Photographic Standards for Patients With Facial Palsy and Recommendations by Members of the Sir Charles Bell Society Photographic Standards for Patients With Facial Palsy and Recommendations by Members of the Sir Charles Bell Society Katherine B. Santosa, MD; Adel Fattah, MD, PhD; Javier Gavilán, MD; Tessa A. Hadlock, MD; Alison K. Snyder-Warwick, MD IMPORTANCE There is no widely accepted assessment tool or common language used by clinicians caring for patients with facial palsy, making exchange of information challenging. Standardized photography may represent such a language and is imperative for precise exchange of information and comparison of outcomes in this special patient population. OBJECTIVES To review the literature to evaluate the use of facial photography in the management of patients with facial palsy and to examine the use of photography in documenting facial nerve function among members of the Sir Charles Bell Society—a group of medical professionals dedicated to care of patients with facial palsy. DESIGN, SETTING, AND PARTICIPANTS A literature search was performed to review photographic standards in patients with facial palsy. In addition, a cross-sectional survey of members of the Sir Charles Bell Society was conducted to examine use of medical photography in documenting facial nerve function. The literature search and analysis was performed in August and September 2015, and the survey was conducted in August and September 2013. MAIN OUTCOMES AND MEASURES The literature review searched EMBASE, CINAHL, and MEDLINE databases from inception of each database through September 2015. Additional studies were identified by scanning references from relevant studies. Only English-language articles were eligible for inclusion. Articles that discussed patients with facial palsy and outlined photographic guidelines for this patient population were included in the study. The survey was disseminated to the Sir Charles Bell Society members in electronic form. It consisted of 10 questions related to facial grading scales, patient-reported outcome measures, other psychological assessment tools, and photographic and videographic recordings. RESULTS In total, 393 articles were identified in the literature search, 7 of which fit the inclusion criteria. Six of the 7 articles discussed or proposed views specific to patients with facial palsy. However, none of the articles specifically focused on photographic standards for the population with facial palsy. Eighty-three of 151 members (55%) of the Sir Charles Bell Society responded to the survey. All survey respondents used photographic documentation, but there was variability in which facial expressions were used. Eighty-two percent (68 of 83) used some form of videography. From these data, we propose a set of minimum photographic standards for patients with facial palsy, including the following 10 static views: at rest or repose, small closed-mouth smile, large smile showing teeth, elevation of eyebrows, closure of eyes gently, closure of eyes tightly, puckering of lips, showing bottom teeth, snarling or wrinkling of the nose, and nasal base view. CONCLUSIONS AND RELEVANCE There is no consensus on photographic standardization to report outcomes for patients with facial palsy. Minimum photographic standards for facial paralysis publications are proposed. Videography of the dynamic movements of these views should also be recorded. LEVEL OF EVIDENCE NA. JAMA Facial Plast Surg. 2017;19(4):275-281. doi:10.1001/jamafacial.2016.1883 Published online January 26, 2017. Video Supplemental content Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Alison K. Snyder-Warwick, MD, Facial Nerve Institute, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8238, St Louis, MO 63110 (snyderak @wudosis.wustl.edu). Research JAMA Facial Plastic Surgery | Original Investigation (Reprinted) 275 © 2017 American Medical Association. All rights reserved. D ow nl oa de d by C ar ne gi e M el lo n U ni ve rs it y fr om w w w .l ie be rt pu b. co m a t 04 /0 5/ 21 . F or p er so na l us e on ly . http://jamanetwork.com/journals/jamafacialplasticsurgery/pages/instructions-for-authors/#SecLevelofEvidence/Ethnicity/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 http://jama.jamanetwork.com/article.aspx?doi=10.1001/jamafacial.2016.1883&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 http://jama.jamanetwork.com/article.aspx?doi=10.1001/jamafacial.2016.1883&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 http://jama.jamanetwork.com/article.aspx?doi=10.1001/jamafacial.2016.1883&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 mailto:snyderak@wudosis.wustl.edu mailto:snyderak@wudosis.wustl.edu To date, facial expression has been found to be the richest source of information about emotions. Paul Ekman1(p3449) R egarded as a pioneer in the study of emotions and mi-croexpressions, psychologist Paul Ekman1 captures theintegral