Novel online enfacement illusion for investigating self-perception in mental disorders: an experimental study protocol.

BACKGROUND: Remote research methods and interventions for mental health disorders have become increasingly important, particularly for conditions like eating disorders (EDs). Embodiment illusions, which induce feelings of ownership over another person?s body or body parts, offer valuable insights into the mechanisms underlying self-perception issues in EDs and potential interventions. However, existing research using these illusions has been limited to face-to-face settings. We illustrate a novel online protocol to induce the enfacement illusion (embodiment illusion principles applied to one's face) in an ED-based sample. METHODS: Participants complete a 2-hr virtual session with a researcher. First, baseline trait/state ED psychopathology measures and a self-face recognition task occur. Second, participants experience two testing blocks of the enfacement illusion involving synchronously and asynchronously mimicking a pre-recorded actor's facial expressions. After each block, subjective and objective enfacement illusion measures occur alongside state ED psychopathology reassessment. DISCUSSION: Successfully inducing enfacement illusions online could provide an affordable, accessible virtual approach to further elucidate the mechanistic role of self-perception disturbances across psychopathologies such as EDs. Moreover, this protocol may represent an innovative, remotely-delivered intervention strategy, as 'enfacement' over another face could update negative self-representations in a cost-effective, scalable manner.

The "Central Tendency Bias" in the assessment of facial attractiveness in group-based and individual ratings-A survey-based study in 727 volunteers.

BACKGROUND: The increasing number of esthetic procedures emphasizes the need for effective evaluation methods of outcomes. Current practices include the individual practitioners' judgment in conjunction with standardized scales, often relying on the comparison of before and after photographs. This study investigates whether comparative evaluations influence the perception of beauty and aims to enhance the accuracy of esthetic assessments in clinical and research settings. OBJECTIVE: To compare the evaluation of attractiveness and gender characteristics of faces in group-based versus individual ratings. METHODS: A sample of 727 volunteers (average age of 29.5 years) assessed 40 facial photographs (20 male, 20 female) for attractiveness, masculinity, and femininity using a 5-point Likert scale. Each face was digitally edited to display varying ratios in four lip-related proportions: vertical lip position, lip width, upper lip esthetics, and lower lip esthetics. Participants rated these images both in an image series (group-based) and individually. RESULTS: Differences in the perception of the most attractive/masculine/feminine ratios for each lip proportion were found in both the group-based and individual ratings. Group ratings exhibited a significant central tendency bias, with a preference for more average outcomes compared with individual ratings, with an average difference of 0.50 versus 1.00. (p = 0.033) CONCLUSION: A central tendency bias was noted in evaluations of attractiveness, masculinity, and femininity in group-based image presentation, indicating a bias toward more "average" features. Conversely, individual assessments displayed a preference for more pronounced, "non-average" appearances, thereby possibly pointing toward a malleable "intrinsic esthetic blueprint" shaped by comparative context.

Human vs machine towards neonatal pain assessment: A comprehensive analysis of the facial features extracted by health professionals, parents, and convolutional neural networks.

Neonates are not able to verbally communicate pain, hindering the correct identification of this phenomenon. Several clinical scales have been proposed to assess pain, mainly using the facial features of the neonate, but a better comprehension of these features is yet required, since several related works have shown the subjectivity of these scales. Meanwhile, computational methods have been implemented to automate neonatal pain assessment and, although performing accurately, these methods still lack the interpretability of the corresponding decision-making processes. To address this issue, we propose in this work a facial feature extraction framework to gather information and investigate the human and machine neonatal pain assessments, comparing the visual attention of the facial features perceived by health-professionals and parents of neonates with the most relevant ones extracted by eXplainable Artificial Intelligence (XAI) methods, considering the VGG-Face and N-CNN deep learning architectures. Our experimental results show that the information extracted by the computational methods are clinically relevant to neonatal pain assessment, but yet do not agree with the facial visual attention of health-professionals and parents, suggesting that humans and machines can learn from each other to improve their decision-making processes. We believe that these findings might advance our understanding of how humans and machines code and decode neonatal facial responses to pain, enabling further improvements in clinical scales widely used in practical situations and in face-based automatic pain assessment tools as well.

Perception of aesthetic features after surgical treatment of craniofacial malformations by observers of the same age: An eye-tracking study.

