Outcomes in facial aesthetics in cleft lip and palate surgery: a systematic review

Condylar Volumetric Asymmetry Predicts Need for Surgical Intervention in Patients With Cleft Lip and/or Palate

OBJECTIVE

In this study, the authors investigate the associations between the mandibular condyle and facial asymmetry in patients with cleft lip and/or palate (CLP).

METHODS

Condylar volume was calculated by measuring the bony volume of the posterior mandible superior to the sigmoid notch in skeletally mature patients with CLP and controls. Relationships between condylar asymmetry, facial deviation, and malocclusion were compared using t-tests, correlation analysis, and receiver operating characteristic curves.

RESULTS

This study included 118 patients: 60 with CLP preparing for orthognathic surgery, 17 with CLP who did not undergo orthognathic surgery, and 41 controls. Condylar volumes in patients with CLP preparing for orthognathic surgery were more asymmetric than those with CLP not requiring surgery (16.4 ± 17.4% vs 7.1 ± 6.0%, P = 0.03). Patients with CLP who did not undergo orthognathic surgery and controls had similar degrees of condylar asymmetry (7.1 ± 6.0% vs 5.9 ± 3.8%, P = 0.35). Condylar asymmetry correlated with chin deviation (P < 0.01). Patients with CLP and clinically significant chin deviation (>4 mm) had more asymmetric condyles than those without significant chin deviation, and the chin usually deviated toward the smaller condyle (P = 0.03). Condylar asymmetry >11% predicted undergoing orthognathic surgery in CLP with 70% sensitivity and 67% specificity.

CONCLUSION

Condylar asymmetry is associated with facial asymmetry in patients with CLP, and the facial midline often deviates towards the smaller condyle. Condylar volumetric asymmetry in patients with CLP may be a predictor for needing orthognathic surgery, useful information for surgeons and families alike.

Evaluation of a Novel Objective Method for The Assessment of Nasal Symmetry Among Patients with Unilateral Cleft Lip

OBJECTIVE

This is a cross sectional study aimed to asses novel semi objectve compter assisted method to asses the symmetry amog unilateral cleft lip patients.

DESIGN

using Standard inferior view nose photos that were uploaded to Digimizer© Version 4.6.1 (2005-2016 MedCalc Software) Image Analysis, symmetry percentage was calculated and compared between cleft and non-cleft neonates. This method was compared to two subjective methods of rating symmetry.

SETTING

This a cross sectional pilot study performed in the Univresity Medical Center using standard inferior views of unilateral cleft patients which were compared to non-cleft neonates.

PATIENTS

Photographs of 71 neonates with unilateral complete and incomplete cleft lip and 30 neonates without facial cleft, which were born at the university medical center, Beer Sheba, Israel, were analyzed in a standard manner to determine nasal symmetry.

MAIN MEASURES

the novel method proposed produced a nominal value for percentage of symmetry.

RESULTS

Using Pearson's correlation test we found intra-rater reliability of 91.2% (p < 0.001) and Inter-rater reliability of 82.9% (p < 0.001). The analysis correlated with the surgeons subjective scores in both the numerical ranking method at 73% (p < 0.001) and 72.6% (p < 0.001) and the Ordinal ranking method at 87.6% (p < 0.001) and 77.7% (p < 0.001). The ability of the method to discriminate healthy from Cleft Lip patients overall was 92.3% With high sensitivity and specificity.

CONCLUSIONS

This method accurately distinguishes healthy patients from cleft lip patients. We have achieved High levels of inter and intra-rater reliability. Significant correlations were found between our semiobjective method and the subjective scores.

Cleft Lip and Palate Correction: The Utah Protocol

Background

Cleft repair remains a contentious issue in craniofacial surgery, especially regarding the optimal timing and techniques. This study aims to present our institutions' current protocol for cleft lip and palate repair, including alveolar bone grafting (ABG).

