Behavioural and Neural Responses to Facial Disfigurement

Only human after all? a pre-registered study on gaze behavior and humanity attributions to people with facial difference

There is a great deal of indirect evidence suggesting that people with facial difference (FD) may be dehumanized. This research aimed to provide direct evidence of the dehumanization of people with FD based on the stigmatizing reactions they elicit. More precisely, previous findings revealed that the specific way people with FD are looked upon is related to the feelings of disgust they elicit. Since disgust fosters dehumanization, our aim was to confirm the modified pattern of visual attention towards people with FD and to determine whether it was also related to humanness perception. For that purpose, a preregistered eye-tracking study (N = 97) using a former experimental design extended to humanity attributions was conducted. This research replicates findings showing that the face of people with FD is explored differently in comparison with other human faces. However, the hypothesis that people with FD were given fewer humanity attributions was not supported. Therefore, the hypothesis of a "dehumanizing gaze" towards people with FD-beyond humanity-related attributions-is discussed in light of these findings.

Oral health-related quality of life in patients aged 8 to 19 years with cleft lip and palate: a systematic review and meta-analysis

BACKGROUND

Cleft lip and palate (CLP) is the most common facial birth defect worldwide and causes morphological, aesthetic, and functional problems with psychosocial implications for an individual's life and well-being. The present systematic review and meta-analysis assessed whether the treatment of CLP impacts the oral health-related quality of life (OHRQoL) in children and adolescents in comparison to healthy controls.

METHODS

We searched MEDLINE/PubMed, EMBASE, and PsycINFO databases using terms related to CLP, and included articles until August 2023. Observational comparison studies that assessed OHRQoL in non-syndromic CLP patients aged 8-19 years with validated scales designed to such aim or scales capable to identify aspects related to oral health compared to healthy controls were included. We used the ROBINS-I tool for risk of bias assessment. A meta-analysis of continuous variables was performed using inverse variance for pooling estimates, Standardized Mean Difference (SMD) as a summary measure, with random effects model. Heterogeneity was estimated by the I2 statistics. Sensitivity analyses included subgrouping based on the scale, risk of bias and scale domains. Meta-regression was performed under a mixed-effects model considering the variables type of scale, scale domains and risk of bias.

RESULTS

Fourteen studies were included comprising 1,185 patients with CLP and 1,558 healthy controls. The direction of the effect of OHRQoL favoured the healthy group (-0.92; 95% CI:-1,55;-0,10) and I2 = 95%. After removing three studies, I2 dropped to 80%. Meta-regression showed no influence on risk of bias (p = 0.2240) but influence of scale type (p = 0.0375) and scale domains (p < 0.001). The subgroup analysis indicated that the CPQ and COHIP scales presented very discrepant SMD values, despite pointing to the same effect direction. In contrast, the OHIP scale showed a non-significant difference between cases and controls, with estimates much lower than the other two scales. Results also suggest that OHRQoL associated with oral functionality and social well-being is more influential on outcomes than emotional well-being.

CONCLUSION

The global OHRQoL is slightly worst in the CLP patients than control group. The difference between OHRQoL was mainly detected through OHIP. The most affected domains are functional, emotional and social.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022336956.

Visual Attention, Bias, and Social Dispositions Toward People With Facial Anomalies: A Prospective Study With Eye-Tracking Technology

BACKGROUND

Facial attractiveness influences our perceptions of others, with beautiful faces reaping societal rewards and anomalous faces encountering penalties. The purpose of this study was to determine associations of visual attention with bias and social dispositions toward people with facial anomalies.

METHODS

Sixty subjects completed tests evaluating implicit bias, explicit bias, and social dispositions before viewing publicly available images of preoperative and postoperative patients with hemifacial microsomia. Eye-tracking was used to register visual fixations.

RESULTS

Participants with higher implicit bias scores fixated significantly less on the cheek and ear region preoperatively (P = 0.004). Participants with higher scores in empathic concern and perspective taking fixated more on the forehead and orbit preoperatively (P = 0.045) and nose and lips (P = 0.027) preoperativel.

CONCLUSIONS

Participants with higher levels of implicit bias spent less visual attention on anomalous facial anatomy, whereas participants with higher levels of empathic concern and perspective taking spent more visual attention on normal facial anatomy. Levels of bias and social dispositions such as empathy may predict layperson gaze patterns toward those with facial anomalies and provide insights to neural mechanisms underlying the "anomalous is bad" paradigm.

