Upper and Lower Limb Anomalies in Craniofacial Microsomia and Its Relation to the OMENS+ Classification: A Multicenter Study of 688 Patients.

BACKGROUND: Craniofacial microsomia (CFM) is characterized by several malformations related to the first and second pharyngeal arch. Patients typically present with facial asymmetry, but extracraniofacial organ systems might be involved, including limb anomalies. The purpose of this study was to analyze the occurrence of upper and lower limb anomalies in CFM patients. Furthermore, the relation between limb anomalies and the OMENS+ (orbital distortion; mandibular hypoplasia; ear anomaly; nerve involvement; soft-tissue deficiency; and associated extracraniofacial anomalies) classification was examined. METHODS: A retrospective study was conducted including patients with CFM from craniofacial units in three different countries. Patients were included when clinical and/or radiographic images were available. Demographic, radiographic, and clinical information was obtained. RESULTS: A cohort of 688 patients was available and selected for analysis. In total, 18.2% of the patients were diagnosed with at least one upper and/or lower limb anomaly. Upper and lower limb anomalies were seen in, respectively, 13.4% and 7.8% of patients. Patients with other extracraniofacial anomalies had a significantly higher risk for limb anomalies (OR, 27.98; P = 0.005). Laterality of CFM and a higher OMENS score were not associated with limb anomalies. CONCLUSIONS: More than one in six patients with craniofacial microsomia have limb anomalies. Therefore, clinical awareness for these anomalies is warranted. Examination and, if present, follow-up on limb abnormalities in patients with CFM should be implemented in the standard assessment of CFM patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

A rare case of pediatric ptosis: Coexistence of giant intracranial arachnoid cyst and facial asymmetry.

BACKGROUND: Intracranial arachnoid cysts are cystic congenital malformations, filled with cerebrospinal fluid (CSF) originating from the arachnoid membrane. Generally, giant arachnoid cysts present with symptoms related to increased intracranial pressure, hydrocephalus or cognitive disorders, endocrinological problems, growth retardation, seizures, headache, and nonspecific symptoms such as dizziness. They can be detected by imaging when they become symptomatic or incidentally in childhood and adulthood. Our case was referred to our clinic because of ptosis and facial asymmetry found on examination. Subsequently, a intracranial giant arachnoid cyst was found incidentally on cranial computed tomography (CT). CASE: In an 18-month-old male infant admitted with ptosis, left frontal bulging and a dystopic globe with ptosis of the left upper lid were noted. The left half of the facial region and the left nostril also appeared to be asymmetrically elongated downward relative to the right. Fundus examination revealed an optic disc coloboma in the left eye. On general physical examination, he was unable to walk. A giant fronto-temporo-parietal arachnoid cyst with the cerebral parenchyma shifted 2cm to the right of the midline was observed on cranial CT. After a cysto-peritoneal shunt was performed, the physical appearance of our patient returned to normal. CONCLUSION: Ptosis cases accompanied by abnormalities such as optic disc coloboma and facial asymmetry should be evaluated for possible midline defects and intracranial pathologies prior to eyelid surgery.

[A case report of the first and second branchial arch syndrome with torticollis].

A 54-month-old female patient presented to the department of ophthalmology with abnormal head posture and facial asymmetry for two years. The patient's facial development was asymmetrical, with the middle 1/3 of the left side shorter than the right side. The left ear is less malformed than the right. There was no obvious abnormality in corneal light reflex and eye movement. Head tilt test ( -). So, paralysis of the superior oblique muscle was excluded. In consultation with the department of maxillofacial surgery, the patient was confirmed as the first and second branchial arch syndrome and torticollis.

Does positional plagiocephaly affect the need for orthodontic treatment, and the mandibular and occlusal symmetry? / La plagiocéphalie positionnelle a-t-elle des répercussions sur le besoin de traitement orthodontique et sur la symétrie mandibulaire et occlusale ?

