"It's a Little Different for Men"-Sponsorship and Gender in Academic Medicine: a Qualitative Study.

BACKGROUND: Women remain underrepresented in top leadership positions in academic medicine. In business settings, a person with power and influence actively supporting the career advancement of a junior person is referred to as a sponsor and sponsorship programs have been used to diversify leadership. Little is known about how sponsorship functions in academic medicine. OBJECTIVE: To explore perceptions of sponsorship and its relationship to gender and career advancement in academic medicine. DESIGN: Qualitative study using semi-structured, one-on-one interviews with sponsors and protégés. PARTICIPANTS: Twelve sponsors (clinical department chairs) and 11 protégés (participants of a school of medicine executive leadership program [N = 23]) at the Johns Hopkins School of Medicine. KEY RESULTS: All sponsors were men and all were professors, six of the 11 protégés were women, and four of the 23 participants were underrepresented minorities in medicine. We identified three themes: (1) people (how and who): women seek out and receive sponsorship differently; (2) process (faster and further): sponsorship provides an extra boost, especially for women; and (3) politics and culture (playing favorites and paying it forward): sponsorship and fairness. Informants acknowledge that sponsorship provides an extra boost for career advancement especially for women. Sponsors and protégés differ in their perceptions of how sponsorship happens. Informants describe gender differences in how sponsorship is experienced and specifically noted that women were less likely to actively seek out sponsorship and be identified as protégés compared to men. Informants describe a tension between sponsorship and core academic values such as transparency, fairness, and merit. CONCLUSION: Sponsorship is perceived to be critical to high-level advancement and is experienced differently by women. Increased understanding of how sponsorship works in academic medicine may empower individual faculty to utilize this professional relationship for career advancement and provide institutions with a strategy to diversify top leadership positions.

The Valuation of Rhytidectomy in Different Economic Markets.

This study demonstrates that the trend of how rhytidectomy is valued can be used to determine not only the pricing of this good but also how receptive developing economic markets are to the export of cosmetic facial plastic surgery. This study seeks to analyze and compare the value of rhytidectomy in an established market and an emerging market. A cross-sectional survey was administered through public online forums to 162 casual observers in the United States and 74 casual observers in India. Participants were shown pre- and postoperative photos of 10 patients who underwent cosmetic rhinoplasty and 2 patients who did not undergo surgery. Observers were asked to quantify the perceived change in attractiveness, change in age, and willingness to pay (WTP). There is a similar nonlinear trend between WTP and change in attractiveness in both the United States and India. Baseline values of rhytidectomy in the United States and India have a similar ratio of 2.122 compared with the ratio between both countries in the 2018 Big Mac index. The comparison of the trend in WTP in the United States and India shows that facial cosmetic surgery functions as a luxury good in both an established market and an emerging market. Our model successfully approximates the relationship between each country's purchasing power parity. Since the market behavior of rhytidectomy can be predicted based on purchasing power parity, there may be an untapped market for facial cosmetic surgery among populations with growing economies.

Exploring Patient Motivations and Impact of Asian Blepharoplasty.

To date, patient motivations for Asian blepharoplasty and the surgery's impact on quality of life have not been quantified. Here, we employed structured interviews and a web-based survey to better characterize patient motivations for Asian blepharoplasty and the impact of Asian blepharoplasty on self-reported domains of happiness, self-esteem, attractiveness, social life, and professional life. Structured interviews were conducted to inform a web-based survey regarding Asian blepharoplasty. Survey respondents used visual analog scales to rate their satisfaction with their eye shape, motivations for undergoing Asian blepharoplasty, and perceived outcomes after surgery. A total of 315 participants (mean 25.7 [18-58] years) of East or Southeast Asian descent were included. 185 participants expressed no desire for Asian blepharoplasty, 76 expressed some desire, and 54 had already undergone surgery. There were statistically significant differences regarding baseline satisfaction, perceived social limitation, and perceived professional limitations regarding eye shape (p < 0.0001). The Looking Glass Self index (comprised of media exposure, low self-esteem, and negative stereotypes related to eye shape) is negatively associated with preoperative satisfaction with eye shape (rho = -0.29, p < 0.01). The desire for social-professional advancement and the Looking Glass Self index significantly predict self-reported improvements in professional and social life, respectively (both p < 0.01). Asian blepharoplasty may be driven by functional, social, or economic patient motivations. Some patients may see Asian blepharoplasty as a potential solution for sociological concerns. These expectations should be further explored in physician-patient discussions regarding candidacy for surgery and establishing expectations for postoperative outcomes.

