The Cleft Palate–Craniofacial Journal 53(3) pp. e45–e52 May 2016 Ó Copyright 2016 American Cleft Palate–Craniofacial Association
ORIGINAL ARTICLE Judgment of Nasolabial Esthetics in Cleft Lip and Palate Is Not Influenced by Overall Facial Attractiveness Katharina Kocher, D.D.S., Piotr Kowalski, D.D.S., Olga-Elpis Kolokitha, D.D.S., Ph.D., Christos Katsaros, Dr. med. dent., Odont. Dr./Ph.D., Piotr S. Fudalej, D.D.S., M.S.D., Ph.D. Objective: To determine whether judgment of nasolabial esthetics in cleft lip and palate (CLP) is influenced by overall facial attractiveness. Design: Experimental study. Setting: University of Bern, Switzerland. Subjects and Methods: Seventy-two fused images (36 of boys, 36 of girls) were constructed. Each image comprised (1) the nasolabial region of a treated child with complete unilateral CLP (UCLP) and (2) the external facial features, i.e., the face with masked nasolabial region, of a noncleft child. Photographs of the nasolabial region of six boys and six girls with UCLP representing a wide range of esthetic outcomes, i.e., from very good to very poor appearance, were randomly chosen from a sample of 60 consecutively treated patients in whom nasolabial esthetics had been rated in a previous study. Photographs of external facial features of six boys and six girls without UCLP with various esthetics were randomly selected from patients’ files. Eight lay raters evaluated the fused images using a 100-mm visual analogue scale. Method reliability was assessed by reevaluation of fused images after .1 month. A regression model was used to analyze which elements of facial esthetics influenced the perception of nasolabial appearance. Results: Method reliability was good. A regression analysis demonstrated that only the appearance of the nasolabial area affected the esthetic scores of fused images (coefficient ¼ 11.44; P , .001; R2 ¼ 0.464). The appearance of the external facial features did not influence perceptions of fused images. Conclusion: Cropping facial images for assessment of nasolabial appearance in CLP seems unnecessary. Instead, esthetic evaluation can be performed on images of full faces. KEY WORDS:
cleft lip, cleft palate, esthetics
Orofacial clefts (OFCs) can cause many structural and functional deficiencies, negatively affecting facial appearance and speech. As a result, result, individuals with cleft lip and palate (CLP) may experience various psychological problems. Children with a cleft may exhibit increased anxiety, emotional problems, and lower self-esteem, and
they are less satisfied with their physical appearance compared to their peers without CLP (Pillemer and Cook, 1989; Hunt et al., 2007). Self-perceived facial appearance is especially important for their adjustment, because it is positively correlated with global self-esteem and selfperceived social acceptance and negatively correlated with loneliness (Pope and Ward, 1997; Feragen et al., 2009). Also, in adults, CLP is a risk factor for poorer self-esteem, social relations, and adjustment (Broder and Strauss, 1989; Ramstad et al., 1995). Due to the association between facial appearance and psychological well-being in subjects with CLP, assessment of nasolabial esthetics is routinely used in evaluating the outcome of treatment of OFC. In the Eurocleft (Brattstrom ¨ et al., 2005), Dutchcleft (Bongaarts et al., 2008), and Americleft (Mercado et al., 2011) studies, all of which were large multicenter investigations, scores rating patients’ nasolabial appearance were used to differentiate the results of various cleft centers (Brattstrom ¨ et al., 2005; Mercado et al., 2011) or results obtained with various treatment methods (Bongaarts et al., 2008). In each of these studies, the rating panel, which consisted of judges familiar
Dr. Kocher is doctoral candidate and Dr. Katsaros is Professor and Chair, Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Bern, Switzerland. Dr. Kowalski is Orthodontist, Department of Orthodontics, Palacky University Olomouc, Olomouc, Czech Republic. Dr. Kolokitha is Assistant Professor, Department of Orthodontics, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece. Dr. Fudalej is Associate Professor, Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Bern, Switzerland, and Department of Orthodontics, Palacky University Olomouc, Olomouc, Czech Republic. Submitted February 2014; Revised June 2014; Accepted September 2014. Address correspondence to: Dr. Piotr S. Fudalej, Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Freiburgstrasse 7, 3006 Bern, Switzerland. E-mail Piotr.Fudalej@ zmk.unibe.ch. DOI: 10.1597/14-019 e45
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(Brattstrom ¨ et al., 2005; Mercado et al., 2011) or unfamiliar (Bongaarts et al., 2008) with treatment of OFCs, was asked to rate the appearance of the nose and upper lip, the region directly affected by the cleft, on cropped facial photographs. Cropping of images was done to mask facial features unrelated to the cleft area, such as eyes, chin, cheeks, haircut, or facial shape, which could influence the rating. The need to crop images was based on the finding that judgments of nasolabial esthetics and esthetics of the full face with an obscured nasolabial region are highly correlated (Asher-McDade et al., 1991; Kuijpers-Jagtman et al., 2009). Asher-McDade et al. (1991) surmised that nasolabial appearance in subjects with attractive faces would be rated higher than in subjects with less attractive faces. In other words, overall facial attractiveness would artificially improve or worsen the judgment of the nasolabial area. To prevent this, Asher-McDade et al. (1991) proposed that photographs of children with CLP should be cropped so that only the nose and lips are shown during assessment. However, the correlation between esthetic scores assigned to various regions of the face does not equate to causation. In statistics, the correlation coefficient is a measure of dependence between two events. Correlations are useful because they can indicate a predictive relationship, which can be exploited in practice; however, statistical dependence is not sufficient to demonstrate the presence of a causal relationship (Holland, 1986). To emphasize that the determination of a cause-and-effect relationship requires more than establishing correlation, Holland (1986) and Rubin (1986) coined the statement ‘‘no causation without manipulation.’’ This widely used statement strongly implies that causation can be identified only through experimentation (manipulation). The objective of our experiment was to test the research hypothesis that the judgment of nasolabial esthetics in subjects with CLP is influenced by overall facial attractiveness. SUBJECTS
AND
METHODS
The ethics committee of the Canton of Bern approved this study (KEK-Nr.: 237-14). Subjects Two groups were selected: subjects without CLP (noncleft group) and subjects with complete unilateral CLP (UCLP) (cleft group). Noncleft Group The files of the Department of Orthodontics and Dentofacial Orthopedics at the University of Bern were searched for Caucasians who met the following inclusion criteria: (1) approximately 10 years of age, (2) healthy, (3) no prior history of trauma or surgery in the