Do congenital and acquired causes of visible difference predict distinct appearance-related psychosocial outcomes?

Having a visible difference caused by an appearance-altering condition or injury can impact psychosocial wellbeing. It remains unestablished whether the time at which a visible difference manifests, namely pre-memory (congenital) or later (acquired), predicts psychosocial outcomes associated with adjustment. In this survey study of 331 adults with visible differences, we tested whether their type, congenital (n = 161) or acquired (n = 170), would predict four key psychosocial outcomes: Appearance satisfaction, social appearance anxiety, life disengagement and intimacy distress. To account for other potential predictors and to test whether other variables would moderate any predictive effect found from the type of visible difference, the analyses also included demographic variables, visible difference characteristics and history, and interpersonal and intrapersonal factors. Four regression models were tested. With all variables entered, we found no evidence of type of visible difference as a significant predictor of any psychosocial outcome. Instead, the only consistent predictors of outcomes were optimism, social support and the extent to which participants felt able to disguise their difference. Overall, findings do not support the idea that there is a psychosocial advantage to having a congenital nor acquired visible difference, and broadly reinforce commonalities in adjusting to any cause.

A Functional and Neuroanatomical Model of Dehumanization

The dehumanization of others is a major scourge of mankind; however, despite its significance, physicians have little understanding of the neurobiological mechanisms for this behavior. We can learn much about dehumanization from its brain-behavior localization and its manifestations in people with brain disorders. Dehumanization as an act of denying to others human qualities includes two major forms. Animalistic dehumanization (also called infrahumanization) results from increased inhibition of prepotent tendencies for emotional feelings and empathy for others. The mechanism may be increased activity in the inferior frontal gyrus. In contrast, mechanistic dehumanization results from a loss of perception of basic human nature and decreased mind-attribution. The mechanism may be hypofunction of a mentalization network centered in the ventromedial prefrontal cortex and adjacent subgenual anterior cingulate cortex. Whereas developmental factors may promote animalistic dehumanization, brain disorders, such as frontotemporal dementia, primarily promote mechanistic dehumanization. The consideration of these two processes as distinct, with different neurobiological origins, could help guide efforts to mitigate expression of this behavior.

Patient Unique Stigmatization Holistic tool in dermatology (PUSH-D): Development and validation of a dermatology-specific stigmatization assessment tool

BACKGROUND

The skin plays an important role in establishing interpersonal relationships, and thus visible skin disorders, which have a significant impact on physical appearance, influence other people's behaviours and attitudes.

OBJECTIVE

To develop and validate a dermatologic-specific questionnaire to evaluate stigmatization in individuals with visible skin conditions.

METHODS

Items were generated by a verbatim report based on qualitative interviews with patients with various dermatologic conditions. Subsequently, a study was implemented for psychometric analysis. A dermatology-specific stigmatization questionnaire (PUSH-D) was refined via item reduction according to inter-question correlations, consensus among experts and exploratory factor analysis. Internal consistency was determined by calculating Cronbach's α. Concurrent validity was determined by calculating the correlation between PUSH-D and the Dermatology Life Quality Index (DLQI) and the Rosenberg Self-Esteem Scale (RSES).

RESULTS

From a primary list of 22 items, PUSH-D was reduced to a 17-item questionnaire, covering two pertinent dimensions based on the exploratory factor analysis. Construct validity was demonstrated, and PUSH-D showed good internal consistency (Cronbach's α = 0.9). PUSH-D correlated strongly with the DLQI 0.72 (p < 0.001) and moderately with the RSES 0.49 (p < 0.001).

CONCLUSION

PUSH-D allows a comprehensive view of the degree of stigmatization in visible skin disorders, as well as the comparability of stigmatization levels across various skin conditions.

Towards a better understanding of the social stigma of facial difference

Facial difference (FD) is not only an individual experience; it is inherently social, reflecting interactions between social norms and individual attitudes. Often FD is stigmatized. In this paper, we employ a widely used stigma framework, namely the social stigma framework put forth by Pryor and Reeder (2011), to unpack the stigma of FD. This framework posits that there are four forms of stigma: public stigma, self-stigma, stigma by association, and structural stigma. We first discuss the social and psychological literature on FD as it pertains to these various forms of stigma. We then describe coping approaches for FD stigma. Lastly, we delineate evidence-based methods for addressing the various forms of FD stigma, such that future efforts can more effectively tackle the stigma of facial difference.