Methods

A total of 17 patients (20 clefts) treated with the latest protocol from 2016 to 2023 were evaluated. Demographic and clinical data were obtained from electronic charts. The protocol includes lip repair at 3 months, soft palate repair at 1 year, and hard palate closure with concurrent ABG at 2 years.

Results

Mean graft height and thickness scores were 2.3 and 2.2, respectively. Three clefts showed scores marginally below the threshold for thickness, potentially requiring regrafting. Malocclusion was minimal with no significant crossbites or velopharyngeal insufficiency.

Conclusions

Our modified protocol, emphasizing early hard palate closure with ABG, yields satisfactory outcomes in terms of graft height and thickness. Although long-term follow-up is warranted, our approach seems safe and efficient, potentially improving outcomes compared with traditional methods.

Patient-reported outcomes in Irish adolescents who were born with cleft lip and palate

BACKGROUND & PURPOSE

Cleft Lip and/or Palate, which affects approximately 1:650 live births in Ireland, is a complex congenital condition with lifelong implications. It can affect upper airway function, feeding, hearing, speech development, dental development as well as oral functioning, facial growth and physical appearance. Within cleft surgery, rigorous audit of speech, facial growth and nasolabial aesthetic outcomes is well-established. The importance of including patient-reported outcomes in our routine data-collection is now recognised. The purpose of the current study was to examine patient-reported outcomes (PROs) in a consecutive series of adolescents attending the Dublin Cleft Centre (DCC).

METHODS

A validated patient-reported outcome measure (PROM), the CLEFT-Q, was prospectively administered to 156 patients attending the cleft clinic. Results were analysed according to cleft type and compared to those recorded in the CLEFT-Q validation study.

RESULTS

Between (February 2020 and March 2022), the CLEFT-Q was administered to 156 patients with a mean age of 13.5 years (range 10-19 years). Males scored higher satisfaction across all subdomains irrespective of age. Satisfaction was higher in younger age groups compared to older patients in both appearance and quality of life outcomes. Patients with isolated cleft palate scored highest for satisfaction in school, social and psychological function.

CONCLUSIONS

PRO data now informs consultations with patients and families at the DCC. This information is also useful in targeting service development to the specific needs of this patient group.

Integration of the CLEFT-Q Patient-Reported Outcome Tool into a Multidisciplinary Cleft and Craniofacial Clinic: A Proof of Concept

SUMMARY

Implementation of patient-reported outcome (PRO) tools has increased internationally in a variety of clinical settings, with emerging evidence suggesting benefits for patient satisfaction, improved patient-provider communication, and management of chronic conditions. However, integrating PROs into clinical workflow remains a barrier to implementation, with common challenges including patient completion, provider review of results, and future accessibility of data. Cleft lip and/or palate presents with a variety of aesthetic, functional, and psychosocial sequelae optimally managed by a multidisciplinary team, and the CLEFT-Q is a validated 12-module PRO that captures patient perception in these domains. Given the emerging proven benefits of using PROs in a clinical setting, the authors integrated the CLEFT-Q PRO at a multidisciplinary cleft and craniofacial clinic at a large, urban, tertiary care center. The authors collaborated with their institution's electronic health record clinical informatics team to automatically identify eligible cleft lip and/or palate patients and generate the CLEFT-Q PRO before weekly multidisciplinary cleft and craniofacial clinic days. Patient results were automatically scored, compared with age-based normative data, and populated into the electronic health record patient note. CLEFT-Q results were viewed by clinicians during patient visits to initiate module-specific discussion in relation to patient age-based normative results. Patient-specific CLEFT-Q data were also discussed during multidisciplinary cleft and craniofacial team discussions to aid in clinical decision-making. This experience may have applicability to other PRO tools in plastic surgery and other medical specialties where integrating PROs may yield superior patient experience and outcomes.

Effect of facial and nasolabial asymmetry on perceived facial esthetics in children with non-syndromic cleft lip and palate

OBJECTIVE

The aim of the present study was to objectively assess the degree of residual facial asymmetry after primary treatment of non-syndromic unilateral cleft lip and palate (UCLP) in children and to correlate it with subjective ratings of facial appearance.