facial region, (4) available frontal photograph of the face with neutral expression, and (5) Angle Class I malocclusion. The exclusion criteria were (1) cleft lip and/or palate, (2) other congenital syndrome affecting facial appearance, and (3) Angle Class II or III malocclusion. Sixty randomly selected subjects (30 boys and 30 girls) were used in the experiment. All subjects had extraoral photographs taken in the same setting with a white background. The photographs were taken with the same camera. Image data were saved as .jpg files. Cleft Group Caucasian subjects in whom nasolabial esthetics had been assessed previously (Fudalej et al., 2009) were used in this study. In summary, the sample consisted of 60 individuals with nonsyndromic complete UCLP consecutively treated according to a one-stage surgical protocol in the Warsaw Center for Craniofacial Disorders, Warsaw, Poland. The same high-volume surgeon performed all operations at the mean age of 9 months. The subjects had extraoral frontal photographs taken by a photographer against a light background at the mean age of 10.8 years. Methods Evaluation Procedure in Noncleft Group Facial attractiveness was evaluated on the basis of (1) full frontal images (Fig. 1) and (2) frontal images with a masked nasolabial area (Fig. 2). First, the frontal pictures were adjusted so that all faces visible on the photographs were of comparable size. Then the pictures were cropped to remove the excess background. Subsequently, pictures of boys and girls were loaded separately, in random order, into PowerPoint (Microsoft Corp., Redmond, WA) with an identifying case number on each slide. As a result, two PowerPoint presentations were created, one for boys and the other for girls. Based on these two presentations, eight judges of varying ages (four judges were ,50 years and four judges were .50 years of age), gender (three men, five women), and educational background (five judges had at least a college degree) evaluated facial esthetics. None of the authors of this study participated in the rating session. The PowerPoint presentations were shown on a 15inch laptop screen individually to each judge in a quiet room with adequate lighting. The judges were asked to (1) manually advance the slides and return to previous slide(s), if needed; and then to (2) decide spontaneously. They were also instructed that the ratings were comparative, i.e., each judge should ask himself/herself
Kocher et al., NASOLABIAL AND FACIAL ESTHETICS
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FIGURE 1 Facial image with an identifying case number used for ratings.
FIGURE 2 Facial image with masked nasolabial area and an identifying case number used for ratings.
the question, ‘‘Which face is more attractive, this one or the previous one?’’ The judges were asked to assess facial esthetics on a 100-millimeter visual analogue scale (VAS) on which 0 corresponded with an unattractive face and 100 with a very attractive face. Prior to the rating session, each judge was shown each presentation to allow familiarization with the material. Two weeks later, the same judges were asked to rate the attractiveness of facial images with a masked nasolabial area, as proposed by Asher-McDade et al. (1991). In contrast to the PowerPoint presentations in which full faces were shown, each subject had the nose and both lips masked by a white triangle, as demonstrated in Figure 2. Also, the order of images was rearranged at random to prevent a memory effect.
Construction of Fused Images
Evaluation Procedure in Cleft Group Nasolabial esthetics in the cleft group was rated on the basis of cropped facial images that showed only the region of the nose and lips. The panel comprised four orthodontists and rated four elements of nasolabial morphology (nasal shape, nasal deviation, vermilion border, and profile view) using a 5-point Asher-McDade esthetic index (1 ¼ best appearance to 5 ¼ worst appearance) (Fudalej et al., 2009). The overall esthetic score was calculated as the average of the scores for three judged nasolabial elements (nasal shape, nasal deviation, and vermilion border). The mean overall esthetic score was 2.4 (standard deviation [SD] ¼ 1.1; 95% confidence interval of the mean, 2.33 to 2.48; 90% central range, 1.4 to 3.3).
Fused images were constructed by fusing a frontal photograph of a subject from the noncleft group with the nasolabial image of a subject from the cleft group (Fig. 3A and 3B). Six boys and six girls representing the full esthetic range according to the mean VAS score were selected from the noncleft group. Their frontal images were manipulated in such a way that the region of the nose and both lips was replaced with nasolabial areas of subjects of the corresponding gender from the cleft group, who also represented the whole spectrum of nasolabial appearance. The procedure of construction of a fused image was repeated six times for each of six boys and six girls from the noncleft group, i.e., each noncleft boy and girl had a nasolabial area replaced six times with the nasolabial area of a boy and girl with the cleft, respectively. As a result, 72 fused images were constructed (36 each of boys and girls). Each fused image consisted of elements derived from the same gender. All manipulations were performed with Adobe Photoshop Elements 11 (Adobe Corp., San Jose, CA). During manipulation, the size, color, hue, saturation, brightness, and contrast were adjusted so that donor and recipient images matched as well as possible. Evaluation of Fused Images The fused images of boys and girls were loaded together, i.e., without gender separation, into PowerPoint. The same panel of eight judges who had assessed facial esthetics in subjects from the noncleft group evaluated the fused images. The rating session took
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assessment procedure was similar to that used in the noncleft group, except that here, the judges were instructed to focus on evaluation of the nasolabial area during rating, especially on assessment of the shape and symmetry of the nose and the upper vermilion border. The nomenclature for the 100-mm VAS was adapted slightly from the earlier session; 0 signified poor nasal shape/missing symmetry/unesthetic vermilion border and 100 signified good nasal shape/good symmetry/ esthetic vermilion border. The judges were not informed about the manipulation of the pictures. Method Error and Statistical Analysis To assess intrarater reliability of the esthetic scores, 20 randomly selected constructed pictures were rerated by the panel within 2 months. Intrarater reliability was assessed by calculating correlation coefficients, duplicate measurement error (DME), and the difference between paired observations and running t tests for paired observations. Interrater reliability was evaluated by calculating Cronbach’s alpha and intraclass correlation coefficients. The consistency between ratings of full faces and faces with a masked nasolabial area was assessed by calculating correlation coefficients, paired differences, and running t tests for paired observations. A regression model with esthetic scores for constructed images as the dependent variable and esthetic scores for (1) full face in the noncleft group, (2) full face with masked nasolabial area in the noncleft group, and (3) nasolabial area in the cleft group as independent variables was used. RESULTS Method Reliability The esthetic outcome of full faces and full faces without nasolabial area (Table 1) showed that masking the area of the nose and lips did not affect the score. The mean difference between the scores was only 0.22 (P ¼ .797) and the correlation coefficient was 0.853. Intrarater reliability of esthetic assessment was good; the correlation coefficient was high and DME was well within the SD of the esthetic outcome (Table 2). However, the judges were less critical during the second rating session and gave esthetic scores that were, on
FIGURE 3 Example of two constructed fused images of a boy with different nasolabial areas taken from two boys with complete UCLP.
place more than 4 weeks after the previous session. Prior to the rating session, the rating panel was shown extraoral pictures of five boys and five girls with complete UCLP to familiarize the judges with the range of possible esthetic outcomes in this condition. The TABLE 1
Comparison of Esthetic Ratings of Full-Face Images With and Without Nasolabial Area
Full Face
Full Face Without Nasolabial Area
Paired Differences
95% Confidence Interval of the Difference
Mean
SD*
Mean
SD*
Correlation Coefficient
Mean
Standard Error of the Mean
Lower Limit
Upper Limit
P
49.63
12.41
49.41
12.07
0.853
0.22
0.86
1.50
1.94
.797
* SD ¼ standard deviation.
