these techniques yield good results and can be used for smile restoration in FP. This technique is faster and easier than a free flap and has a same result, which is why we consider this technique as a reference on smile reanimation in FP.

Facial reanimation with masseteric to facial nerve transfer: A three-dimensional longitudinal quantitative evaluation

Facial paralysis is a severe pathological condition, negatively affecting patients' quality of life. The altered tone and mobility of the mimetic musculature provoke both functional and morphological deficits. In the present study, we longitudinally measured facial movements in 14 patients (21-69 years) affected by unilateral facial paralysis not lasting longer than 23 months. The patients were analyzed before and after surgical masseteric to facial nerve neurorrhaphy. Examinations were performed at least 3 months after they had clinically started to regain facial mimicry. The displacement of selected facial landmarks was measured using an optoelectronic three-dimensional motion analyzer during: maximum smile without clenching (pre- and postsurgery), maximum smile by clenching on their posterior teeth (only postsurgery), and spontaneous smile (recorded during the vision of a funny video in both examinations). Before facial surgery, in all smiles facial landmarks moved more in the healthy than in the paretic side; after surgery, the differences decreased for both reduction of the healthy-side motion, and increment of the paretic-side motion (motion ratio before 52%, after 87%, p<0.05, Students' t-test). The ratio between the paretic and healthy-side total motion (asymmetry) did not modify for maximum and spontaneous smiles, but significantly increased for the maximum smiles made with teeth clenching (asymmetry before 32%, after 11%, p<0.001). Spontaneous smiles were recorded only in a subset of patients, but their execution was modified by surgery, with more symmetrical movements of the rehabilitated-side landmarks (asymmetry before 33%, after 10%), and reduced motion of the healthy-side ones (motion ratio before 51%, after 83%). In conclusion, the significant asymmetry in the magnitude of facial movements that characterized the analyzed patients before surgery reduced after surgery, at least in those facial areas interested by the masseteric to facial nerve reanimation.

Bradykinesia of posed smiling and voluntary movement of the lower face in Parkinson's disease

ObjectiveImpaired facial expression, including spontaneous and emotional movements such as smiling, has been often reported in Parkinson's disease (PD). There is a general consensus that spontaneous smiling is abnormal in PD. Investigations on posed smiling yield contrasting results. Moreover, no study has yet addressed the relationship between posed smiling and abnormalities of voluntary movements of the lower face, global motor impairment and the effects of dopaminergic medication. MethodsWe investigated the kinematics of posed smiling (mimicking a smile shown in a picture) and those of voluntary movements of the lower face (showing the teeth as fast as possible – voluntary grinning) in 15 patients with PD (ON and OFF therapy) and in 16 healthy controls. Facial movements were recorded using a 3D optoelectronic system and analyzed using dedicated software. ResultsSome kinematic parameters of both posed smiling and voluntary grinning were abnormally lower in PD patients in comparison to healthy subjects. The kinematics of posed smiling correlated with those of voluntary grinning in PD patients but not in healthy controls. Posed smiling and voluntary grinning abnormalities were related to global motor severity but did not significantly improve upon L-dopa administration. ConclusionsThese results suggest that posed smiling and voluntary grinning are both abnormal in PD patients and that they are likely mediated by a common pathophysiological mechanism.

Vergleichende Untersuchung des Cross Face Nerve Graft und des N. massetericus als Spendernerven für den freien funktionellen Muskeltransfer zur dynamischen Mundwinkelreanimation bei Fazialisparese

Several surgical techniques have been proposed for the reconstruction of the smile in facial paralysis. The 2-stage approach utilising a cross-facial nerve graft (CFNG) and subsequent free functional muscle transfer represents the "gold standard". A single-stage alternative is the use of the masseteric nerve as donor nerve. Here we have retrospectively analysed the outcome of 8 patients who were treated with either of these procedures (4 per treatment group). We compared the oral commisure excursion between the 2 groups. Use of the masseteric nerve led to reinnervation of the muscle graft within 3 months. The 2-stage procedure required more than 12 months from the first procedure until first muscle contractions could be observed. A spontaneous smile could not be achieved in all patients when the masseteric nerve was used. The oral commisure excursion was symmetrical when compared to the healthy side in both groups, however the excursion was significantly higher in the masseteric nerve group compared to the CFNG group of patients. Most patients with the masseteric nerve as a donor nerve underwent a secondary procedure, which involved thinning of the muscle flap. In conclusion, the use of the masseteric nerve as a donor nerve for facial reanimation surgery is a single-stage alternative to the use of a CFNG as donor nerve. It delivers reliable results with strong muscle contractions with limitations in regard to achieving a spontaneous smile.

