The Laryngoscope V C 2011 The American Laryngological, Rhinological and Otological Society, Inc. What Faces Reveal: Impaired Affect Display in Facial Paralysis Lisa E. Ishii, MD, MHS; Andres Godoy, MD; Carlos O. Encarnacion, BS; Patrick J. Byrne, MD; Kofi D. O. Boahene, MD; Masaru Ishii, MD, PhD Objectives/Hypothesis: To evaluate affect display in patients with facial paralysis as compared with normal subjects. We hypothesized that patients with facial paralysis would have impaired affect display and be perceived as displaying a nega- tive affect as compared with normal subjects. Study Design: Randomized controlled experiment. Methods: Forty naive observers viewed pictures of patients with facial paralysis and normal faces. Observers classified the affect display of the patients and normal subjects by using a survey containing choices regarding primary emotions and personal attributes. Results: An exploratory latent class analysis was performed on the survey results, and the faces were categorized into three types: positive, negative, and neutral. The probability of interpreting normal smiling faces as positive was 98%; the probability of interpreting those in repose as neutral or positive was 60%. The faces with facial paralysis were much more likely to be regarded as negative or neutral. The probability for classification into the negative class was 73% for the para- lyzed faces in repose and 69% for the paralyzed smiling faces. In the latent class regression, smiling normal faces were six times more likely to be classified as positive, and smiling paralyzed faces were three times less likely to be in that class. Conclusions: Patients with facial paralysis were classified as having a negative affect display the vast majority of the time. Antithetically, normal faces in repose were classified as neutral the majority of the time; they were classified as positive the major- ity of the time when smiling. These novel results demonstrate the impact of the facial paralysis defect on perception by observers. Key Words: Facial paralysis, affect display, emotion. Laryngoscope, 121:1138–1143, 2011 INTRODUCTION Our face speaks volumes about us before we ever say a word. Faces convey a wealth of information such as identity and gender. They also play a key role in affect display, the external display of one’s emotions. As Darwin noted more than a century ago in The Expres- sion of the Emotions in Man and Animals, 1 facial expressions of emotion are universal and highly con- served. Vitally important for verbal and nonverbal communication, facial expression is also fundamental to one’s sense of well-being and ability to integrate into a social network. 2 ‘‘Emotional contagion’’ is the psychology term referring to the ability to communicate a certain mood on the one hand and to be empathic with people on the other hand. 3 In other words, it is our ability to get ‘‘in tune’’ with those around us. Impaired ability to form facial expressions therefore has the potential to result in dramatic social and emotional disruption. 4 Patients with facial paralysis have impaired facial movement and facial asymmetry at rest. The muscles of facial expression are critically important for affect dis- play and communication. This restriction of facial expression can have a dramatic impact on interpersonal relations. 4 Communication with others is disrupted when limitation of their facial actions prevents the cas- cade of emotional contagion. We have a reasonable understanding on how these impairments lead to a diminished quality of life from survey data completed by patients. 5 We have limited objective data on the impact of facial paralysis on affect display. The objective of the present study was to evaluate affect display in patients with facial paralysis as compared with normal individu- als. We hypothesized that patients with facial paralysis would have impaired affect display as compared with normal individuals when they were attempting to per- form the same facial expressions. Our subhypothesis was that the observers would assign negative emotional states and personal attributes to faces with facial paraly- sis. These hypotheses were explored with a latent class analysis. MATERIALS AND METHODS Participants Institutional review board approval was received for this study. A group of 40 randomly selected subjects (17 females and 23 males) participated in the study from March to July 2010. An investigator stood at the entrance to the Johns Hopkins From the Division of Facial Plastic and Reconstructive Surgery (L.I., P. J. B., K. D. O. B.) and Division of Rhinology ( M. I.), Department of Otolaryngology–Head and Neck Surgery (A.G.), Johns Hopkins School of Medicine, Baltimore, Maryland, U.S.A., San Juan Bautista School of Medicine (C.O.E.), San Juan, Puerto Rico. Editor’s Note: This Manuscript was accepted for publication January 26, 2011. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Lisa E. Ishii, MD, MHS, Assistant Profes- sor, Department of Otolaryngology–Head and Neck Surgery, Johns Hop- kins School of Medicine, 601 North Caroline Street, Baltimore, MD. E-mail: Learnes2@jhmi.edu DOI: 10.1002/lary.21764 Laryngoscope 121: June 2011 Ishii et al.: Affect Display in Facial Paralysis 1138