Implementing a Health System-wide Patient Blood Management Program with a Clinical Community Approach.

BACKGROUND: Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results. METHODS: We formed the Johns Hopkins Health System blood management clinical community to reduce transfusion overuse across five hospitals. This physician-led, multidisciplinary, collaborative, quality-improvement team (the clinical community) worked to implement best practices for patient blood management, which we describe in detail. Changes in blood utilization and blood acquisition costs were compared for the pre- and post-patient blood management time periods. RESULTS: Across the health system, multiunit erythrocyte transfusion orders decreased from 39.7 to 20.2% (by 49%; P < 0.0001). The percentage of patients transfused decreased for erythrocytes from 11.3 to 10.4%, for plasma from 2.9 to 2.2%, and for platelets from 3.1 to 2.7%, (P < 0.0001 for all three). The number of units transfused per 1,000 patients decreased for erythrocytes from 455 to 365 (by 19.8%; P < 0.0001), for plasma from 175 to 107 (by 38.9%; P = 0.0002), and for platelets from 167 to 141 (by 15.6%; P = 0.04). Blood acquisition cost savings were $2,120,273/yr, an approximate 400% return on investment for our patient blood management efforts. CONCLUSIONS: Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.

Treatment of the periocular complex in paralytic lagophthalmos.

OBJECTIVES: Paralytic lagophthalmos can lead to devastating exposure keratitis. The main surgical intervention consists of upper eyelid loading. However, adjunctive lower eyelid and brow procedures are also available as necessary. We sought to analyze the use of periocular procedures in paralytic lagophthalmos at Johns Hopkins. METHODS: The method was a retrospective review of patients treated at a single tertiary care center from 2006 to 2012. RESULTS: One hundred one patients met inclusion criteria, and 20 patients were excluded for not meeting the minimum follow-up. Upper eyelid loading was required on 95/101 patients (95%). Adjunctive procedures were necessary in 73% (73/101) of patients. Lower eyelid procedures were used in 47% (47/101) and brow lifts in 47% (47/101). Older patients (>50 years) were more likely to require lower eyelid procedures (P=.04) and more likely to require revision (P=.003). Medial canthopexy and direct brow lift were associated with the need for revision (P=.006, P=.03). CONCLUSION: Paralytic lagophthalmos management is not one-size-fits-all. Upper eyelid loading is the mainstay of treatment; however, adjunctive procedures to the lower eyelid and brow are indicated in the majority of patients. Our retrospective review has allowed us to continue to refine our strategy for managing these patients.

Correcting for Rater Effects in Operating Room Surgical Skills Assessment.

OBJECTIVE: To estimate and adjust for rater effects in operating room surgical skills assessment performed using a structured rating scale for nasal septoplasty. METHODS: We analyzed survey responses from attending surgeons (raters) who supervised residents and fellows (trainees) performing nasal septoplasty in a prospective cohort study. We fit a structural equation model with the rubric item scores regressed on a latent component of skill and then fit a second model including the rating surgeon as a random effect to model a rater-effects-adjusted latent surgical skill. We validated this model against conventional measures including the level of expertise and post-graduation year (PGY) commensurate with the trainee's performance, the actual PGY of the trainee, and whether the surgical goals were achieved. RESULTS: Our dataset included 188 assessments by 7 raters and 41 trainees. The model with one latent construct for surgical skill and the rater as a random effect was the best. Rubric scores depended on how severe or lenient the rater was, sometimes almost as much as they depended on trainee skill. Rater-adjusted latent skill scores increased with attending-estimated skill levels and PGY of trainees, increased with the actual PGY, and appeared constant over different levels of achievement of surgical goals. CONCLUSION: Our work provides a method to obtain rater effect adjusted surgical skill assessments in the operating room using structured rating scales. Our method allows for the creation of standardized (i.e., rater-effects-adjusted) quantitative surgical skill benchmarks using national-level databases on trainee assessments. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients.