Kocher et al., NASOLABIAL AND FACIAL ESTHETICS
TABLE 2
Intrarater Reliability of Esthetic Ratings of Fused Images Paired Differences
Correlation Coefficient 0.943
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95% Confidence Interval of the Difference
DME*
Mean
Standard Error of the Mean
Lower Limit
Upper Limit
P
4.22
5.97
1.22
8.50
3.45
,.001
* DME ¼ duplicate measurement error.
average, 5.97 points higher than during the first session (P , .001). The high values of Cronbach’s alpha (0.919) and the intraclass correlation (0.900) coefficients demonstrated very good consistency among different raters (Table 3). Ratings of Fused Images Mean values, SDs, medians, and percentile distributions of scores are presented in Table 4. Table 5 demonstrates the esthetic results of the 25% highestrated fused images (n ¼ 18). The mean values for esthetic outcomes for full-face images and full-face images without the nasolabial area in the noncleft subjects used in the preparation of fused images were in the middle of the scale (51.47 and 51.95 points, respectively, on a 100point scale). The mean value for esthetic outcome of the nasolabial area of cleft subjects used in preparation of the fused images was shifted toward the more esthetic end of the 5-point ordinal scale (2.25 points). The regression model with esthetic score for fused images as the dependent variable and esthetic scores for (1) full face, (2) full face with masked nasolabial area in the noncleft group, and (3) nasolabial area in the cleft group as independent variables demonstrated that only the appearance of the nasolabial area affected the esthetic result of the constructed images (Table 6). DISCUSSION Determination of causality plays a key role in the understanding of many biological processes and the development of effective treatment strategies. Originally, it was proposed that causal criteria are characterized by high strength of association, consistency, specificity, temporality of association (i.e., the cause must precede the effect), biological gradient, plausibility, and coherence (Hill, 1965). However, although these criteria are helpful, they may not be sufficient to prove a causal relationship between two events. The possibility of identifying causal factors can be increased with the use of experimentation (Rutter, 2007). In fact, the Oxford Centre for EvidenceBased Medicine (CEBM) ranks experimental investigations at the top level of evidence (CEBM, 2013). In the current experiment, we manipulated facial morphology to identify which element—the nasolabial area or the surrounding features—has a stronger effect on the perception of nasolabial appearance.
Our findings indicate that the esthetics of the area surrounding the nose and lips does not affect the outcome of assessment of nasolabial appearance in children with CLP. The only feature associated with esthetic ratings in these subjects was the appearance of the nose and lips. This is in contrast to the judgment of facial attractiveness performed in subjects without clefts, in whom attractiveness was demonstrated to be related to general qualities, such as facial symmetry and averageness (Langlois and Roggman, 1990; Perrett et al., 1999) and health of the skin (Jones et al., 2004), as well as specific nasolabial features such as the thickness of the lips and the size of the nose (Baudouin and Tiberghien, 2004). For example, female faces are judged as more attractive when they are symmetrical, when they are close to the average, and when they have big eyes, a small nose, prominent and high cheekbones, a small chin, and a thick mouth and upper lip (Baudouin and Tiberghien, 2004). The difference in the perception of facial attractiveness in subjects with and without a cleft may be a result of the way they are viewed. Looking involves coordinated movements of the body, the head, and, above all, the eyes. The brain signals received by the eye muscles cause the eyes to make rapid, jerking movements, after which the eyes remain fixed in their new position (so-called saccades or saccadic eye movements). During normal viewing, several saccades are made each second, and their destinations are selected by cognitive brain process without the involvement of any awareness. Visual perception, as well as judgment of facial attractiveness, is dependent upon the information taken in during fixation pauses between saccades; no useful visual information is taken in while the eyes are making a saccadic movement (Findlay and Walker, 2012). MeyerMarcotty et al. (2010) analyzed saccadic eye movements and fixation patterns while people were viewing photographs of persons with and without CLP. It turned out that the anomalous mouth area of subjects with a cleft captured more fixations of viewers than the normal nasolabial area of subjects without a cleft. Moreover, the selective attention of the viewers toward the cleft region came at the cost of the eyes, which were looked at less frequently. Therefore, it is TABLE 3 Images
Interrater Reliability of Esthetic Ratings of Fused
95% Confidence Interval of the ICC* Cronbach’s Alpha ICC* 0.919
0.900
Lower Limit
Upper Limit
P
0.860
0.932
,.001
* ICC ¼ intraclass correlation coefficient.
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TABLE 4
Esthetic Ratings of Fused Images
Mean
SD*
Median
Minimum
Maximum
5
10
25
50
75
90
95
45.24
16.05
43.7
10.1
82.4
17.7
22.14
35.3
43.7
56.4
63.26
79.38
Percentiles
* SD ¼ standard deviation.