MATERIALS AND METHODS

Stereophotometry was used to record the faces of 89 children with UCLP for comparison of cleft and non-cleft sides up to 5 years after primary cleft closure. Root mean square values were calculated to measure the difference between the shape of cleft and non-cleft sides of the face and were compared to controls without a cleft lip. The Asher-McDade Aesthetic Index (AMAI) was used for subjective rating of the nasolabial area through 12 laypersons.

RESULTS

Children with a cleft lip (CL) showed no significant difference in RMS values compared to controls. Significant differences occurred when the evaluation was limited to the nasolabial area, however only in patients with cleft lip alveolus (CLA) and cleft lip palate (CLAP)(p < 0.001). In contrast, subjective ratings showed significantly higher values for all three cleft severity groups (CL, CLA, CLAP) compared to controls (p < 0.001). There was a non-linear correlation between the RMS (root mean square) values and the AMAI score.

CONCLUSIONS

Even non-significant discrete objective deviations from facial symmetry in children after primary closure of UCLP are vigilantly registered in subjective ratings and implemented in the judgement of facial appearance.

CLINICAL RELEVANCE

3D stereophotometry is a usefull tool in monitoring asymmetry in patients with a cleft.

Assessment of Nasal Aesthetic Parameters in Patients with Unilateral Cleft Lip and Palate - A Retrospective Study

OBJECTIVES

To assess and compare the deviating nasal cephalometric parameters of patients with unilateral cleft lip and palate (UCLP) with a control group. The study also aims to correlate the deviating cephalometric parameters with two aesthetic scoring systems.

DESIGN

A retrospective study.

SETTING

Dental college and hospital.

PARTICIPANTS

Pre-treatment lateral cephalograms and extra oral photographs of 20 adult patients with repaired UCLP presenting for orthodontic treatment. 20 patients with age and type of malocclusion matched control were selected.

MAIN OUTCOME

The nasal cephalometric parameters of patients with UCLP and a control group were compared. The nasolabial region of patients with cleft lip and palate (CLP) was scored using Asher McDade Aesthetic Index (AMAI) and Cleft Aesthetic Rating Scale (CARS). The scoring was done by six different groups assessors to study their perception of the nasolabial region. Correlation between cephalometric parameters and the aesthetic scores was done.

RESULTS

The study found significant differences in nasal length (P = .003) and depth (P < .001) between UCLP and the non-cleft control group. In the aesthetic assessment, orthodontist gave the least scores, while layman group scored the highest. The CARS nose aesthetic scores showed statistically significant high, negative correlation with the nasal length (P = .01).

CONCLUSION

The cephalometric parameters and the aesthetic indices can be aid the orthodontists in the assessment of nasolabial aesthetics and additionally refer for further definitive rhinoplasty to improve the patient's overall facial aesthetics.

Prospective study of nasal growth in bilateral cleft lip and palate patients after naso-alveolar moulding and primary columella lengthening compared to controls at 5, 10 and 20 years

INTRODUCTION

A short columella, wide nostrils and a flat nasal tip are common features in patients with bilateral complete cleft lip and palate (BCLP). The objective of this study was to evaluate nasal morphology during growth in patients treated with naso-alveolar moulding (NAM) and primary surgical columella lengthening (PCL) compared with matched non-cleft individuals.

STUDY DESIGN

Prospective longitudinal case-control study.

PARTICIPANTS AND METHODS

Thirty-four consecutively treated BCLP patients at 5 and 10 years and at the end of growth (19.7 ± 2.0 years) were compared through normalized photogrammetry to a control of 34 age and sex-matched non-cleft individuals. Regression Models for Panel Data assessed how nasal measurements were influenced by surgery, age and gender.

RESULTS

Nasal protrusion was equal to non-cleft controls at all ages. Length of the columella was also comparable to controls at 5 and 10 years, but significantly shorter at the end of growth. Inter-alar and nasal tip width and nasolabial angle were significantly wider than controls at all ages: More than 60% of the patients have asked for correction of the nasal width, but no early surgery for columella lengthening was needed.