role of facial expressions in recognizing emo- tions, which allows us to connect with one another on the most basic level. However, for patients with facial palsy, this fun- damental visual tool of communication is compromised. The inability to communicate thoughts and interact with others is debilitating and results in substantial psychosocial morbidity in this patient population.2,3 In addition, treatment of facial nerve disorders is chal- lenging. Patients are seen with a diverse array of deficits, and various procedures and interventions exist for management. Given the amount of variability that can exist in how patients with facial palsy are seen and treated, it is imperative that cli- nicians caring for these patients use a uniform tool to docu- ment their outcomes. In essence, a single language is needed to allow meaningful comparison of outcomes. The use of standardized high-quality medical photogra- phy is one method that can improve information exchange and outcome comparison in this patient population. Standards and guidelines for medical photography within various disci- plines in plastic surgery, such as hand surgery, body contour- ing, and cosmetic surgery, have been thoroughly described.4-6 For example, in cosmetic surgery alone, a literature review revealed 79 articles describing photographic standards for various procedures, with most dedicated to standards for pa- tients with rhinoplasty. Moreover, outcomes of facial reani- mation procedures, similar to cosmetic surgery cases, are largely based on visual improvements after surgery.3 How- ever, while a few studies7-9 have proposed the need for pho- tographic standards for patients with facial palsy, no studies have addressed this specific topic in detail. In this study, we performed a literature review of photo- graphic standards among patients with facial palsy and per- formed a cross-sectional survey of members of the Sir Charles Bell Society (SCBS) (http://www.sircharlesbell.org) to examine the use of medical photography among clinicians devoted to treating patients with facial palsy. The SCBS is an international multidisciplinary group of health care professionals dedicated to progressing the management of facial nerve disorders. Because this group of practitioners focuses on care of the population with facial palsy, the society membership is a valuable group from which to canvas information. From these data, we propose a set of minimum photographic standards for patients with facial palsy and anticipate that they will be widely adopted and ultimately improve outcomes and enhance progress in the management of patients with facial paralysis. Methods Institutional review board approval was not required be- cause this study involved a survey of health care profession- als and a literature review; it did not involve patients or inter- ventions and did not include research on patients or animals. Patient information and care were not included in the study. The cross-sectional survey was disseminated to SCBS mem- bers in electronic form using an online tool. Participation in this web-based survey was voluntary, all responses were anony- mous, and informed consent was waived given the minimal risks to participants. Waiver of informed consent was the con- sensus of multiple participating institutions. The literature review searched EMBASE, CINAHL, and MEDLINE databases from inception of each database through September 2015. Under the guidance of a medical librarian, this search strategy involved Medical Subject Headings and free- text terms relating to facial palsy and photography (ie, facial paralysis, facial reanimation, facial nerve weakness, facial nerve dysfunction, facial palsy, photography, and standards). Addi- tional studies were identified by scanning references from rel- evant studies. Only English-language articles were eligible for inclusion. These citations were imported into a computer pro- gram (EndNote X7; Clarivate Analytics), and any duplicates were identified and discarded. Articles that were included met the following criteria: they (1) discussed patients with facial palsy and (2) outlined photographic guidelines for this pa- tient population. The lead authors (K.B.S. and A.K.S.