OBJECTIVE: To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx. METHODS: Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible. RESULTS: The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus. CONCLUSION: Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Visual Attention to Facial Defects Predicts Willingness to Pay for Reconstructive Surgery.

Background: The relationship between the value of reconstructive surgery and the visual attention drawn by facial deformity has not been studied. Objectives: We hypothesized that willingness to pay (WTP) for reconstructive surgery would increase as visual attention to deformity increased in a Mohs defect eye-tracking model. Methods: We conducted a randomized observational study. Eighty casual observers participated in timed eye-tracking trials utilizing preoperative and postoperative photographs from 32 patients with facial Mohs defects. Fixation on each defect was quantified in milliseconds. For each photograph, casual observers reported how much they would be willing to pay for a perfect reconstruction and rated defect severity and patient attractiveness. The associations between defect fixation time and WTP, attractiveness, and severity were modeled using a multivariate mixed-effects model. Results: Increased defect fixation time was associated with increased WTP (regression coefficient = 0.332651, p < 0.001), decreased attractiveness (regression coefficient = -0.221779, p < 0.001), and increased severity (regression coefficient = 0.363111, p < 0.001). As defect fixation time increased, WTP increased exponentially. Conclusions: Observer WTP for facial reconstruction increases exponentially as defects become more distracting. These findings justify the dedication of health care resources to reconstructive procedures that decrease attentional distraction to the greatest extent possible.

Do Attending and Trainee Surgeons Agree on What Happens in the Operating Room During Septoplasty?

Background: Surgeons must select cases whose complexity aligns with their skill set. Objectives: To determine how accurately trainees report involvement in procedures, judge case complexity, and assess their own skills. Methods: We recruited attendings and trainees from two otolaryngology departments. After performing septoplasty, they completed identical surveys regarding case complexity, achievement of goals, who performed which steps, and trainee skill using the septoplasty global assessment tool (SGAT) and visual analog scale (VAS). Agreement regarding which steps were performed by the trainee was assessed with Cohen's kappa coefficients (κ). Correlations between trainee and attending responses were measured with Spearman's correlation coefficients (rho). Results: Seven attendings and 42 trainees completed 181 paired surveys. Trainees and attendings sometimes disagreed about which steps were performed by trainees (range of κ = 0.743-0.846). Correlation between attending and trainee responses was low for VAS skill ratings (range of rho = 0.12-0.34), SGAT questions (range of rho = 0.03-0.53), and evaluation of case complexity (range of rho = 0.24-0.48). Conclusion: Trainees sometimes disagree with attendings about which septoplasty steps they perform and are limited in their ability to judge complexity, goals, and their skill.

Free Functional Gracilis Flaps for Facial Reanimation in Elderly Patients.

