Assessment of deformities of the lip and nose in cleft lip alveolus and palate patients by a rating scale

Nasolabial morphological changes in patients with unilateral cleft lip and palate using a Korat-modified nasoalveolar moulding appliance with primary correction

OBJECTIVE

The objective of this study is to measure the morphological changes of the nose and lip in patients with unilateral cleft lip and palate before and after cheiloplasty with primary rhinoplasty (primary correction) in conjunction with Korat-NAM usage.

DESIGN

Longitudinal cohort study.

SETTING

Cleft Center Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand.

SUBJECTS

Twenty-six patients with unilateral cleft lip and palate.

INTERVENTIONS

Control group: only active obturator before primary correction. Experimental group: an active obturator and Korat-NAM I before primary correction. A customized endotracheal tube was retained in the nostril for 3 weeks before switching to Korat-NAM II for 1 year.

MAIN OUTCOME MEASURES

Six measurements comprising nostril rim length, nostril height, nostril sill width, columella angle, vertical lip height, and horizontal lip length were measured from the patients' photographs. All measurements, except the columella angle, were reported as the cleft side/non-cleft side value ratio. Measurements were taken at the initial appointment, immediately before, 3 weeks after, and 1 year after primary correction.

RESULTS

Nostril rim length ratio, nostril height ratio, nostril sill width ratio, columella angle on the cleft side, and vertical lip height ratio were improved using Korat-NAM before and 3 weeks after primary correction. Nostril rim length and height ratios were significantly better than the control group.

CONCLUSIONS

Korat-NAM improved nose and lip morphology before primary correction. An overcorrection improved the nose and lip morphology on the cleft side. The nostril rim length and vertical lip height on the cleft side also improved with Korat-NAM II 1 year after primary correction.

Aesthetic evaluation of nasolabial reconstruction using abbe flap in bilateral cleft lip patients with secondary deformities

BACKGROUND

The Abbe flap is a common technique frequently utilized in secondary surgery for bilateral cleft lip deformities, but objective indications for the Abbe flap remain unclear, and postoperative aesthetic evaluations are limited.

METHODS

The study group consisted of 92 bilateral cleft lip patients with secondary deformities aged 7-39 years, and the control group consisted of 33 people aged 19-35 years. Thirteen objective nasolabial aesthetic parameters were selected to evaluate patients' nasolabial aesthetics.

RESULTS

Minor secondary deformities were characterized by a smaller lip height index than severe deformities, as well as a smaller columellar angle compared with moderate and severe deformities (P < 0.05). For all patients, significant differences were found between preoperative and postoperative values of intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, lip vermilion height index, lip protrusion angle, columellar-labial angle, and nasal tip angle (P < 0.05). For patients with minor deformity, intercanthal distance/philtrum width ratio and intercanthal distance/medial cutaneous upper lip height ratio showed no significant change postoperatively (P > 0.05), and labial protrusion angle was smaller than the control group (P < 0.05).

CONCLUSIONS

Patients undergoing secondary surgery using an Abbe flap achieved good nasolabial aesthetics. Intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, columellar-labial angle, nasolabial angle, nasal tip angle, and columellar angle are the objective aesthetic indicators for Abbe flap selection. Intercanthal distance/philtrum width ratio, intercanthal distance/medial cutaneous upper lip height ratio, and labial protrusion angle are reference parameters for choosing an Abbe flap for secondary bilateral cleft lip revision.

Proposed grading system of unilateral cleft lip to predict surgical challenges

Background

It is a common practice to subjectively categorize cleft lip deformities into narrow and wide cleft. The proposed grading of unilateral cleft lip can serve as a predictive factor of the difficulties to be encountered during repair and the expected outcome of surgery.

Materials and Methods

This was a 5-years retrospective study of the records of 32 patients with unilateral cleft lip that presented to a single surgical unit. We grouped the patients based on the age at surgery. We calculated the alar base width ratios of the cleft to non-cleft sides, and this was used for grading. We graded the clefts using ratio of 1.00-1.50 for mild cleft, 1.51 to 2.00 for moderate cleft, 2.01-3.00 for severe cleft, and >3.00 for extensive cleft lip.

Results

The youngest child was 1 month old, while the oldest was 50 years. Majority of the patients (17) were older than 2 years at the time of surgery. Only nine babies (28.1% of the patients) were able to have their surgery done within the age of 6 months. Those that had extensive unilateral cleft lip were 10 (31.3%). However, a total of 18 (56.3% of the patients) had cleft lips that were either mild or moderate grade.

