[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Views 486
Citations 0
Original Investigation
Jan/Feb 2017

Effect of Weakening of Ipsilateral Depressor Anguli Oris on Smile Symmetry in Postparalysis Facial Palsy

Author Affiliations
  • 1Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston
  • 2Health Sciences and Technology Program, Harvard Medical School and the Massachusetts Institute of Technology, Boston
JAMA Facial Plast Surg. 2017;19(1):29-33. doi:10.1001/jamafacial.2016.1115
Key Points

Question  How does weakening of the ipsilateral depressor anguli oris (DAO) muscle affect smile dynamics in the setting of postparalysis facial palsy (facial synkinesis)?

Findings  This prospective, pretest-posttest study found that weakening of the ipsilateral DAO by simple injection of lidocaine significantly improved smile dynamics and communication of positive emotion on the paretic hemiface to observers naive to the attempted expression.

Meaning  Ipsilateral DAO weakening is a simple yet powerful means of improving smile quality in patients with postparalysis facial palsy and may be of great benefit to patients who develop this disfiguring complication of Bell palsy and other facial nerve insults.


Importance  Aberrant depressor anguli oris (DAO) activity may arise after recovery from acute facial paralysis and restrict movement of the oral commissure.

Objective  To quantify the degree to which DAO inhibition affects smile dynamics and perceived emotional state.

Design, Setting, and Participants  In this prospective, pretest-posttest study performed at an academic tertiary referral hospital, patients with unilateral postparalysis facial palsy were studied from January 16 through April 30, 2016.

Interventions  Local anesthetic injection into the ipsilateral DAO.

Main Outcomes and Measures  Healthy- and paretic-side commissure displacements from the midline lower vermillion border referenced to the horizontal plane were calculated from random-ordered photographs of full-effort smile before and after injection, and random-ordered hemifacial photographs of the paretic side were assessed as expressing positive, negative, or indiscernible emotion.

Results  Twenty patients were identified as having unilateral postparalysis facial palsy with marked synkinesis of the ipsilateral DAO. Patient mean age was 46 years (range, 24-67 years), with a male to female ratio of 1:3. Mean paretic-side commissure displacement increased from 27.45 mm at 21.65° above the horizontal plane to 29.35 mm at 23.58° after DAO weakening (mean difference, 1.90 mm; 95% CI, 1.26-2.54 mm; and 1.93°; 95% CI, 0.34°-3.51°; P < .001 and P = .20, respectively). Symmetry of excursion between sides improved by 2.00 mm (95% CI, 1.16-2.83 mm; P < .001) and 2.71° (95% CI, 1.38°-4.03°; P < .001). At baseline, observers assessed 7 of 20 paretic hemifaces (35%) as expressing positive emotion; this proportion increased to 13 of 20 (65%) after DAO weakening (P = .03).

Conclusions and Relevance  Ipsilateral DAO weakening results in significant improvements in smile dynamics and perceived expression of positive emotion on the paretic hemiface in postparalysis facial palsy. A trial of DAO weakening should be offered to patients with this disfiguring complication of Bell palsy and similar facial nerve insults.

Level of Evidence  3.