Importance: The free functional gracilis flap (FFGF) is a versatile procedure in reanimating the paralyzed face, yet its application in seniors is limited by perceptions of morbidity and inefficacy. Objective: The study objective was to compare the morbidity and effectiveness of FFGF reanimation among senior and younger patients. Design, Setting, and Participants: A retrospective chart review was performed on 20 consecutive patients aged 60 years and above (seniors) and 35 patients aged 40 years and below (juniors) who underwent FFGF for facial reanimation. Among this group, 16 senior and 22 junior patients with available long-term follow-up data were analyzed for functional outcomes. Main Outcomes and Measures: The length of postoperative stay and postoperative complications were compared with assess immediate results. A second analysis for functional outcomes was assessed by resting and smile facial asymmetry index (FAI), as well as maxillary dental display to compare facial tone and lip excursion. Results: The average age of seniors was 67 ± 5 years and that of juniors was 27 ± 10 years. Mean lengths of postoperative stay were 4 ± 2 versus 3 ± 1 days in seniors versus Juniors, respectively (p = 0.16). There were no intraoperative complications and postoperative complications in one (5%) senior and four (11%) juniors (p = 0.64). There was functional muscle recovery in all cases, with more pronounced correction of both resting (Δ3.0 mm vs. Δ2.4 mm, p = 0.66) and dynamic (Δ5.2 mm vs. Δ4.2 mm, p = 0.37) FAI in seniors than in juniors. Among patients who underwent a multivector FGFF, there was an additional three versus one visualized maxillary teeth (p = 0.03) in seniors versus juniors, respectively. Conclusions and Relevance: The FFGF is effective for facial reanimation among seniors and can be performed with minimal morbidity. Age alone should not preclude the application of the FFGF in seniors with a preference for more dynamic options.

Hair Transplantation for Scarring Alopecia.

Hair loss can be a debilitating condition, especially for individuals who already have chronic underlying medical conditions that complicate the treatment of hair loss. This article addresses the challenges posed by scarring alopecia in hair-loss treatment and the evidence-based practices that exist for hair transplantation in scarring alopecia.

How You See Yourself: Cultural Considerations and Self-Image for Rhinoplasty Patients.

The motivations to pursue ethnically sensitive rhinoplasty and associated expectations are nuanced and influenced by the culture and institutional forces in a community. This article seeks to elucidate those nuances and the impact on self-image of patients seeking this procedure.

The Health Utility and Valuation of Cosmetic Rhinoplasty.

Importance: The importance of this study is to understand the impact of rhinoplasty as perceived by society and to conceptualize the health utility metric of cosmetic rhinoplasty in relation to other health interventions. Objective: This novel study seeks to measure and quantify the health state utility and valuation of cosmetic rhinoplasty. Design, Setting, Participants: This is a cross-sectional survey administered through public online forums to 161 casual observers in America. Main Outcomes and Measures: Participants were shown pre- and postoperative photographs of six patients who underwent cosmetic rhinoplasty and two patients who did not undergo surgery. Observers were asked to imagine that the external nose in each image was on their own face and rated (1) their health state utility and (2) how much they were willing to pay (WTP) to have the ideal nose. Results: Established metrics of standard gamble and visual analog scale were explored in detail. Using these valuation and health utility data, we calculated WTP per quality-adjusted-life-year (WTP/QALY). The WTP/QALY for cosmetic rhinoplasty is $12,264 per QALY, which is significantly below cost-effective thresholds. Participants were willing to accept 10% risk of death to undergo cosmetic rhinoplasty. Conclusions and Relevance: Calculating WTP/QALY as a metric, we assess and quantify the social importance of rhinoplasty. This is the first study to demonstrate that elective cosmetic rhinoplasty can be a high-value intervention as perceived by society. Furthermore, the high percentage of risk of death that participants are willing to accept for cosmetic rhinoplasty suggests there is a profound psychosocial impact of external nasal deformity. These findings have implications for patients, surgeons, and health policy makers.

How Old Do I Look? Exploring the Facial Cues of Age in a Tasked Eye-Tracking Study.