possible that the subconsciously diversified attention of the visual system toward the facial features of subjects with and without a cleft forms the biological foundation for the judgment of facial appearance in these individuals. The current findings imply that preparations for ratings of the nasolabial area in subjects with a cleft do not have to include cropping of the images. Instead, pictures of full faces can be used as stimulus material. This is important, because cropping is relatively arduous and time-consuming. Moreover, with the increasing popularity of three-dimensional (3D) imaging, cropping of 3D facial images may be more complicated and more time-consuming than cropping conventional photographs and may also require additional resources, such as computer software, for processing. At the beginning of the study, the rating panel evaluated the facial esthetics of full faces and of full faces with a masked nasolabial area in children without a cleft. This step was necessary to ensure that the rankings of the attractiveness of faces with a masked nasolabial area (later used in fused images) were comparable with the rankings for full faces. We found no difference in the mean esthetic scores. Our results differ from the findings of Santos and Young (2011), who examined whether the level of interjudge agreement in various social attributions is affected by presentation of only the internal (i.e., eyes, nose, lips) or external features of the face (i.e., hair, ears, chin) in comparison to judgments made on the basis of the whole face. Santos and Young found that judgments of facial attractiveness differed if only internal or external features were assessed in comparison to the assessment of the whole face. This difference between our findings and the results of Santos and Young may be a result of differences in methodology. In our study, the internal features included only the nose and lips, whereas Santos and Young also included the eyes. Because the eyes are the preferred target of the center of gaze (Mertens et al., 1993; Pellicano et al., 2006; Bindemann et al., 2009), masking the nasolabial area in our study did not affect the esthetic score. A related problem—the association between social attractiveness and the dentofacial appearance (including a cleft lip)—was TABLE 5 Esthetic Ratings of Particular Elements of Facial Morphology Found in the 25% Top-Rated Fused Images (n ¼ 18)
investigated by Shaw et al. (1985). The authors found a strong predictive effect of background facial attractiveness on social desirability, and the effects of facial attractiveness were stronger than the effects of dental appearance. The disagreement between our findings and those of Shaw et al. may result from differences in the stimulus material. In the former study, subjects with a cleft lip, a relatively mild cleft deformity in which the nose remains unaffected, were evaluated, and in our study, subjects with a severe cleft (complete UCLP), in which nasal disfigurement almost always occurs, were assessed. The composition of the rating panel may influence esthetic scores during evaluations of facial appearance in subjects with CLP. It was demonstrated that rating panels comprising laypersons were more critical than (Eliason et al., 1991; Papamanou et al., 2012; Gkantidis et al., 2013), less critical than (Mani et al., 2010; Offert et al., 2013), or just as critical as (Bongaarts et al., 2008) rating panels that consisted of professionals (i.e., persons involved in treatment of CLP). In the evaluation of subjects without a cleft, it has also been demonstrated that the gender of the subject and the size of the panel also may affect the outcome. For example, Tedesco et al. (1983) suggested that women were less critical than men, whereas Kiekens et al. (2007) made the opposite claim: the men in their panel rated subjects as more attractive than the women in their study. Moreover, Kiekens et al. noticed an influence of the geographical origin of the members of the panel. This apparent chaos does not imply that rating facial esthetics is unfeasible because of the impossibility of producing consistent results. Instead, the variations in the scores assigned by various panels indicate simply that some panels are more critical and some are less critical than others. If, however, panels with various cultural or ethnic backgrounds were asked to rank facial attractiveness (i.e., to place faces in order from the least to most attractive), the obtained rankings TABLE 6 Results of Regression Analysis With Esthetic Rating of Fused Images as Dependent Variable and Esthetic Ratings of Full Face, Full Face Without Nasolabial Area, and Nasolabial Area as Independent Variables
Independent Variable Evaluated Element
Mean
SD*
Minimum
Maximum
Full face Full face without nasolabial area Nasolabial area
51.47 51.95 2.25
11.83 14.64 0.70
36.88 30.19 1.50
72.31 76.25 3.25
* SD ¼ standard deviation.
Full face Full face without nasolabial area Nasolabial area
Coefficient (B)
P Value
Lower Limit of 95% CI*
Upper Limit of 95% CI*
0.098
.756
0.723
0.528
0.107 11.437
.672 ,.001
0.395 14.451
0.609 8.423
* CI ¼ confidence interval. R for the model is 0.681; R2 for the model is 0.464.
Kocher et al., NASOLABIAL AND FACIAL ESTHETICS
would likely be comparable, irrespective of panel composition (Langlois et al., 2000). Therefore, the choice of rating panel can be based on issues such as research question or availability of judges. This study has limitations that might have affected the results. We prepared fused images of 36 boys and 36 girls for assessment. To do this, we used facial photographs of six subjects with UCLP and six subjects without clefts of each gender. The relatively small number of component images might have contributed to the memory effect, i.e., the judges might have remembered previously assigned scores during evaluation of the next fused image. To minimize the memory effect, we alternated images of boys and girls. On the other hand, an increase in the number of component images (resulting in an increase in the number of fused images) could have fatigued judges by presenting too many sets of photographs for assessment. Furthermore, the esthetic evaluation in this study was conducted on 2D photographs, which usually have distortion errors caused by the projection of a 3D object onto a 2D image and differences in lighting or head orientation. However, the relatively easy preparation of fused images as a quick and affordable means of evaluation offsets the limitations of 2D photographs. Based on our findings, we conclude that cropping facial images of children with complete UCLP for assessment of nasolabial appearance seems unnecessary. Instead, an esthetic evaluation can be performed on photographs of full faces. REFERENCES Asher-McDade C, Roberts C, Shaw WC, Gallager C. Development of a method for rating nasolabial appearance in patients with clefts of the lip and palate. Cleft Palate Craniofac J. 1991;28:385–390. Baudouin JY, Tiberghien G. Symmetry, averageness, and feature size in the facial attractiveness of women. Acta Psychologica. 2004;117:313–332. Bindemann M, Scheepers C, Burton AM. Viewpoint and center of gravity affect eye movements to human faces. J Vis. 2009;9:1–16. Bongaarts CA, Prahl-Andersen B, Bronkhorst EM, Spauwen PH, Mulder JW, Vaandrager JM, Kuijpers-Jagtman AM. Effect of infant orthopedics on facial appearance of toddlers with complete unilateral cleft lip and palate (Dutchcleft). Cleft Palate Craniofac J. 2008;45:407–413. Brattstrom ¨ V, Mølsted K, Prahl-Andersen B, Semb G, Shaw WC. The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 2: craniofacial form and nasolabial appearance. Cleft Palate Craniofac J. 2005;42:69–77. Broder H, Strauss RP. Self-concept of early primary school age children with visible or invisible defects. Cleft Palate J. 1989;26:114–117. Centre for Evidence Based Medicine (CEBM). Levels of evidence (March 2009). Available at http://www.cebm.net/index. aspx?o¼1025. Accessed November 22, 2013. Eliason MJ, Hardin MA, Olin WH. Factors that influence ratings of facial appearance for children with cleft lip and palate. Cleft Palate Craniofac J. 1991;28:190–193.
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Pope AW, Ward J. Self-perceived facial appearance and psychosocial adjustment in preadolescents with craniofacial anomalies. Cleft Palate Craniofac J. 1997;34:396–401. Ramstad T, Ottem E, Shaw W. Psychosocial adjustment in Norwegian adults who had undergone standardised treatment of comlete cleft lip and palate. II. Self-reported problems and concerns with appearance. Scand J Plast Reconstr Hand Surg. 1995;29:329–336. Rubin DB. Statistics and causal inference: comment: which ifs have causal answers? J Am Stat Assoc. 1986;81:961–962.