CONCLUSIONS

NAM and PCL have provided a nasal projection close to that of non-cleft individuals until adulthood, while length of the columella was physiological at 5 and 10, but shorter than controls at age 20. Width of the nasal tip and width of the alar bases were significantly wider than the controls and eventually required secondary nasal width correction in over two thirds of the sample.

Geospatial and Socioeconomic Factors Interact to Predict Management and Outcomes in Cleft Lip and Palate Surgery: A Single Institution Study of 740 Patients

OBJECTIVE

Determine interactions between geospatial and socioeconomic factors influencing cleft lip and/or cleft palate (CL/P) management and outcomes.

DESIGN

Retrospective review and outcomes analysis (n = 740).

SETTING

Urban academic tertiary care center.

PATIENTS

740 patients undergoing primary (CL/P) surgery from 2009 to 2019.

MAIN OUTCOMES MEASURES

Prenatal evaluation by plastic surgery, nasoalveolar molding, cleft lip adhesion, and age at CL/P surgery.

RESULTS

Prenatal evaluation by plastic surgery was predicted by the interaction between higher patient median block group income and shorter patient distance from the care center (OR = 1.07, p = 0.022). Nasoalveolar molding was also predicted by the interaction between higher patient median block group income and shorter distance from the care center (OR = 1.28, p = 0.016), whereas cleft lip adhesion was predicted by higher patient median block group income alone (OR = 0.41, p < 0.001). Lower patient median block group income predicted later age at cleft lip (β = -67.25, p = 0.011) and cleft palate (β = -46.35, p = 0.050) repair surgery.

CONCLUSIONS

Distance from the care center and lower median income by block group interacted to significantly predict prenatal evaluation by plastic surgery and nasoalveolar molding for patients with CL/P at a large, urban, tertiary care center. Patients living farthest from the care center who received prenatal evaluation by plastic surgery or who underwent nasoalveolar molding had higher median block group income. Future work will determine mechanisms perpetuating these barriers to care.

Choice of Surgeons in Retractors used in Cleft Lip and Palate Surgery: An Original Research

Background

To ensure optimal exposure and enable precise tissue manipulation, cleft lip and palate abnormalities require surgical repair utilizing retractors. Different retractors may affect surgical outcomes; however, this is not yet evident. Examining surgeon preferences for retractors in cleft lip and palate surgery and assessing their impact on patient outcomes were the goals of this study.

Materials and Methods

The patients who underwent primary cleft lip and palate repair were retrospectively analyzed. This study evaluated three widely used retractors: the Langenbeck, Gelpi, and Moult Mouth Gag retractors. This study looked at demographic information, surgical results (including scarring, aesthetic outcomes, and wound healing issues), and surgeon preferences for retractors.

Results

The study identified differences in surgical outcomes related to various retractor types. Both Group A (Langenbeck retractor) and Group B (Gelpi retractor) demonstrated similar favorable results, such as little wound healing issues, less scarring, and pleasing cosmetic results. The wound healing issues, scarring, and cosmetic outcomes were all worse in Group C (Moult Mouth Gag retractor).

Conclusion

Retractors were not always preferred by surgeons doing cleft lip and palate surgery. The type of retractor had an impact on the surgical results; the Moult Mouth Gag retractor performed less well than the Langenbeck and Gelpi retractors. These results highlight the value of using evidence-based criteria to select retractors more effectively and enhance surgical methods for better patient outcomes in cleft lip and palate repair.

Reliability of the novel cleft lip and palate smile esthetic index (CLP-SEI)

BACKGROUND/OBJECTIVES

The aim of this research was to determine the reliability of a novel index for the assessment of smile esthetics in patients with cleft lip and/or palate (CL ± P) at the end of their multidisciplinary treatment, for use in clinical and academic settings.