One-Stage Procedure Using Spinal Accessory Nerve (XI)–Innervated Free Muscle for Facial Paralysis Reconstruction

For the treatment of facial paralysis, functioning free muscle transplantation has become accepted standard treatment. Choice of donor nerve and number of surgery stages, however, are still matters of great debate. Between 2000 and 2011, 36 patients (out of 329; 11 percent) with 42 functioning free muscle transplantations were treated using spinal accessory nerve (XI)-innervated muscle for facial reanimation as a one-stage procedure. Indications included bilateral or unilateral Möbius syndrome, severe postparetic facial synkinesis, and patient preference. Postoperative smile training was required to achieve spontaneous smile. For outcome assessment, patients were evaluated using multidisciplinary methods, including objective smile excursion score (range, 0 to 4), cortical adaptation stage (range, I to V), tickle test, and subjective patient questionnaire and satisfaction score (range, 1 to 5). Mean smile excursion score improved from 0.5 preoperatively to 3.4 postoperatively. Eighty-three percent of patients were able to perform independent and even spontaneous smile after 1 year of follow-up. Ninety percent of patients had a mean satisfaction score of 3.4 out of 5. However, 50 percent expressed more concern with aesthetic appearance than functional status. There was no functional morbidity of the donor shoulder in daily life. The classic two-stage procedure is still the first choice for facial paralysis reconstruction. However, the effectiveness of XI-innervated free muscle for facial reanimation in a one-stage procedure has proven it to be a good alternative treatment. It has become second in popularity for facial paralysis reconstruction in the authors' center. Therapeutic, IV.

Lengthening temporalis myoplasty and brain plasticity: A functional magnetic resonance imaging study

Lengthening temporalis myoplasty (LTM) is a technique developed since ten years for facial paralysis. A spontaneous smile is acquired after this surgery explains by brain plasticity and the aim of the study is to confirm this plasticity by functional magnetic resonance imaging. A functional magnetic resonance imaging (fMRI) was performed at various time points in ten patients who were operated on LTM during one year. Two different areas were found to be involved in chewing and smiling. We observed changes in the areas involved in smiling and chewing three months after surgery, and these changes persisted for at least one year. Our findings thus confirm that brain plasticity underlies the clinical observation of acquisition of a spontaneous smile.

Analysis of dynamic smile and upper lip curvature in young Chinese

During smile evaluation and anterior esthetic construction, the anatomic and racial variations should be considered in order to achieve better matching results. The aims of this study were to validate an objective method for recording spontaneous smile process and to categorize the smile and upper lip curvature of Chinese Han-nationality youth. One hundred and eighty-eight Chinese Han-nationality youths (88 males and 100 females) ranged from 20 to 35 years of age were selected. Spontaneous smiles were elicited by watching comical movies and the dynamics of the spontaneous smile were captured continuously with a digital video camera. All subjects' smiles were categorized into three types: commissure, cuspid and gummy smile based on video editing software and final images. Subjects' upper lip curvatures were also measured and divided into three groups: upward, straight and downward. Reliability analysis was conducted to obtain intra-rater reliabilities on twice measurements. The Pearson Chi-square test was used to compare differences for each parameters (α=0.05). In smile classification, 60.6% commissure smile, 33.5% cuspid smile and 5.9% gummy smile were obtained. In upper lip measurement, 26.1% upward, 39.9% straight and 34.0% downward upper lip curvature were determined. The commissure smile group showed statistically significant higher percentage of straight (46.5%) and upward (40.4%) in upper lip curvatures (P<0.05), while cuspid smile group (65.1%) and gummy smile group (72.7%) showed statistically significant higher frequency in downward upper lip curvature (P<0.05). It is evident that differences in upper lip curvature and smile classification exist based on race, when comparing Chinese subjects with those of Caucasian descent, and gender.

