Not just another face in the crowd: Society's perceptions of facial paralysis

Objectives/Hypothesis: There is a paucity of data showing the perception penalty caused by facial paralysis. Our objective was to measure society's perception of facial paralysis on the characteristic of beauty. We hypothesized that patients with paralysis would be considered by society as less attractive than normals, a difference amplified by smiling. Study Design: Randomized controlled experiment. Methods: Forty subjects viewed photographs of normal and paralyzed faces. They rated attractiveness, identified paralysis if present, its severity, and the feature most affected. Results: There were significant differences in attractiveness scores for normal and paralyzed faces (Wilcoxon rank sum test, z = 16.912; P < .001). A mixed effects regression model was used to explain differences in the scores. The fixed portion of the model shows paralyzed faces were 1 standard deviation less attractive than normal faces. Smiling increased attractiveness for normals (constant, 5.9; smile effect, 0.735; P < .001). The smile x paralysis interaction term was -0.892; P < .001, but not significantly different from the smile term (chi(2)(1) = 0.87; P = .352). The random effects model showed an intersubject rating variability of 1.32. Conclusions: The attractiveness penalty imposed by facial paralysis is significant, with paralyzed faces considered markedly less attractive than normals. However, the ratings did not change significantly when patients smiled, despite the increased asymmetry that occurs through smiling. Observers were moderately good at identifying the presence of facial paralysis, but less good at distinguishing side of involvement. These results have important implications for patient counseling and management of facial paralysis patients in an evidence-based manner.