MATERIALS AND METHODS

Five orthodontists, five periodontologists, five general practitioners, five dental students, and five laypeople rated the smiles of 10 patients with CL ± P twice at a 2 weeks interval. The rating scale consisted of four main categories: 1. nasolabial esthetics, 2. gingival esthetics, 3. dental esthetics, and 4. overall esthetics. A total of 15 parameters were rated. Intra- and inter-rater agreements were calculated using SPSS.

RESULTS

The inter-rater agreement varied between good and excellent whereby the orthodontists, periodontists, general practitioners, dental students, and laypeople obtained agreement scores of 0.86, 0.92, 0.84, 0.90, and 0.89, respectively. The intra-rater agreement was good with agreement scores of 0.78, 0.84, 0.84, 0.80, and 0.79, respectively.

LIMITATIONS

Smile esthetics were rated on static pictures, not in real life or by video recordings in a young adult population.

CONCLUSIONS/IMPLICATIONS

The cleft lip and palate smile esthetic index is a reliable tool for the assessment of smile esthetics in patients with CL ± P.

An innovative analysis of nasolabial dynamics of surgically managed adult patients with unilateral cleft lip and palate using 3D facial motion capture

AIM

To compare dynamic nasolabial movement between end-of-treatment cleft and a matched non-cleft group in adult patients.

MATERIALS AND METHODS

Thirteen treated adult participants with unilateral cleft lip and palate had images taken using a facial motion capture system performing a maximum smile. Seventeen landmarks were automatically tracked. For each landmark pair, on either side of the midline, changes in the x, y, and z directions were used to analyze the magnitude of displacement and path of motion. An asymmetry score was developed at rest, mid-smile, and maximum smile to assess the shape of the mouth and/or nose.

RESULTS

At maximum smile, displacement of right and left cheilion was clinically and statistically (p < 0.05) less in the cleft group. The lip asymmetry score was greater (p < 0.05) at each time point in the cleft group using the clinical midline. Using Procrustes superimposition, the differences were significant (p < 0.05) only at rest and mid-smile. The alar bases were displaced significantly less (p < 0.05) in the z direction in the cleft group. The asymmetry score of the alar base was significantly higher using the clinical midline than using Procrustes superimposition in patients with cleft conditions (p < 0.001). In the cleft group, at maximum smile, the right and left cristae philter moved significantly less (p < 0.05) in the x and z directions.

CONCLUSIONS

There was an increase in asymmetry score of the corners of the mouth and alar bases from rest to maximum smile. The lips were similar in shape but oriented differently in the faces of patients with cleft conditions than in individuals without those conditions.

The Use of Eye-tracking Technology in Cleft Lip: A Literature Review

Eye-tracking has become an increasingly popular research tool within the field of cleft lip and/or palate (CL+/-P). Despite this, there are no standardized protocols for conducting research. Our objective was to conduct a literature review of the methodology and outcomes of previous publications using eye-tracking in CL+/-P.

Methods

The PubMed, Google Scholar, and Cochrane databases were searched to identify all articles published up to August 2022. All articles were screened by two independent reviewers. Inclusion criteria included using eye-tracking, image stimuli of CL+/-P, and outcome reporting using areas of interest (AOIs). Exclusion criteria included non-English studies, conference articles, and image stimuli of conditions other than CL+/-P.

Results

Forty articles were identified, and 16 met the inclusion/exclusion criteria. Thirteen studies only displayed images of individuals following cleft lip surgery with three only displaying unrepaired cleft lips. Significant variation was found in study design, particularly in the AOIs used to report gaze outcomes. Ten studies asked participants to provide an outcome score alongside eye-tracking; however, only four compared outcome data to eye-tracking data. This review is primarily limited by the minimal number of publications in this area.

Conclusions

Eye-tracking can be a powerful tool in evaluating appearance outcomes following CL+/-P surgery. It is currently limited by the lack of standardized research methodology and varied study design. Before future work, a replicable protocol should be developed to maximize the potential of this technology.