Rutter M. Proceeding from observed correlation to causal inference. The use of natural experiments. Perspect Psychol Sci. 2007:377–395. Santos IM, Young AW. Inferring social attributes from different face regions: evidence for holistic processing. Q J Exp Psychol (Hove). 2011;64:751–766. Shaw WC, Rees G, Dawe M, Charles CR. The influence of dentofacial appearance on the social attractiveness of young adults. Am J Orthod. 1985;87:21–26. Tedesco LA, Albino JE, Cunat JJ, Slakter MJ, Waltz KJ. A dentalfacial attractiveness scale. Part II. Consistency and perception. Am J Orthod. 1983;83:44–46.
ORIGINAL ARTICLE Judgment of Nasolabial Esthetics in Cleft Lip and Palate Is Not Influenced by Overall Facial Attractiveness Katharina Kocher, D.D.S., Piotr Kowalski, D.D.S., Olga-Elpis Kolokitha, D.D.S., Ph.D., Christos Katsaros, Dr. med. dent., Odont. Dr./Ph.D., Piotr S. Fudalej, D.D.S., M.S.D., Ph.D. Objective: To determine whether judgment of nasolabial esthetics in cleft lip and palate (CLP) is influenced by overall facial attractiveness. Design: Experimental study. Setting: University of Bern, Switzerland. Subjects and Methods: Seventy-two fused images (36 of boys, 36 of girls) were constructed. Each image comprised (1) the nasolabial region of a treated child with complete unilateral CLP (UCLP) and (2) the external facial features, i.e., the face with masked nasolabial region, of a noncleft child. Photographs of the nasolabial region of six boys and six girls with UCLP representing a wide range of esthetic outcomes, i.e., from very good to very poor appearance, were randomly chosen from a sample of 60 consecutively treated patients in whom nasolabial esthetics had been rated in a previous study. Photographs of external facial features of six boys and six girls without UCLP with various esthetics were randomly selected from patients’ files. Eight lay raters evaluated the fused images using a 100-mm visual analogue scale. Method reliability was assessed by reevaluation of fused images after .1 month. A regression model was used to analyze which elements of facial esthetics influenced the perception of nasolabial appearance. Results: Method reliability was good. A regression analysis demonstrated that only the appearance of the nasolabial area affected the esthetic scores of fused images (coefficient ¼ 11.44; P , .001; R2 ¼ 0.464). The appearance of the external facial features did not influence perceptions of fused images. Conclusion: Cropping facial images for assessment of nasolabial appearance in CLP seems unnecessary. Instead, esthetic evaluation can be performed on images of full faces. KEY WORDS:
cleft lip, cleft palate, esthetics
Orofacial clefts (OFCs) can cause many structural and functional deficiencies, negatively affecting facial appearance and speech. As a result, result, individuals with cleft lip and palate (CLP) may experience various psychological problems. Children with a cleft may exhibit increased anxiety, emotional problems, and lower self-esteem, and
they are less satisfied with their physical appearance compared to their peers without CLP (Pillemer and Cook, 1989; Hunt et al., 2007). Self-perceived facial appearance is especially important for their adjustment, because it is positively correlated with global self-esteem and selfperceived social acceptance and negatively correlated with loneliness (Pope and Ward, 1997; Feragen et al., 2009). Also, in adults, CLP is a risk factor for poorer self-esteem, social relations, and adjustment (Broder and Strauss, 1989; Ramstad et al., 1995). Due to the association between facial appearance and psychological well-being in subjects with CLP, assessment of nasolabial esthetics is routinely used in evaluating the outcome of treatment of OFC. In the Eurocleft (Brattstrom ¨ et al., 2005), Dutchcleft (Bongaarts et al., 2008), and Americleft (Mercado et al., 2011) studies, all of which were large multicenter investigations, scores rating patients’ nasolabial appearance were used to differentiate the results of various cleft centers (Brattstrom ¨ et al., 2005; Mercado et al., 2011) or results obtained with various treatment methods (Bongaarts et al., 2008). In each of these studies, the rating panel, which consisted of judges familiar
Dr. Kocher is doctoral candidate and Dr. Katsaros is Professor and Chair, Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Bern, Switzerland. Dr. Kowalski is Orthodontist, Department of Orthodontics, Palacky University Olomouc, Olomouc, Czech Republic. Dr. Kolokitha is Assistant Professor, Department of Orthodontics, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece. Dr. Fudalej is Associate Professor, Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Bern, Switzerland, and Department of Orthodontics, Palacky University Olomouc, Olomouc, Czech Republic. Submitted February 2014; Revised June 2014; Accepted September 2014. Address correspondence to: Dr. Piotr S. Fudalej, Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Freiburgstrasse 7, 3006 Bern, Switzerland. E-mail Piotr.Fudalej@ zmk.unibe.ch. DOI: 10.1597/14-019 e45
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(Brattstrom ¨ et al., 2005; Mercado et al., 2011) or unfamiliar (Bongaarts et al., 2008) with treatment of OFCs, was asked to rate the appearance of the nose and upper lip, the region directly affected by the cleft, on cropped facial photographs. Cropping of images was done to mask facial features unrelated to the cleft area, such as eyes, chin, cheeks, haircut, or facial shape, which could influence the rating. The need to crop images was based on the finding that judgments of nasolabial esthetics and esthetics of the full face with an obscured nasolabial region are highly correlated (Asher-McDade et al., 1991; Kuijpers-Jagtman et al., 2009). Asher-McDade et al. (1991) surmised that nasolabial appearance in subjects with attractive faces would be rated higher than in subjects with less attractive faces. In other words, overall facial attractiveness would artificially improve or worsen the judgment of the nasolabial area. To prevent this, Asher-McDade et al. (1991) proposed that photographs of children with CLP should be cropped so that only the nose and lips are shown during assessment. However, the correlation between esthetic scores assigned to various regions of the face does not equate to causation. In statistics, the correlation coefficient is a measure of dependence between two events. Correlations are useful because they can indicate a predictive relationship, which can be exploited in practice; however, statistical dependence is not sufficient to demonstrate the presence of a causal relationship (Holland, 1986). To emphasize that the determination of a cause-and-effect relationship requires more than establishing correlation, Holland (1986) and Rubin (1986) coined the statement ‘‘no causation without manipulation.’’ This widely used statement strongly implies that causation can be identified only through experimentation (manipulation). The objective of our experiment was to test the research hypothesis that the judgment of nasolabial esthetics in subjects with CLP is influenced by overall facial attractiveness. SUBJECTS
AND
METHODS
The ethics committee of the Canton of Bern approved this study (KEK-Nr.: 237-14). Subjects Two groups were selected: subjects without CLP (noncleft group) and subjects with complete unilateral CLP (UCLP) (cleft group). Noncleft Group The files of the Department of Orthodontics and Dentofacial Orthopedics at the University of Bern were searched for Caucasians who met the following inclusion criteria: (1) approximately 10 years of age, (2) healthy, (3) no prior history of trauma or surgery in the
