[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 54.159.197.114. Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Download PDF
Figure 1.
Assessment of frontalis hyperkinetic facial lines with the Rated Numeric Kinetic Line Scale (RNKLS): A, RNKLS 0; B, RNKLS 1; C, RNKLS 2; D, RNKLS 3; E, RNKLS 4.

Assessment of frontalis hyperkinetic facial lines with the Rated Numeric Kinetic Line Scale (RNKLS): A, RNKLS 0; B, RNKLS 1; C, RNKLS 2; D, RNKLS 3; E, RNKLS 4.

Figure 2.
Assessment of corrugator hyperkinetic facial lines with the Rated Numeric Kinetic Line Scale (RNKLS): A, RNKLS 0; B, RNKLS 1; C, RNKLS 2; D, RNKLS 3; E, RNKLS 4.

Assessment of corrugator hyperkinetic facial lines with the Rated Numeric Kinetic Line Scale (RNKLS): A, RNKLS 0; B, RNKLS 1; C, RNKLS 2; D, RNKLS 3; E, RNKLS 4.

Figure 3.
Assessment of orbicularis oculi hyperkinetic facial lines with the Rated Numeric Kinetic Line Scale (RNKLS): A, RNKLS 0; B, RNKLS 1; C, RNKLS 2; D, RNKLS 3; E, RNKLS 4.

Assessment of orbicularis oculi hyperkinetic facial lines with the Rated Numeric Kinetic Line Scale (RNKLS): A, RNKLS 0; B, RNKLS 1; C, RNKLS 2; D, RNKLS 3; E, RNKLS 4.

Rated Numeric Kinetic Line Scale Scores for Facial Wrinkles Secondary to Hyperkinetic Function
Rated Numeric Kinetic Line Scale Scores for Facial Wrinkles Secondary to Hyperkinetic Function
1.
Kligman  AMZheng  PLavker  RM The anatomy and pathogenesis of wrinkles Br J Dermatol. 1985;11337- 42
PubMedArticle
2.
Maas  CSDenton  AB Synthetic soft tissue substitutes: 2001 Facial Plast Surg Clin North Am. 2001;9219- 227
PubMed
3.
Monheit  GDChastain  A Chemical peels Facial Plast Surg Clin North Am. 2001;9239- 255
PubMed
4.
Roberts  TL  IIIEllis  LB In pursuit of optimal rejuvenation of the forehead: endoscopic brow lift with simultaneous carbon dioxide laser resurfacing Plast Reconstr Surg. 1998;1011075- 1084
PubMedArticle
5.
Zimbler  MSHolds  JBKokoska  MS  et al.  Effect of botulinum toxin pretreatment on laser resurfacing results: a prospective, randomized, blinded trial Arch Facial Plast Surg. 2001;3165- 169
PubMedArticle
6.
Daniell  HW Smoker's wrinkles: a study in the epidemiology of "crow's feet" Ann Intern Med. 1971;75873- 880
PubMedArticle
7.
Lowe  NJMaxwell  AHarper  H Botulinum A exotoxin for glabellar folds: a double-blind, placebo-controlled study with an electromyographic injection technique J Am Acad Dermatol. 1996;35569- 572
PubMedArticle
8.
Blitzer  ABrin  MFKeen  MSAviv  JE Botulinum toxin for the treatment of hyperfunctional lines of the face Arch Otolaryngol Head Neck Surg. 1993;1191018- 1022
PubMedArticle
9.
Foster  JABarnhorst  DPapay  FOh  PMWulc  AE The use of botulinum A toxin to ameliorate facial kinetic frown lines Ophthalmology. 1996;103618- 622
PubMedArticle
10.
Bikhazi  NBMaas  CS Refinement in the rehabilitation of the paralyzed face using botulinum toxin Otolaryngol Head Neck Surg. 1997;117303- 307
PubMedArticle
11.
Blitzer  ABinder  WJAviv  JEKeen  MSBrin  MF The management of hyperfunctional facial lines with botulinum toxin: a collaborative study of 210 injection sites in 162 patients Arch Otolaryngol Head Neck Surg. 1997;123389- 392
PubMed
12.
Ahn  KYPark  MYPark  DHHan  DG Botulinum toxin A for the treatment of facial hyperkinetic wrinkle lines in Koreans Plast Reconstr Surg. 2000;105778- 784
PubMedArticle
13.
Keen  MBlitzer  AAviv  J Botulinum toxin A for hyperkinetic facial lines: results of a double-blind, placebo-controlled study Plast Reconstr Surg. 1994;9494- 99
PubMedArticle
14.
Ahn  MSCatten  MMaas  CS Temporal brow lift using botulinum toxin A. Plast Reconstr Surg. 2000;1051129- 1135discussion 1136-1139
PubMedArticle
15.
Heckmann  MSchon-Hupka  G Quantification of the efficacy of botulinum toxin type A by digital image analysis J Am Acad Dermatol. 2001;45508- 514
PubMedArticle
16.
Grove  GLGrove  MJLeyden  JJ Optical profilometry: an objective method for quantification of facial wrinkles J Am Acad Dermatol. 1989;21631- 637
PubMedArticle
17.
Landis  JRKoch  GG The measurement of observer agreement for categorical data Biometrics. 1977;33159- 174
PubMedArticle
18.
Landis  JRKoch  GG An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers Biometrics. 1977;33363- 374
PubMedArticle
19.
Ramirez  ALReeck  JMaas  CS Botulinum toxin type B (Myobloc) in the management of hyperkinetic facial lines Otolaryngol Head Neck Surg. 2002;126459- 467
PubMedArticle
Citations 0
Original Article
July 2004