The psychosocial burden of visible disfigurement following traumatic injury

Hundreds of thousands of individuals experience traumatic injuries each year. Some are mild to moderate in nature and patients experience full functional recovery and little change to their physical appearance. Others result in enduring, if not permanent, changes in physical functioning and appearance. Reconstructive plastic surgical procedures are viable treatments options for many patients who have experienced the spectrum of traumatic injuries. The goal of these procedures is to restore physical functioning and reduce the psychosocial burden of living with an appearance that may be viewed negatively by the patient or by others. Even after receipt of reconstructive procedures, many patients are left with residual disfigurement. In some, disability and disfigurement may be so profound that individuals are candidates for vascularized composite allotransplantation (VCA) procedures, i.e., the transplantation of a vascularized human body part containing multiple tissue types (skin, muscle, bone, nerves, and blood vessels) as an anatomical and/or structural unit. This narrative review paper summarizes the literature on the psychosocial burden experienced by those who have visible disfigurement. While many of these individuals experience stigma and discrimination, relatively few studies have employed a stigma framework to understand the psychosocial sequelea. This paper briefly addresses this framework. Last, particular focus is given to the psychosocial issues of individuals with particularly severe injuries who are potential candidates for VCA procedures.

Evidence against the "anomalous-is-bad" stereotype in Hadza hunter gatherers

People have an "anomalous-is-bad" stereotype whereby they make negative inferences about the moral character of people with craniofacial anomalies like scars. This stereotype is hypothesized to be a byproduct of adaptations for avoiding pathogens. However, evidence for the anomalous-is-bad stereotype comes from studies of European and North American populations; the byproduct hypothesis would predict universality of the stereotype. We presented 123 Hadza across ten camps pairs of morphed Hadza faces-each with one face altered to include a scar-and asked who they expected to be more moral and a better forager. Hadza with minimal exposure to other cultures chose at chance for both questions. Hadza with greater exposure to other cultures, however, expected the scarred face to be less moral and a better forager. These results suggest the anomalous-is-bad stereotype may be culturally shared or learned erroneously through associations with population-level differences, providing evidence against a universal pathogen avoidance byproduct hypothesis.

Evaluating Symptomatic and Psychosocial Well-being After Keloid Treatment With SCAR-Q

BACKGROUND

Many patients with keloids experience symptoms, such as pain and pruritus, and may present with significant psychosocial burdens. However, no single therapeutic regimen has been firmly established for treatment of keloids.

OBJECTIVES

The aim of this study was to assess patients' perspectives on their keloids after treatment by comparing preoperative and postoperative surveys.

METHODS

All patients seen at the keloid clinic, both preoperatively and postoperatively, were contacted by telephone call. Information about demographics, keloid characteristics, and levels of pain and pruritus were recorded. Participants also completed all 3 parts (appearance, symptoms, and psychosocial impact) of the SCAR-Q, a validated patient-reported outcome measure questionnaire. Statistical analysis was performed with SPSS version 23 (IBM Corp., Armonk, NY).

RESULTS

Of the 60 patients who participated in the study, 35 preoperative and 34 postoperative surveys were completed. Patients experienced significant reductions in mean [standard deviation] pain levels (from 5.6 [4.0] to 0.1 [0.4], P < 0.001) and pruritus (from 6.5 [3.0] to 0.8 [1.5], P < 0.001) postintervention. Significant improvements in all 3 parts of the SCAR-Q were noted. Appearance improved from 26.5 [22.3] to 73.4 [23.0] (P < 0.001); symptoms from 44.0 [15.7] to 81.4 [16.7] (P < 0.001); and psychosocial impact from 27.7 [30.7] to 82.6 [26.3] (P < 0.001).

CONCLUSIONS

Patients with keloids experience significant improvement in their symptomatic and psychosocial burden after treatment. Although management modalities are not well established, it is essential that plastic surgeons do not overlook the therapeutic benefits for their patients' well-being.

Look me in the eyes! A pre-registered eye-tracking study investigating visual attention and affective reactions to faces with a visible difference

This research aims to determine how disfigurement alters visual attention paid to faces and to examine whether such a potential modified pattern of visual attention to faces with visible difference was associated, in turn, with perceiver's stigmatizing affective reactions. A pilot study (N = 38) and a pre-registered experimental eye-tracking study (N = 89) were conducted. First, the visual explorations of faces with and without disfigurement were compared. The association of these visual explorations with affective reactions were investigated next. Findings suggest that disfigurement impacts visual attention toward faces; attention is not merely attracted to the disfigured area but it is also diverted particularly from the eye area. Disfigurement also eases disgust-related, surprise-related, anxiety-related, and, to a lesser extent, hostility-related affective states. Exploratory interaction effects between attention to the eyes and to the disfigured part of the face revealed a hybrid effect on disgust-related affect and an increase in surprise-related affect when participants fixated more upon the disfigured area and fixated less upon the eyes. Thus, perceiver's attention is captured by disfigurement and also diverted from face internal features which seems to play a role in the affective reactions elicited.

