Facial Aesthetic Outcomes of Cleft Surgery: Assessment of Discrete Lip and Nose Images Compared with Digital Symmetry Analysis.

BACKGROUND: High-quality aesthetic outcomes are of paramount importance to children growing up after cleft lip and palate surgery. Establishing a validated and reliable assessment tool for cleft professionals and families will facilitate cleft units, surgeons, techniques, and protocols to be audited and compared with greater confidence. This study used exemplar images across a five-point aesthetic scale, identified in a pilot project, to score lips and noses as separate units and compared these human scores with computer-based SymNose symmetry scores. METHODS: Forty-five assessors (17 cleft surgeons nationally and 28 other cleft professionals from the UK South West Tri-centre units), scored 25 standardized photographs, uploaded randomly onto a Web-based platform, twice. Each photograph was shown in three forms: lip and nose together, and separately cropped images of nose only and lip only. The same images were analyzed using the SymNose software program. RESULTS: Scoring lips gave the best intrarater and interrater reliabilities. Nose scores were more variable. Lip scoring associated most closely with the whole-image score. SymNose ranking of the lip images related highly to the same ranking by humans (p = 0.001). The exemplar images maintained their established previous ranking. CONCLUSIONS: Images illustrating the aesthetic outcome grades are confirmed. The lip score is reliable and seems to dominate in the whole-image score. Noses are much harder to score reliably. It appears that SymNose can score lip images very effectively by symmetry. Further use of SymNose will be investigated, and families of children with cleft will trial the scoring system. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cutaneous chemical burns in children - a comparative study.

Exposure to chemicals is an unusual causation of cutaneous burns in children. The aim of this study is to look at childhood chemical burns and compare this to adult chemical burns from the same population. A total of 2054 patients were referred to the pediatric burns unit during the study period. This included 24 cutaneous chemical burns, equating to an incidence of 1.1%. Over half of the injuries occurred in the domestic setting. The mean total body surface area (TBSA) affected was 1.9%. When compared to a cohort of adult patients from the same population with cutaneous chemical burns, the TBSA affected was identical (1.9%) but distribution favored the buttock and perineum in children, rather than the distal lower limb in adults. Children presented earlier, had lower rates of surgical intervention and had a shorter length of stay in hospital (p < 0.001). Children also had a lower rate of appropriate first aid treatment. Chemical burns in children are rare, but are becoming more common in our region. It is important to be aware of the characteristic distribution, etiology and need to identify children at risk of child protection issues.

Development and validation of a computerized model of smiling: Modeling the percentage movement required for perception of smiling in unilateral facial nerve palsy.

BACKGROUND: The inability to smile stands out as a notable difficulty for individuals with facial nerve palsies; a problem that facial reanimation surgery aims to rectify. However, smile reconstruction currently lacks quantitative data by which to objectively measure outcomes. This study aims to identify the relative importance of different oral muscles in terms of smiling, and explore the percentage function that needs to be restored for a smile to be perceived by an observer. METHODS: A computer animation tool was developed to model the oral facial muscles and demonstrate the facial expressions produced by contraction of different muscle groups. By programming a variable unilateral paralysis of the zygomaticus major, the effects of 0-100% function of this muscle can also be seen in a further set of animations using the basic muscular structure of a smile to produce a computerized proxy smile. These animations were shown to 75 adults from the general population who reported those expressions they perceived as a smile. RESULTS: The only facial expression consistently associated with a perceived smile was caused by the combined contraction of the zygomaticus major and the levator anguli oris (P < 0.001). This concurs with previously reported observations of the human smile. Over 70% of the subjects were able to perceive a smile with just 40% function of the unilateral paralyzed zygomaticus major. CONCLUSIONS: These results present an objective target for facial reanimation surgery by which outcomes may be measured. This computerized model also provides a valuable tool for patient education during pre-operative consent.

A clinical characterization of familial keloid disease in unique African tribes reveals distinct keloid phenotypes.

BACKGROUND: This study is a clinical characterization of keloid scars in an African population comprising three rural tribes with familial keloids. Site distribution, morphologic features, and other characteristics of the scars were studied to assess whether each tribe had a specific scar phenotype. METHODS: Keloid scar clinics were set up at Soba Hospital in Khartoum, Sudan, for patient recruitment and management. In addition, familial keloid cases were recruited from rural tribal populations during field trips. A database including clinical and demographic data and digital photographs of all keloid cases was established. Statistical analysis was conducted using SPSS and SAS software. RESULTS: One hundred eleven individuals with keloid scarring (67 male subjects and 44 female subjects) were recruited. Patients were predominantly from three multigenerational pedigrees (total of 38 nuclear families) afflicted with keloid scars residing in different rural regions of Sudan. Two distinct morphologic phenotypes of keloid scarring were observed. The first phenotype has been designated "superficial spreading" (horizontal) keloid and the second has been designated "raised" (vertical) keloid. Clinically significant features and statistically measurable morphologic parameters were compared among these phenotypes (p = 0.001). Furthermore, linear claw-like extensions of keloid (transgression) were noted to be significantly higher in the superficial spreading keloid phenotype (p = 0.03). CONCLUSIONS: There is strong evidence of different phenotypes of keloid scarring. Two distinct phenotypes have been observed, described, and statistically verified. Each tribe demonstrated one particular phenotype, with two being superficial spreading and one being raised. Other significant clinical characteristics have been described. This is of significance in understanding both the clinical basis and the genetic basis of keloid scarring.