Key Points
Question How is facial paralysis associated with the perception of attractiveness, femininity or masculinity, and personality, and do patient-reported outcome measures correlate with how patients are perceived by others?
Findings In this cross-sectional study including 20 patients with facial paralysis and 122 survey respondents, respondents rated photographs of patients with facial paralysis significantly lower in likeability, trustworthiness, attractiveness, and femininity or masculinity compared with the digitally edited images of patients without facial paralysis. Higher social function and total Facial Clinimetric Evaluation scores were associated with increased trustworthiness and attractiveness scores.
Meaning These results broaden understanding of how facial paralysis is associated with societal perceptions of persona.
Abstract
Importance Facial paralysis has a significant effect on affect display, with the most notable deficit being patients’ the inability to smile in the same way as those without paralysis. These impairments may result in undesirable judgements of personal qualities, thus leading to a significant social penalty in those who have the condition.
Objective To quantify the association of facial paralysis with the way smiling patients are perceived by others with respect to personality traits, attractiveness, and femininity or masculinity and to evaluate the potential association of facial palsy–related patient-reported outcome measures with how patients are perceived by others.
Design, Setting, and Participants This retrospective cross-sectional study used 20 images of smiling patients with facial paralysis evaluated between January 1, 2014, and December 31, 2016. Using photograph editing software, the photographs were edited to create a simulated nonparalysis smiling facial appearance. A total of 40 photographs were split into 4 groups of 10 photographs, each with 5 altered and 5 unaltered photographs. The surveys were designed such that altered and unaltered photographs of the same patient were not placed in the same survey to avoid recall bias. Anonymous raters used a 7-point Likert scale to rate their perception of each patient’s personality traits (ie, aggressiveness, likeability, and trustworthiness), attractiveness, and femininity or masculinity based on photographs in their assigned survey. Raters were blinded to study intent. Scores from the Facial Clinimetric Evaluation questionnaire were included to assess self-perception. Data were analyzed from November 11, 2019, to February 20, 2020.
Main Outcomes and Measures Ratings of personality traits, attractiveness, and femininity or masculinity. Social function domain scores and overall scores were analyzed from the Facial Clinimetric Evaluation questionnaire.
Results This study included photographs of 20 patients with facial paralysis (mean [range] age, 54 [28-69] years; 15 [75%] women). A total of 122 respondents completed the survey (71 [61%] women). Most respondents were between the ages of 25 and 34 years (79 participants [65%]). Overall, smiling photos of patients with facial paralysis were perceived as significantly less likeable (difference, −0.29; 95% CI, −0.43 to −0.14), trustworthy (difference, −0.25; 95% CI, −0.39 to −0.11), attractive (difference, −0.47; 95% CI, −0.62 to −0.32), and feminine or masculine (difference, −0.21; 95% CI, −0.38 to −0.03) compared with their simulated preparalysis photographs. When analyzed by sex, smiling women with facial paralysis experienced lower ratings for likeability (difference, −0.34; 95% CI, −0.53 to −0.16), trustworthiness (difference, −0.24; 95% CI, −0.43 to −0.06), attractiveness (difference, −0.74; 95% CI, −0.94 to −0.55), and femininity (difference, −0.35; 95% CI, −0.58 to −0.13). However, smiling men with facial paralysis only received significantly lower ratings for likeability (difference, −0.24; 95% CI, −0.47 to −0.01) and trustworthiness (difference, −0.30; 95% CI, −0.53 to −0.07). As patients’ self-reported social function and total Facial Clinimetric Evaluation scores increased, there was an increase in perceived trustworthiness (rs[480] = 0.11; P = .02) and attractiveness (rs[478] = 0.10; P = .04) scores by raters.
Conclusions and Relevance In this study, photographs of patients with facial paralysis received lower ratings for several personality and physical traits compared with digitally edited images with no facial paralysis. These findings suggest a social penalty associated with facial paralysis.
Discussion
The Duchenne smile is classically described as the anatomical marker of the genuine smile. The smile is distinctive, with the mouth turning up from the activation of the zygomatic major muscle, the cheeks lifting, and the appearance of wrinkles around the eyes (also known as crow’s feet) associated with simultaneous contraction of the orbicularis oculi. The absence of the Duchenne smile not only influences how people evaluate smiles but also how they are judged by others.29,30
The findings of this cross-sectional study suggest that the inability to effectively smile is associated with negative perceptions in likeability, trustworthiness, attractiveness, and femininity or masculinity for patients with facial paralysis. Paralysis affecting the mouth is among the most notable of facial asymmetries, such that palsies of the zygomatic and marginal branches of the facial nerve are considered to have a significantly greater need for correction.11,12 Interestingly, reanimation surgery of the lip significantly decreases the degree of attention to the mouth and can help decrease negative perceptions of patients with facial paralysis.31
A universal finding for our patient population was lower perceived trustworthiness for the photographs of patients with facial paralysis vs their digitally altered counterparts. Research in the psychological and social sciences corroborate these findings, such that a happy facial expression makes a person appear more trustworthy.31,32 Furthermore, having a facial appearance that conveys a positive emotional state enhances trust.33-35 These findings highlight the social significance of the asymmetric smile and the importance of further progress in the development of techniques to assist in mitigating the effects of facial paralysis.
It is interesting to find that men and women with facial paralysis did not experience the same social penalty with respect to their facial paralysis. The relative decrease in attractiveness and femininity perceived in women with facial paralysis likely reflects the different social expectations by sex in our society. This is consistent with the results reported in a 2019 study36 that suggest that the appearance of a smile is not as integral to the perception of masculinity as it is to femininity.
Lastly, there was a correlation between the way patients with facial paralysis perceived themselves and how they were perceived by others. Specifically, as self-perception of social function and overall facial function improved, there was an increase in perceived trustworthiness and attractiveness by others. This is similar to the results reported by Lyford-Pike et al37 that suggest that higher FaCE scores correspond with decreased perception of disfigurement by patients.
It is important to note that this study included patients with facial paralysis presenting with a range of facial impairment. Not all patients with facial paralysis experienced a significant decrease in the perception of their personality traits, femininity or masculinity, and attractiveness. More research is needed to better understand the different variables that can optimize outcomes at the individual patient level.
Limitations
There are several limitations to this study. This study was performed using static smiling images, but other studies have found that observers judged the severity of paralyzed faces to be more noticeable when viewing dynamic expressions.38 In addition, as this study included only patients willing to have their photos viewed by others, there may have been a selection bias rendering the study patient group to be less reflective of the true gamut of patients with facial paralysis.39
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