Introduction: Positional plagiocephaly (PP) is characterized by an asymmetrical flatness of the posterior part of the skull which may involve the frontal part of the skull and the face. The aim is to assess whether children and adolescents with PP have more occlusal and skeletal asymmetries and whether the need for orthodontic treatment is greater than in the healthy population. Material and Method: A comparative cross-sectional epidemiological study was carried out. One hundred children and adolescents were included: 50 in the PP group and 50 in the control group. The need for orthodontic treatment was assessed by the Index of Orthodontic Treatment Need (IOTN). The mandibular and dental asymmetries were measured on lateral cephalometry by two indexes: index of mandibular asymmetry (IMA) and index of dental asymmetry (IDA) respectively. Chi and Student independence tests were performed with a threshold of 5%. Results: The tests are significant for IMA (p = 0.02) and IOTN (p = 0.000012). IDA is insignificant. Discussion: Orthosurgical treatment of mandibular laterognathies by mandibular recentering sometimes creates mandibular asymmetry, while the shift is basal. We must be able to act early on the vault of the skull to hope to obtain a consecutive effect on the base and therefore on the position of the glenoid cavities. Management by manual therapy and early cranial orthosis could be estimated. Conclusion: The need for orthodontic treatment is significantly greater in PP. Unlike mandibular asymmetry, dental asymmetry is not significantly greater than in the control group, testifying to the adaptive capacities of the organism.

Introduction: Les plagiocéphalies positionnelles (PP) sont caractérisées par un aplatissement asymétrique de la partie postérieure du crâne pouvant impliquer la partie frontale du crâne et la face. L'objectif de cet article était d'évaluer si les enfants et les adolescents atteints de PP ont davantage de dissymétries occlusales et squelettiques, et si le besoin de traitement orthodontique est plus important que dans la population saine. Matériel et méthode: Une étude épidémiologique transversale comparative a été menée. Cent enfants et adolescents ont été inclus : 50 dans le groupe PP et 50 dans le groupe témoin. Le besoin de traitement orthodontique a été évalué par l'Index of Orthodontic Treatment Need (IOTN). La dissymétrie squelettique et dentaire a été évaluée radiologiquement par deux indices : l'Index of Mandibular Asymmetry (IMA) et l'Index of Dental Asymmetry (IDA). Des tests d'indépendance du Chi et Student ont été effectués avec un seuil de 5 %. Résultats: L'IMA (p = 0,02) et l'IOTN (p = 0,000012) sont significatifs. L'IDA est non significatif. Discussion: Le traitement ortho-chirurgical des latéromandibulies par recentrage mandibulaire crée parfois une dissymétrie mandibulaire, alors que le décalage est basal. Il faudrait pouvoir agir précocement sur la voûte du crâne pour espérer obtenir un effet consécutif sur la base et donc sur la position des cavités glénoïdes. Une prise en charge par thérapies manuelles et orthèse crânienne précoce pourrait être évaluée. Conclusion: Le besoin de traitement orthodontique est significativement plus important en cas de PP. Contrairement à la dissymétrie mandibulaire, la dissymétrie dentaire n'est pas significativement plus importante que dans le groupe témoin, témoignant des capacités adaptatives de l'organisme.

Evaluation of the relationship between nasal septal deviation and development of facial asymmetry with anthropometric measurements depending on age.