A Functional Magnetic Resonance Imaging Paradigm to Identify Distinct Cortical Areas of Facial Function

Irreversible facial paralysis can be surgically treated by importing both a new neural and a new motor muscle supply. Various donor nerves can be used. If a nerve supply other than the facial nerve is used, the patient has to adapt to generate a smile. If branches of the fifth cranial nerve are used, the patient has to learn to clench teeth and smile. Currently, controversy exists regarding whether a patient develops a spontaneous smile if a nerve other than the facial nerve is used. The authors postulate that brain adaptation in facial palsy patients can occur because of neural plasticity. The authors aimed to determine whether functional magnetic resonance imaging could topographically differentiate activity between the facial nerve- and the trigeminal nerve-related cortical areas. A new paradigm of study using functional magnetic resonance imaging based on blood oxygen level-dependent signal activation was tested on 15 voluntary healthy subjects to find a sensitive localizer for teeth clenching and smiling. Subjects smiled to stimulate the facial nerve-related cortex, clenched their jaws to stimulate the trigeminal nerve-related cortex, and tapped their finger as a control condition. Smiling and teeth clenching showed distinct and consistent areas of cortical activation. Trigeminal and facial motor cortex areas were found to be distinct areas with minimal overlapping. The authors successfully devised a functional magnetic resonance imaging paradigm effective for activating specific areas corresponding to teeth clenching and smiling. This will allow accurate mapping of cortical plasticity in facial reanimation patients.

One-Stage Reconstruction for Bilateral Möbius Syndrome

Möbius syndrome (MS) can present with unilateral or bilateral facial paralysis. In performing 1-stage bilateral MS facial reanimation, we used bilateral spinal accessory (XI) nerves to innervate 2 free functional muscle transfers (FFMTs). Of 12 MS patients, 6 had bilateral facial paralysis. Bilateral gracilis were transferred and innervated using bilateral XI nerves. Results were evaluated using smile excursion score, cortical adaptation stage, and patient satisfaction questionnaire. In all, 13 FFMTs were performed (with 1 gracilis failure). Mean smile excursion score improved from 0.7 to 3.4 (out of 5) postoperatively. Four patients achieved spontaneous smile, 1 achieved independent smile, and 1 achieved dependent smile. Mean satisfaction score was 2.8 (out of 5). One-stage bilateral FFMTs neurotized by bilateral XI nerves are effective in treating bilateral MS patients. Careful patient selection, adequate neurologic and psychologic examination, and postoperative smile training are all important factors in achieving optimal outcomes.

Recycle of temporal muscle in combination with free muscle transfer in the treatment of facial paralysis

We experienced three patients with long-standing unilateral complete facial paralysis who previously underwent temporalis muscle transfer to the cheek for smile reconstruction. All patients complained of insufficient and uncomfortable buccal motion synchronised with masticatory movements and incomplete eyelid closure with ptotic eyebrow. To attain a near-natural smile and reliable eyelid closure, temporalis muscle was displaced from the cheek to the eyelid, and a neurovascular free latissimus dorsi muscle was transferred for the replacement of cheek motion. As a result, cheek motion synchronised with the contralateral cheek upon smiling and sufficient eyelid closure were obtained in all cases. Smile reconstruction using the temporal muscle is an easy and a versatile way in general. However, spontaneous smile is not achieved and peculiar movement of the cheek while eating is conspicuous in some cases. Replacement with neurovascular free latissimus dorsi muscle and recycling previously used temporalis muscle for eyelid closure are considered to be valuable for such cases.

STUDENTS’ SPONTANEOUS SMILE IN EFL CLASSROOM

This article discusses the importance of the students’ spontaneous smile in EFL classroom interaction, and its implication to their oral production. Findings proved that the students’ spontaneous smile served as a fundamental interactive nonverbal sign for it not only favors a closer relation among students, but also helps them in the co-construction of oral activities in group works. In sum, the students’ spontaneous smile appeared to be a nonverbal indicative of proximity and of increasing oral interaction among them.

Students’ spontaneous smile in the EFL classroom

This article discusses the importance of the students’ spontaneous smile in the EFL classroom interaction and its implication for their oral production. The ...

Preliminary study on analysis method of spontaneous smile and application

To investigate the smile esthetic elements of Chinese Han-nationality female based on high definition (HD) digital camera with computer-image measuring technique. HD digital camera was used to capture spontaneous smile process combined with computer-image measuring technique to establish the analysis method of smile. Ninety-nine Han-nationality female with normal gingiva, aged from 20 to 30 years were recruited. The lip-incisor edge distance, gingival display were measured. The data was statistically analyzed. A standard and objective method to analyze spontaneous smile was established. Forty-three percent (43/99) of the subjects studied were classified as having a high smile and average smile respectively, 13% (13/99) as having a low smile. Gingival display accounted for (1.34 ± 0.98) mm in high smile type. Average smile and high smile type were most common in the Chinese Han-nationality female studied.