-W.) re- viewed each study according to these criteria. The literature review and analysis were performed in August and Septem- ber 2015. The cross-sectional survey (eFigure 1 in the Supplement) was disseminated to SCBS members in electronic form using an online tool (Qualtrics; http://www.qualtrics.com). This survey consisted of 10 questions related to facial grading scales, patient-reported outcome measures, other psycho- logical assessment tools, and photographic and videographic recordings. Of these 10 questions, 6 were spec ific ally directed toward the use of photography and videography in the practice of these clinicians. Careful attention to the cre- ation of these questions was taken to avoid bias in responses. Closed single-response questions were used to categorize responses. Where necessary, open-ended “other” categories were used to allow respondents to specify details in free-text form. The survey and analysis were performed in August and September 2013. Key Points Question How do clinicians specializing in facial paralysis use photography and videography to document facial nerve function in this special patient population? Findings A cross-sectional survey of the Sir Charles Bell Society members, a group of professionals dedicated to caring for patients with facial palsy, revealed that all members used some form of photography to document outcomes; however, there was variability in which facial expressions were used. Meaning There is no consensus on photographic standardization to report outcomes for patients with facial palsy; therefore, we propose minimum photographic standards for facial paralysis publications to improve exchange of information and comparison of outcomes. Research Original Investigation Photographic Standards for Patients With Facial Palsy 276 JAMA Facial Plastic Surgery July/August 2017 Volume 19, Number 4 (Reprinted) jamafacialplasticsurgery.com © 2017 American Medical Association. All rights reserved. D ow nl oa de d by C ar ne gi e M el lo n U ni ve rs it y fr om w w w .l ie be rt pu b. co m a t 04 /0 5/ 21 . F or p er so na l us e on ly . http://www.sircharlesbell.org http://jama.jamanetwork.com/article.aspx?doi=10.1001/jamafacial.2016.1883&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 http://www.qualtrics.com http://www.jamafacialplasticsurgery.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 Results Summary of the Literature Review In total, the database searches retrieved 435 citations. After re- view in the computer program, 43 duplicates were identified, leaving 392 citations that fit our search criteria. One addi- tional citation was included after scanning references of rel- evant articles. After title, abstract, and full-text analysis by the lead authors, 7 studies met the final inclusion criteria. Publi- cation dates ranged from 1979 to 2015. Six of the 7 articles dis- cussed or proposed views specific to patients with facial palsy. However, none of the articles specifically focused on photo- graphic standards for the population with facial palsy. Details of the literature search are listed in Table 1. Survey Findings We received responses from 83 of the 151 SCBS members (55%). All survey respondents used still photography. Of all views to capture facial nerve function, the 4 views that were most com- monly used by respondents were at rest or repose (99.8% [82 of 83]), large smile showing teeth (92.8% [77 of 83]), eleva- tion of eyebrows (88.0% [73 of 83]), and closure of eyes gen- tly (88.0% [73 of 83]) (Figure 1A). These views are included in the House-Brackmann Facial Nerve Grading System and the Sunnybrook Facial Grading System, which were the 2 most commonly used grading systems by respondents in our sur- vey. Of all respondents, 60.2% (50 of 83) reported using the House-Brackmann Facial Nerve Grading System to monitor fa- cial nerve function, while 51.8% (43 of 83) reported using the Sunnybrook Facial Grading System. The views not specifi- cally mentioned in common grading scales were used less fre- quently and included closure of eyes tightly (78.3% [65 of 83]), small closed-mouth smile (73.4% [61 of 83]), showing bottom teeth (51.8% [43 of 83]), and nasal base view (18.1% [15 of 83]) (Figure 1B). Puckering of lips and snarling or wrinkling of the nose, which are described in the Sunnybrook Facial Grading System but not in the House-Brackmann Facial Nerve Grad- ing System, were used by 81.9% (68 of 83) and 61.4% (51 of 83) of SCBS members, respectively. Additional free-texted views included puffing out cheeks (n = 1) and lateral views (n = 2). Our group has reported videography use rates among SCBS members in a previous publication.14 In summary, 81.9% (68 of 83) of survey respondents reported using videography, of whom 70.6% (48 of 68) reported documenting the same move- ments on videography as in still photography. Discussion Although photographic standards have been well described and adopted in other highly visual fields of plastic surgery, such as cosmetic surgery, to our knowledge, no universal stan- dards exist for patients with facial palsy or facial reanima- tion. Our literature search revealed few studies of photo- graphic standards in patients with facial palsy, with only 7 articles describing the importance of medical photography in our patient population. Even among 6 of the 7 articles that pro- pose specific photographic views for patients with facial palsy, there are notable differences in the number and selection of Table 1. Results From the Literature Review Source Study Title Views Discussed Summary of Article Ellis and Gillies,10 1979 “Evaluation of