Conclusion

This grading of unilateral cleft lip helps in objective preoperative assessment of the severity and in predicting the difficulty expected during lip repair. It is also helpful in assigning clefts to trainees and in determining which patients should be referred to an experienced surgeon.

Stability of nasal symmetry following primary cleft lip and nasal repair: five years of follow-up

Despite advances in cleft lip treatment, various levels of residual deformity remain after primary repair of cleft lip and palate. The aim of the current study was to compare the stability of short- and long-term postoperative nasal symmetry. This retrospective study included 100 consecutive non-syndromic patients with unilateral complete cleft lip who underwent primary cleft lip repair with follow-up of 5 years. Measurements taken from basal and frontal standard photograph views, obtained preoperatively (T1) and immediately (T2), 1 year (T3), and 5 years postoperative (T4), were analysed. Paired and independent t-tests were applied to assess the significance of differences and relationships, while the inter-class correlation coefficient was used to assess reliability; P < 0.05 was considered significant. The male to female ratio was 1:1; mean age at the time of surgery was 0.43 ± 0.25 years. All patients showed significant improvements following unilateral complete cleft lip repair. All variables measured at T3 revealed a significant relapse when compared to T2, except alar base position, which showed a constant mean across all postoperative follow-ups. Late relapse (T3-T4) was not significant for alar collapse, alar base position, or columellar angle (all P > 0.05). On the other hand, columellar height (P = 0.003), and nostril height (P = 0.038) and width (P = 0.007) showed significant improvements during the late relapse period. In conclusion, the majority of the relapse and changes following the nasal cleft repair occurred within the first postoperative year. However, nasal asymmetries tended to remain stable or reduced during the first 5 postoperative years.

Cleft Lip/Nasal Deformities After Plastic Surgery for Unilateral Cleft Lip/Palate: A Prospective Study at a Large Hospital in Vietnam

INTRODUCTION

Congenital cleft lip, with or without cleft palate, is the most common deformity of the face. Primary plastic surgery for rehabilitation and esthetics is important for patients and their parents; however, secondary deformities of the lip and nose can occur after the primary surgery. Therefore, we performed assessment of secondary cleft lip/nasal deformities to aid in planning of surgical repair of these deformities.

MATERIALS AND METHODS

Forty-six patients with unilateral cleft lip, with or without cleft palate, were operated with different techniques and examined post-surgery at the Department of Maxillofacial Surgery, University of Medicine and Pharmacy Hospital and Center of Odonto-Stomatology, Hue Central Hospital. They were assessed according to Motier's post-operative evaluation scale (1997), including the red lip, white lip, scars, and nose.

RESULTS

V notch and defect on the shift line were the most common deformities on the red lip (52.2%). About 34.8% of the patients had a short white lip on the cleft side. Straight and prominent scars were observed in 52.2% of the patients. The most common deformities of the nose were septal deviation (78.3%), followed by defects in the upper part of the nostril contour (78.3%), narrow sill (52.2%), and low position of the ala (47.8%).

CONCLUSION

Secondary cleft lip/nasal deformities are unavoidable. It is necessary to develop a plan for surgical repair of these deformities. There is no single method of cleft lip surgery that gives perfect results. Therefore, clinicians choose a combination of methods to bring optimal results for each patient.

Convolutional Neural Network Models for Automatic Preoperative Severity Assessment in Unilateral Cleft Lip

BACKGROUND

Despite the wide range of cleft lip morphology, consistent scales to categorize preoperative severity do not exist. Machine learning has been used to increase accuracy and efficiency in detection and rating of multiple conditions, yet it has not been applied to cleft disease. The authors tested a machine learning approach to automatically detect and measure facial landmarks and assign severity grades using preoperative photographs.

METHODS

Preoperative images were collected from 800 unilateral cleft lip patients, manually annotated for cleft-specific landmarks, and rated using a previously validated severity scale by eight expert reviewers. Five convolutional neural network models were trained for landmark detection and severity grade assignment. Mean squared error loss and Pearson correlation coefficient for cleft width ratio, nostril width ratio, and severity grade assignment were calculated.

RESULTS

All five models performed well in landmark detection and severity grade assignment, with the largest and most complex model, Residual Network, performing best (mean squared error, 24.41; cleft width ratio correlation, 0.943; nostril width ratio correlation, 0.879; severity correlation, 0.892). The mobile device-compatible network, MobileNet, also showed a high degree of accuracy (mean squared error, 36.66; cleft width ratio correlation, 0.901; nostril width ratio correlation, 0.705; severity correlation, 0.860).