Recovery of Emotional Smiling Function in Free-Flap Facial Reanimation

Long-standing unilateral facial palsy is treated primarily with free-flap surgery using the masseteric or contralateral facial nerve as a motor source. The use of a gracilis muscle flap innervated by the masseteric nerve restores the smiling function, without obtaining spontaneity. Because emotional smiling is an important factor in facial reanimation, the facial nerve must serve as the motor source to achieve this fundamental target. From October 1998 to October 2009, 50 patients affected by long-standing unilateral facial paralysis underwent single-stage free-flap reanimation procedures to recover smiling function. A latissimus dorsi flap innervated by the contralateral facial nerve was transplanted in 40 patients, and a gracilis muscle flap innervated by the masseteric nerve in 10 patients. All patients underwent a clinical examination that analyzed voluntary and spontaneous smiling. All patients who received a latissimus dorsi flap innervated by the contralateral facial nerve and recovered muscle function (92.5%) showed voluntary and spontaneous smiling abilities. All patients who received a gracilis free flap innervated by the masseteric nerve recovered function, but only 1 (10%) showed occasional spontaneous flap activation. During those rare activations, much less movement was visible on the operated side than when the patient was asked to smile voluntarily. The masseteric nerve is a powerful motor source that guarantees free voluntary gracilis muscle activation; however, it does not guarantee any spontaneous smiling. Single-stage procedures that use a latissimus dorsi flap innervated by the contralateral facial nerve have a lower success rate and obtain less movement; however, spontaneous smiling is always observed.

P-1128 - Acute effects of different stimulation settings via implanted electrodes in the bed nucleus of the stria terminalis/ventral striatum-internal capsule in treatment-resistant obsessive compulsive disorder

Deep brain stimulation (DBS) in different targets emerges as a promising therapeutic option for patients with treatment-resistant obsessive compulsive disorder (trOCD). We here describe the acute effects of different stimulation settings on OCD symptoms and mood states in a patient with trOCD after implantation of DBS electrodes in the bed nucleus of the stria terminalis/ventral striatum-internal capsule (BNST/VS-IC). Quadripolar DBS electrodes (Medtronic 3387) were implanted bilaterally with stereotactic guidance and microelectrode recordings in the BNST/VS-IC. Electrode location was confirmed via postoperative stereotactic CT. On the following day, the target was stimulated using different amplitudes (1V, 2V, 3.5V) and different contacts (0−/1+, 0−/3+, 2−/3+) with a constant pulse width of 210 μsec and a frequency of 130 Hz for 5 minutes, respectively. OCD symptoms and mood states were assessed by an independent rater using visual analogue scales. Subjective intensity of obsessive-compulsive thoughts was reduced most by acute stimulation with 2V but, however, deteriorated with higher amplitudes. Subjective feelings of pleasure and spontaneous smiling were induced also at low voltage. Stimulation of different contact pairs located either in the BNST (0−/1+) or in the IC (2−/3+), and combined stimulation (0−/3+) produced differential and particularly specific effects. We show acute effects on core symptoms of OCD after stimulation in the BNST/VS-IC. The induction of positive feelings accompanied symptom reduction. One hypothesis to explain our finding is that the induction of pleasure and smiling may be an epiphenomenon of stimulation of a ‘sweet-spot’ that ameliorates OCD symptoms after stimulation.

Treatment of Facial Paralysis

Six hundred fifty-five cases of unilateral facial paralysis were treated by different surgical methods to achieve dynamic reanimation of facial muscle movement. In a retrospective study, the recovery of both truly spontaneous smile and facial muscle movement was evaluated independently. The authors performed 505 two-stage gracilis, one rectus abdominis, and 14 single-stage latissimus dorsi microneurovascular muscle transfers, in addition to 28 cross-facial facial nerve neurotization procedures. These procedures were based on neurotization of the paralyzed region by the contralateral healthy facial nerve. Procedures involving motor nerves or muscle beyond the territory of the facial nerve included 73 temporalis muscle transpositions, four lengthening temporalis myoplasty procedures, 26 neurotizations by the hypoglossal nerve, and four neurotizations by the spinal accessory nerve. Patients treated by techniques based on the motor function of nerves other than the facial nerve did not recover spontaneous smile. Neurotization by the facial nerve, however, did result in the recovery of spontaneous smile in all satisfactory or better outcomes. Recovery of lip commissure movement based on neurotization by the contralateral healthy facial nerve was better than that of the remaining groups (p < 0.0001). Temporalis muscle transposition and lengthening myoplasty are acceptable options for patients who are not good candidates for neurotization by the facial nerve. For the restoration of both truly spontaneous smile and facial muscle movement, free microneurovascular muscle transfer neurotized by the contralateral healthy facial nerve has become the authors' first-choice surgical technique. Therapeutic, IV.