The aim of this study is to evaluate where exactly children and adolescents of the same group look when they interact with each other, and attempt to record and analyse the data recorded by eye-tracking technology. MATERIALS AND METHODS: 60 subjects participated in the study, evenly divided into three age categories of 20 each in pre-school/primary school age (5-9 years), early adolescence (10-14 years) and late adolescence/transition to adulthood (15-19 years). Age groups were matched and categorized to be used both for creating the picture series and testing. Photographs of patients with both unilateral and bilateral cleft lip and palate were used to create the series of images which consisted of a total of 15 photos, 5 of which were photos of patients with surgically treated cleft deformity and 10 control photos with healthy faces, that were presented in random order. Using the eye-tracking module, the data on "area of first view" (area of initial attention), "area with longest view" (area of sustained attention), "time until view in this area" (time of initial attention) and "frequency of view in each area" (time of sustained attention) were calculated. RESULTS: Across all groups, there was no significant difference for the individual regions for the parameters of initial attention (area of first view), while the time until first fixation of one of the AOIs (time until view in this area) was significant for all facial regions. A predictable path of the facial scan is abandoned when secondary facial deformities are present and attention is focused more on the region of an existing deformity, which are the nose and mouth regions. CONCLUSIONS: There are significant differences in both male and female participants' viewing of faces with and without secondary cleft deformity. While in the age group of the younger test persons it was still the mouth region that received special attention from the male viewers, this shifted in the male test persons of the middle age group to the nose region, which was fixed significantly more often and faster. In the female participants, the mouth and nose regions were each looked at for twice as long compared to the healthy faces, making both the mouth and the nose region are in the focus of observation.

Perception of Emergent Leaders' Faces and Evolution of Social Cheating: Cross-Cultural Experiments.

The aim of the present study was to investigate whether neutral faces of individuals with different propensities for leadership may convey information about their personal qualities, and are there impacts of sex, population and social environment on the facial perception. This study is based on a previous experiment ( Rostovtseva et al., 2022), where emergent leadership in the context of male group cooperation was investigated in Buryats (Mongolian population of Siberia). In the previous study three behavioural types of participants were revealed: non-leaders, prosocial leaders and leaders-cheaters, each having a set of distinguishing personality, communicative, and cooperative features. In the current study, three composite portraits representing different leadership qualities of Buryat men from the prior experiment were created. The composites were then scored on a number of traits by male and female Russian and Buryat independent raters (N = 435). The results revealed that ratings on masculinity, physical strength, dominance, competitiveness, and perceived leadership were positively correlated, while perceived trustworthiness was negatively associated with these traits. However, the composite portraits of actual leaders generally were scored as more trustworthy, masculine, and physically strong, with the prosocial leaders' portrait being perceived as healthier than others. Surprisingly, the composite of leaders-cheaters was scored as the most trustworthy and generous, and the least competitive than others. No significant effects of raters' sex, origin, or degree of familiarity with Mongolian appearance were revealed. We conclude that static facial morphology contributes to appearing trustworthy, which may allow exploitation of others.

A systematic review and meta-analysis of facial emotion recognition in autism spectrum disorder: The specificity of deficits and the role of task characteristics.

This review assessed the specificity of facial emotion recognition impairment and the role of task characteristics in facial emotion recognition in autism spectrum disorder (ASD). Based on subsets of 148 studies identified in PubMed and PsycINFO, random-effects meta-analyses showed significant impairment in recognizing all basic facial emotions in ASD. Additionally, ASD involves poorer facial emotion recognition than other clinical conditions and has similar impairment in recognizing emotional and nonemotional facial attributes, as well as in recognizing emotion in faces and other modalities. Furthermore, there are significant moderating effects for emotion complexity and holistic processing, a statistical trend for task type, and no significant effect for motion, social relevance, or stimulus salience on facial emotion recognition in ASD. Altogether, this review suggests nonselective facial emotion recognition impairment in ASD. Such impairment is relatively specific to ASD but is not specific to the recognition of emotional facial attributes or emotion recognition in the face modality. Identifying the role of task characteristics improves our understanding of the mechanisms underlying facial emotion recognition in ASD.

Atypical Facial Emotion Recognition in Children with Autism Spectrum Disorders: Exploratory Analysis on the Role of Task Demands.