CONCLUSIONS

Machine learning models demonstrate the ability to accurately measure facial features and assign severity grades according to validated scales. Such models hold promise for the creation of a simple, automated approach to classifying cleft lip morphology. Further potential exists for a mobile telephone-based application to provide real-time feedback to improve clinical decision making and patient counseling.

Unilateral Cleft Lip Repair Using the Chang Gung Technique: An Outcome Analysis

OBJECTIVE

This retrospective study analyzed the outcomes of patients undergoing complete or incomplete unilateral cleft lip repair using the Chang Gung technique. The goal was to compare the symmetry and change of the technique through the measurement of anthropometric points on digital photographs.

METHODS

From 2010 to 2016, a total of 274 complete and incomplete cleft lip patients without other craniofacial deformities were included in the study. All included patients had a minimum 1-year follow-up with frontal view photographs taken. The vermilion area, lip width, vermilion height, lateral lip length, lip height, and Cupid's bow width of both cleft and noncleft sides were measured for all patients. The Cleft Lip Component Symmetry Index was used to determine the symmetry of the cleft and noncleft sides in both incomplete and complete cleft groups.

RESULTS

A total of 152 complete and 122 incomplete cleft lip patients were included in the study. The mean Cleft Lip Component Symmetry Index values showed that the vermilion area, lip height, and Cupid's bow width were symmetric on both cleft and noncleft sides. Lip width and lateral lip length were noted to be shorter, whereas the vermilion height was thicker on the cleft side than on the noncleft side. Significant differences between the complete and incomplete cleft group measurements were found for lateral lip length and lip height, and complete cleft measurements were shorter than those for incomplete clefts. There were no significant differences in vermilion area, lip width, vermilion height, and Cupid's bow width.

CONCLUSIONS

The outcome analysis showed that vermilion height reduction and modifications could be made for both complete and incomplete groups. The complete cleft lip has been found to have a significantly shorter lateral lip length and lip height, reflecting a more severe anatomical soft tissue deficiency in this group. A long-term outcome anthropometric point study may further verify the results of this surgical technique.

Validation of the Hubli Grading System for Assessing Unilateral and Bilateral Cleft Lip Outcomes

BACKGROUND

When determining whether a cleft lip repair outcome is acceptable, the severity of a patient's cleft at initial presentation must be considered. Currently, there is not a widely agreed upon scale for grading the pre-operative severity or post-operative surgical outcome for patients with unilateral and/or bilateral cleft lip. The aim of this study is to validate the Hubli grading system as a reliable and reproducible system for characterizing cleft lip repair outcomes.

METHODS

Craniofacial surgeon graders independently evaluated 2489 patients from 56 different countries undergoing both unilateral and bilateral cleft lip repair from April 2004 to December 2018. Preoperative severity and postoperative surgical results were assessed, and these grades were combined to determine surgical outcome acceptability based on initial cleft severity. Intrarater and interrater reliability were calculated as percentages of agreement.

RESULTS

Intrarater and interrater acceptability scores had an agreement of 94.50% and 87.04%, respectively. These results indicate that using the Hubli grading system, independent raters are able to reliably and reproducibly measure the acceptability of a cleft lip repair.

CONCLUSIONS

This study validates the use of the Hubli grading system to evaluate the acceptability of unilateral and bilateral cleft lip repairs. This is the largest study to date to evaluate cleft lip severity and repair outcomes, and the Hubli grading system is the only scale to determine the acceptability of surgical outcomes based on initial cleft severity. This system is designed to identify surgeons with sub-optimal outcomes in order to implement timely, individualized training on a global scale.

Breaking Symmetry: A Quantitative Analysis of Facial Skeleton Disharmony in Children Born with Bilateral Cleft Lip and Palate