Importance: This is the first eye-tracking study to use a tasked age estimation paradigm to explore the facial cues of age as seen by casual observers. Objectives: Determine where observers gaze on faces when tasked with estimating an individual's age. Design, Setting, and Participants: This was a prospective controlled experiment, which took place at an academic tertiary referral center. In total, 220 casual observers (80 untasked, 140 tasked) viewed frontal facial images of women while an infrared eye-tracking monitor recorded their eye movements and fixations in real time. Main Outcomes and Measures: Multivariate Hotelling's analysis followed by planned posthypothesis testing was used to compare fixation durations for predefined regions of interest, including the central triangle, upper face, midface, lower face, and neck between tasked and untasked observers. Results: A total of 80 observers (mean age 23.6 years, 53% female) successfully completed the first untasked eye-tracking experiment. A total of 140 observers (mean age 26.1 years, 60% female) successfully completed the second age estimation experiment. On multivariate analysis, there were significant differences in the distribution of attention between observers in the two experiments (T2 = 99.70; F(5,2084) = 19.9012, p < 0.0001). On planned posthypothesis testing, observers attended significantly more to the lower third of the face (0.20 s, p < 0.0001, 95% confidence interval (CI) 0.14-0.27 s) and neck (0.05 s, p = 0.0074, 95% CI 0.01-0.08 s) and less to the upper third of the face (-0.27 s, p < 0.0001, 95% CI -0.40 to -0.14 s) when tasked. There was no significant difference in time spent on the whole face in the two experiments, suggesting that peripheral elements such as hair color or jewelry did not significantly influence gaze patterns. Conclusions and Relevance: Humans form judgments about others every day of their lives, and age perception colors their every interaction. To our knowledge, this study is the first to use eye tracking to investigate facial cues of age. The results showed that when tasked with estimating age, casual observer visual attention was shifted toward the lower face when compared with those who were untasked. These data inform our understanding of facial age perception and potential areas to target for facial rejuvenation. Level of Evidence: NA.

Transoral neck surgery prevents attentional bias towards the neck compared to open neck surgery.

OBJECTIVE: Measure attentional distraction of neck scars after open neck surgery compared to transoral endoscopic thyroidectomy via a vestibular approach (TOETVA) or transoral endoscopic parathyroidectomy via a vestibular approach (TOEPVA) using eye-tracking technology. METHODS: Casual observers viewed facial images of patients who underwent open neck surgery, TOETVA/TOEPVA, or no surgery (controls). An eye-tracking monitor recorded eye fixations in real time. Multivariate Hotelling's analysis followed by post-hypothesis testing compared fixation durations for predefined regions of interest, including the eyes, nose, mouth, neck, and remaining face between open neck surgery patients, transoral neck surgery patients, and controls. RESULTS: One hundred forty observers completed the experiment. The majority of their attention was directed towards the central triangle (eyes, nose, mouth). On multivariate analysis, distribution of attention was significantly different on the faces of those who underwent open neck surgery versus TOETVA/TOEPVA (T2 = 43.66; F[32,131] = 14.5389, P < .0001). Observers attended significantly more to the neck (0.20 seconds, P < .0001; 95% CI, 0.13, 0.26 s) and less to the peripheral face (-0.24 seconds, P = .0031; 95% CI, -0.39, -0.08 s) of open neck surgery patients. In patients who followed up months after surgery, significant differences persisted (T2 = 13.97; F[3451] = 4.6377, P = .0033). By contrast, fixation patterns for TOETVA/TOEPVA patients were not significantly different from controls (T2 = 5.59, F[31,186] = 1.8602, P = .1345). Observer race and gender did not significantly affect attention to neck scars. CONCLUSION: Scars following open neck surgery draw attention in casual observers. This attentional distraction is prevented in TOETVA/TOEPVA patients due to the absence of a scar, even months after surgery. Moreover, visual processing of TOETVA/TOEPVA patients' faces is similar to that of controls. These data support the effectiveness of transoral neck surgery in giving patients a cosmetic result that does not distract the attention of observers. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1603-1608, 2020.

Normal Gaze Patterns of the Face in Lateral View.

