Asymmetrical Smiles Corrected by Botulinum Toxin Serotype A

OBJECTIVE The objective was to identify the cause of an asymmetrical smile and to ascertain whether or not it would be correctable by injections of Botulinum toxin A (BTX-A).
METHODS Five patients with asymmetrical smiles were identified and found to lower one side of their lower lip in an exaggerated fashion when smiling or laughing. After close observation, it was determined that the ipsilateral depressor labii inferioris of the lower lip was hyperkinetic and retracted that side of the lips lower than its contralateral side when smiling or laughing. Injections of low-volume and low-dose BTX-A (BOTOX, Allergan, Inc.) were placed into the depressor labii inferioris on the side where the lower lip retracted the lowest.
RESULTS All of the five patients with asymmetrical smiles presented with unilateral hyperkinetic depressor labii inferioris and responded to injections of BOTOX. Their lower lips became level and their smiles were symmetrical within 1 week of the BOTOX treatments. Their lip symmetry lasted for at least 6 months after their initial treatment. With each additional treatment, the duration of BOTOX lasted even longer, averaging approximately 7 months.
CONCLUSION BOTOX is an effective, safe, and long-lasting treatment for lower lip asymmetries caused by a hyperkinetic depressor labii inferioris.     

A simple and quantitative method for three-dimensional measurement of normal smiles

Smile reconstruction is one of the most challenging fields in plastic surgery. An understanding of the normal smile is essential in planning surgery for facial paralysis. The purpose of this study was to suggest a simple and quantitative method for the 3-dimensional analysis of smiles and to establish a basis for smile reconstruction in facial paralysis patients. The smiles of 50 volunteers (25 men and 25 women) were observed using a 6-mm digital video camera. Each subject had 10 points marked on the lips and nasolabial creases. Video editing programs were used to capture images of the resting and maximum smiles. The opacity of the image of maximum smile was adjusted and was merged with the resting image so that the migration of the points could be observed in 1 image. The migration distance (in millimeters) and the direction (in degrees) between each point were measured in frontal and both lateral views, and thus 3-dimensional vectors (x, y, z scalars) were obtained. The scalar values were converted to the values of a spherical coordinate system (distance, angle alpha and beta). Our work may offer a simple and quantitative method for measuring the smile and accurate guidance for reconstructive surgery.     

微笑的解剖学基础与面中下部年轻化

目的 从解剖学角度研究微笑产生的机制,研究微笑状态下面中下部老化特征的变化.方法 对10具（20侧）成人新鲜尸头行甲醛溶液固定后,在10倍解剖显微镜下对鼻唇沟区域进行形态学观测,并根据50例门诊医师和患者的照片观察,对静态与微笑时面中下部老化特征的变化进行对比.结果 （1）鼻唇沟是面中部多脂肪区与无脂肪区的分界,外侧为颧脂肪垫.（2）鼻唇沟是7种表情肌在皮肤上止点形成的连线区域.（3）微笑时,使鼻唇沟脊深度加深、延长,颊沟加深、延长,颊纹加深、延长.（4）微笑时,颧脂肪垫上移,泪槽畸形：64％消失、36％变浅,形态得到改善;眶颊联合：水平部100％消失,垂直部74％变浅,26％无变化,外观得到改善;颊中沟：78％消失,22％变浅得到改善;口下颌沟：Ⅲ度100％消失,Ⅱ度100％消失,Ⅰ度74％消失,26％变浅,外形得到改善.下颌缘流畅：18％得到改观,82％无变化.结论 肌肉收缩产生微笑,鼻唇沟是微笑的起点;微笑可以使颧脂肪垫上移,能掩盖一部分面中下部老化特征,使人显现年轻化效果.     

