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Bian Y, Küster D, Liu H, Krumhuber EG. Understanding Naturalistic Facial Expressions with Deep Learning and Multimodal Large Language Models. SENSORS (BASEL, SWITZERLAND) 2023; 24:126. [PMID: 38202988 PMCID: PMC10781259 DOI: 10.3390/s24010126] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024]
Abstract
This paper provides a comprehensive overview of affective computing systems for facial expression recognition (FER) research in naturalistic contexts. The first section presents an updated account of user-friendly FER toolboxes incorporating state-of-the-art deep learning models and elaborates on their neural architectures, datasets, and performances across domains. These sophisticated FER toolboxes can robustly address a variety of challenges encountered in the wild such as variations in illumination and head pose, which may otherwise impact recognition accuracy. The second section of this paper discusses multimodal large language models (MLLMs) and their potential applications in affective science. MLLMs exhibit human-level capabilities for FER and enable the quantification of various contextual variables to provide context-aware emotion inferences. These advancements have the potential to revolutionize current methodological approaches for studying the contextual influences on emotions, leading to the development of contextualized emotion models.
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Affiliation(s)
- Yifan Bian
- Department of Experimental Psychology, University College London, London WC1H 0AP, UK;
| | - Dennis Küster
- Department of Mathematics and Computer Science, University of Bremen, 28359 Bremen, Germany; (D.K.); (H.L.)
| | - Hui Liu
- Department of Mathematics and Computer Science, University of Bremen, 28359 Bremen, Germany; (D.K.); (H.L.)
| | - Eva G. Krumhuber
- Department of Experimental Psychology, University College London, London WC1H 0AP, UK;
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Johns AL, Stock NM, Costa B, Feragen KB, Crerand CE. Psychosocial and Health-Related Experiences of Individuals With Microtia and Craniofacial Microsomia and Their Families: Narrative Review Over 2 Decades. Cleft Palate Craniofac J 2023; 60:1090-1112. [PMID: 35382590 PMCID: PMC10803131 DOI: 10.1177/10556656221091699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This paper describes 20 years of microtia and craniofacial microsomia (CFM) psychosocial and healthcare studies and suggests directions for clinical care and research. A narrative review of papers January 2000 to July 2021 related to psychosocial and healthcare experiences of individuals with microtia and CFM and their families. Studies (N = 64) were mainly cross-sectional (69%), included a range of standardized measures (64%), and were with European (31%), American (27%), or multinational (23%) samples. Data were generally collected from both patients and caregivers (38%) or patient self-report (35%). Sample sizes were 11 to 25 (21%), 26 to 50 (19%), 51 to 100 (22%), or over 100 (38%). Studies addressed 5 primary topics: (1) Healthcare Experiences, including Medical Care, Hearing Loss/Amplification, Diagnostic Experiences, and Information Preferences; (2) Psychosocial Experiences, including Teasing, Behavioral Adjustment, Psychosocial Support, and Public Perception; (3) Neurocognitive Functioning and Academic Assistance; (4) Pre- and Post-Operative Psychosocial Outcomes of Ear Reconstruction/Canaloplasty; and (5) Quality of Life and Patient Satisfaction. Care involved multiple specialties and was often experienced as stressful starting at diagnosis. Psychosocial and neurocognitive functioning were generally in the average range, with possible risk for social and language concerns. Coping and resiliency were described into adulthood. Satisfaction and positive benefit of ear reconstruction/canaloplasty were high. Care recommendations include increasing: hearing amplification use, microtia and CFM knowledge among providers, efficient treatment coordination, psychosocial support, academic assistance, and advances to minimize surgical scarring. This broad literature overview informs clinical practice and research to improve psychosocial outcomes.