People with autism spectrum disorders (ASDs) have difficulty with socio-emotional functioning; however, research on facial emotion recognition (FER) remains inconclusive. Individuals with ASD might be using atypical compensatory mechanisms that are exhausted in more complex tasks. This study compared response accuracy and speed on a forced-choice FER task using neutral, happy, sad, disgust, anger, fear and surprise expressions under both timed and non-timed conditions in children with and without ASD (n = 18). The results showed that emotion recognition accuracy was comparable in the two groups in the non-timed condition. However, in the timed condition, children with ASD were less accurate in identifying anger and surprise compared to children without ASD. This suggests that people with ASD have atypical processing of anger and surprise that might become challenged under time pressure. Understanding these atypical processes, and the environmental factors that challenge them, could be beneficial in supporting socio-emotional functioning in people ASD.

Do We See Masculine Faces as Competent and Feminine Faces as Warm? Effects of Sexual Dimorphism on Facial Perception.

Previous research on non-facial features demonstrated that masculinity and femininity correlated highly with perceived competence and warmth, respectively. Several studies focused on dimorphic facial cues and found an association between masculine faces and competence. However, there's no study exploring the association between facial dimorphism and social judgment both using explicit and implicit experimental paradigms, i.e. Triad Classification Task, Implicit Associate Task. This study examined the association of masculinity/femininity and competence/warmth via explicit and implicit measures in three experiments. The results showed that participants saw feminine/masculine faces as more consistent with warmth/competence for both male and female faces. Besides, it was found that the above associations were more obvious in female participants. The current studies extended research of effects of dimorphic facial cue in social judgment and provided direct evidence linking facial masculinity with perceived competence, and facial femininity with perceived warmth.

Unsupervised inference approach to facial attractiveness.

The perception of facial attractiveness is a complex phenomenon which depends on how the observer perceives not only individual facial features, but also their mutual influence and interplay. In the machine learning community, this problem is typically tackled as a problem of regression of the subject-averaged rating assigned to natural faces. However, it has been conjectured that this approach does not capture the complexity of the phenomenon. It has recently been shown that different human subjects can navigate the face-space and "sculpt" their preferred modification of a reference facial portrait. Here we present an unsupervised inference study of the set of sculpted facial vectors in such experiments. We first infer minimal, interpretable and accurate probabilistic models (through Maximum Entropy and artificial neural networks) of the preferred facial variations, that encode the inter-subject variance. The application of such generative models to the supervised classification of the gender of the subject that sculpted the face reveals that it may be predicted with astonishingly high accuracy. We observe that the classification accuracy improves by increasing the order of the non-linear effective interaction. This suggests that the cognitive mechanisms related to facial discrimination in the brain do not involve the positions of single facial landmarks only, but mainly the mutual influence of couples, and even triplets and quadruplets of landmarks. Furthermore, the high prediction accuracy of the subjects' gender suggests that much relevant information regarding the subjects may influence (and be elicited from) their facial preference criteria, in agreement with the multiple motive theory of attractiveness proposed in previous works.

Impaired Recognition of Negative Facial Expressions is Partly Related to Facial Perception Deficits in Adolescents with High-Functioning Autism Spectrum Disorder.

Accumulating studies have reported facial emotion recognition or facial perception impairments in autism spectrum disorder (ASD). To clarify the specificity of the emotion recognition impairment, this study examined the relationships between facial emotion recognition and facial perception abilities in ASD. Twenty-two adolescents with high-functioning ASD (20 males) and 22 typically developing (TD) adolescents (16 males) aged 11-18 years undertook a facial emotion labeling task and a facial perception test. We found that adolescents with ASD had deficits in recognizing negative facial expressions, which correlated with both facial perception deficits and severity of social impairment. In addition, the emotion recognition deficits remained after adjusting for facial perception performance. Thus, our findings suggest an emotion-specific impairment in facial emotion recognition in ASD.

Facial perception, self-esteem and psychosocial well-being in patients after nasal surgery due to trauma, cancer and aesthetic needs (cluster analysis of multiple interrelations).

Background: Facial anthropometric measurements in relation to self-esteem and self-perception have become a very popular topic, not only in anthropological and psychological research, but also in plastic reconstructive surgery.Aim: To compare the interrelations between facial perception, self-esteem and psychosocial well-being in patients after nasal surgery due to trauma, cancer and aesthetic needs.Subjects and methods: In total, ninety patients after nasal surgery (due to trauma, cancer and aesthetic reasons), and thirty control persons underwent facial anthropometry and answered questions related to facial perception (FP), self-esteem (SE) and psychosocial well-being (PW). Cluster analysis was performed.Results: Facial measurements were not related to the perception of the whole face in all investigated persons. The whole face and nasal perception were interrelated in the majority of male groups and in the control female group. SE in females from the control and cancer groups was not related to real facial parameters or FP, however, in females after aesthetic surgery it was related to nasal tip protrusion. SE in females after nasal surgery due to trauma was strongly related to FP. SE in almost all groups of males was related to real facial parameters, and in males after aesthetic surgery it was related to FP. PW was mostly linked to SE in males and females after aesthetic surgery, in other groups it was related to FP.Conclusions: FP was most frequently not related to real facial measurements; however, it was related to PW. Patients after aesthetic nasal surgery had specific relations between FP, SE and PW.