Workhorse Free Functional Muscle Transfer Techniques for Smile Reanimation in Children with Congenital Facial Palsy: Case Report and Systematic Review of the Literature

BackgroundPediatric facial palsy represents a rare multifactorial entity. Facial reanimation restores smiling, thus boosting self-confidence and social integration of the affected children. The purpose of this paper is to present a systematic review of microsurgical workhorse free functional muscle transfer procedures with emphasis on the long-term functional, aesthetic, and psychosocial outcomes.Materials and methodsWe performed a literature search of the PubMed database from 1995 to 2019 using the following search strategy: "facial paralysis"[Title/Abstract] OR "facial palsy"[Title]. We used as limits: full text, English language, age younger than 18 years, and humans. Two independent reviewers performed the online screening process using Covidence. Forty articles met the inclusion criteria. The protocol was aligned with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and was registered at the International Prospective Register of Systematic Reviews (PROSPERO, CRD42019150112) of the National Institute for Health Research.ResultsFree functional muscle transfer procedures include mainly segmental gracilis, latissimus dorsi, and pectoralis minor muscle transfer. Facial reanimation procedures with the use of the cross-face nerve graft (CFNG) or masseteric nerve result in almost symmetric smiles. The transplanted muscle grows harmoniously along with the craniofacial skeleton. Muscle function and aesthetic outcomes improve over time. All children presented improved self-esteem, oral commissure opening, facial animation, and speech.ConclusionsA two-stage CFNG plus an FFMT may restore a spontaneous emotive smile in pediatric facial palsy patients. Superior results of children FFMT compared to adults FFMT are probably attributed to greater brain plasticity.     

Patient experience in nerve-to-masseter-driven smile reanimation

IntroductionThe nerve-to-masseter is one of the most frequently used neural sources in smile reanimation surgery. Very little information has been reported on patient experience with regard to reanimated smile usage and sequelae following transfer. The aim of this study was to quantify patient perception of nerve-to-masseter use in smile reanimation surgery.MethodsAn online questionnaire was developed based on the clinical expertise of our team, patient interviews, and existing questionnaires of facial palsy-related quality of life and temporomandibular joint dysfunction. All patients treated with nerve-to-masseter-driven smile reanimation surgery, both nerve transfers and muscle transplantations, between 2007 and 2016 with a valid email address were invited to participate.ResultsOf 171 operated patients, 122 with a valid email address were invited to participate. Seventy-one patients responded (63.4% female, mean age 51.1 years) after a median follow-up of 3.8 years. A voluntary smile while biting down at least “most of the time” was reported by 83.1% of patients; 46.5% reported ability to smile on the affected side without bite. A “normal” or “almost normal” spontaneous smile was reported in 23.9% of patients. A total of 18.3% of patients self-reported masseter muscle atrophy, and 1.4–14.1% reported temporomandibular joint dysfunction. Forty-one patients (57.7%) reported prandial movement of the face at least “most of the time,” with 9 patients (12.7%) considering this bothersome.ConclusionPatients report good voluntary smiling ability following nerve-to-masseter-driven smile reanimation surgery, with low rates of sequelae.     

中国美貌汉族女性的微笑特征研究

目的:初步对中国汉族美貌女性微笑的相关指标进行测量分析,为正畸、正颌外科临床微笑美学的评估和治疗提供依据。方法:选取2008~2013年中国电影、电视剧及时尚期刊杂志中面型协调美观的中国美貌汉族女性65例,年龄18~30岁,对所有研究对象采用Photoshop CS3图像处理软件进行定点测量,并运用spss17.0进行统计分析。结果:获得中国美貌汉族女性微笑的相关数据,单侧颊旁间隙宽度与微笑宽度的比值为8.95%±1.24%;单侧颊旁间隙与微笑间隙的面积之比为4.00%±1.12%;高位、中位、低位微笑分别为6.1%、73.9%、20.0%;笑容指数与牙龈暴露指数分别为7.21±1.8和0.11±0.04。结论:中国美貌汉族女性微笑的相关指标测量分析结果可为正畸、正颌临床治疗方案的制定和疗效评估提供美学参考依据。     