Importance: Current efforts to quantify the attentional distraction of facial deformities have been limited to deformities that are best perceived when the face is in frontal view, and there remains a paucity of knowledge of societal perception of the face in lateral view. To date, no attempts have been made to characterize the fixation patterns of the face in lateral view. Objective: To characterize the fixation patterns and gaze patterns of the face in lateral view. Design, Setting, and Participants: This was a prospective randomized controlled trial at an academic tertiary medical center. Eighty participants (mean age 23.6 ± 1.7 years, 52.5% female) gazed freely at 11 images of faces in lateral view for 10 s each as an infrared eye-tracker recorded eye movements in real time. Main Outcomes and Measures: Recorded eye movements are superimposed on the images to visualize areas of interest (AOIs) that attract the most attention. Fixation duration targeted at each AOI is transformed into relative fixation of the entire face and neck. Hotelling's test of variance followed by post hoc t-testing assessed for the significance of fixation differences between the mouth and cheeks. Results: Participants spent an average of 6.0 (95% CI 5.8-6.2) s gazing at the face and neck areas of each image. Of this attention, 2.8 s or 49.8% (45.4-54.2%) was directed toward the eye, followed distantly by the nose (mean, 95% CI) (16.4%, 14.5-18.3%), cheek (12.0%, 11.4-14.5%), neck (4.6%, 3.8-5.4%), and mouth (4.0%, 3.4-4.6%). These differences were found to be significant by Hotelling's analysis and post hoc testing. A student's t-test also indicated observers directed significantly more attention within the eye-nose-cheek triangle [4.6 s or 79.5% (75.6-83.5)] compared with the eye-nose-mouth triangle [4.1 s or 71.2% (66.9-75.5)] (p < 0.001). Conclusions and Relevance: When perceiving novel faces in lateral view, casual observers preferentially directed attention toward the eye, nose, and cheek. These findings suggest that we draw from a slightly different collection of features to build a schema of the sagittal face, which may serve to complement the central triangle and build upon a three-dimensional model of the "normal" human face. Level of Evidence: NA.

Measuring Outcomes of Mohs Defect Reconstruction Using Eye-Tracking Technology.

IMPORTANCE: Objectively measuring how Mohs defect reconstruction changes casual observer attention has important implications for patients and facial plastic surgeons. OBJECTIVE: To use eye-tracking technology to objectively measure the ability of Mohs facial defect reconstruction to normalize facial attention. DESIGN, SETTING, AND PARTICIPANTS: This observational outcomes study was conducted at an academic tertiary referral center from January to June 2016. An eye-tracking system was used to record how 82 casual observers directed attention to photographs of 32 patients with Mohs facial defects of varying sizes and locations before and after reconstruction as well as 16 control faces with no facial defects. Statistical analysis was performed from November 2018 to January 2019. MAIN OUTCOMES AND MEASURES: First, the attentional distraction caused by facial defects was quantified in milliseconds of gaze time using eye tracking. Second, the eye-tracking data were analyzed using mixed-effects linear regression to assess the association of facial defect reconstruction with normalized facial attention. RESULTS: The 82 casual observers (63 women and 19 men; mean [SD] age, 34 [12] years) viewed control faces in a similar and consistent fashion, with most attention (65%; 95% CI, 62%-69%) directed at the central triangle, which includes the eyes, nose, and mouth. The eyes were the most visually important feature, capturing a mean of 60% (95% CI, 57%-64%) of fixation time within the central triangle and 39% (95% CI, 36%-43%) of total observer attention. The presence of Mohs defects was associated with statistically significant alterations in this pattern of normal facial attention. The larger the defect and the more centrally a defect was located, the more attentional distraction was observed, as measured by increased attention on the defect and decreased attention on the eyes, ranging from 729 (95% CI, 526-931) milliseconds for small peripheral defects to 3693 (95% CI, 3490-3896) milliseconds for large central defects. Reconstructive surgery was associated with improved gaze deviations for all faces and with normalized attention directed to the eyes for all faces except for those with large central defects. CONCLUSIONS AND RELEVANCE: Mohs defects are associated with altered facial perception, diverting attention from valuable features such as the eyes. Reconstructive surgery was associated with normalized attentional distraction for many patients with cutaneous Mohs defects. These data are important to patients who want to know how reconstructive surgery could change the way people look at their face. The data also point to the possibility of outcomes prediction based on facial defect size and location before reconstruction. Eye tracking is a valuable research tool for outcomes assessment that lays the foundation for understanding how reconstructive surgery may change perception and normalize facial deformity.