Smile Esthetics: Age Related Changes, and Objective Differences between Social and Spontaneous Smiles

To evaluate the importance of age in orthodontic treatment by studying the dependence of smile and resting parameters on age and to expose differences between social and spontaneous smiles. Subjects consisted of 67 individuals aged between 17 and 55. The video recordings were transferred to a computer 200 still frames were captured for each individual 50 were captured in resting position, 50 during speech, 50for social, and 50for spontaneous smiles. One picture was selectedfrom each group based on how pictures reflected the desired point ANOVA and Scheffe Post-hoc tests were performed on smile measurements. In all the resting parameters, statistically significant differences were observed among age groups. Also, the response of these parameters to age differs between men and women. Statistically significant diferences were found in some smile parameters among diferent age groups, for both smile types. We find significant differences between social and spontaneous smiles. Age related alterations should be taken into consideration during treatment planning, especially in women. Due to its high consistency, there are advantages with using a spontaneous smile in soft-hard tissue evaluations. We also emphasize the necessity to take dynamic registrations for a true functional evaluation.

Activation of the masseter muscle during normal smile production and the implications for dynamic reanimation surgery for facial paralysis

In cases of unilateral facial paralysis, free muscle transfer with coaptation to the motor nerve of the Masseter is gaining popularity as a primary alternative to cross-facial nerve grafting. Despite initial expectations, a majority of these subjects can achieve a spontaneous smile. The mechanism behind this spontaneity is unclear. Plasticity of the cerebral cortex as well as the relative proximity of the motor centres of the mimetic and Masseter muscles has been used in explanation. This study demonstrates the involvement of the Masseter muscle during normal smile production, suggesting a more direct explanation for the spontaneous smile seen following reanimation procedures innervated by the Masseter nerve. Twenty healthy volunteers were subjected to electromyography of the Masseter muscle bilaterally to demonstrate whether contraction of the Masseter muscle occurred during voluntary and involuntary smile production. Patient age ranged from 20 to 61 years (mean 41.6 years) with an equal male to female ratio. Activation of the Masseter occurred in 40 percent of individual muscles during smile production, occurring bilaterally in six participants, and unilaterally in four. There was no correlation between muscle activation and patient age or gender. Natural contraction of the Masseter muscle during normal smile production helps to explain the high rate of spontaneous smile development in subjects with facial paralysis who have undergone a free muscle reanimation procedure powered by the nerve to the Masseter muscle.

The Face of Love

The present research investigated whether accommodation, typically formulated as the tendency to deliberately inhibit a destructive reaction in response to a partner's destructive behavior, could also occur spontaneously. Supporting this notion, results of the first study revealed that participants respond to their partner's angry face with a spontaneous smile, whereas strangers' angry faces are mimicked and thus lead to a spontaneous frown. Importantly, the facial EMG data are moderated by participants' daily interaction styles: People perceiving themselves in a communal relationship show spontaneous acts of accommodation, whereas this is not the case for people in exchange relationships. The moderation occurred in our first (spontaneous) and third (forced accommodation) studies. The results of the second study replicated the first study in that participants in communal relationships frowned less toward partner's subliminally presented angry faces but more to their sad faces. The authors discuss their findings as spontaneous social emotion regulation.

Smile Reconstruction Through Bilateral Muscular Transplants Neurotized by Hypoglossal Nerves

Free transplant of gracilis muscle is the criterion-standard technique in dynamic rehabilitation of long-standing facial paralysis in which the facial musculature is atrophied. When the facial nerve is not available because of a bilateral lesion, other sources are the masseteric, hypoglossal, or accessory nerves. Although the use of hypoglossal nerve has been relegated to the background because of the morbidity caused by its loss, there are special situations in which the hypoglossal nerve should be considered the first option as donor motor nerve. The present article discusses the case of a patient with dynamic reanimation of bilateral facial paralysis with free-muscle transfer neurotized to the hypoglossal nerve. End-to-side coaptation of gracilis motor nerve and hypoglossal motor nerve allows neurotization of the transplanted muscle with minimum repercussion in speech or swallowing and can provide an adequate spontaneous smile with time.