Botulinum Toxin A Can Positively Impact First Impression

BACKGROUND First impression is influenced by facial appearance and improved by cosmetic surgery.
OBJECTIVE We wanted to determine if treatment with botulinum toxin A (BTxnA) would improve first impression.
MATERIALS AND METHODS Women received BTxnA in the forehead. Photos were taken prior to, and 1 week after, final BTxnA injection in smiling and relaxed poses. Photos were divided into books with each subject represented only once. Evaluators completed a survey rating first impression on various measures of success for each photo.
RESULTS No differences were seen for social skills, financial, or relationship success scales. A significant decrease in first impression scores between treatment photos was seen for academic performance and occupational success. However, analysis of between-subject effects found that "smile/relax" accounted for the decreased score in both scales. Significant increases in first impression scores were seen for dating success, attractiveness, and athletic success scales where smile/relax and BTxnA contributed significantly to the improved scores.
CONCLUSIONS BTxnA improved first impression scores for dating success, attractiveness, and athletic success scales. Academic performance and occupational success scores were not affected by BTxnA when the smile/relax variable was included. The smile/relax variable was a more important predictor for academic performance and occupational success scores.     

Specific Impairment of Smiling Increases the Severity of Depressive Symptoms in Patients with Facial Neuromuscular Disorders

Depressive symptoms and related emotional distress are prevalent among patients with facial neuromuscular disorders, and the psychological distress impacts the functional disabilities associated with the facial impairment. A specific impairment in the ability to smile may elevate the risk for depression, with patients experiencing a reduced physiological feedback associated with smiling as well as the social consequences of the inability to communicate positive emotion. We tested the hypothesis that specific impairments in the ability to smile increase the severity of depressive symptoms in patients with facial neuromuscular disorders. Twenty-nine consecutive patients (mean age, 50.2 years; SD, 17.0 years; range, 18–81 years) with a facial neuromuscular disorder, who volunteered and completed all of the assessment measures participated. Facial neuromuscular impairments were assessed using multiple measures of facial motility and dysfunction, and emotional functioning was assessed using self-report measures of depression, anxiety, and positive and negative affect. Severity of global facial impairment was statistically controlled in evaluating the association between specific impairment in smiling and the degree of depressive symptoms. Separate hierarchical linear regression analyses indicated the specific impairment of smiling contributed to the prediction of depression (R ²= .41, df = 3,25, p= .00) and anxiety (R ²= .35, df = 3,25, p= .00), controlling first for the contribution of global impairment and facial physical disability. The specific impairment of smiling did not contribute to the prediction of positive emotional experience. Specific impairment of smiling and physical disability, but not global impairment of facial motion, were key predictors of depression in patients with facial neuromuscular disorders. The results emphasize the need to assess and treat depression and anxiety in patients with a facial neuromuscular disorder.     

Rhinoplasty and facial expression.

Based on the philosophical concept that facial beauty is not merely harmony of static anatomical structures but also the dynamic expression of the face (especially when one smiles), I propose that plastic surgeons approach the problem of aesthetic improvement of the human face not only in response but also when the face moves. I call this "surgery of the facial expression." I describe here the use of a new surgical procedure to correct a certain condition with which plastic surgeons are frequently confronted when patients consult and request rhinoplasty. Many patients have added defects that are exposed only when they begin to make facial movements and gestures; moreover, these added defects become even more manifest when they smile. I call this phenomenon "rhino-gingivolabial syndrome of the smile," and describe the technique I have used not only to improve the form of the nose but also to enhance the patient's smile.     

Upper lip shortening combined with Lefort 1 maxillary intrusion: a novel approach to correct the long face syndrome

Lip lengthening is a common characteristic of aging caused by the weakening of the fascial attachments and decrease of lip volume. We report a comprehensive combined plastic-orthognathic surgery of a long face syndrome uncharacteristically associated with a long upper lip in a 37-year-old Caucasian woman. The deformity comprised increased lower face height, vertical maxillary excess, and increased gingival display upon smiling. The long lip (30.7 mm; norm, 20.1?+?2 mm) constituted a limitation to the routine maxillary Lefort impaction because of the expected deficient display of maxillary teeth at rest and during smile. Lip shortening (5 mm) through a crescent flap was combined with maxillary impaction (6 mm), mandibular advancement (8 mm), and genioplasty (8 mm). Post-treatment results revealed normal relations between the upper lip and both the lower facial features and the dentition, at rest and during smile. Research should explore the predictability of the observed hard and soft tissue changes in similar dysmorphologies. Level of Evidence: Level V, therapeutic study.     