Nasolabial appearance in unilateral cleft lip and palate patients: A comparison of aesthetics using two scoring systems: A cross-sectional study

OBJECTIVE

The objective of the study was to assess nasolabial aesthetics in patients with complete unilateral cleft lip, with or without cleft palate (UCL ± P) using two scoring systems.

DESIGN

A cross-sectional study conducted in a tertiary care government hospital.

PATIENTS

Photographic records of 91 patients with complete UCL ± P from the age group of 5-18 years (mean age = 13.2 ± 3.14 years) were included.

METHOD

A panel of three orthodontists with varying experience in cleft management rated nasolabial aesthetics using two scoring systems, that is Asher Mc-Dade index (AMAI) and Cleft Aesthetic Rating Scale (CARS). Intraclass correlation coefficient, Fleiss' kappa and Cronbach's alpha were used to measure the internal consistency amongst three raters and Spearman-Brown formula was used for measuring overall reliability. Time required for assessment of each photograph was compared with ANOVA.

RESULTS

Overall, both AMAI and CARS showed high reliability and outcome assessment with good inter-rater reliability and internal consistency, when used independently by orthodontists having varied experience. Statistically significant difference was present in time taken for assessment of nasolabial aesthetics with CARS index (8.75 ± 1.65 seconds) as compared to AMAI (18.62 ± 3.49 seconds).

CONCLUSION

Asher Mc-Dade index and CARS are equally reliable and consistent for the assessment of nasolabial aesthetics in patients with UCL ± P. However, considerably less time was taken for the assessment using CARS index as compared to AMAI. The use of CARS index is recommended for the initial assessment and screening of patients by orthodontists using two dimensional photographs.

Lip symmetry following rotation advancement cleft lip repair in 5-year-old children treated by Ralph Millard and Ron Pigott

Objective

To compare the symmetry of the lip following Rotation-Advancement cleft lip repair by Millard and Pigott and to investigate the effect on the symmetry of cleft side and gender by using different surgical protocols. Symmetry following cleft surgery was compared to that of non-cleft children.

Design

Retrospective study of photographs of children aged 5 years.

Setting

Three decades of post-operative photographs of children treated by Millard and Pigott.

Patients

Eighty-nine children treated by Millard, 87 by Pigott and 91 non-cleft children.

Interventions

Photographs were assessed using the Symnose Computer program, a rapid semi-objective quantitative assessment of lip symmetry.

Main Outcome Measure(s)

Asymmetry score for each surgeon, and non-cleft children.

Results

There was no significant difference in the median lip % mismatch score of Millard, 36.65% and Pigott, 38.52%. Right-sided clefts showed better symmetry than left-sided clefts for Millard (p<.001). This was reversed for Pigott (P=.0121). There was a difference (P<.001) between the symmetry of the two cleft cohorts and the non-cleft children (asymmetry 19.9%), and between Millard's outcomes following different lip surgical protocols (P < .0001), but no difference between Pigott's outcomes using different palate surgical protocols (P = 0.59).

Conclusions

Cleft lip repair by Millard and Pigott resulted in similar lip asymmetry (37% and 39% symmetry mismatch, respectively). Lip surgical protocol and cleft side may affect lip asymmetry. Palate surgery did not affect lip asymmetry. Following cleft surgery, children were more asymmetric than non-cleft children.

Development and Initial Validation of a Novel Professional Aesthetic Scale for the Female Abdomen

BACKGROUND

A growing body of literature aims to describe abdominal aesthetic goals in order to tailor surgical and non-surgical treatment options to meet patient goals. We aimed to integrate lay-person perceptions into the design of a novel professional aesthetic scale for the abdomen.

METHODS

An iterative process of expert consensus was used to choose 5 domains -1) abdominal muscle lines, 2) abdominal shape, 3) scar, 4) skin, and 5) umbilicus. A survey was developed to measure global and domain-specific aesthetic preferences on 5 abdomens. This was distributed through Amazon Mechanical Turk to 340 respondents. Principal component analysis was used to integrate survey data into weights for each of the scale's sub-questions. Attending plastic surgeons then rated abdomens using the final scale, and reliability and validity were calculated.