AIM: It was aimed to determine the change of facial asymmetry resulting from nasal septal deviation (SD) depending on age, gender, degree of deviation and the affected area besides the effect of SD on somatotype and craniofacial morphology. MATERIALS AND METHODS: 171 volunteers (90 males, 81 females), 27 individuals aged 9-13, 44 individuals aged 14-18, 44 individuals aged 19-23 and 56 individuals in control group participated in the study conducted in otorhinolaryngology polyclinic.11 photometric, 16 anthropometric measurements were taken from the participants. RESULTS: SD affects facial asymmetry formation, although not statistically significant compared to healthy individuals asymmetry rates (p˃0.05). It was determined that the degree of SD affected asymmetry only between the ages of 14-18 (in adolescence) and the development of asymmetry in all SD patients was not statistically dependent on age and gender (p˃0.05). Photometric measurements demonstrated asymmetries in horizontally-extending parameters of 1/3 middle part of face. There was no statistically significant difference in the cranial anthropometric measurements of the upper and lower 1/3 of the face compared to the control group (p˃0.05). The order of the most asymmetrical parameters is Alare-Zygion, Alare-Subnasale, Cheilion-Gonion, Exocanthion-Cheilion, Midsagittal plane-Zygion, Zygion-Cheilion, Zygion-Gonion, Subalare-Cheilion, Glabella-Exocanthion. In all participants were determined that endomorph somatotype was dominant in female and mesomorph somatotype was dominant in male besides SD did not affect somatotype and somatotype did not alter with age. CONCLUSION: The development of facial asymmetry due to SD is not affected by age and gender furthermore SD does not affect craniofacial asymmetry and somatotype.

Facial Asymmetry in Children With Unilateral Congenital Ptosis.

PURPOSE: To analyze facial asymmetry in children with unilateral congenital ptosis. METHODS: This is a retrospective review of pediatric patients undergoing ptosis repair between January 1, 2017, and December 31, 2020. Charts were reviewed to ensure a diagnosis of idiopathic unilateral congenital ptosis. Sex, age, laterality, margin to reflex distance 1, levator function, and surgical intervention were collected.Clear preoperative photos without head turn were included. Using the ImageJ software ( nih.gov ), landmarks of the periorbital region, midface, and lower face were marked, and measurements between these landmarks were taken.Two-tailed Student t tests were used to compare measurements between the ptotic and non-ptotic sides. Relationships between different measurements on the same side of the face were analyzed using paired-variable regressions. RESULTS: Forty-four patients with unilateral congenital ptosis were included. The surgical management consisted of Mullerectomy in 9 of 44 (20%), levator resection in 15 of 44 (34%), and frontalis suspension in 20 of 44 (46%) patients. The side of the face with blepharoptosis was found to more often have smaller margin to reflex distance 1 ( p < 0.001), smaller margin to reflex distance 2 ( p < 0.005), smaller horizontal palpebral fissure ( p < 0.05), shorter midface height ( p < 0.001), and a more inferiorly displaced lateral canthus (canthal angle, p < 0.001) relative to the non-ptotic side of the face. The mean head tilt of patients with right sided ptosis (1.37° right tilt) was statistically significantly different from those with left sided ptosis (0.85° left tilt; p = 0.04). CONCLUSIONS: In children with unilateral congenital ptosis, the ptotic side of the face was found to be the nondominant side of the face. Patients were also found to have ipsilateral head tilt.

Surgery-First Orthognathic Approach to Correct Facial Asymmetry: Artificial Intelligence-Based Cephalometric Analysis.

BACKGROUND: The surgery-first orthognathic approach has been applied at our institution since 2007. However, its indications remain debated. The aim of this study was to investigate the reliability of the surgery-first approach to correct facial asymmetry compared to the traditional orthodontics-first approach using a novel artificial intelligence-based cephalometric analysis. METHODS: Intervention outcomes of surgery-first (n = 33) and orthodontics-first (n = 26) approaches to correct facial asymmetry were examined. Patients with facial asymmetry who had undergone orthognathic surgery from January of 2006 to January of 2019 were included in the study. In the surgery-first approach, the novel preoperative simulation process on the dental model was performed to determine the final occlusion without presurgical orthodontic treatment. Changes in cephalometric landmarks were compared using the supervised deep learning process developed at our institution. RESULTS: The surgery-first approach without presurgical orthodontic treatment corrected facial asymmetry and yielded results similar to those of the traditional orthognathic approach. The statistical analysis revealed that changes in skeletal cephalometric landmarks were similar in the two groups. CONCLUSIONS: The surgery-first orthognathic approach without presurgical orthodontic treatment treated facial asymmetry, possibly suggesting a possible paradigm shift in treatment. In addition, artificial intelligence-based cephalometric analysis was an effective tool. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Ideal Reference Lines for Assessment of Facial Asymmetry in Rhinoplasty Patients.