the Paralyzed Face” Resting, frowning, squinting, eyebrow lifting, smiling, smiling with lower lip depression, pursing the lips Authors describe how clinicians should evaluate the paralyzed face. They assert that standardized photographs serve as medicolegal documentation and will allow the surgeon to select the appropriate management strategy. Mitchell,11 1981 “Preoperative and Postoperative Photographic Standards” Repose, maximal mimic muscle contraction This letter to the editor was written in response to an article on interfascicular facial nerve repair. The author’s critique was that there was inadequate documentation of the patient’s outcome in the original article and argues for the need for standardization of photography in publications for this patient population. el-Naggar et al,9 1995 “Life-Size Photograph Transparencies: A Method for the Photographic Detection and Documentation of Recovery From Facial Paralysis” Not applicable By overlapping life-size photographic transparencies, the authors argue that this method provides an objective method to track the progress of a patient with facial palsy. Barrs et al,12 2001 “Digital Camera Documentation System for Facial Nerve Outcome Assessment” Raising eyebrows, eyes closed tightly, smiling, puckering of lips, wrinkling of nose, drawing corner of mouth down The authors describe an easy and efficient method to document facial nerve function by digital photography. Henderson et al,6 2005 “Photographic Standards for Facial Plastic Surgery” Anterior-posterior left and right lateral, left and right oblique, smile, pucker, wrinkle nose, close eyes tight, eyebrows raised Through a series of photographs, the aim of the article is to provide the reader with guidelines and photographic standards for special facial plastic and reconstructive procedures (ie, rhinoplasty, mentoplasty, blepharoplasty, rhytidectomy or facial reanimation, browplasty, cheiloplasty, and cleft lip repair). Schaaf et al,13 2006 “Standards for Digital Photography in Cranio-Maxillo-Facial Surgery, Part II: Additional Picture Sets and Avoiding Common Mistakes” Full frontal view, closed eyes, wrinkling forehead, smiling, front view whistling, blowing out cheeks The 2-part publication provides a set of photographic views for different craniofacial procedures. These standardized sets of photographs were approved and adopted by the Council of the European Association for Cranio-Maxillo- Facial Surgeons in 2005. Niziol et al,7 2015 “Is There an Ideal Outcome Scoring System for Facial Reanimation Surgery? A Review of Current Methods and Suggestions for Future Publications” Repose, eyebrows maximally raised, eyes tightly closed, narrow smile, maximum smile This article was written as a literature review to identify an ideal scoring system for facial palsy. In their discussion, the authors note an abundance of grading scales that exist in the literature and propose a “quick and simple system” using a set of standardized still photographs. Photographic Standards for Patients With Facial Palsy Original Investigation Research jamafacialplasticsurgery.com (Reprinted) JAMA Facial Plastic Surgery July/August 2017 Volume 19, Number 4 277 © 2017 American Medical Association. All rights reserved. D ow nl oa de d by C ar ne gi e M el lo n U ni ve rs it y fr om w w w .l ie be rt pu b. co m a t 04 /0 5/ 21 . F or p er so na l us e on ly . http://www.jamafacialplasticsurgery.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 still views (Table 1). For example, the only view that was con- sistently proposed throughout the 6 articles was the full fron- tal view at rest or repose. Similar to the literature review findings, our survey of SCBS members demonstrated variability in the types of views used by clinicians. Most respondents documented similar static views; however, not all of these views were used by all respon- dents. The 4 most common views (ie, at rest or repose, large smile showing teeth, elevation of eyebrows, and closure of eyes gently) are those that are described in the 2 most commonly used assessment sc ales by SCBS members, the House- Brackmann Facial Nerve Grading System and the Sunny- brook Facial Grading System. Less frequently obtained views, such as closure of eyes tightly, small closed-mouth smile, show- ing bottom teeth, and nasal base view, coincidentally are those not described in the 2 common scales. Visual documentation of outcomes is incomplete even among SCBS members, whose practices focus more on care of patients with facial palsy. In other words, our findings reveal that almost half of the SCBS members are not documenting the function of all branches of the facial nerve. Dysfunction of the marginal mandibular branch commonly occurs in isolation, such as iatrogenically, acquired in association with a man- dible fracture, or congenitally (eg, in asymmetric crying fa- cies). Regardless of the mechanism of injury or presentation, testing