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Affiliation(s)
- Alexis L Johns
- Division of Plastic and Maxillofacial Surgery, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Nicola Marie Stock
- Center for Appearance Research, University of the West of England, Bristol, United Kingdom
| | - Bruna Costa
- Center for Appearance Research, University of the West of England, Bristol, United Kingdom
| | | | - Canice E Crerand
- Departments of Pediatrics and Plastic Surgery, The Ohio State University College of Medicine, Columbus, OH, USA and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
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Stock NM, Crerand CE, Johns AL, McKinney CM, Koudstaal MJ, Drake AF, Heike CL. Establishing an International Interdisciplinary Research Network in Craniofacial Microsomia: The CARE Program. Cleft Palate Craniofac J 2023:10556656231176904. [PMID: 37248561 PMCID: PMC10984877 DOI: 10.1177/10556656231176904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVE Craniofacial microsomia (CFM) is a broad clinical term used to describe a congenital condition most commonly involving the underdevelopment of the external ear, mandible, soft tissues, and facial nerve. Despite medical advances, understanding of the psychological health and healthcare experiences of individuals with CFM and their caregivers remains limited. This article describes a research program designed to address these knowledge gaps, and identify opportunities for psychosocial intervention and improved healthcare provision. DESIGN The Craniofacial microsomia: Accelerating Research and Education (CARE) research program aims to: 1) Conduct up to 160 narrative interviews with individuals and caregivers to validate a conceptual framework; 2) Administer an online international survey of up to 800 individuals with CFM and caregivers to identify predictors of psychological distress; 3) Perform up to 60 semi-structured interviews with healthcare providers and advocacy leaders to examine the extent to which current healthcare provisions address identified patient needs; and 4) Establish a participant registry to build a longitudinal database and develop an international community. RESULTS Teams in the USA and UK have been established, alongside an international, interdisciplinary Advisory Committee. Data analysis for Aim 1 is ongoing and informing the delivery of Aims 2-3. Aim 4 is also in development. A dedicated website serves as a recruitment tool, educational resource, and mechanism for engaging with the CFM community. CONCLUSIONS The CARE program provides a comprehensive approach to understanding the experiences of individuals with CFM and their caregivers. Challenges encountered and lessons learned are shared for the benefit of the community.
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Affiliation(s)
- Nicola M. Stock
- Centre for Appearance Research, University of the West of England, Bristol, BS16 1QY, United Kingdom
| | - Canice E. Crerand
- Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, USA 43205
| | - Alexis L. Johns
- Children’s Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, USA 90027
| | - Christy M. McKinney
- Seattle Children’s Research Institute, 1920 Terry Avenue, Seattle, WA, USA 98101
| | - Maarten J. Koudstaal
- Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Netherlands
| | - Amelia F. Drake
- University of North Carolina at Chapel School of Medicine, 170 Manning Drive, CB 7070, Chapel Hill, NC, USA 27599
| | - Carrie L. Heike
- Seattle Children’s Research Institute, 1920 Terry Avenue, Seattle, WA, USA 98101
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4
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Onal Ertugrul I, Ahn YA, Bilalpur M, Messinger DS, Speltz ML, Cohn JF. Infant AFAR: Automated facial action recognition in infants. Behav Res Methods 2023; 55:1024-1035. [PMID: 35538295 PMCID: PMC9646921 DOI: 10.3758/s13428-022-01863-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/08/2022]
Abstract
Automated detection of facial action units in infants is challenging. Infant faces have different proportions, less texture, fewer wrinkles and furrows, and unique facial actions relative to adults. For these and related reasons, action unit (AU) detectors that are trained on adult faces may generalize poorly to infant faces. To train and test AU detectors for infant faces, we trained convolutional neural networks (CNN) in adult video databases and fine-tuned these networks in two large, manually annotated, infant video databases that differ in context, head pose, illumination, video resolution, and infant age. AUs were those central to expression of positive and negative emotion. AU detectors trained in infants greatly outperformed ones trained previously in adults. Training AU detectors across infant databases afforded greater robustness to between-database differences than did training database specific AU detectors and outperformed previous state-of-the-art in infant AU detection. The resulting AU detection system, which we refer to as Infant AFAR (Automated Facial Action Recognition), is available to the research community for further testing and applications in infant emotion, social interaction, and related topics.