The Face Image Meta-Database (fIMDb) & ChatLab Facial Anomaly Database (CFAD): Tools for research on face perception and social stigma

Investigators increasingly need high quality face photographs that they can use in service of their scholarly pursuits-whether serving as experimental stimuli or to benchmark face recognition algorithms. Up to now, an index of known face databases, their features, and how to access them has not been available. This absence has had at least two negative repercussions: First, without alternatives, some researchers may have used face databases that are widely known but not optimal for their research. Second, a reliance on databases comprised only of young white faces will lead to science that isn't representative of all the people whose tax contributions, in many cases, make that research possible. The "Face Image Meta-Database" (fIMDb) provides researchers with the tools to find the face images best suited to their research, with filters to locate databases with people of a varied racial and ethnic backgrounds and ages. Problems of representation in face databases are not restricted to race and ethnicity or age - there is a dearth of databases with faces that have visible differences (e.g., scars, port wine stains, and cleft lip and palate). A well-characterized database is needed to support programmatic research into perceivers' attitudes, behaviors, and neural responses to anomalous faces. The "ChatLab Facial Anomaly Database" (CFAD) was constructed to fill this gap, with photographs of faces with visible differences of various types, etiologies, sizes, locations, and that depict individuals from various ethnic backgrounds and age groups. Both the fIMDb and CFAD are available from: https://cliffordworkman.com/resources/.

A hidden community: Facial disfigurement as a globally neglected human rights issue

Disability rights continue to lag behind other equality movements worldwide. Disfigurement rights have an even more uncertain position, sometimes included in disability rights law, but often not explicitly. This article describes the efforts of Face Equality International to end "face-ism" worldwide, and how healthcare and mental health providers, community developers, and educators can engage to move this vision forward. Beyond medical and surgical treatments, mental health needs, societal, and legal barriers must be addressed. We call for strong and explicit legal protections for disfigurement. Culturally appropriate public education to counteract stigma is crucial in shaping an inclusive and sustainable environment for people with disfigurements.

The effect of aging on facial attractiveness: An empirical and computational investigation

How does aging affect facial attractiveness? We tested the hypothesis that people find older faces less attractive than younger faces, and furthermore, that these aging effects are modulated by the age and sex of the perceiver and by the specific kind of attractiveness judgment being made. Using empirical and computational network science methods, we confirmed that with increasing age, faces are perceived as less attractive. This effect was less pronounced in judgments made by older than younger and middle-aged perceivers, and more pronounced by men (especially for female faces) than women. Attractive older faces were perceived as elegant more than beautiful or gorgeous. Furthermore, network analyses revealed that older faces were more similar in attractiveness and were segregated from younger faces. These results indicate that perceivers tend to process older faces categorically when making attractiveness judgments. Attractiveness is not a monolithic construct. It varies by age, sex, and the dimensions of attractiveness being judged.

Beauty and Wellness in the Semantic Memory of the Beholder

Beauty and wellness are terms used often in common parlance, however their meaning and relation to each other is unclear. To probe their meaning, we applied network science methods to estimate and compare the semantic networks associated with beauty and wellness in different age generation cohorts (Generation Z, Millennials, Generation X, and Baby Boomers) and in women and men. These mappings were achieved by estimating group-based semantic networks from free association responses to a list of 47 words, either related to Beauty, Wellness, or Beauty + Wellness. Beauty was consistently related to Elegance, Feminine, Gorgeous, Lovely, Sexy, and Stylish. Wellness was consistently related Aerobics, Fitness, Health, Holistic, Lifestyle, Medical, Nutrition, and Thrive. In addition, older cohorts had semantic networks that were less connected and more segregated from each other. Finally, we found that women compared to men had more segregated and organized concepts of Beauty and Wellness. In contemporary societies that are pre-occupied by the pursuit of beauty and a healthy lifestyle, our findings shed novel light on how people think about beauty and wellness and how they are related across different age generations and by sex.

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.