facial region, (4) available frontal photograph of the face with neutral expression, and (5) Angle Class I malocclusion. The exclusion criteria were (1) cleft lip and/or palate, (2) other congenital syndrome affecting facial appearance, and (3) Angle Class II or III malocclusion. Sixty randomly selected subjects (30 boys and 30 girls) were used in the experiment. All subjects had extraoral photographs taken in the same setting with a white background. The photographs were taken with the same camera. Image data were saved as .jpg files. Cleft Group Caucasian subjects in whom nasolabial esthetics had been assessed previously (Fudalej et al., 2009) were used in this study. In summary, the sample consisted of 60 individuals with nonsyndromic complete UCLP consecutively treated according to a one-stage surgical protocol in the Warsaw Center for Craniofacial Disorders, Warsaw, Poland. The same high-volume surgeon performed all operations at the mean age of 9 months. The subjects had extraoral frontal photographs taken by a photographer against a light background at the mean age of 10.8 years. Methods Evaluation Procedure in Noncleft Group Facial attractiveness was evaluated on the basis of (1) full frontal images (Fig. 1) and (2) frontal images with a masked nasolabial area (Fig. 2). First, the frontal pictures were adjusted so that all faces visible on the photographs were of comparable size. Then the pictures were cropped to remove the excess background. Subsequently, pictures of boys and girls were loaded separately, in random order, into PowerPoint (Microsoft Corp., Redmond, WA) with an identifying case number on each slide. As a result, two PowerPoint presentations were created, one for boys and the other for girls. Based on these two presentations, eight judges of varying ages (four judges were ,50 years and four judges were .50 years of age), gender (three men, five women), and educational background (five judges had at least a college degree) evaluated facial esthetics. None of the authors of this study participated in the rating session. The PowerPoint presentations were shown on a 15inch laptop screen individually to each judge in a quiet room with adequate lighting. The judges were asked to (1) manually advance the slides and return to previous slide(s), if needed; and then to (2) decide spontaneously. They were also instructed that the ratings were comparative, i.e., each judge should ask himself/herself
Kocher et al., NASOLABIAL AND FACIAL ESTHETICS
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FIGURE 1 Facial image with an identifying case number used for ratings.
FIGURE 2 Facial image with masked nasolabial area and an identifying case number used for ratings.
the question, ‘‘Which face is more attractive, this one or the previous one?’’ The judges were asked to assess facial esthetics on a 100-millimeter visual analogue scale (VAS) on which 0 corresponded with an unattractive face and 100 with a very attractive face. Prior to the rating session, each judge was shown each presentation to allow familiarization with the material. Two weeks later, the same judges were asked to rate the attractiveness of facial images with a masked nasolabial area, as proposed by Asher-McDade et al. (1991). In contrast to the PowerPoint presentations in which full faces were shown, each subject had the nose and both lips masked by a white triangle, as demonstrated in Figure 2. Also, the order of images was rearranged at random to prevent a memory effect.
Construction of Fused Images
Evaluation Procedure in Cleft Group Nasolabial esthetics in the cleft group was rated on the basis of cropped facial images that showed only the region of the nose and lips. The panel comprised four orthodontists and rated four elements of nasolabial morphology (nasal shape, nasal deviation, vermilion border, and profile view) using a 5-point Asher-McDade esthetic index (1 ¼ best appearance to 5 ¼ worst appearance) (Fudalej et al., 2009). The overall esthetic score was calculated as the average of the scores for three judged nasolabial elements (nasal shape, nasal deviation, and vermilion border). The mean overall esthetic score was 2.4 (standard deviation [SD] ¼ 1.1; 95% confidence interval of the mean, 2.33 to 2.48; 90% central range, 1.4 to 3.3).
Fused images were constructed by fusing a frontal photograph of a subject from the noncleft group with the nasolabial image of a subject from the cleft group (Fig. 3A and 3B). Six boys and six girls representing the full esthetic range according to the mean VAS score were selected from the noncleft group. Their frontal images were manipulated in such a way that the region of the nose and both lips was replaced with nasolabial areas of subjects of the corresponding gender from the cleft group, who also represented the whole spectrum of nasolabial appearance. The procedure of construction of a fused image was repeated six times for each of six boys and six girls from the noncleft group, i.e., each noncleft boy and girl had a nasolabial area replaced six times with the nasolabial area of a boy and girl with the cleft, respectively. As a result, 72 fused images were constructed (36 each of boys and girls). Each fused image consisted of elements derived from the same gender. All manipulations were performed with Adobe Photoshop Elements 11 (Adobe Corp., San Jose, CA). During manipulation, the size, color, hue, saturation, brightness, and contrast were adjusted so that donor and recipient images matched as well as possible. Evaluation of Fused Images The fused images of boys and girls were loaded together, i.e., without gender separation, into PowerPoint. The same panel of eight judges who had assessed facial esthetics in subjects from the noncleft group evaluated the fused images. The rating session took
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assessment procedure was similar to that used in the noncleft group, except that here, the judges were instructed to focus on evaluation of the nasolabial area during rating, especially on assessment of the shape and symmetry of the nose and the upper vermilion border. The nomenclature for the 100-mm VAS was adapted slightly from the earlier session; 0 signified poor nasal shape/missing symmetry/unesthetic vermilion border and 100 signified good nasal shape/good symmetry/ esthetic vermilion border. The judges were not informed about the manipulation of the pictures. Method Error and Statistical Analysis To assess intrarater reliability of the esthetic scores, 20 randomly selected constructed pictures were rerated by the panel within 2 months. Intrarater reliability was assessed by calculating correlation coefficients, duplicate measurement error (DME), and the difference between paired observations and running t tests for paired observations. Interrater reliability was evaluated by calculating Cronbach’s alpha and intraclass correlation coefficients. The consistency between ratings of full faces and faces with a masked nasolabial area was assessed by calculating correlation coefficients, paired differences, and running t tests for paired observations. A regression model with esthetic scores for constructed images as the dependent variable and esthetic scores for (1) full face in the noncleft group, (2) full face with masked nasolabial area in the noncleft group, and (3) nasolabial area in the cleft group as independent variables was used. RESULTS Method Reliability The esthetic outcome of full faces and full faces without nasolabial area (Table 1) showed that masking the area of the nose and lips did not affect the score. The mean difference between the scores was only 0.22 (P ¼ .797) and the correlation coefficient was 0.853. Intrarater reliability of esthetic assessment was good; the correlation coefficient was high and DME was well within the SD of the esthetic outcome (Table 2). However, the judges were less critical during the second rating session and gave esthetic scores that were, on
FIGURE 3 Example of two constructed fused images of a boy with different nasolabial areas taken from two boys with complete UCLP.
