Reconstructing a Smile

By Peter Revenaugh, MD

I spend hours every week staring at videos of people trying to smile. We interpret a simple smiling face in a split second, and based on the symmetry, make many assumptions about a person.

I am a facial plastic and reconstructive surgeon, with expertise in treatment of disorders of the facial nerve. The facial nerve controls the 46 tiny facial muscles that allow an array of nonverbal communication and emotional expression. Nearly everyone takes those 46 tiny muscles for granted, until an accident or illness suddenly alters their facial expression and how they interact with the world. New techniques that allow us to reconstruct a smile also remind us that a simple smile can change a life.

The face is the most important means of social communication. In less than 100 milliseconds — an eye blink takes 300 — humans can see a face, decide whether it is among the thousands stored in our memories and form an opinion. Mere millimeters of facial asymmetry can attract the attention of others and affect perception.

Responding to symmetry

In the animal kingdom, more symmetric animals are better at attracting mates, as their symmetry is thought to signal genetic quality and developmental stability. In humans, the research is more robust, if not creepy. Human body symmetry has been correlated with increased female fertility and male sperm numbers, and more symmetric faces were universally regarded by countless study groups as more attractive. But facial perception studies also show that we subconsciously regard faces with less symmetry as less honest, less employable, less trustworthy, less optimistic, less effective, less capable, less intelligent and less popular.

Such negative perceptions can be psychologically devastating for people with significant facial scars, asymmetries or paralysis. They are constantly trying to catch up with their own emotions and provide the world a face that simply doesn’t garner attention. Many patients actively dampen their emotions because any increase in emotion — a laugh or smile — draws attention to one half of their face moving while the other does not. Some of my patients say it feels like walking into work without pants; others say it is like showing up late for an important meeting. But all of them just want to go unnoticed, to walk to the grocery store without long looks or furtive glances.

‘What can we do?’

Sir Harold Gillies, known as a pioneer of modern reconstructive surgery, described in 1920 facial paralysis with extreme detail — and sympathy:

“This pathetic condition, curious in that there is no loss of skin, muscle or bone, produces one of the most heart-searching deformities that one meets in plastic surgery. The eye is drooped and drips tears onto the cheek, the tip of the nose is pulled towards the sound side, the corner of the mouth is down and the cheek flaps as if a bubble were being blown. When the crooked smile comes with its unbridled overaction, the picture of misery on the paralysed side is matched only by the plea on the normal side for us to do something about it. What can we do?”

Little could be done in the 1920s. Sir Gillies described slings of muscle tendon or suture similar to marionette strings, a technique still used today, but teams from around world have been working feverishly to stimulate nerves to grow, which would be the Holy Grail of smile reconstruction.

‘Exciting’ procedure

Similar to spinal cord injuries, the facial nerve has limited regenerative ability. It spreads out into the face like the branches of a tree, providing electrical signals to those 46 muscles to conjure thousands of unique emotional expressions. But for those with facial paralysis, the wires may all be strung into place and the muscles all ready to go, but the signal never makes it through and that happy thought can turn into frustration and sadness.

One way to replace that signal is to “borrow” nearby muscles and nerves. The most exciting of these procedures is called the gracilis muscle transfer, a procedure that “borrows” a strip of muscle from the inner thigh, complete with its nerve and blood vessels. This muscle is then placed under the facial skin and the nerves and blood vessels are precisely reconnected under a microscope with stitches smaller than a hair. Because the patient’s own muscle is used, there are no worries of rejection. After a few months, the muscle will start tiny movements, but soon strengthens and can become an ear to ear grin.

There is very little in medicine that I have experienced that is more humbling than seeing a full smile where once it was not possible. We should never forget that a simple smile can change lives.

Peter Revenaugh, MD, is a facial plastic and reconstructive surgeon with the Department of Otorhinolaryngology-Head and Neck Surgery at Rush University Medical Center.

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