A Validated Rating Scale for Hyperkinetic Facial Lines

Author Affiliations

From the Division of Facial Plastic Surgery, University of California, San Francisco.

 

From the Division of Facial Plastic Surgery, University of California, San Francisco.

Arch Facial Plast Surg. 2004;6(4):253-256. doi:10.1001/archfaci.6.4.253
Abstract

Objective  To test the reliability of a simple rating system to describe hyperkinetic facial lines.

Methods  A rated numeric kinetic line scale was developed and presented to 11 postresidency physicians specializing in aesthetic facial care. These physicians independently reviewed photographs of 20 patients, first at rest, then with activation of the frontalis, corrugator, and orbicularis oculi muscles. Kappa statistics for multiple raters were used to assess interobserver reliability.

Results  The nonweighted κ values were between 0.4 and 0.8 for the frontalis, corrugator, and orbicularis muscle groups. This represents moderate to substantial observer agreement and is highly significant for each muscle group.

Conclusions  A new rating scale for hyperkinetic facial lines accounts for facial appearance at rest and with expression. It is easily used and has interobserver reliability. As the only objective and validated scale for hyperkinetic facial lines, this rated numeric kinetic line scale is recommended for the evaluation of pretreatment and posttreatment results in patients undergoing therapy for this problem. Moreover, an alternative scale rating resting and kinetic lines as independent variables is also being developed. Both must be considered to evaluate treatment outcomes when using neurotoxins.

Hyperkinetic facial lines are visible signs of facial aging. They arise largely from repetitive contraction of underlying facial muscles and can lead to changes in the elastic properties of the dermis.1 Multiple modalities exist for the aesthetic treatment of this problem, including chemical peels, soft tissue fillers, surgical procedures, and muscle paralysis.2-5 Studies of hyperkinetic facial lines require a system for documenting appearance and change in appearance of the lines.

Multiple subjective evaluation systems appear in the literature. One of the first reported grading systems for facial lines used a 6-point scale to rate "crows' feet" in habitual smokers.6 Studies of botulinum toxin type A for hyperkinetic facial lines have also used subjective rating scales for evaluation. These studies, however, are difficult to compare because a single evaluation system has not been used or validated. In addition, these rating scales do not assess both resting state and dynamic activity. Assessment systems have included patient-rated as well as physician-rated schemata.7-13

Objective measures with quantitative assessment have also been used to evaluate hyperkinetic facial lines. These include computer-assisted and direct measurements of brow mobility and optical profilometry.14-16 The utility of these techniques in clinical practice is undermined by significant equipment requirements and specialized training. A MEDLINE review of the English-language articles published from 1966 to 2002 showed no validated rating scales for the assessment of hyperkinetic facial lines.