place more than 4 weeks after the previous session. Prior to the rating session, the rating panel was shown extraoral pictures of five boys and five girls with complete UCLP to familiarize the judges with the range of possible esthetic outcomes in this condition. The TABLE 1
Comparison of Esthetic Ratings of Full-Face Images With and Without Nasolabial Area
Full Face
Full Face Without Nasolabial Area
Paired Differences
95% Confidence Interval of the Difference
Mean
SD*
Mean
SD*
Correlation Coefficient
Mean
Standard Error of the Mean
Lower Limit
Upper Limit
P
49.63
12.41
49.41
12.07
0.853
0.22
0.86
1.50
1.94
.797
* SD ¼ standard deviation.
Kocher et al., NASOLABIAL AND FACIAL ESTHETICS
TABLE 2
Intrarater Reliability of Esthetic Ratings of Fused Images Paired Differences
Correlation Coefficient 0.943
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95% Confidence Interval of the Difference
DME*
Mean
Standard Error of the Mean
Lower Limit
Upper Limit
P
4.22
5.97
1.22
8.50
3.45
,.001
* DME ¼ duplicate measurement error.
average, 5.97 points higher than during the first session (P , .001). The high values of Cronbach’s alpha (0.919) and the intraclass correlation (0.900) coefficients demonstrated very good consistency among different raters (Table 3). Ratings of Fused Images Mean values, SDs, medians, and percentile distributions of scores are presented in Table 4. Table 5 demonstrates the esthetic results of the 25% highestrated fused images (n ¼ 18). The mean values for esthetic outcomes for full-face images and full-face images without the nasolabial area in the noncleft subjects used in the preparation of fused images were in the middle of the scale (51.47 and 51.95 points, respectively, on a 100point scale). The mean value for esthetic outcome of the nasolabial area of cleft subjects used in preparation of the fused images was shifted toward the more esthetic end of the 5-point ordinal scale (2.25 points). The regression model with esthetic score for fused images as the dependent variable and esthetic scores for (1) full face, (2) full face with masked nasolabial area in the noncleft group, and (3) nasolabial area in the cleft group as independent variables demonstrated that only the appearance of the nasolabial area affected the esthetic result of the constructed images (Table 6). DISCUSSION Determination of causality plays a key role in the understanding of many biological processes and the development of effective treatment strategies. Originally, it was proposed that causal criteria are characterized by high strength of association, consistency, specificity, temporality of association (i.e., the cause must precede the effect), biological gradient, plausibility, and coherence (Hill, 1965). However, although these criteria are helpful, they may not be sufficient to prove a causal relationship between two events. The possibility of identifying causal factors can be increased with the use of experimentation (Rutter, 2007). In fact, the Oxford Centre for EvidenceBased Medicine (CEBM) ranks experimental investigations at the top level of evidence (CEBM, 2013). In the current experiment, we manipulated facial morphology to identify which element—the nasolabial area or the surrounding features—has a stronger effect on the perception of nasolabial appearance.
Our findings indicate that the esthetics of the area surrounding the nose and lips does not affect the outcome of assessment of nasolabial appearance in children with CLP. The only feature associated with esthetic ratings in these subjects was the appearance of the nose and lips. This is in contrast to the judgment of facial attractiveness performed in subjects without clefts, in whom attractiveness was demonstrated to be related to general qualities, such as facial symmetry and averageness (Langlois and Roggman, 1990; Perrett et al., 1999) and health of the skin (Jones et al., 2004), as well as specific nasolabial features such as the thickness of the lips and the size of the nose (Baudouin and Tiberghien, 2004). For example, female faces are judged as more attractive when they are symmetrical, when they are close to the average, and when they have big eyes, a small nose, prominent and high cheekbones, a small chin, and a thick mouth and upper lip (Baudouin and Tiberghien, 2004). The difference in the perception of facial attractiveness in subjects with and without a cleft may be a result of the way they are viewed. Looking involves coordinated movements of the body, the head, and, above all, the eyes. The brain signals received by the eye muscles cause the eyes to make rapid, jerking movements, after which the eyes remain fixed in their new position (so-called saccades or saccadic eye movements). During normal viewing, several saccades are made each second, and their destinations are selected by cognitive brain process without the involvement of any awareness. Visual perception, as well as judgment of facial attractiveness, is dependent upon the information taken in during fixation pauses between saccades; no useful visual information is taken in while the eyes are making a saccadic movement (Findlay and Walker, 2012). MeyerMarcotty et al. (2010) analyzed saccadic eye movements and fixation patterns while people were viewing photographs of persons with and without CLP. It turned out that the anomalous mouth area of subjects with a cleft captured more fixations of viewers than the normal nasolabial area of subjects without a cleft. Moreover, the selective attention of the viewers toward the cleft region came at the cost of the eyes, which were looked at less frequently. Therefore, it is TABLE 3 Images
Interrater Reliability of Esthetic Ratings of Fused
95% Confidence Interval of the ICC* Cronbach’s Alpha ICC* 0.919
0.900
Lower Limit
Upper Limit
P
0.860
0.932
,.001
* ICC ¼ intraclass correlation coefficient.