RESULTS

The final scale included eleven sub-questions - hourglass shape, bulges, hernia, infraumbilical skin, supraumbilical skin, umbilicus shape, umbilicus medialization position, umbilicus height position, semilunar lines, central midline depression, scar - within the 5 domains. Central midline depression held the highest weight (16.1%) when correlated to global aesthetic rating, followed by semilunar lines (15.8%) and infraumbilical skin (11.8%). The final scale demonstrated strong validity (Pearson r=0.99) and was rated as easy to use by 7 attending plastic surgeons.

CONCLUSION

The final scale is the first published professional aesthetic scale for the abdomen that aims to integrate lay-person opinion. In addition, this analysis and survey data provide insights into the importance of eleven components in overall aesthetic appeal of the abdomen.

Nasolabial Appearance in 5-Year-Old Patients with Repaired Complete Unilateral Cleft Lip and Palate: A Comparison of Two Different Techniques of Lip Repair

Different surgical techniques are available to adequately correct the primary cleft lip deformity; however, when compared, none of these techniques have proven superior with regard to achieving optimal aesthetic results. Thus, the aim of this retrospective study was to assess the nasolabial appearance in patients with unilateral cleft lip and palate (UCLP) at age five with reference to two techniques for primary cleft lip repair used in our service: Pfeifer’s wave-line procedure and Randall’s technique. A modified Asher–McDade Aesthetic Index was applied to appraise the nasolabial area by means of 2D photographs of non-syndromic five-year-old patients with a UCLP. In this context, three parameters were assessed: 1. nasal frontal view; 2. shape of the vermilion border and philtrum length; and 3. the nasolabial profile. Five professionals experienced in cleft care were asked to rate the photographs on two occasions. Overall, 53 patients were included in the final analysis, 28 of whom underwent lip repair according to Pfeifer; 25 were treated employing Randall’s technique. Statistically significant differences between the two techniques regarding philtrum length and vermilion border were found (p = 0.046). With reference to the other parameters assessed, no significant differences were determined. The results suggest that Randall’s cleft lip repair may allow for more accurate alignment of the vermilion border and more adequate correction of the cleft lip length discrepancy in comparison to Pfeifer’s wave-line technique.

Lips and noses in 10-year old patients with repaired complete unilateral clefts of lip, alveolus, and palate. A prospective three-centre study of the Baltic Cleft Network

This multicenter study aimed at comparing different techniques of lip and nose repair with or without NAM and primary anterior rhinoplasty in pre-adolescent children. Patients with unilateral clefts of lip, alveolus, and palate who had undergone cleft lip and nose repair were evaluated in a prospective three-centre study using standardized monochromatic, cropped photographs. Four cleft surgeons evaluated the aesthetics of the central part of the face when the patients had reached age ten years. Seventy-six sets of photographs out of 87 patients were evaluated. The overall ratings of lips and noses did not differ much between centres. However, noses of centres 1 (mean 0.74; SD 0.57) and 2 (mean 0.76; SD 0.60) had been rated better than centre 3 (mean 1.32; SD 0.78; p = 0.0078), especially "Deformation of upper part of nostril rim or poor position of alar cartilage". Centre 3 had produced better looking scars (mean 0.33; SD 0.48); p = 0.0036. Within the limitations of the study it seems that NAM and primary anterior rhinoplasty including postoperative nasal stents should be performed whenever possible in order to achieve a favorable shape of the nose and to reduce the need for secondary corrective surgery.

Does Initial Cleft Lip Width Predict Final Aesthetic Outcome?

Background:

A natural aesthetic appearance of the lip and a favorable scar are essential goals of cleft lip repair. Wider clefts intuitively pose a greater technical challenge; however, the relationship between initial width and aesthetic outcome remains controversial. The current study aimed to determine whether lip adhesion can help wider clefts achieve safe, consistent aesthetic outcomes.