Bilateral cleft lip and palate (BCLP) occurs when craniofacial precursors fail to form or fuse properly during development. The aim of this retrospective, cross-sectional investigation was to quantify directional asymmetry (DA) of the facial skeleton of children born with Veau Class IV nonsyndromic BCLP. To accomplish this goal, coordinate values of anatomical landmarks were acquired from three-dimensional cone beam computed tomographic images of the craniofacial skeleton of middle- to late-aged children born with BCLP and age- and sex-matched controls and used to compare patterns of asymmetry variation. Multivariate analyses revealed different patterns of DA variation across samples and identified approximately 30% of DA measures as significantly different. Magnitudes of statistically significant linear distances differ in the craniofacial region, with most smaller DA differences located near the orbits and frontal bone, while larger differences were localized mostly to the midface, alveolar ridge, and nasal borders. Generally, areas of the craniofacial skeleton derived from the maxillary and nasal prominences demonstrated the highest magnitudes of DA. The methods and results presented will be useful to biomedical researchers when identifying the extent to which patients with BCLP diverge from typical developmental expectations. Quantifying DA and assessing local differences across the craniofacial complex can aid medical practitioners when developing treatments to improve BCLP surgical algorithms and outcomes. Anat Rec, 302:1726-1732, 2019. © 2019 American Association for Anatomy.

Facial and Nasolabial Aesthetics of Complete UCLP Submitted to 2-Stage Palate Repair With Vomer Flap

OBJECTIVE

To evaluate the aesthetics of nasolabial appearance and facial profile of children with unilateral cleft lip and palate (UCLP) submitted to 2-stage palate repair with vomerine flap.

DESIGN

Retrospective.

SETTING

Single center.

PATIENTS

Forty patients with UCLP, mean age of 7.81 years of both sexes, rehabilitated at a single center by 1 plastic surgeon.

INTERVENTIONS

Lip and anterior palate repair with nasal alar repositioning was performed at 3 to 6 months of age by Millard technique and vomer flap, respectively. Posterior palate was repaired at 18 months by Von Langenbeck technique.

MAIN OUTCOME MEASURE(S)

Four cropped digital facial photographs of each patient were evaluated by 3 orthodontists to score the nasolabial aesthetics and profile. Frequencies of each score as well means and medians were calculated. Kappa test was used for evaluating inter- and intrarater reproducibility.

RESULTS

The nasal form and deviation was scored as good/very good in 70%, fair in 22.5%, and poor in 7.5% of the sample. The nasal-subnasal aesthetic was considered good/very good in 55%, fair in 30%, and poor in 15% of the sample. The lip vermilion border and the white part of surgical scar aesthetics were good/very good in 77.5% and 80%, fair in 17.5% for both categories, and poor in 5% and 2.5% of the cases, respectively. In all, 67.5% showed convex facial profile, 20% was straight, and 12.5% was concave profile.

CONCLUSIONS

Two-stage palatoplasty presented an adequate aesthetical results for the majority of patients with UCLP in the mixed dentition.

Validation of a Unilateral Cleft Lip Surgical Outcomes Evaluation Scale for Surgeons and Laypersons

BACKGROUND

A standardized evaluation tool is needed for the assessment of surgical outcomes in cleft lip surgery. Current scales for evaluating unilateral cleft lip/nose (UCL/N) aesthetic outcomes are limited in their reliability, ease of use, and application. The Unilateral Cleft Lip Surgical Outcomes Evaluation (UCL SOE) scale measures symmetry of 4 components and sums these for a total score. The purpose of this study was to validate the SOE as a reliable tool for use by both surgeons and laypersons.

METHODS

Twenty participants (9 surgeons and 12 laypeople) used the SOE to evaluate 25 sets of randomly selected presurgical and postsurgical standardized photographs of UCL/N patients. Interrater reliability for surgeon and laypeople was determined using an intraclass correlation coefficient (ICC).

RESULTS

Individual surgeons and laypeople both reached an ICC in the "fair to good" range (ICC = 0.42 and 0.59, respectively). Averaging 2 evaluators in the surgeon group improved the ICC to 0.58 and in the laypeople group to 0.74, respectively. Averaging 3 evaluators increased the ICC for surgeons to the "good" range (ICC = 0.71) and the ICC for laypeople to the "very good" range (ICC = 0.82).

CONCLUSIONS

Surgeon and layperson raters can reliably use the SOE to assess the aesthetics results after surgical repair of UCL/N, and improved reliability and reproducibility is achieved by averaging the scores of multiple reviewers.

Validation of the Unilateral Cleft Lip Severity Index for Surgeons and Laypersons

BACKGROUND

Severity of the primary unilateral cleft lip/nose deformity (UCL/N) is postulated to play a key role in postoperative complications, aesthetic result, and need for secondary surgery. There is no validated and widely accepted classification scheme of initial cleft severity. The purpose of this study was to validate the Unilateral Cleft Lip Cleft Severity Index as a reliable tool for evaluating presurgical UCL/N deformity by both surgeons and laypersons.