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Rooijers W, Tio P, van der Schroeff M, Padwa B, Dunaway D, Forrest C, Koudstaal M, Caron C. Hearing impairment and ear anomalies in craniofacial microsomia: a systematic review. Int J Oral Maxillofac Surg 2022; 51:1296-1304. [DOI: 10.1016/j.ijom.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 01/06/2022] [Accepted: 01/12/2022] [Indexed: 10/19/2022]
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Bergamini LL, Spineli-Silva S, Félix TM, Gil-da-Silva-Lopes VL, Vieira TP, Ribeiro EM, Xavier AC, Lustosa-Mendes E, Fontes MÍB, Monlleó IL. Craniofacial microsomia: Reflections on diagnosis and severity assessment based on a series of cases. Congenit Anom (Kyoto) 2021; 61:148-158. [PMID: 33900643 DOI: 10.1111/cga.12422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/29/2021] [Accepted: 03/22/2021] [Indexed: 12/22/2022]
Abstract
This study aims to discuss diagnostic criteria and severity assessment for craniofacial microsomia (CFM). A series of 61 patients with diverse CFM phenotypes had their clinical data collected by experienced dysmorphologists using a single protocol. Genetic abnormalities were searched through karyotype and chromosomal microarray analysis. Sex ratio, prenatal risk factors, and recurrence rate corroborated the literature. Despite the wide variability of clinical findings, ear disruption was universal. Eight patients were assigned as syndromic, four of whom had demonstrable genetic alterations. The majority of patients (67.2%) fulfilled four known diagnostic criteria, while 9.8% fulfilled one of them. Data strengthened disruptions of the ear and deafness as a semiotically valuable sign in CFM. Facial impairment should consider asymmetry as a mild expression of microsomia. Spinal and cardiac anomalies, microcephaly, and developmental delay were prevalent among extra craniofacial features and should be screened before planning treatment and follow up. The severity index was able to recognize the less and the most affected patients. However, it was not useful to support therapeutic decisions and prognosis in the clinical scenario due to syndromic and non-syndromic phenotypes overlapping. These issues make contemporary the debate on diagnostic methods and disease severity assessment for CFM. They also impact care and etiopathogenetic studies.
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Affiliation(s)
- Luna Lira Bergamini
- Faculty of Medicine, Federal University of Alagoas (UFAL), Maceió, Alagoas, Brazil
| | - Samira Spineli-Silva
- Department of Translational Medicine, Medical Genetics and Genomic Medicine, School of Medical Sciences, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Têmis Maria Félix
- Medical Genetics Service, Clinical Hospital of Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brazil
| | - Vera L Gil-da-Silva-Lopes
- Department of Translational Medicine, Medical Genetics and Genomic Medicine, School of Medical Sciences, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Tarsis P Vieira
- Department of Translational Medicine, Medical Genetics and Genomic Medicine, School of Medical Sciences, State University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Erlane Marques Ribeiro
- Medical Genetics Service, Children's Hospital Albert Sabin (HIAS), Fortaleza, Ceará, Brazil
| | - Ana Carolina Xavier
- Center for Research and Rehabilitation of Lip and Palate Lesions, Prefeito Luiz Gomes Center, Joinville, Santa Catarina, Brazil
| | | | | | - Isabella L Monlleó
- Faculty of Medicine, Federal University of Alagoas (UFAL), Maceió, Alagoas, Brazil.,Clinical Genetics Service, University Hospital, Federal University of Alagoas (UFAL), Maceió, Alagoas, Brazil
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Collett BR, Wallace ER, Kapp-Simon KA, Johns AL, Drake AF, Heike CL, Kinter S, Luquetti DV, Magee L, Norton S, Sie K, Speltz ML. Cognitive, Motor, and Language Development of Preschool Children With Craniofacial Microsomia. Cleft Palate Craniofac J 2020; 58:1169-1177. [PMID: 33322943 DOI: 10.1177/1055665620980223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine neurodevelopment in preschool-aged children with craniofacial microsomia (CFM) relative to unaffected peers. DESIGN Multisite, longitudinal cohort study. SETTING Tertiary care centers in the United States. PARTICIPANTS We included 92 children with CFM ("cases") through craniofacial centers and clinics. Seventy-six children without CFM (controls) were included from pediatric practices and community advertisements. This study reports on outcomes assessed when participants were an average age of 38.4 months (SD = 1.9). MAIN OUTCOME MEASURES We assessed cognitive and motor skills using the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III), and language function using subtests from the Clinical Evaluation of Language Fundamentals-Preschool, second edition (CELF-P2). RESULTS Case-control differences were negligible for Bayley-III cognitive (effect sizes [ES] = -0.06, P = .72) and motor outcomes (ES = -0.19, P = .25). Cases scored lower than controls on most scales of the CELF-P2 (ES = -0.58 to -0.20, P = .01 to .26). Frequency counts for "developmental delay" (ie, one or more scores > 1 SD below the normative mean) were higher for cases (39%) than controls (15%); however, the adjusted odds ratio = 1.73 (P = 0.21) was not significant. Case-control differences were most evident in children with microtia or other combinations of CFM-related facial features. CONCLUSIONS Cognitive and motor scores were similar for preschool-aged children with and without CFM. However, children with CFM scored lower than controls on language measures. We recommend early monitoring of language to identify preschoolers with CFM who could benefit from intervention.