and documenting the function of this branch is an in- tegral aspect of a comprehensive facial nerve examination. Similarly, another view substantially underused by survey re- spondents and absent from our literature review was the na- sal base view, which has also been discussed by Bhama and colleagues.8 This view is especially important to assess sym- metry of the external valve. Nasal obstruction is a common but underrecognized problem among patients with facial palsy, and static or dynamic support of the external nasal valve can im- prove patients’ perception of nasal airflow.15 As demonstrated by our literature review and survey find- ings, there is substantial heterogeneity and a lack of consen- sus in photographic documentation of this patient popula- tion. Therefore, we propose a standardized set of photographs that should be used in outcomes analysis to improve informa- tion exchange and data comparison. This minimum set con- sists of the following 10 static views (Figure 2): (1) at rest or re- pose, (2) small closed-mouth smile, (3) large smile showing teeth, (4) elevation of eyebrows, (5) closure of eyes gently, (6) closure of eyes tightly, (7) puckering of lips, (8) showing bot- tom teeth, (9) snarling or wrinkling of the nose, and (10) nasal base view. Table 2 lists the different views in greater detail. An- other view that can be considered is having patients puff out their cheeks. This view can help evaluate the severity of peri- oral incompetence in paralyzed faces and severity and tight- ness in patients with synkinesis (eFigure 2 in the Supple- ment). Moreover, because many approaches to reanimate the face include nerve substitutions or transfers (eg, masseteric nerve or hypoglossal nerve), it is imperative for clinicians to assess and document the function of any potential donor nerve on physical examination. The function of these common donors will not be captured with the standardized photo- graphic and videographic views discussed in this study. While these 10 static views are important, we should not underestimate the power of videography in capturing spon- taneity of movement, synkinesis, and speech production. We encourage clinicians to record patients performing the views mentioned previously and to have patients recite simple sen- tences that require the production of bilabial and plosive sounds to assess speech (Video). We recommend using a sen- tence from the Goldman-Fristoe Test of Articulation 3 (Pear- son Education, Inc), which incorporates most motor move- ments required for articulate speech production. Incorporating speech assessment may provide important assessments of im- provement when comparing preintervention and postinter- vention function. Strengths and Limitations A strength of our study is the inclusion of a cross-sectional sur- vey of SCBS members, an international group of clinicians who specialize in the care of patients with facial palsy. By leverag- ing the expertise of this group of practitioners, we present a minimum set of photographs and videography that can be eas- Figure 1. Survey Findings 82 Elevation of Eyebrows At Rest or Repose Closure of Eyes Gently 100 88 90 92 94 96 98 Su rv ey R es po nd en ts , % View 86 84 Large Smile Showing Teeth Use of views described in common grading scalesA 0 Showing Bottom Teeth Closure of Eyes Tightly Nasal Base View 100 30 40 50 60 70 80 90 Su rv ey R es po nd en ts , % View 20 10 Small Closed-Mouth Smile Use of views not described in common grading scalesB Responses were received from 83 of the 151 Sir Charles Bell Society members (55.0%). All survey respondents used still photography. Research Original Investigation Photographic Standards for Patients With Facial Palsy 278 JAMA Facial Plastic Surgery July/August 2017 Volume 19, Number 4 (Reprinted) jamafacialplasticsurgery.com © 2017 American Medical Association. All rights reserved. D ow nl oa de d by C ar ne gi e M el lo n U ni ve rs it y fr om w w w .l ie be rt pu b. co m a t 04 /0 5/ 21 . F or p er so na l us e on ly . http://jama.jamanetwork.com/article.aspx?doi=10.1001/jamafacial.2016.1883&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 http://jama.jamanetwork.com/article.aspx?doi=10.1001/jamafacial.2016.1883&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 http://www.jamafacialplasticsurgery.