A need for a reliable rating system exists for several reasons. A common diagnostic tool would create a clear, definable language for discussion with colleagues and patients and enhance research by providing a single evaluation method to compare data between studies. Additionally, after significant data are compiled, a single evaluation tool for hyperkinetic facial lines could provide a method for treatment stratification of patients.

The ideal rating system for hyperkinetic facial lines would be easy to use, noninvasive, allow for repeated evaluations, and show interobserver reliability. In addition, this rating system would account for the dynamic nature of hyperkinetic facial lines as subjects are evaluated at rest and with effort of the facial musculature. We developed a rating system for hyperkinetic facial lines and tested its reliability.

METHODS

The Rated Numeric Kinetic Line Scale (RNKLS) was developed to rate hyperkinetic facial lines in the context of facial expression (Table 1). Dermal lines or lines of relaxed skin tension are excepted from the scale as they are not secondary to hyperkinetic function. A PowerPoint (Microsoft Corp, Redmond, Wash) slide presentation was created for each of the 3 muscle groups: frontalis, corrugator, and orbicularis oculi. Each presentation explained the rating system, showed photographic examples of each score (RNKLS 0-4), and presented a series of 20 subjects at rest and with expression (Figure 1, Figure 2, and Figure 3). Eleven postresidency physicians specializing in aesthetic facial care reviewed the presentations and independently assigned RNKLS scores to each series of 20 photographs.

Interobserver reliability was analyzed using a nonweighted κ statistic for each of the 3 muscle groups. Nonweighted κ statistics measure interobserver agreement and represent a standard method for evaluating reliability among multiple raters. More specifically, they test whether there is more agreement between observers than can be expected by chance.17-18

RESULTS

Nonweighted κ statistics for the 11 observers' hyperkinetic facial lines caused by the frontalis, corrugator, and orbicularis oculi muscles are shown in the following tabulation:Article

As κ scores approach 1.0, the degree of interobserver agreement increases. Although arbitrary, κ statistics are labeled according to ranges originally described by Landis and Koch.18 They are poor (<0.00), slight (0.00-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), and almost perfect (0.81-1.00). The frontalis ratings (0.64) showed substantial interobserver agreement. The corrugator (0.52) and orbicularis (0.43) both yielded moderate levels of agreement. All 3 series were highly statistically significant (P<.001).

COMMENT

The RNKLS has demonstrated moderate to substantial reliability among observers, with high statistical significance. In this series, the rating for the frontalis group showed relatively higher interobserver agreement than the ratings for the corrugator and the orbicularis oculi groups. This finding may indicate that this site is easier to categorize within the RNKLS.

It should be stressed that one of the advantages of the RNKLS is to allow evaluation of patients both at rest and with expression. Since hyperkinetic facial lines by definition are a function of muscle contraction, the ability of the RNKLS to take this into account makes it a more useful instrument. By easily learning how to use the scale with a simple set of instructions and examples, the observers demonstrated its ease of use. Objective measures such as computer-assisted measurements or optical profilometry are more tedious to achieve, more expensive, and more difficult to learn.

We believe that the RNKLS is a valuable tool for the assessment of hyperkinetic facial lines. It has potential as a highly useful rating system. We used the RNKLS successsfully in the study of botulinum toxin type B (MyoBloc) and in our pilot study.19 The former showed the RNKLS to correlate with age in patients treated with botulinum toxin type B. In short, the RNKLS is valuable to assess outcome measures, especially in prospective studies on hyperkinetic facial lines and their treatment. However, a scale used for outcome measures of treatments using neurotoxins should take into account resting and dynamic facial lines, and one is being developed.

Back to top
Article Information

Correspondence: Corey S. Maas, MD, The Maas Clinic, 2400 Clay St, San Francisco, CA 94115 (drmaas@drmass.com).

Accepted for publication April 14, 2004.