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Affiliation(s)
- Brent R Collett
- Department of Psychiatry and Behavioral Sciences, 7284University of Washington, Seattle, WA, USA
| | - Erin R Wallace
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Kathleen A Kapp-Simon
- Department of Surgery, University of Illinois at Chicago and 24183Shriners Hospitals for Children, Chicago, IL, USA
| | - Alexis L Johns
- Clinical Pediatrics, 5150Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Amelia F Drake
- Department of Otolaryngology/Head and Neck Surgery, 2331University of North Carolina, Chapel Hill, NC, USA
| | - Carrie L Heike
- Division of Craniofacial Medicine, Department of Pediatrics, 7274Seattle Children's Hospital, Seattle, WA, USA
| | - Sara Kinter
- Seattle Children's Craniofacial Center, Seattle, WA, USA
| | - Daniela V Luquetti
- Division of Craniofacial Medicine, Department of Pediatrics, 7274Seattle Children's Hospital, Seattle, WA, USA
| | - Leanne Magee
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan Norton
- Department of Otolaryngology, 7284University of Washington, Seattle, WA, USA
| | - Kathleen Sie
- Department of Otolaryngology, 7284University of Washington, Seattle, WA, USA
| | - Matthew L Speltz
- Department of Psychiatry and Behavioral Sciences, 7284University of Washington, Seattle, WA, USA
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Johns AL, Wallace ER, Collett BR, Kapp-Simon KA, Drake AF, Heike CL, Kinter SL, Luquetti DV, Magee L, Norton S, Sie K, Speltz ML. Behavioral Adjustment of Preschool Children With and Without Craniofacial Microsomia. Cleft Palate Craniofac J 2020; 58:42-53. [PMID: 32783465 DOI: 10.1177/1055665620947987] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The study aim was to assess behavioral adjustment in preschool children with and without craniofacial microsomia (CFM). DESIGN Multisite cohort study of preschoolers with CFM ("cases") or without CFM ("controls"). PARTICIPANTS Mothers (89%), fathers (9%), and other caregivers (2%) of 161 preschoolers. OUTCOME MEASURE Child Behavior Check List (CBCL 1.5-5); linear regressions with standardized effect sizes (ES) adjusted for sociodemographic confounds. RESULTS Child Behavior Check Lists for 89 cases and 72 controls (average age 38.3 ± 1.9 months). Children were male (54%), white (69%), and of Latino ethnicity (47%). Cases had microtia with mandibular hypoplasia (52%), microtia only (30%), or other CFM-associated features (18%). Nearly 20% of cases had extracranial anomalies. Composite CBCL scores were in the average range compared to test norms and similar for cases and controls. On the subscales, cases' parents reported higher Anxious/Depressed scores (ES = 0.35, P = .04), Stress Problems (ES = 0.40, P = .04), Anxiety Problems (ES = 0.34, P = .04), and Autism Spectrum Problems (ES = 0.41, P = .02); however, the autism subscale primarily reflected speech concerns. Among cases, more problems were reported for children with extracranial anomalies and certain phenotypic categories with small ES. CONCLUSIONS Behavioral adjustment of preschoolers with CFM was comparable to peers. However, parental reports reflected greater concern for internalizing behaviors; thus, anxiety screening and interventions may benefit children with CFM. Among cases, more problems were reported for those with more complex presentations of CFM. Craniofacial microsomia-related speech problems should be distinguished from associated psychosocial symptoms during developmental evaluations.