Orofacial myofunctional changes in skeletal Class III patients after bimaxillary orthognathic surgery

The aim of this study is to investigate the effect of bimaxillary orthognathic surgery on orofacial myofunctional changes in skeletal class III patients.35 patients who received Le Fort I maxillary advancement osteotomy and mandibular SSRO setback were included in this study. Facial expression function was analyzed by “placid” or “smile” expressions using chL-chR, ∠chRnchL, and ls-li. Occlusal force and balance were analyzed using a T-scan III digital occlusal analysis system. Maximum mouth opening (MMO) was measured prior to surgery and 2/14/28/42/90/180/360 days after surgery.After surgery, patients recovered facial expressions in no less than 3 months for both the “placid” or “smile” facial expression. Patients obtained significantly improved ‘smile’ expressions 3 months after the operation compared to preoperative “smiles”, and this improvement remained stable 12 months after the operation. Occlusal force was significantly decreased with the balance of occlusion lost immediately after surgery. These conditions gradually recovered, and patients finally obtained a more balanced and stronger occlusion [occlusion balance: 6.7 ± 2.7 mm vs. 4.1 ± 3.0 mm (day -7 vs. day 42); occlusion force: 19.6 ± 7.0 kg vs. 24.2 ± 9.3 kg (day -7 vs. day 180)]. However, patients had smaller postoperative mouth opening compared to preoperation opening during our follow-up.Our results confirmed that orthognathic surgery obstructs orofacial myofunctions of skeletal class III patients in the short-term. In the long-term, orthognathic surgery results in more stable and balanced orofacial myofunctions. By understanding the process of functional recovery of orofacial muscles after orthognathic surgery, we hope to accelerate patient's recovery from surgery.     

Comparative objective and subjective analysis of temporalis tendon and microneurovascular transfer for facial reanimation.

The aim of this study was to compare objectively and subjectively the results after temporalis tendon and microneurovascular transfer for reanimation of the paralysed face. For the objective analysis, measurements of the distances between static and dynamic points in three-dimensional space were performed at rest and during smiling. The patients were assessed subjectively by non-professionals scoring videotapes. The range of motion of the oral commissure on smiling was 1.7 mm (0.8, mean and SE) after tendon and 5.5 mm (1.6) after microneurovascular transfer (P < 0.05) without showing teeth, and 0.6 mm (1.3) vs 3.6 mm (2.4, ns) with showing teeth. Compared with the healthy side, the excursions reached 6% (16) after tendon and 71% (26, P < 0.05) after microneurovascular transfer for smiling without, and -4% (14) vs 19% (14, ns) for smiling with showing teeth, respectively. Virtually no difference was found in the measurements at rest as well as in the subjective evaluation. Swelling of the cheek (28%) and tethering of the skin (24%) were shown to be the most disturbing symptoms after microneurovascular transfer. Better excursion and symmetry of the oral commissure were achieved by microneurovascular reconstruction for voluntary smile. However, the aesthetic outcome after microneurovascular transfer is markedly impaired by chronic complications including swelling of the cheek and tethering of the skin, which were not detected by the three-dimensional measurement technique used. We conclude that the aesthetic appearance should be considered equally important as the range of motion in the reanimated face.     

210例脑血管疾病患者的康复治疗分析

目的降低脑血管疾病的致残程度,提高患者的生活质量。方法对210例脑血管病患者早期及时干预及康复锻炼。结果所有患者的各项功能均有所好转。结论对脑血管疾病患者康复治疗可提高患者生活质量。     

The “Unpleasant” smile

A simple procedure is described to correct what the authors call the unpleasant smile. The procedure consists of hiding the excessively visible upper arch mucosa exposed during smiling, and it usually solves the aesthetic problem in patients who reject a more complicated maxillofacial approach. Basically, the technique involves creating a synechia between the upper lip and the periosteum of the maxillary arch. This synechia eliminates overexcursion of the lip during smiling.Presented at the First Congress of the Sociedad Argentina de Cirugía Estética, Buenos Aires, November 1972.     