This work was presented at the Eighth International Symposium of Facial Plastic Surgery; May 3, 2002; New York, NY.

We thank Charles E. McCulloch, PhD, for the statistical analysis.

References
1.
Kligman  AMZheng  PLavker  RM The anatomy and pathogenesis of wrinkles Br J Dermatol. 1985;11337- 42
PubMedArticle
2.
Maas  CSDenton  AB Synthetic soft tissue substitutes: 2001 Facial Plast Surg Clin North Am. 2001;9219- 227
PubMed
3.
Monheit  GDChastain  A Chemical peels Facial Plast Surg Clin North Am. 2001;9239- 255
PubMed
4.
Roberts  TL  IIIEllis  LB In pursuit of optimal rejuvenation of the forehead: endoscopic brow lift with simultaneous carbon dioxide laser resurfacing Plast Reconstr Surg. 1998;1011075- 1084
PubMedArticle
5.
Zimbler  MSHolds  JBKokoska  MS  et al.  Effect of botulinum toxin pretreatment on laser resurfacing results: a prospective, randomized, blinded trial Arch Facial Plast Surg. 2001;3165- 169
PubMedArticle
6.
Daniell  HW Smoker's wrinkles: a study in the epidemiology of "crow's feet" Ann Intern Med. 1971;75873- 880
PubMedArticle
7.
Lowe  NJMaxwell  AHarper  H Botulinum A exotoxin for glabellar folds: a double-blind, placebo-controlled study with an electromyographic injection technique J Am Acad Dermatol. 1996;35569- 572
PubMedArticle
8.
Blitzer  ABrin  MFKeen  MSAviv  JE Botulinum toxin for the treatment of hyperfunctional lines of the face Arch Otolaryngol Head Neck Surg. 1993;1191018- 1022
PubMedArticle
9.
Foster  JABarnhorst  DPapay  FOh  PMWulc  AE The use of botulinum A toxin to ameliorate facial kinetic frown lines Ophthalmology. 1996;103618- 622
PubMedArticle
10.
Bikhazi  NBMaas  CS Refinement in the rehabilitation of the paralyzed face using botulinum toxin Otolaryngol Head Neck Surg. 1997;117303- 307
PubMedArticle
11.
Blitzer  ABinder  WJAviv  JEKeen  MSBrin  MF The management of hyperfunctional facial lines with botulinum toxin: a collaborative study of 210 injection sites in 162 patients Arch Otolaryngol Head Neck Surg. 1997;123389- 392
PubMed
12.
Ahn  KYPark  MYPark  DHHan  DG Botulinum toxin A for the treatment of facial hyperkinetic wrinkle lines in Koreans Plast Reconstr Surg. 2000;105778- 784
PubMedArticle
13.
Keen  MBlitzer  AAviv  J Botulinum toxin A for hyperkinetic facial lines: results of a double-blind, placebo-controlled study Plast Reconstr Surg. 1994;9494- 99
PubMedArticle
14.
Ahn  MSCatten  MMaas  CS Temporal brow lift using botulinum toxin A. Plast Reconstr Surg. 2000;1051129- 1135discussion 1136-1139
PubMedArticle
15.
Heckmann  MSchon-Hupka  G Quantification of the efficacy of botulinum toxin type A by digital image analysis J Am Acad Dermatol. 2001;45508- 514
PubMedArticle
16.
Grove  GLGrove  MJLeyden  JJ Optical profilometry: an objective method for quantification of facial wrinkles J Am Acad Dermatol. 1989;21631- 637
PubMedArticle
17.
Landis  JRKoch  GG The measurement of observer agreement for categorical data Biometrics. 1977;33159- 174
PubMedArticle
18.
Landis  JRKoch  GG An application of hierarchical kappa-type statistics in the assessment of majority agreement among multiple observers Biometrics. 1977;33363- 374
PubMedArticle
19.
Ramirez  ALReeck  JMaas  CS Botulinum toxin type B (Myobloc) in the management of hyperkinetic facial lines Otolaryngol Head Neck Surg. 2002;126459- 467
PubMedArticle
×