The “scarred villain” trope, where facial differences like scars signify moral corruption, is ubiquitous in film (e.g., Batman’s The Joker). Strides by advocacy groups to undermine the trope, however, suggest cinematic representations of facial differences could be improving with time. This preregistered study characterized facial differences in film across cultures (US vs. India) and time (US: 1980-2019, India: 2000-2019). Top-grossing films by country and decade were screened for characters with facial differences. We found that the scarred villain trope has actually worsened with time, although in tandem with progress in also representing non-villainous characters with facial anomalies. Country of origin did not predict the presence of facial differences in villains or heroes. “Action” and “fantasy” movies were the most likely genres to depict villains with facial differences. Finally, villains’ facial differences crossed more facial subunits and were more likely to involve lips, chin, and mandible than when present in heroes. Our findings underscore the need for critical reflection on the role of cultural practices—even when seemingly innocuous—in shaping and maintaining negative biases against already stigmatized groups.
Introduction: The LeFort III and monobloc are commonly used midface advancement procedures for patients with syndromic craniosynostosis with well characterized postoperative skeletal changes. However, the differential effects of these procedures on facial soft tissues are less understood. The purpose of this study was to critically analyze and compare the effects of these 2 procedures on the overlying soft tissues of the face. Methods: Frontal and lateral preoperative and postoperative photographs of patients undergoing monobloc or LeFort III were retrospectively analyzed using ImageJ to measure soft tissue landmarks. Measurements included height of facial thirds, nasal length and width, intercanthal distance, and palpebral fissure height and width. Facial convexity was quantified by calculating the angle between sellion (radix), subnasale, and pogonion on lateral photographs. Results: Twenty-five patients with an average age of 6.7 years (range 4.8-14.5) undergoing monobloc (n=12) and LeFort III (n=13) were identified retrospectively and analyzed preoperatively and 6.4±3.6 months postoperatively. Patients undergoing LeFort III had a greater average postoperative increase in facial convexity angle acuity (28.2°) than patients undergoing monobloc (17.8°, P =0.021). Patients in both groups experience postoperative increases in nasal width ( P <0.001) and decreases in palpebral fissure height ( P <0.001). Conclusions: Both subcranial LeFort III advancements and monobloc frontofacial advancements resulted in significant changes in the soft tissues. Patients undergoing LeFort III procedures achieved greater acuity of the facial convexity angle, likely because the nasion is not advanced with the LeFort III segment.
PURPOSE: The LeFort III and monobloc are commonly employed midface advancement procedures for patients with syndromic craniosynostosis. While the postoperative skeletal changes are well characterized, objective assessments of overlying soft tissues changes are lacking despite their contribution towards the aesthetic outcome. The purpose of this study was to critically analyze and compare the effects of these two procedures on the overlying soft tissues of the face. METHODS: Frontal and lateral pre- and postoperative photos of patients undergoing monobloc or LeFort III were retrospectively analyzed using ImageJ to measure change in soft tissue landmarks, canthal position, and facial convexity. RESULTS: Twenty-five patients with an average age of 6.7 years (range 4.8-14.5) undergoing monobloc (n=12) and LeFort III (n=13) were identified and analyzed preoperatively and 6.4 ± 3.6 months postoperatively. Patients undergoing LeFort III had a greater average postoperative increase in facial convexity angle acuity (28.2°) than patients undergoing monobloc (17.8°, p = 0.021). Both groups experienced postoperative increases in nasal width (p < 0.001) and decreases in palpebral fissure height (p < 0.001). Subgroup analysis of those undergoing staged FOAR + LeFort III achieved greater facial convexity relative to those undergoing monobloc (p = 0.022). CONCLUSION: Both LeFort III and monobloc advancements resulted in significant changes in midfacial soft tissue relationships. Patients undergoing LeFort III procedures achieve greater acuity of the facial convexity angle. The results also provide evidence that a staged approach to frontofacial advancement may provide more optimal aesthetic facial convexity than a single-staged approach.