Fast-track rehabilitation in elective colorectal surgery patients: a prospective clinical and immunological single-centre study

BACKGROUND: Recent clinical data indicate that fast-track surgery (multimodal rehabilitation) leads to shorter postoperative length of hospital stay, faster recovery of gastrointestinal function as well as reduced morbidity and mortality rates. To date, no study has focused on the effects of fast-track surgery on postoperative immune function. This study was initiated to determine whether fast-track rehabilitation results in improved clinical and immunological outcome of patients undergoing colorectal surgery. METHODS: Forty patients underwent either conventional or fast-track rehabilitation after colorectal surgery. In addition to clinical parameters (return of gastrointestinal function, food intake, pain score, complication rates and postoperative length of stay), we determined parameters of perioperative immunity by flow cytometry (lymphocyte subgroups) and enzyme-linked immunosorbent assay (interleukin-6). RESULTS: Our findings indicate a better-preserved cell-mediated immune function (T cells, T-helper cells, natural killer cells) after fast-track rehabilitation, whereas the pro-inflammatory response (C-reactive protein, interleukin-6) was unchanged in both study groups. Furthermore, we detected a significantly faster return of gastrointestinal function (first bowel movement P<0.001, food intake P<0.05), significantly reduced pain scores in the postoperative course (P < 0.05) and a significantly shorter length of postoperative stay (P<0.001) in patients undergoing fast-track rehabilitation. CONCLUSION: Fast-track rehabilitation after colorectal surgery results in better-preserved cell-mediated immunity when compared with conventional postoperative care. Furthermore, patients undergoing fast-track rehabilitation suffer from less pain and have a faster return of gastrointestinal function in the postoperative course. In addition, postoperative length of hospital stay was significantly shorter in fast-track patients.     

普通人与正畸医生对姿势位微笑的审美观差异

目的:对比普通人与正畸医生对姿势位微笑的审美观异同.方法:用CanonEOS50D数码相机拍摄60例个别正常牙合的青少年面部正面微笑像数张(男30例,女30例),由正畸医生和普通人两组用(visual analog scale,VAS)评判美的微笑.结果:经t检验(t=4.941,P=0.000＜0.05)显示正畸医生与普通人的微笑主观评分有统计学差异.结论:正畸医生与普通人对姿势位微笑的审美观有差异,正畸临床诊治患者过程中,双方需加强沟通.     

Efficacy of Home-Based Kinesthesia,Balance & Agility Exercise Training Among Persons with Symptomatic Knee Osteoarthritis

The purpose of this study was to determine the efficacy of a home-based kinesthesia, balance and agility (KBA) exercise program to improve symptoms among persons age ≥ 50 years with knee osteoarthritis (OA). Forty-four persons were randomly assigned to 8-weeks, 3 times per week KBA, resistance training (RT), KBA + RT, or Control. KBA utilized walking agility exercises and single-leg static and dynamic balancing. RT used elastic resistance bands for open chain lower extremity exercises. KBA + RT performed selected exercises from each technique. Control applied inert lotion daily. Outcomes included the OA specific WOMAC Index of Pain, Stiffness, and Physical Function (PF), community activity level, exercise self-efficacy, self-report knee stability, and 15m get up & go walk (GUG). Thirty-three participants [70.7 (SD 8.5) years] completed the trial. Analysis of variance comparing baseline, mid-point, and follow-up measures revealed significant (p < 0.05) improvements in WOMAC scores among KBA, RT, KBA + RT, and Control, with no differences between groups. However, Control WOMAC improvements peaked at mid-point, whereas improvement in the exercise conditions continued at 8-weeks. There were no significant changes in community activity level. Only Control improved exercise self-efficacy. Knee stability was improved in RT and Control. GUG improved in RT and KBA+RT. These results indicate that KBA, RT, or a combination of the two administered as home exercise programs are effective in improving symptoms and quality of life among persons with knee OA. Control results indicate a strong placebo effect in the short term. A combination of KBA and RT should be considered as part of the rehabilitation program, but KBA or RT alone may be appropriate for some patients. Studies with more statistical power are needed to confirm or refute these results. Patient presentation, preferences, costs, and convenience should be considered when choosing an exercise rehabilitation approach for persons with knee OA.