From Visual Perception to Aesthetic Appeal: Brain Responses to Aesthetically Appealing Natural Landscape Movies

During aesthetically appealing visual experiences, visual content provides a basis for computation of affectively tinged representations of aesthetic value. How this happens in the brain is largely unexplored. Using engaging video clips of natural landscapes, we tested whether cortical regions that respond to perceptual aspects of an environment (e.g., spatial layout, object content and motion) were directly modulated by rated aesthetic appeal. Twenty-four participants watched a series of videos of natural landscapes while being scanned using functional magnetic resonance imaging (fMRI) and reported both continuous ratings of enjoyment (during the videos) and overall aesthetic judgments (after each video). Although landscape videos engaged a greater expanse of high-level visual cortex compared to that observed for images of landscapes, independently localized category-selective visual regions (e.g., scene-selective parahippocampal place area and motion-selective hMT+) were not significantly modulated by aesthetic appeal. Rather, a whole-brain analysis revealed modulations by aesthetic appeal in ventral (collateral sulcus) and lateral (middle occipital sulcus, posterior middle temporal gyrus) clusters that were adjacent to scene and motion selective regions. These findings suggest that aesthetic appeal per se is not represented in well-characterized feature- and category-selective regions of visual cortex. Rather, we propose that the observed activations reflect a local transformation from a feature-based visual representation to a representation of "elemental affect," computed through information-processing mechanisms that detect deviations from an observer's expectations. Furthermore, we found modulation by aesthetic appeal in subcortical reward structures but not in regions of the default-mode network (DMN) nor orbitofrontal cortex, and only weak evidence for associated changes in functional connectivity. In contrast to other visual aesthetic domains, aesthetically appealing interactions with natural landscapes may rely more heavily on comparisons between ongoing stimulation and well-formed representations of the natural world, and less on top-down processes for resolving ambiguities or assessing self-relevance.

Morality is in the eye of the beholder: the neurocognitive basis of the "anomalous-is-bad" stereotype

Are people with flawed faces regarded as having flawed moral characters? An "anomalous-is-bad" stereotype is hypothesized to facilitate negative biases against people with facial anomalies (e.g., scars), but whether and how these biases affect behavior and brain functioning remain open questions. We examined responses to anomalous faces in the brain (using a visual oddball paradigm), behavior (in economic games), and attitudes. At the level of the brain, the amygdala demonstrated a specific neural response to anomalous faces-sensitive to disgust and a lack of beauty but independent of responses to salience or arousal. At the level of behavior, people with anomalous faces were subjected to less prosociality from participants highest in socioeconomic status. At the level of attitudes, we replicated previously reported negative character evaluations made about individuals with facial anomalies, and further identified explicit biases directed against them as a group. Across these levels of organization, the specific amygdala response to facial anomalies correlated with stronger just-world beliefs (i.e., people get what they deserve), less dispositional empathic concern, and less prosociality toward people with facial anomalies. Characterizing the "anomalous-is-bad" stereotype at multiple levels of organization can reveal underappreciated psychological burdens shouldered by people who look different.

Bias in a blink: Shedding light on implicit attitudes toward patients with a cleft lip

INTRODUCTION

Previous studies have shown that patients with cleft lip and/or palate may be stigmatized in society. The objective of this study was to use an implicit association test to evaluate the subconscious biases of non-health care providers and orthodontists against patients with a repaired cleft lip (CL).

METHODS

Respondents participated in an implicit association test. Pictures of patients with CL and controls were shown to participants, along with terms representing positive and negative attributes. Participants were prompted to match pictures to the attributes. The software algorithm detected whether the participants were more likely to associate CL with positive or negative terms than controls. Demographic information was collected to measure the association between some sociodemographic factors and implicit biases.

RESULTS

Of 130 valid participants, 52 were orthodontists and 78 were non-health care providers. The entire sample displayed a significant implicit bias against CL (P <0.001). Overall, orthodontists tended to exhibit slightly higher levels of implicit biases against CL than non-health care providers, but the difference was not significant when controlling for sociodemographic factors (P = 0.34). Females showed significantly lower implicit biases against CL than males (P = 0.046). Spearman correlations showed that older people and those who reported a more conservative political affiliation tended to show slightly higher levels of implicit biases against CL (P <0.007).

CONCLUSIONS

Orthodontists and non-health care providers showed moderate but significant levels of implicit biases against patients with clefts. Males, older age groups, and patients with a more conservative political affiliation tended to exhibit slightly higher levels of biases than females, younger people, and those with a more liberal political affiliation.