Concerning the Article Entitled "Judgment of Nasolabial Esthetics in Cleft Lip and Palate is Not Influenced by Overall Facial Attractiveness"
Venue: The Cleft palate craniofacial journal official publication of the American Cleft Palate Craniofacial Association

With much interest we read the article by Kocher et al. (2016) The authors argue that cropping facial images seems unnecessary for assessing the nasolabial appearance of children with a complete unilateral cleft lip and palate. This article did raise some questions regarding the methods and used statistics. First of all, we find it a complicated design. A different group of judges was used to score only the nose and lip comparedwith the other ratings. Presumably, thiswas done so the latter group would not realize that the clefts in the fused images were from other patients. However, in this way judges were determining the effect of a cleft on facial attractiveness instead of the other way around. The fact that facial esthetics were judged instead of nasolabial esthetics demonstrates this as well. Besides, out of the 60 available photographs of both cleft and noncleft patients, only six photographs of boys and six of girls were used to create the fused images,making it prone to selection bias. In our opinion, a better method to test the effect of overall facial attractiveness is to compare the scores of the nasolabial area with both full face photographs and cropped photographs. To evaluate if an assessment method is reliable, mostly kappa statistics, intraclass correlation coefficients (ICCs) and Cronbach alphas are used (Mosmuller et al. 2013) The Cronbach alpha used as a correlation coefficient shows the interobserver score of all observers together; in this study it was four or eight. Single observer reliability is calculated with ICC or kappa statistics (de Vet et al. 2011) For the AsherMcDade aesthetic rating scale it is known that the single interobserver reliability lies around 0.60 and the intraobserver reliability is around 0.70 (Asher McDade et al. 1991; Mercado et al. 2015; Mosmuller et al. 2015) The very high ICC (0.90) in this study needs to be questioned since in our experience, and in looking at earlier publications, it is very unlikely that the interobserver reliability is this high when eight different observers judge 72 photographs with a visual analog scale. As described by the authors, an explanation for these high scores could be that only 12 component images were used to create the fused images, therefore contributing to a strong memory effect. The article states that the raters were not informed about the manipulation of the photographs. However, the raters could return to previous slides to compare photographs if needed, which makes the method of scoring inconsistent and increases the likelihood that they noticed the duplicates during the rating process.Moreover, only the ICC is mentioned for the assessment of the fused images and not for the other ratings. This raises questions as to whether this implies that the ICC scores for the other ratings were insufficient. The authors point out that the difference in perception of facial attractiveness in patients with andwithout a cleftmay be the result of the way they are viewed. It is rather obvious that more attention is drawn to the nasolabial area in patients with cleft lip and palate. In our opinion this has nothing to do with difference of perception but with the attention drawn by the defect itself. Although it is an interesting outlook, this does not prove that the surrounding features are not influencing the rating in patients with cleft. Multiple earlier studies have shown that surrounding features, such as eye color, hairstyle, jewelry, and glasses, influence ratings and that full face photographs are judged to bemore attractive (Tobiasen, 1989; Asher McDade et al. 1991; Prahl et al. 2006) Later, the article states that cropping the photographs is a complicated and time consuming process. However, with some experience using Photoshop, cropping two dimensional photographs is rather easy and fast. When threedimensional photographs are used this might be more complicated, but should in time pose no problem either. Apart from surrounding features possibly influencing the ratings, cropping is also done to keep the photographs anonymous. Moreover, when using full face photographs the nasolabial area is a smaller part of the image, making it less visible and thus harder to judge properly. In conclusion, we believe cropping is still necessary. This article lacks good methodology and statistics to come to a conclusive decision regarding cropping in patients with cleft lip and palate. In addition, cropping has practical benefits, such as being able to enlarge the nasolabial area in the photograph and keeping the patient anonymous. We suggest that further research be done before full face Submitted December 2015;   10.1597/15 343