title: Changing perception: facial reanimation surgery improves attractiveness and decreases negative facial perception.
abstract: OBJECTIVE
  Determine the effect of facial reanimation surgery on observer-graded attractiveness and negative facial perception of patients with facial paralysis.
  
  
  METHODS
  Randomized controlled experiment.
  
  
  METHODS
  Ninety observers viewed images of paralyzed faces, smiling and in repose, before and after reanimation surgery, as well as normal comparison faces. Observers rated the attractiveness of each face and characterized the paralyzed faces by rating severity, disfigured/bothersome, and importance to repair. Iterated factor analysis indicated these highly correlated variables measure a common domain, so they were combined to create the disfigured, important to repair, bothersome, severity (DIBS) factor score. Mixed effects linear regression determined the effect of facial reanimation surgery on attractiveness and DIBS score.
  
  
  RESULTS
  Facial paralysis induces an attractiveness penalty of 2.51 on a 10-point scale for faces in repose and 3.38 for smiling faces. Mixed effects linear regression showed that reanimation surgery improved attractiveness for faces both in repose and smiling by 0.84 (95% confidence interval [CI]: 0.67, 1.01) and 1.24 (95% CI: 1.07, 1.42) respectively. Planned hypothesis tests confirmed statistically significant differences in attractiveness ratings between postoperative and normal faces, indicating attractiveness was not completely normalized. Regression analysis also showed that reanimation surgery decreased DIBS by 0.807 (95% CI: 0.704, 0.911) for faces in repose and 0.989 (95% CI: 0.886, 1.093), an entire standard deviation, for smiling faces.
  
  
  CONCLUSIONS
  Facial reanimation surgery increases attractiveness and decreases negative facial perception of patients with facial paralysis. These data emphasize the need to optimize reanimation surgery to restore not only function, but also symmetry and cosmesis to improve facial perception and patient quality of life.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A.
authors.forename: Jacob K
authors.initials: JK
authors.lastname: Dey
authors.forename: Masaru
authors.initials: M
authors.lastname: Ishii
authors.forename: Kofi D O
authors.initials: KD
authors.lastname: Boahene
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Byrne
authors.forename: Lisa E
authors.initials: LE
authors.lastname: Ishii
mesh_terms: D000328:Adult; D000368:Aged; D001504:Beauty; D005158:Facial Paralysis / Q000534:rehabilitation / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010465:Perception; D010865:Pilot Projects; D019651:Plastic Surgery Procedures; D012904:Smiling; D055815:Young Adult
keywords: DIBS score; Facial paralysis; attractiveness; facial reanimation surgery; psychosocial outcomes; smiling