Key points

• Kinesthesia, balance and agility programs, as well as lower extremity resistance training programs, or a combination of the two appeared equally effective in reducing symptoms of knee osteoarthritis.
• A placebo control intervention also appeared effective, but improvements reached a plateau at mid-point (4 weeks), unlike exercise program improvement which continued between mid-point and follow-up (8 weeks).
• Our results, along with two previous small studies, provide preliminary evidence that kinesthesia, balance, and agility programs without additional resistance training could be effective in treating knee osteoarthritis symptoms.
• Some evidence was found to suggest programs that include resistance training may be more effective for improving function, but more research is needed to confirm or refute this finding.

Key words: Exercise therapy, rehabilitation, postural balance, resistance training     

Síndrome urofacial de ochoa: caso clínico

An 11 year-old girl had an urinary diversión because of a complex uropathy with vesical sphincter dyssinergism. Her inexpressive face with lost eyes and forced gestures, especially when smiling –her smile looking rather like weeping- was the clue to the diagnosis of Ochoa’s syndromeShe underwent psoic bladder fixation, right ureteral reimplantation, bladder neck losening and cystostomy undiversion. At follow-up, renal function deteriorated. She has recently received a kidney transplantation in another institution, and is now symptom-free     

Nerve sources for facial reanimation with muscle transplant in patients with unilateral facial palsy: clinical analysis of 3 techniques

Ninety-one patients with long-standing unilateral facial palsy and submitted to reanimation of the face with muscle transplant were divided into 3 nonrandomized groups: group I: 2-stage facial reanimation, cross face followed by gracilis muscle transplant, 58 patients; group II: 1-stage reanimation with latissimus dorsi muscle transplant, 11 patients (a branch of the facial nerve on the nonparalyzed side of the face was used as the nerve source for reanimation in groups I and II); group III: 1-stage reanimation with gracilis muscle transplant and neural coaptation of the respective nerve and the ipsilateral masseteric branch of the trigeminal nerve, 22 patients. No microvascular complications were observed. The average interval between surgery and initial muscle contractions was 11.1 months, 7.2 months, and 3.7 months in group I, group II, and group III, respectively. The quality (intensity and shape) of the smile, voluntary or involuntary, obtained on the reanimated side in relation to the unaffected side was considered good or excellent in 53.4%, 54.5%, and 86.3% of the patients in groups I, II, and III, respectively. In group I, the average age of the patients with excellent or good results (19.8 + 10.5 years) was significantly lower than that of the patients with fair or poor results or absence of movement (36.5 + 13.3 years). The smile was considered emotional or involuntary in 34% of the patients in group I and 45% in group II. Most of the patients in each group were only able to produce "voluntary smiles". Crossed synkinesis with lip puckering was observed in 48% of the patients in group I and 90% in group II. The results obtained with 1-stage facial reanimation with masseteric nerve were more uniform and predictable than those obtained with the other techniques evaluated in this study.     

上颌前部骨切开术改善上唇软组织与微笑的美学效果

目的 通过分析上颌前部骨切开术矫正上颌前突畸形软、硬组织侧貌的变化特点,探讨正畸正颌等多学科联合治疗改善上唇软组织和微笑的美学效果,为手术设计和预测提供参考.方法 16例行上颌前部骨切开术的上颌前突患者,术前1周和术后6个月拍摄X线头颅侧位定位片,对相关软、硬组织的变化进行测量和统计学分析.结果 术后上切牙倾斜角平均减少8.8°,上唇高度平均增大2.44 mm,两者呈负相关(r=-0.807);上前牙槽高度、唇间隙、露齿距分别平均减少2.17、4.62、3.33mm,三者呈正相关(r=0.863或0.949).结论 上颌前部骨切开术,可根据患者的容貌特征并结合软组织与微笑的审美要求进行设计,通过术前正畸的调整及牙周、整形的辅助治疗,在矫正牙颌畸形的同时改善上唇软组织和微笑形态的美观.