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Affiliation(s)
- Alexis L Johns
- Division of Plastic and Maxillofacial Surgery, 5150Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Erin R Wallace
- Center for Child Health, Behavior, and Development, 145793Seattle Children's Research Institute, Seattle, WA, USA
| | - Brent R Collett
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Kathleen A Kapp-Simon
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA.,24183Shriners Hospitals for Children, Chicago, IL, USA
| | - Amelia F Drake
- Otolaryngology, 2331University of North Carolina, Chapel Hill, NC, USA
| | - Carrie L Heike
- Craniofacial Center, 7274Seattle Children's Hospital, Seattle, WA, USA
| | - Sara L Kinter
- Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Leanne Magee
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan Norton
- Department of Otolaryngology, University of Washington, Seattle, WA, USA
| | - Kathleen Sie
- Department of Otolaryngology, University of Washington, Seattle, WA, USA
| | - Matthew L Speltz
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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Siebold B, Heike CL, Leroux BG, Speltz ML, Drake AF, Johns AL, Kapp-Simon KA, Magee L, Luquetti DV. Evaluation of prenatal diabetes mellitus and other risk factors for craniofacial microsomia. Birth Defects Res 2019; 111:649-658. [PMID: 30927385 DOI: 10.1002/bdr2.1502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/03/2019] [Accepted: 03/13/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Craniofacial microsomia (CFM) is a congenital condition that typically involves hypoplasia of the ear and jaw. It is often associated with adverse effects such as hearing loss and sleep-disordered breathing. There is little research on its etiology. METHODS We conducted a case-control study from maternal interview data collected from mothers of infants with and without CFM. The study included 108 children with and 84 children without CFM. Logistic regression with adjustment for demographic factors was used to evaluate associations between maternal exposures of interest and risk for CFM overall, as well as for different phenotypic sub-groups of children on the CFM spectrum. RESULTS We found a statistically significant association between diabetes mellitus (DM) and CFM (OR 4.01, 95% CI 1.6-10.5). The association was slightly attenuated after adjustment for BMI. Higher parity was also associated with increased risk for CFM (OR 2.0, 95% CI 1.0-4.0). Vitamin A consumption and/or liver consumption was associated with a 70% lower risk compared with non-users (OR 0.3, 95% 0.1-0.8). Maternal age at the time of pregnancy was not associated with CFM. CONCLUSIONS These analyses contribute evidence linking maternal DM with an elevated risk of having an infant with CFM, which is consistent with previous research and adds to the body of knowledge about the strength of this association. Further study is warranted to understand the potential mechanisms underlying the effect of DM in the developing embryo.
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Affiliation(s)
- Babette Siebold
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington.,Craniofacial Division, Seattle Children's Hospital, Seattle, Washington
| | - Carrie L Heike
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington.,Craniofacial Division, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, Division of Craniofacial Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Brian G Leroux
- Department of Biostatistics, University of Washington School of Dentistry, Seattle, Washington
| | - Matthew L Speltz
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington.,Craniofacial Division, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, Division of Craniofacial Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Amelia F Drake
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Alexis L Johns
- Division of Plastic and Maxillofacial Surgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Kathleen A Kapp-Simon
- Cleft-Craniofacial Center, Shriners Hospital for Children, Chicago, Illinois.,Craniofacial Center, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Leanne Magee
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniela V Luquetti
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington.,Craniofacial Division, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, Division of Craniofacial Medicine, University of Washington School of Medicine, Seattle, Washington
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