PURPOSE: The mandibular condyle is important to facial growth, but its role in mandibular asymmetry in patients with cleft lip and/or palate (CLP) is poorly described. METHODS: Condylar volumetric asymmetry was obtained by generating three-dimensional reconstructions of computed tomography scans on Mimics Version 23.0. Relationships among variables were compared with appropriate statistics. RESULTS: Our cohort of 119 skeletally mature patients consisted of 60 (50%) CLP who underwent orthognathic surgery, 18 (15%) CLP who did not, and 41 (35%) controls. Condylar volumes in CLP who had orthognathic surgery were more asymmetric than CLP who did not have orthognathic surgery (16.4±17.4% vs 7.0±4.7%, p<0.05). CLP without an orthognathic surgical history had similar condylar volumetric asymmetry to controls (7.0±4.7% vs 5.9±3.8%, p>0.05). CLP with clinically significant chin deviation (>4 mm) had more asymmetric condyles than those without significant chin deviation (p=0.003). The chin deviated toward the smaller condyle in patients with facial asymmetry more often than in patients without facial asymmetry (81% vs. 62%, p=0.033). On receiver operating characteristic curve analysis, condylar volume predicted the need for orthognathic surgery in CLP with a sensitivity of 70% and specificity of 67%. CONCLUSION: Patients with cleft lip and/or palate who had orthognathic surgery have more asymmetric condyles than CLP without an orthognathic surgical history and the general population. Facial asymmetry in CLP is associated with increased condylar asymmetry, with the facial midline deviating toward the smaller condyle. Condylar volumetric asymmetry can help predict the need for orthognathic surgery in CLP with moderate accuracy.
PURPOSE: Following modified-Furlow palatoplasty, patients may demonstrate velopharyngeal dysfunction necessitating secondary speech surgery. However, speech outcomes at skeletal maturity and the incidence of speech surgery by this age remain under-reported. This study updates our institutional experience with modified-Furlow palatoplasty to report speech outcomes at completion of facial growth. METHODS: Nonsyndromic patients undergoing palatoplasty from 1980-2005 with follow-up at 15 years of age were reviewed for history of speech surgery and Pittsburgh Weighted Speech Scale assessments and compared to historical data published for the same cohort. Incidence of speech surgery and speech scores were assessed across all patients as well as by Veau type, age at palatoplasty, gender, race, and time period of repair. RESULTS: Three hundred sixty-four patients underwent palatoplasty in the study period and met inclusion with 15-year follow-up (average follow-up 17.5±4.6 years). Age at palatoplasty was 11.9±9.1 months. Seventy-two (19.8%) patients underwent secondary speech surgery at 11.7±4.1 years. Veau types 1 and 2 predicted need for speech surgery compared to types 3 and 4 (p < 0.001). No other factors were predictive (p > 0.05). 167 patients without prior speech surgery had speech assessments beyond 15 years of age, 77% of whom had a competent-borderline competent velopharyngeal mechanism. There was no association between speech scores and any measured factor (p > 0.05). CONCLUSION: When followed to skeletal maturity after modified-Furlow palatoplasty, the incidence of secondary speech surgery is higher than previous reports with shorter follow up. Veau types 1 and 2 may be susceptible to poorer speech outcomes.
PURPOSE: Monobloc frontofacial advancement and multi-piece midfacial osteotomies such as facial bipartition have profound benefits for patients with syndromic craniosynostosis but also carry the highest published potential for morbidity. Owing to rarity of these procedures, it has been difficult to assess whether perioperative morbidity is evenly distributed across surgical candidates, or rather, if certain patient factors portend increased risk. This study utilized a long-term institutional experience to reevaluate the risk profile of transcranial midface advancement. METHODS: Patients undergoing transcranial frontofacial advancement from 2000-2022 were included. Prior surgical history was recorded, as were perioperative characteristics including minor (surface infection, seroma) and major complications (infection requiring reoperation, CSF leak) graded on the Clavien-Dindo scale. Factors predicting complications were assessed with univariate and multivariate statistics. RESULTS: Thirty-seven patients were included. The complication rate from transcranial midface advancement was 49% (11% minor, 38% major). Predictors of major complications included history of tracheostomy (p = 0.012), prior fronto-orbital advancement (FOAR) (p = 0.021), and age at surgery (p = 0.035). Prior FOAR was the sole predictor of intraoperative dural injury (p = 0.020). Multiple logistic regression identified age at surgery (p = 0.021) and preoperative tracheostomy (p = 0.035) as predictors of major complications. CONCLUSION: This study presents key predictors of morbidity after transcranial midface advancement in patients with syndromic craniosynostosis, namely presence of a tracheostomy, history of prior FOAR, and older age. This is important information for surgeons and families, alike, providing surgeons with targets for risk reduction and families with appropriate risk stratification.