METHODS

Twenty-five participants (10 surgeons and 15 laypeople) evaluated 25 sets of randomly selected presurgical standardized photographs of UCL/N patients. Each participant rated patients on a scale of 1-4 using the Cleft Severity Index. Interrater reliability for surgeons, laypersons, and all participants was determined using an intraclass correlation coefficient. Histograms and regression analysis were performed to compare average ratings between groups.

RESULTS

Interrater reliability for all groups was classified as "very good" determined by intraclass correlation coefficients of 0.837 (laymen), 0.885 (surgeons), and 0.848 (all participants). These results indicate that there was a high degree of interrater across all 3 groups and that both surgeons and laypersons can reliability rate cleft severity using the Cleft Severity Index.

CONCLUSIONS

This study validates the use of the Cleft Severity Index by both surgeons and laypersons as a reliable tool for evaluating the degree of presurgical severity of patients with UCL/N. The Unilateral Cleft Lip Cleft Severity Index can thus serve as a reproducible and reliable grading system for primary UCL/N deformity and to categorize patients for future outcomes studies.

Postoperative alar base symmetry in complete unilateral cleft lip and palate:A prospective study

In the evolution of cleft lip repair, there have been continuous attempts to minimize local trauma and to improve lip and nasal appearances. In order to obtain an aesthetically balanced development of midface, the primary surgical correction of the nasolabial area is of paramount importance. In this study, the importance of a back-cut extending cephalically above the inferior turbinate at the mucocutaneous junction which elevates the nostril floor on the cleft side for the purpose of achieving symmetry of the alar bases are analyzed by pre and postoperative photographic anthropometry. This study comprised of fifty cases of the unilateral complete cleft lip. At the time of surgery, the patient age ranged from 3-9 months. The surgeries, performed by a single surgeon, employed the standard Millard technique, incorporating Mohler modifications of lip repair. Anthropometric analysis revealed that the preoperative mean difference between the normal side and the cleft side was 0.2056 with a standard deviation of 0.133. In the postoperative analysis, the mean difference was reduced to 0.0174 with a standard deviation of 0.141. The paired t-test showed that the p-value is <0.001, indicating high statistical significance. To conclude, in complete unilateral cleft lip and palate, the geometrically placed nasal back-cut incision has a definite role in the correction of the alar base symmetry during primary surgery.

Outcomes of Primary Unilateral Cheiloplasty in Same-Day Surgical Settings

BACKGROUND

Financial, clinical, and psychological considerations have made same-day surgery an attractive option for a variety of procedures. This article aimed to analyse the postoperative results of same-day primary unilateral cleft nasolabial repair.

METHODS

This study was performed from 2011 to 2014. Unilateral cleft lip patients fulfilling the inclusion criteria were preoperatively classified as mild, moderate, and severe. All patients underwent same-day surgery and were discharged after satisfying the appropriate clinical criteria, receiving thorough counselling, and the establishment of a means of communication by phone. Postoperative outcomes were assessed and stratified according to preoperative severity and the type of repair.

RESULTS

A total of 423 primary unilateral cleft lip patients were included. Fisher's anatomical subunit approximation technique was the most common procedure, followed by Noordhoff's technique. The postoperative outcome was good in 89.8% of cases, fair in 9.9% of cases, and poor in 0.2% of cases. The complication rate was 1.18% (n=5), and no instances of mortality were observed. The average hospital stay was 7.5 hours, leading to a cost reduction of 19% in comparison with patients who stayed overnight for observation.

CONCLUSIONS

Mild unilateral cleft lip was the most common deformity for which Fisher's anatomical subunit approximation technique was performed in most of the cases, with satisfactory postoperative outcomes. Refinements in the cleft rhinoplasty techniques over the course of the study improved the results regarding cleft nasal symmetry. Single-day primary unilateral cleft cheiloplasty was found to be a cost-effective procedure that did not pose an additional risk of complications.

Analysis of alar balance in secondary cleft lip with Z-plasty technique of nasal cartilage

The cleft nasal deformity is a prevailing problem of complex challenge for plastic surgery, especially in the secondary correction. We mainly chose 40 patients with unilateral secondary cleft lip nasal deformity with alar collapse. Based on biomechanics and anatomy of nasal cartilage, we adapt a Z-plasty with cartilage mucosa using the deformed lateral crus of the upper lateral cartilage to support the collapse of lower lateral cartilage. All of our patients were satisfied with the aesthetic morphology after surgery, so we are confident that this method should be considered as an auxiliary treatment to rhinoplasty.