Measuring visual attention to faces with cleft deformity.

BACKGROUND: Limited data are available regarding observers' visual attention to faces with congenital difference. We implemented eye tracking technology to examine this issue, as it pertains particularly to faces with cleft deformity. METHOD: Four hundred three observers assessed 273 clinical images, while their eye movements were unobtrusively tracked using an infrared sensor. Forty-one facial images of the repaired cleft lip, 137 images of other facial conditions, and 95 images of matched controls were assessed. Twenty facial regions of interest ("lookzones") were considered for all images observed. A separate cohort of 720 raters evaluated the images for attractiveness. Observer and image demographic information was collected. Visual fixation counts and durations were computed across all 20 lookzones for all images. The effect of a variety of variables on lookzone fixation was analyzed using factorial ANOVA testing. RESULTS: Cleft-repaired faces were rated as less attractive and drew observers' attention preferentially to the affected upper lip lookzone (p<.001). Images rated as less attractive garnered greater visual attention in the cleft-affected lookzones (p<.001). The eye tracking methodology demonstrated exquisite sensitivity to laterality of cleft deformity (p<.001). Individuals reporting a personal or a family history of facial deformity fixated more on the perioral region of cleft-repaired faces than did naïve observers (p<.001). CONCLUSION: These findings highlight the utility of eye tracking measures for understanding critical variables that influence the visual processing of faces with cleft deformity. The data may provide analytical tools for assessing surgical outcome and direct priority setting during surgeons' conversations with patients.

Chronic sleep restriction affects the association between implicit bias and explicit social decision making.

OBJECTIVES: Previous work suggests that sleep restriction (SR) reduces cognitive control and may increase negative implicit biases. Here we investigated whether SR might influence decision making on a social-evaluative task where individuals had to make judgments of threat based on facial photographs. Furthermore, we investigated the effect of changes in negative implicit biases as a result of sleep restriction on this decision-making task. DESIGN: Fourteen healthy adults underwent two 3-week counterbalanced in-laboratory stays (chronic SR and control sleep [CS] conditions). Participants completed the Arab Muslim Names implicit association test (a measure of implicit bias/attitudes toward Arab Muslims) and the Karolinska Airport Task (a measure of explicit decision making). The Karolinska Airport Task requires participants to judge the potential dangerousness of individuals based on facial photographs. RESULTS: After SR, participants were more likely to deem individuals with less positive and more negative facial features as dangerous than after CS. In addition, after SR, those participants showing higher negative implicit bias toward Arab Muslims tended to consider as more dangerous individuals with more quintessentially untrustworthy facial features (r = 0.76, P = .007), whereas this relationship was nonsignificant after CS (r = 0.33, P = .28). CONCLUSIONS: These findings show not only that SR may increase implicit biases against a particular minority group but that SR also modifies how individuals make explicit decisions about another's trustworthiness based on facial features. These findings may have important implications for many occupations where workers who are routinely restricted of sleep are also responsible for making judgments about other people's trustworthiness (eg, police, security, military personnel).

Costs of reproduction are reflected in women's faces: Post-menopausal women with fewer children are perceived as more attractive, healthier and younger than women with more children.

OBJECTIVES: The costs associated with reproduction (i.e., gestation, lactation, childcare) have long-term negative consequences by elevating risk of disease and reducing lifespan. We tested the hypotheses that high parity, and thus high reproductive costs bear by women, is perceived by other people when they evaluate facial appearance of health, attractiveness and age of mothers. MATERIALS AND METHODS: Using computer software we created average facial images based on real photographs of post-menopausal women with varying number of children; 3 parity categories were created (1-2, 4-5, and 7-9 children). Study participants (N = 571) were asked to choose the face they perceived as more attractive, younger and healthier via two-alternative forced choice questions asked in three randomized blocks. RESULTS: Women who had given birth to fewer children were judged both by men and women as more attractive, younger and healthier than women with more children. In each category the lowest scores were received by women from highest parity category (7-9 children). DISCUSSION: Mechanisms behind the observed variation in facial appearance are not known but higher levels of oxidative stress among women with high parity may explain their faster aging and lower attractiveness in older age. These results suggest that costs of reproduction might affect women's physical appearance.