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 ily adopted by others caring for this special patient popula- tion. However, there are limitations that remain. Because of the paucity of literature dedicated to photographic standards for patients with facial palsy, we were not able to conduct a meta-analysis or systematic review, which would provide more robust evidence. In addition, because our study was cross- sectional in design, we capture the practice patterns of clini- cians at a given snapshot of time, which for us in this study was August and September 2013. Since the surveying of these SCBS members in 2013, practice patterns, specifically the use of medical photography and videography, could have evolved. Moreover, while out of the scope of this study, we acknowl- edge the need for a standardized approach to incorporate medi- c al photography and v ideography along w ith patient- reported outcomes for patients who undergo facial reanimation surgery for facial palsy. The benefits of standardized medical photography and vid- eography in this patient population are several. First, images and video obtained before and after surgery can demonstrate functional deficits or improvements over time, which can pro- vide invaluable feedback to the surgeon and reassurance to the patient. This feedback to the patient with facial palsy is espe- cially critical because improvements in facial nerve function are often subtle and slow progressing. Standardized photo- graphs and videos in tandem with objective scoring and pa- tient-reported outcome measures provide a comprehensive evaluation of the patient’s progression over time. Second, medical photography is a useful teaching tool. High-quality im- ages of our proposed 10 static views can help trainees better understand how different functions are related to the intri- cate branching patterns and course of the facial nerve, which can sometimes be challenging to comprehend. Third, and most Figure 2. Facial Palsy Static Views At rest or repose Large smile showing teethSmall closed-mouth smile Nasal base view Elevation of eyebrows Closure of eyes tightlyClosure of eyes gently Puckering of lips Showing bottom teethSnarling or wrinkling of the nose Nasal base view A standardized set of photographs is proposed that should be used in outcomes analysis to improve information exchange and data comparison. This minimum set consists of 10 static views. Photographic Standards for Patients With Facial Palsy Original Investigation Research jamafacialplasticsurgery.com (Reprinted) JAMA Facial Plastic Surgery July/August 2017 Volume 19, Number 4 279 © 2017 American Medical Association. All rights reserved. D ow nl oa de d by C ar ne gi e M el lo n U ni ve rs it y fr om w w w .l ie be rt pu b. co m a t 04 /0 5/ 21 . F or p er so na l us e on ly . http://www.jamafacialplasticsurgery.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 important, standardized medical photography and videogra- phy are integral to communicating results to other clinicians caring for these patients. Studies involving this patient popu- lation are often underpowered and anecdotal because the clini- cal volume of patients with facial nerve disorders is low. One solution to this problem is to use standardized medical pho- tographs and videos in scientific presentations and publica- tions. It is equally important to adopt standardized videogra- phy to monitor the progress of these patients before and after surgery. Because medical photography captures the patient’s facial nerve function at a single moment in time, it can occa- sionally be misleading and should be supported and corrobo- rated by standardized videography. While grading of these suggested views and movements was out of the scope of the present article, other groups have successfully developed and validated an electronic, clinician- graded facial function scale, referred to as the eFACE,16 which can be applied to these proposed standards. Furthermore, as a result of the findings of the present study, the SCBS urges practitioners to use these minimum photographic and video- graphic standards in practice. In addition, we also urge jour- nal editors to adopt these standards for submission of manu- scripts related to facial palsy. This requirement would improve exchange of information and may assist with execution of high- quality, multicenter studies needed in this patient population.8 Conclusions With currently available techniques, it is difficult to compare outcomes of patients with facial palsy. To bridge this gap, we propose guidelines for photographic and videographic stan- dards among patients with facial palsy consisting of 10 static views and their respective dynamic functions. Scientific pre- sentations and publications related to facial palsy should fulfill these minimum photographic standards to encourage uniformity in depicting outcomes. Standardized medical pho- tography is integral to allow exchange of information and ul- timately to optimize the management of this complex and chal- lenging condition. ARTICLE INFORMATION Accepted for Publication: September 30, 2016. Published Online: January 26, 2017. doi:10.1001/jamafacial.2016.1883 Author Affiliations: Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri (Santosa); Facial Nerve Programme, Regional Paediatric Burns and Plastic Surgery Service, Alder Hey Children’s National Health Service Foundation Trust, Liverpool, England (Fattah); Department of Otorhinolaryngology, La Paz University Hospital, Madrid, Spain (Gavilán); Facial Nerve Center, Division of Facial and Plastic and Reconstructive Surgery, Department of Otology and Laryngology, Harvard Medical School and Massachusetts Eye and Ear, Boston (Hadlock); Facial Nerve Institute, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri (Snyder-Warwick). Table 2. Minimum Standard Photographic Views for Patients With Facial Palsy View Facial Nerve Branch Tested Muscles Activated Special Notes At rest or repose All Not applicable. Symmetry at rest is one of the most important views to capture. Specifically, the clinician should evaluate the position of the eyebrows, canthi, and oral commissures from side to side. With regard to the eye in this view, specific attention should be made to the height of palpebral aperture and lower eyelid position. Patients with unilateral facial palsy typically deviate the tip of their nose and upper and lower lips toward the uninjured or unaffected side. This view can also help assess the patient’s resting tone. Small closed-mouth smile Zygomatic, buccal Upper lip levators (major is levator labii superioris) Not applicable. Large smile showing teeth Zygomatic, buccal, marginal mandibular Upper lip levators, levators of the corner of the mouth, depressors of lower lip (innervated by marginal mandibular) Damage of the marginal mandibular branch in a smile showing no teeth will produce little alteration. However, this view would capture obvious asymmetry of the lower lip depressors. Elevation of eyebrows Frontal Frontalis Not applicable. Closure of eyes gently Frontal Orbicularis oculi Eye closure is a complex action. The upper lid is controlled by the following 2 synergistic muscles and nerves: the palpebral portion of the orbicularis oculi (innervated by the frontal branch of the facial nerve) and the levator palpebrae (innervated by the superior ramus of the oculomotor nerve). Closure of eyes tightly Frontal Orbicularis oculi, corrugator supercilii Not applicable. Puckering of lips Buccal Orbicularis oris, buccinator Not applicable. Showing bottom teeth Marginal mandibular, cervical Depressors of lower lip (innervated by marginal mandibular), platysma Not applicable. Snarling or wrinkling of the nose Frontal, buccal Corrugator supercilii, nasalis, depressor septi nasii, levator labii superioris aleque nasii Not applicable. Nasal base view Buccal Nasalis, depressor septi nasii, levator labii superioris aleque nasii This view allows for an improved assessment of midline structures and symmetry. In addition, external nasal valve symmetry is best assessed using this view. Research Original Investigation Photographic Standards for Patients With Facial Palsy 280 JAMA Facial Plastic Surgery July/August 2017 Volume 19, Number 4 (Reprinted) jamafacialplasticsurgery.com © 2017 American Medical Association. All rights reserved. D ow nl oa de d by C ar ne gi e M el lo n U ni ve rs it y fr om w w w .l ie be rt pu b. co m a t 04 /0 5/ 21 . F or p er so na l us e on ly . http://jama.jamanetwork.com/article.aspx?doi=10.1001/jamafacial.2016.1883&utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 http://www.jamafacialplasticsurgery.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamafacial.2016.1883 Author Contributions: Drs Fattah and Snyder-Warwickhad full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Santosa, Fattah, Hadlock, Snyder-Warwick. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Santosa, Snyder-Warwick. Critical revision of the manuscript for important intellectual content: Fattah, Gavilán, Hadlock, Snyder-Warwick. Statistical analysis: Santosa, Snyder-Warwick. Administrative, technical, or material support: Santosa, Fattah, Hadlock, Snyder-Warwick. Study supervision: Santosa, Fattah, Snyder-Warwick. Conflict of Interest Disclosures: None reported. Funding/Support: Dr Santosa was in part supported by grant F32NS098561 from the National Institute of Neurological Disorders and Stroke, National Institutes of Health. Role of the Funder/Sponsor: The National Institutes of Health did not have a role in any of the following: design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Additional Contributions: Andrew Yee, BS, provided the photographs and video, and Kim Lipsey, MLS, assisted with the literature search. Both are affiliated with Washington University in St Louis and received no compensation outside of their usual salary. 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Plast Reconstr Surg. 2015;136(2):223e-230e. doi:10.1097/PRS .0000000000001447 Photographic Standards for Patients With Facial Palsy Original Investigation Research jamafacialplasticsurgery.com (Reprinted) JAMA Facial Plastic Surgery July/August 2017 Volume 19, Number 4 281 © 2017 American Medical Association. All rights reserved. D ow nl oa de d by C ar ne gi e M el lo n U ni ve rs it y fr om w w w .l ie be rt pu b. co m a t 04 /0 5/ 21 . 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