BACKGROUND: Assessing facial asymmetry is important to prevent unsatisfactory results in rhinoplasty. There has yet to be a consensus on reference lines for determining asymmetry. This study aimed to determine ideal reference lines to assess facial asymmetry and identify predictors of subjective perceptions of facial asymmetry. METHODS: Preoperative photographs of 47 patients who underwent rhinoplasty were adjusted according to two reference lines (vertical line from the mid-glabella to Cupid's bow and horizontal interpupillary line). In total, 94 photographs were generated, randomly ordered, and evaluated by two independent observers for anthropometric measurements including six distances (distances from the midline to the medial and lateral canthi, ala, oral commissure, width of midface at maximum distance, and mandible width) and three angles (lateral canthal, lateral alar, and lip margin angles). Photographs were rated by 18 independent observers for subjective perceptions of facial asymmetry. RESULTS: Observers perceived faces as asymmetric if accompanied by nasal deviation, irrespective of the reference line (p < 0.001). Based on the horizontal reference line, subjective perceptions of asymmetry were correlated with the midline to lateral alar margin distance (r = 0.489, p = 0.003) and sum of the distance ratios (r = 0.354, p = 0.037). None of the objective parameters correlated with subjective perceptions when adopting the vertical reference line. A deviated nose and lateral alar angle were significant predictors of subjective perceptions of facial asymmetry. CONCLUSION: To assess facial asymmetry, the horizontal reference line should be determined first followed by the perpendicular vertical line. The nose is the most important feature determining overall facial asymmetry. LEVEL OF EVIDENCE V: "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Three-Dimensional Motion Capture of a Smile in Repaired Unilateral Cleft Lip: What's Our Vector, Victor?

INTRODUCTION: Following surgical repair, patients with unilateral cleft lip (UCL) exhibit dynamic asymmetry during facial expressions compared to healthy individuals. Previous studies using Euclidean distances to describe this asymmetry fail to take the direction of the movement into account. The aim of this study is to compare differences in participants with UCL and controls using analysis of motion vectors during facial expressions. METHODS: In this cross-sectional study, twenty-six pediatric participants were recruited: 13 participants with repaired left UCL and 13 participants with no craniofacial diagnosis. Participants were recorded performing a maximal smile by a 4D stereophotogrammetric system. Phases of the smile were divided into closed lip and open lip smiles. Ten regions of interest were analyzed: subnasal area, upper lip, lower lip, oral commissure, and ala on both sides. The motion vectors were calculated and vector magnitude and direction for each region was compared. RESULTS: Between cleft and control groups, the differences in vector direction were greater than the magnitude differences. Significant differences in vector direction were identified at both oral commissures in the closed lip smile; and at the oral commissure, subnasal, upper lip, and lower lip regions during open lip smile. CONCLUSIONS: Vector analysis demonstrated significant movement asymmetry during facial animation in participants following UCL repair, not previously identified when analyzing magnitude of skin displacement.

Three-Dimensional Quantification of Facial Asymmetry in Children with Positional Cranial Deformity.