Abnormal brain activation during threatening face processing in schizophrenia: A meta-analysis of functional neuroimaging studies.

Impairment of face perception in schizophrenia is a core aspect of social cognitive dysfunction. This impairment is particularly marked in threatening face processing. Identifying reliable neural correlates of the impairment of threatening face processing is crucial for targeting more effective treatments. However, neuroimaging studies have not yet obtained robust conclusions. Through comprehensive literature search, twenty-one whole brain datasets were included in this meta-analysis. Using seed-based d-Mapping, in this voxel-based meta-analysis, we aimed to: 1) establish the most consistent brain dysfunctions related to threating face processing in schizophrenia; 2) address task-type heterogeneity in this impairment; 3) explore the effect of potential demographic or clinical moderator variables on this impairment. Main meta-analysis indicated that patients with chronic schizophrenia demonstrated attenuated activations in limbic emotional system along with compensatory over-activation in medial prefrontal cortex (MPFC) during threatening faces processing. Sub-task analyses revealed under-activations in right amygdala and left fusiform gyrus in both implicit and explicit tasks. The remaining clusters were found to be differently involved in different types of tasks. Moreover, meta-regression analyses showed brain abnormalities in schizophrenia were partly modulated by age, gender, medication and severity of symptoms. Our results highlighted breakdowns in limbic-MPFC circuit in schizophrenia, suggesting general inability to coordinate and contextualize salient threat stimuli. These findings provide potential targets for neurotherapeutic and pharmacological interventions for schizophrenia.

The Positivity Bias Phenomenon in Face Perception Given Different Information on Ability.

The negativity bias has been shown in many fields, including in face processing. We assume that this bias stems from the potential threat inlayed in the stimuli (e.g., negative moral behaviors) in previous studies. In the present study, we conducted one behavioral and one event-related potentials (ERPs) experiments to test whether the positivity bias rather than negativity bias will arise when participants process information whose negative aspect involves no threat, i.e., the ability information. In both experiments, participants first completed a valence rating (negative-to-positive) of neutral facial expressions. Further, in the learning period, participants associated the neutral faces with high-ability, low-ability, or control sentences. Finally, participants rated these facial expressions again. Results of the behavioral experiment showed that compared with pre-learning, the expressions of the faces associated with high ability sentences were classified as more positive in the post-learning expression rating task, and the faces associated with low ability sentences were evaluated as more negative. Meanwhile, the change in the high-ability group was greater than that of the low-ability group. The ERP data showed that the faces associated with high-ability sentences elicited a larger early posterior negativity, an ERP component considered to reflect early sensory processing of the emotional stimuli, than the faces associated with control sentences. However, no such effect was found in faces associated with low-ability sentences. To conclude, high ability sentences exerted stronger influence on expression perception than did low ability ones. Thus, we found a positivity bias in this ability-related facial perceptual task. Our findings demonstrate an effect of valenced ability information on face perception, thereby adding to the evidence on the opinion that person-related knowledge can influence face processing. What's more, the positivity bias in non-threatening surroundings increases scope for studies on processing bias.

Task-Related Functional Connectivity Analysis of Emotion Discrimination in a Family Study of Schizophrenia.

Poor emotion recognition is a core deficit in schizophrenia and is associated with poor functional outcome. Functional magnetic resonance imaging (fMRI) multivariate analysis methods were used to elucidate the neural underpinnings of face and emotion processing associated with both genetic liability and disease-specific effects. Schizophrenia patients, relatives, and controls completed a task that included 4 facial emotion discrimination conditions and an age discrimination condition during fMRI. Three functional networks were derived from the data: the first involved in visual attention and response generation, the second a default mode network (DMN), and a third involved in face and emotion processing. No differences in activation were found between groups for the visual attention and response generation network, suggesting that basic processes were intact. Both schizophrenia patients and relatives showed evidence for hyperdeactivation in the DMN compared to controls, with relatives being intermediate, suggesting a genetic liability effect. Both disease-specific and genetic liability effects were found for the face processing network, which included the amygdala. Patients exhibited lower coordinated network activity compared to controls and relatives across all facial discrimination conditions. Additionally, in relation to the other emotion discrimination conditions, a heightened coordinated response during fear and anger discrimination was observed in schizophrenia compared to other conditions, whereas relatives demonstrated heightened coordinated activity for anger discrimination only relative to other emotion conditions. With regards to brain functioning, this study found that schizophrenia is associated with abnormal processing of threat-related information, and that in part may be associated with the genetic risk for the disorder, suggesting that the facial and emotion processing network could be targeted for intervention.