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TABLE 4
Esthetic Ratings of Fused Images
Mean
SD*
Median
Minimum
Maximum
5
10
25
50
75
90
95
45.24
16.05
43.7
10.1
82.4
17.7
22.14
35.3
43.7
56.4
63.26
79.38
Percentiles
* SD ¼ standard deviation.
possible that the subconsciously diversified attention of the visual system toward the facial features of subjects with and without a cleft forms the biological foundation for the judgment of facial appearance in these individuals. The current findings imply that preparations for ratings of the nasolabial area in subjects with a cleft do not have to include cropping of the images. Instead, pictures of full faces can be used as stimulus material. This is important, because cropping is relatively arduous and time-consuming. Moreover, with the increasing popularity of three-dimensional (3D) imaging, cropping of 3D facial images may be more complicated and more time-consuming than cropping conventional photographs and may also require additional resources, such as computer software, for processing. At the beginning of the study, the rating panel evaluated the facial esthetics of full faces and of full faces with a masked nasolabial area in children without a cleft. This step was necessary to ensure that the rankings of the attractiveness of faces with a masked nasolabial area (later used in fused images) were comparable with the rankings for full faces. We found no difference in the mean esthetic scores. Our results differ from the findings of Santos and Young (2011), who examined whether the level of interjudge agreement in various social attributions is affected by presentation of only the internal (i.e., eyes, nose, lips) or external features of the face (i.e., hair, ears, chin) in comparison to judgments made on the basis of the whole face. Santos and Young found that judgments of facial attractiveness differed if only internal or external features were assessed in comparison to the assessment of the whole face. This difference between our findings and the results of Santos and Young may be a result of differences in methodology. In our study, the internal features included only the nose and lips, whereas Santos and Young also included the eyes. Because the eyes are the preferred target of the center of gaze (Mertens et al., 1993; Pellicano et al., 2006; Bindemann et al., 2009), masking the nasolabial area in our study did not affect the esthetic score. A related problem—the association between social attractiveness and the dentofacial appearance (including a cleft lip)—was TABLE 5 Esthetic Ratings of Particular Elements of Facial Morphology Found in the 25% Top-Rated Fused Images (n ¼ 18)
investigated by Shaw et al. (1985). The authors found a strong predictive effect of background facial attractiveness on social desirability, and the effects of facial attractiveness were stronger than the effects of dental appearance. The disagreement between our findings and those of Shaw et al. may result from differences in the stimulus material. In the former study, subjects with a cleft lip, a relatively mild cleft deformity in which the nose remains unaffected, were evaluated, and in our study, subjects with a severe cleft (complete UCLP), in which nasal disfigurement almost always occurs, were assessed. The composition of the rating panel may influence esthetic scores during evaluations of facial appearance in subjects with CLP. It was demonstrated that rating panels comprising laypersons were more critical than (Eliason et al., 1991; Papamanou et al., 2012; Gkantidis et al., 2013), less critical than (Mani et al., 2010; Offert et al., 2013), or just as critical as (Bongaarts et al., 2008) rating panels that consisted of professionals (i.e., persons involved in treatment of CLP). In the evaluation of subjects without a cleft, it has also been demonstrated that the gender of the subject and the size of the panel also may affect the outcome. For example, Tedesco et al. (1983) suggested that women were less critical than men, whereas Kiekens et al. (2007) made the opposite claim: the men in their panel rated subjects as more attractive than the women in their study. Moreover, Kiekens et al. noticed an influence of the geographical origin of the members of the panel. This apparent chaos does not imply that rating facial esthetics is unfeasible because of the impossibility of producing consistent results. Instead, the variations in the scores assigned by various panels indicate simply that some panels are more critical and some are less critical than others. If, however, panels with various cultural or ethnic backgrounds were asked to rank facial attractiveness (i.e., to place faces in order from the least to most attractive), the obtained rankings TABLE 6 Results of Regression Analysis With Esthetic Rating of Fused Images as Dependent Variable and Esthetic Ratings of Full Face, Full Face Without Nasolabial Area, and Nasolabial Area as Independent Variables
Independent Variable Evaluated Element
Mean
SD*
Minimum
Maximum
Full face Full face without nasolabial area Nasolabial area
51.47 51.95 2.25
11.83 14.64 0.70
36.88 30.19 1.50
72.31 76.25 3.25
* SD ¼ standard deviation.
Full face Full face without nasolabial area Nasolabial area
Coefficient (B)
P Value
Lower Limit of 95% CI*
Upper Limit of 95% CI*
0.098
.756
0.723
0.528
0.107 11.437
.672 ,.001
0.395 14.451
0.609 8.423
* CI ¼ confidence interval. R for the model is 0.681; R2 for the model is 0.464.
Kocher et al., NASOLABIAL AND FACIAL ESTHETICS
would likely be comparable, irrespective of panel composition (Langlois et al., 2000). Therefore, the choice of rating panel can be based on issues such as research question or availability of judges. This study has limitations that might have affected the results. We prepared fused images of 36 boys and 36 girls for assessment. To do this, we used facial photographs of six subjects with UCLP and six subjects without clefts of each gender. The relatively small number of component images might have contributed to the memory effect, i.e., the judges might have remembered previously assigned scores during evaluation of the next fused image. To minimize the memory effect, we alternated images of boys and girls. On the other hand, an increase in the number of component images (resulting in an increase in the number of fused images) could have fatigued judges by presenting too many sets of photographs for assessment. Furthermore, the esthetic evaluation in this study was conducted on 2D photographs, which usually have distortion errors caused by the projection of a 3D object onto a 2D image and differences in lighting or head orientation. However, the relatively easy preparation of fused images as a quick and affordable means of evaluation offsets the limitations of 2D photographs. Based on our findings, we conclude that cropping facial images of children with complete UCLP for assessment of nasolabial appearance seems unnecessary. Instead, an esthetic evaluation can be performed on photographs of full faces. REFERENCES Asher-McDade C, Roberts C, Shaw WC, Gallager C. Development of a method for rating nasolabial appearance in patients with clefts of the lip and palate. Cleft Palate Craniofac J. 1991;28:385–390. Baudouin JY, Tiberghien G. Symmetry, averageness, and feature size in the facial attractiveness of women. Acta Psychologica. 2004;117:313–332. Bindemann M, Scheepers C, Burton AM. Viewpoint and center of gravity affect eye movements to human faces. J Vis. 2009;9:1–16. Bongaarts CA, Prahl-Andersen B, Bronkhorst EM, Spauwen PH, Mulder JW, Vaandrager JM, Kuijpers-Jagtman AM. Effect of infant orthopedics on facial appearance of toddlers with complete unilateral cleft lip and palate (Dutchcleft). Cleft Palate Craniofac J. 2008;45:407–413. Brattstrom ¨ V, Mølsted K, Prahl-Andersen B, Semb G, Shaw WC. The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 2: craniofacial form and nasolabial appearance. Cleft Palate Craniofac J. 2005;42:69–77. Broder H, Strauss RP. Self-concept of early primary school age children with visible or invisible defects. Cleft Palate J. 1989;26:114–117. Centre for Evidence Based Medicine (CEBM). Levels of evidence (March 2009). Available at http://www.cebm.net/index. aspx?o¼1025. Accessed November 22, 2013. Eliason MJ, Hardin MA, Olin WH. Factors that influence ratings of facial appearance for children with cleft lip and palate. Cleft Palate Craniofac J. 1991;28:190–193.
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