BACKGROUND: The extent of facial involvement in positional plagiocephaly is only little investigated so far. Investigation methods that take into account the challenging anatomical conditions and growth of infants' faces are desirable. In this study, the authors established a new three-dimensional photogrammetry quantification method evaluating pretherapeutic and posttherapeutic facial asymmetry in positional plagiocephaly. Furthermore, a facial asymmetry index was established and evaluated. METHODS: Three-dimensional photographs of 100 children undergoing treatment with head orthoses were analyzed by constructing a standardized interindividual coordinate system. Defining landmarks, section planes, and point coordinates with a computer-aided design software, both sides of the faces were compared. Facial asymmetry was quantified by measuring differences between left and right sides and pretherapeutic and posttherapeutic changes in each patient. The facial asymmetry index was calculated by putting the absolute differences in relation with the coordinates of the nonaffected side. RESULTS: Present results indicate that positional plagiocephaly results in a distinct facial asymmetry (range, -3.8 to 9.6 mm) in nearly all spatial directions and facial regions. Helmet therapy led to a significant reduction (p < 0.05) of intraindividual facial asymmetry (median change in facial asymmetry index, -1.9 to 3.1 percent). However, no correlation of the Cranial Vault Asymmetry Index and facial asymmetry (Spearman rank correlation coefficient, ρ = -0.09 to 0.47) has been seen. According to these results, severe occipital deformation does not necessarily provoke distinct facial asymmetry. CONCLUSIONS: Present three-dimensional photogrammetry method allows the longitudinal quantification of facial involvement in positional plagiocephaly. Asymmetry has been determined in all facial regions. The facial asymmetry decreased through helmet therapy but was not eliminated completely.

Facial Asymmetry in Unilateral Congenital Superior Oblique Muscle Palsy.

SIGNIFICANCE: This study was conducted to evaluate facial asymmetry in unilateral congenital superior oblique muscle palsy (SOP). The results showed that all facial asymmetry parameters had a higher frequency in SOP patients compared with orthotropic individuals. PURPOSE: This study aimed to evaluate the characteristics of facial asymmetry in unilateral congenital SOP and compare with orthotropic individuals. METHODS: This cross-sectional comparative case series was conducted in 58 patients with ocular torticollis caused by SOP (mean ± standard deviation age, 18 ± 12 years) and 58 orthotropic individuals (mean ± standard deviation age, 19 ± 13 years). The exact form of torticollis was determined by direct observation from yaw, roll, and pitch axes. Four photographs were taken from patients: (1) with torticollis to calculate the amount of head tilt; (2) with the head in the straight position to calculate the facial angle and relative facial size (RFS); and (3 and 4) with the head positioned downward (to compare the cheek size) and upward (to assess columella deviation and nostril asymmetry). RESULTS: Twenty-nine patients (50%) had a head tilt, 23 (39.66%) had combined head tilt and a face turn, and 6 (10.44%) had a pure face turn. The mean ± standard deviation of head tilt, facial angle, and RFS was 10.11 ± 6.31°, 1.11 ± 1.67°, and 1.003 ± 0.126 in SOP patients, respectively, and the mean RFS and facial angle were significantly higher in SOP patients compared with orthotropic individuals (both P < .001). Facial hemihypoplasia, unilateral cheek compression, nostril asymmetry, and columella deviation were observed in 43 (74.1%), 31 (53.4%), 39 (67.2%), and 38 patients (65.5%), respectively, which were all significantly more common compared orthotropic individuals (P < .001). Facial asymmetry was seen in 52 patients (91.2%) and 17 orthotropic subjects (29.3%), respectively (P < .001). CONCLUSIONS: All quantitative and qualitative facial asymmetry parameters had a higher frequency in SOP patients compared with orthotropic subjects.

Evaluation of an automated approach for facial midline detection and asymmetry assessment: A preliminary study.