Intact social cognitive processes in outpatients with anorexia nervosa: a pilot study.

OBJECTIVE: The aim of the study was to assess social cognition in community patients suffering from anorexia nervosa (AN) compared to healthy controls. METHODS: 25 women diagnosed with AN and 25 women matched for education level and age were involved in the study. Both subject groups were assessed using a set of validated experimental tasks, such as the facial expression recognition test, short recognition memory test for faces, 'Reading the mind in the eyes' test. Patients were assessed for symptoms of: eating disorder (the eating attitudes test-EAT-26), OCD (the Yale-Brown obsessive compulsive scale-Y-BOCS) and depression (Beck depression inventory-BDI). The research hypothesis indicated that patients suffering from anorexia represent no significant difference in social cognitive functioning in comparison to the healthy controls. These assessment scales were used to identify whether there are any problems according to social cognitive functioning especially emotion recognition and theory of mind (ToM). The primary outcome assessment was to identify social cognitive deficits in anorexic outpatients and secondary outcome was to verify whether these problems in emotional functioning found in women in acute phase of AN are state or trait effects. RESULTS: Anorexic patients showed significantly higher scores on EAT-26, BDI and Y-BOCS. No significant differences were found in performance of social cognitive tests and facial perception test. DISCUSSION: No marked alterations were found in social cognitive functioning in community patients with average body mass index (BMI) of 17.6. This may indicate that social cognition is a very complex construct to be reliably measured in anorexia nervosa considering relatively limited psychometric data for many social cognitive tasks. Further longitudinal studies are needed to untangle ongoing controversy whether social cognitive deficits in AN could be state or trait related.

Long-Term Exposure to American and European Movies and Television Series Facilitates Caucasian Face Perception in Young Chinese Watchers.

Most young Chinese people now learn about Caucasian individuals via media, especially American and European movies and television series (AEMT). The current study aimed to explore whether long-term exposure to AEMT facilitates Caucasian face perception in young Chinese watchers. Before the experiment, we created Chinese, Caucasian, and generic average faces (generic average face was created from both Chinese and Caucasian faces) and tested participants' ability to identify them. In the experiment, we asked AEMT watchers and Chinese movie and television series (CMT) watchers to complete a facial norm detection task. This task was developed recently to detect norms used in facial perception. The results indicated that AEMT watchers coded Caucasian faces relative to a Caucasian face norm better than they did to a generic face norm, whereas no such difference was found among CMT watchers. All watchers coded Chinese faces by referencing a Chinese norm better than they did relative to a generic norm. The results suggested that long-term exposure to AEMT has the same effect as daily other-race face contact in shaping facial perception.

Nasal appearance after secondary cleft rhinoplasty: comparison of professional rating with patient satisfaction.

OBJECTIVE: The purpose of this study was to compare professional rating and patient satisfaction of nasal appearance after secondary cleft rhinoplasty. METHOD: We used a cross-sectional study design and enrolled German adults with nonsyndromic unilateral or bilateral cleft lip and/or palate (UCLP and BCLP, respectively) undergoing secondary cleft rhinoplasty from January 2001 to December 2013. The predictor variable was professional rating. The outcome variable was patient satisfaction with postoperative nasal aesthetics. Other study variables included patient age and gender, type of surgery, and patient rating of nasal function. Appropriate descriptive and univariate statistics were computed, and a P value of <0.05 was regarded as statistically significant. Inter-rater reliability was assessed by the use of Cohen's kappa coefficient. RESULTS: The study sample consisted of 242 adult cleft patients of mean age of 22.1 ± 9.2 years (range 14-64), including 97 females (40 %) and 176 unilateral clefts (73 %). Most of the patients reported good function (82 %) and good aesthetics (74 %). The main professional rating was good aesthetics (65 %). Analysis of inter-observer reliability revealed significant differences between patient satisfaction and professional assessment (κ = 0.385; P < 0.0001). CONCLUSIONS: Although most of the patients were satisfied with the functional and aesthetic results of secondary cleft rhinoplasty, patient self-assessment of nasal appearance differed from professional assessment.