A 4-month-old female infant presented for a well-child visit. Her parents were concerned about the left side of her face. Since birth, she had an asymmetrical smile, and her left eye could not be closed and had excessive tear production. She was otherwise healthy and met all developmental milestones.

The infant was born at 38 weeks of gestation by uncomplicated spontaneous vaginal delivery to a multiparous mother. Labor was induced due to the mother's chronic hypertension and uncontrolled type 2 diabetes that required insulin. With oxytocin augmentation, labor lasted 13 hours, with less than 1 hour of pushing. During birth, the infant aspirated meconium, which required deep suctioning and positive pressure ventilation for 8 minutes. Apgar scores were 6, 7, and 9 (at 1, 5, and 10 minutes, respectively), and birth weight was 3,530 g (76th percentile). Initially, she had difficulty feeding but had been eating well and gaining weight appropriately for the past few months.

On examination, the infant had a flat left nasolabial fold, did not fully close the left eye when closing the right eye, and had asymmetrical forehead wrinkling (Figure 1). Her extraocular movements were intact, and her pupils were equal and reactive to light. Magnetic resonance imaging of the brain showed no abnormality.