OBJECTIVE: To examine the level of agreement between the conventional method and a machine-learning approach to facial midline determination and asymmetry assessment. SETTINGS AND SAMPLE POPULATION: The study included a total of 90 samples (53 females; 37 males) with different levels of mandibular asymmetry. MATERIALS AND METHODS: Two researchers placed predefined soft tissue landmarks individually on selected facial frontal photographs and created 10 reference lines. The midsagittal line was determined as perpendicular to the midpoint of the bipupillary line, and the same two reference lines and facial landmarks were automatically determined by the software using machine-learning algorithms, and researchers created the other 8 reference lines using the facial landmarks that were determined automatically by the software. In the following stage, 2 linear and 10 angular measurements were made by a single researcher on 270 photographs, and the consistency and differences between the measurements were evaluated with a one-sample t test, an intraclass correlation coefficient (ICC) and Bland-Altman Plots. RESULTS: The level of agreement of measurements between the researchers and the software was low for eight parameters (ICC˂0.70). The one-sample t test revealed that differences between the software and researcher measurements of lip canting and pronasale deviation were not statistically significantly different (P > .05). Aside from the body inclination difference in Group 3 (samples with a mandibular body inclination difference >6°), there was no clinically significant difference (˂3°) between the measurements of the two methods. CONCLUSIONS: Machine-learning algorithms have the potential for clinical use in asymmetry assessment and midline determination and can help clinicians in a manual approach.

Impairment in facial expression generation in patients with repaired unilateral cleft lip: Effects of the physical properties of facial soft tissues.

Patients with repaired unilateral cleft lip with palate (UCLP) often show dysmorphology and distorted facial motion clinically, which can cause psychological issues. However, no report has clarified the details concerning distorted facial motion and the corresponding possible causative factors. In this study, we hypothesized that the physical properties of the scar and surrounding facial soft tissue might affect facial displacement while smiling in patients with UCLP (Cleft group). We thus examined the three-dimensional (3D) facial displacement while smiling in the Cleft and Control groups in order to determine whether or not the physical properties of facial soft tissues differ between the Cleft and Control groups and to examine the relationship between the physical properties of facial soft tissues on 3D facial displacement while smiling. Three-dimensional images at rest and while smiling as well as the facial physical properties (e.g. viscoelasticity) of both groups were recorded. Differences in terms of physical properties and facial displacement while smiling between the two groups were examined. To examine the relationship between facial surface displacement while smiling and physical properties, a canonical correlation analysis (CCA) was conducted. As a result, three typical abnormal features of smiling in the Cleft group compared with the Control group were noted: less upward and backward displacement on the scar area, downward movement of the lower lip, and a greater asymmetric displacement, including greater lateral displacement of the subalar on the cleft side while smiling and greater alar backward displacement on the non-cleft side. The Cleft group also showed greater elastic modulus at the upper lip on the cleft side, suggesting hardened soft tissue at the scar. The CCA showed that this hard scar significantly affected facial displacement, inducing less upward and backward displacement on the scar area and downward movement of the lower lip in patients with UCLP (correlation coefficient = 0.82, p = 0.04); however, there was no significant relationship between greater nasal alar lateral movement and physical properties of the skin at the scar. Based on these results, personalizing treatment options for dysfunction in facial expression generation may require quantification of the 3D facial morphology and physical properties of facial soft tissues.

Predicting Resting Oral Commissure Tone Outcomes Following Masseter Nerve Transfer in Facial Reanimation.

Objective: To quantify the degree of oral commissure resting tone improvement in patients undergoing masseter to facial nerve transfer. Methods: A retrospective cohort study was completed in a tertiary academic medical practice. Consecutive cases of masseter nerve transfer patients within a patient database were evaluated from 6/2012 to 9/2017. Inclusion criteria were patients >18 years of age, with complete unilateral paralysis, receiving a masseter to facial nerve transfer, with at least 12 months of recovery, and possessing complete pre- and postoperative data. Patients were excluded if a simultaneous adjunctive procedure was performed so that tone could not be attributed to masseter transfer alone. The main outcome measure was the facial asymmetry index (FAI): the measured difference in distance between the medial canthus and oral commissure of the healthy and paralyzed sides. Results: Twenty-nine patients met inclusion and exclusion criteria and were further analyzed for this study. The oral commissure symmetry improved from 4.7 ± 2.8 mm preoperatively to 2.2 ± 2.3 mm postoperatively. In multivariate analysis, the preoperative FAI was the only significant predictive factor for improvement in commissure symmetry at rest (r = 0.589). This suggests that for each 1.0 mm of worse preoperatively oral commissure asymmetry, the improvement postoperatively was 0.6 mm. Age, gender, body mass index, side of paralysis, duration of paralysis, and recipient branch of facial nerve were not significant predictors in a multivariate analysis. Conclusion: Masseter to facial nerve transfer yields an estimated 60% correction in the oral commissure asymmetry. This estimation may be helpful in determining if adjunctive procedures should be utilized.

The Auto-eFACE: Machine Learning-Enhanced Program Yields Automated Facial Palsy Assessment Tool.

BACKGROUND: Facial palsy assessment is nonstandardized. Clinician-graded scales are limited by subjectivity and observer bias. Computer-aided grading would be desirable to achieve conformity in facial palsy assessment and to compare the effectiveness of treatments. This research compares the clinician-graded eFACE scale to machine learning-derived automated assessments (auto-eFACE). METHODS: The Massachusetts Eye and Ear Infirmary Standard Facial Palsy Dataset was employed. Clinician-graded eFACE assessment was performed on 160 photographs. A Python script was used to automatically generate auto-eFACE scores on the same photographs. eFACE and auto-eFACE scores were compared for normal, flaccidly paralyzed, and synkinetic faces. RESULTS: Auto-eFACE and eFACE scores differentiated normal faces from those with facial palsy. Auto-eFACE produced significantly lower scores than eFACE for normal faces (93.83 ± 4.37 versus 100.00 ± 1.58; p = 0.01). Review of photographs revealed minor facial asymmetries in normal faces that clinicians tend to disregard. Auto-eFACE reported better facial symmetry in patients with flaccid paralysis (59.96 ± 5.80) and severe synkinesis (62.35 ± 9.35) than clinician-graded eFACE (52.20 ± 3.39 and 54.22 ± 5.35, respectively; p = 0.080 and p = 0.080, respectively); this result trended toward significance. CONCLUSIONS: Auto-eFACE scores can be obtained automatically using a freely available machine learning-based computer software. Automated scores predicted more asymmetry in normal patients, and less asymmetry in patients with flaccid palsy and synkinesis, compared to clinician grading. Auto-eFACE is a quick and easy-to-use assessment tool that holds promise for standardization of facial palsy outcome measures and may eliminate observer bias seen in clinician-graded scales. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, III.

Serial measurements of facial asymmetry using a wooden tongue depressor in patients with congenital microtia.

BACKGROUND AND OBJECTIVES: Congenital microtia may be associated with hemifacial microsomia, but little is known about their correlation and development with aging. Historically, facial asymmetry is easily assessed by observing the occlusal cant using a tongue depressor. We serially measured the occlusal cant in children with microtia to evaluate change in facial asymmetry with growth. METHODS: Since 2011, frontal photographs of patients with congenital microtia biting a tongue depressor were obtained and reviewed. The occlusal angle was compared between the baseline and final photographs, and the change was compared between cant-positive (>3° at baseline) and cant-negative (<3° at baseline) groups. Multivariate analysis was conducted to determine variables associated with the change in occlusal angle. RESULTS: Overall, 105 patients were enrolled. With a mean age of 5.4 years at baseline and a mean follow-up of 3.9 years, clinically significant aggravation was observed in 15.4% and 24.2% of cant-positive and cant-negative patients, respectively. Hemifacial microsomia (OR, 4.825; p = 0.005) and occlusal angle at baseline (OR, 0.821; p = 0.045) were associated with aggravation, but the severity of microtia showed no significant association. CONCLUSIONS: When hemifacial microsomia was present, the occlusal cant seemed to be aggravated in children with microtia at later ages. When the occlusal cant was present without noticeable hemifacial microsomia, some compensation in facial asymmetry was expected. The use of a wooden tongue depressor is a simple, non-invasive, and radiologic hazard-free aid to detect notable change in facial asymmetry in children with microtia.