Methods:

A retrospective cohort study was conducted on unilateral cleft lip patients who underwent lip repair within a 2-year period by the senior author. Subjects were divided into three groups based on cleft severity: (1) wide complete clefts that required lip adhesion before definitive repair, (2) narrower complete clefts that did not require lip adhesion, and (3) incomplete clefts. Aesthetic outcomes related to the vermillion and upper lip scar were rated by 48 blinded observers. Statistical analysis was performed using Kruskal-Wallis and Mann-Whitney tests. Nasal outcomes were not assessed.

Results:

Seventeen patients were included in the study: five in group 1, six in group 2, and six in group 3. Patients with the widest clefts did not have inferior results compared with the other groups. In fact, they had statistically significantly higher aesthetic scores in all scar-related outcomes compared with those in groups 2 and 3 (P < 0.0001).

Conclusions:

This study suggests that a wide cleft does not necessarily foreshadow a poor surgical outcome. In fact, wide clefts may have pleasing results, and the use of a staged lip adhesion approach can be useful for achieving the desired outcome in wider clefts.

Long-Term Comparison of the Aesthetic Outcomes between Nasoalveolar Molding- and Non-Nasoalveolar Molding-Treated Patients with Unilateral Cleft Lip and Palate

BACKGROUND

The cleft lip-nose deformity in unilateral cleft lip and palate is one of the most challenging problem for surgeons to correct. Although nasoalveolar molding has been shown to be effective in improving presurgical symmetry in patients with complete unilateral cleft lip and palate, there is need for better evidence regarding the long-term nasolabial aesthetics of patients who have received this therapy.

METHODS

Thirty-eight patients treated with nasoalveolar molding and 48 patients not treated with nasoalveolar molding (but otherwise treated similarly) with unilateral cleft lip and palate were studied to assess and compare the nasolabial aesthetics. The objective evaluation of the nasal symmetry was performed on the basal view of two-dimensional photographs and the subjective nasolabial aesthetic evaluation was performed using the Asher-McDade scale.

RESULTS

At 5-year postoperative follow-up, nasoalveolar molding group patients had better mean values on the objective scores; however, these were not statically significant. The nasoalveolar molding group of patients had a statistically significant improvement in the subjective evaluation in comparison to the non-nasoalveolar molding-treated patients. The number of lip revisions was also statistically higher in the non-nasoalveolar molding-treated group of patients.

CONCLUSIONS

In this retrospective, single-center study, the authors found that at 5-year postoperative follow-up, nasoalveolar molding-treated patients had improved nasolabial aesthetics and fewer revision operations. These are, however, preliminary results and the patients will be followed up until the end of growth to assess the longer term effects of nasoalveolar molding on the nasolabial aesthetics in unilateral cleft lip and palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Use of Fractional CO2 Laser in Cleft Lip Scars: Does It Make a Difference?

BACKGROUND

Whatever the technique of the surgical repair, the scar remains and it is the most common cause for parent's and patient's dissatisfaction. We aimed in this work to evaluate the efficacy of the fractional CO2 (FCO2) laser on the later appearance of cleft lip scars in general and to compare between the early and late use of this tool to know its ideal application time in particular. To our knowledge, there are no published reports about this objective with regard to the number of patients and the concerned designated study.

PATIENTS AND METHODS

One hundred twenty patients complaining of cleft lip scar were divided into 3 groups. Group 1 started FCO2 application 3 weeks postoperatively, group 2 started it 3 months postoperatively, and group 3 applied local creams only as a control group. Fractional CO2 laser had been applied for 5 to 7 sessions. Vancouver scar scale was used for scar evaluation determining vascularity, pigmentation, pliability, and height. Visual analog scale was also used depending on 5 independent physicians and nonmedical personnel to rate results on a graded scale from 0 to 10. Moreover, the scar width had been assessed through studying the final images by Photoshop CS5 Extended Version, in 2 fixed points of the scar width.

RESULTS

Patients showed a great degree of improvement in their lip scar after FCO2 laser sessions. Vancouver Scar Scale score had insignificant differences between studied groups at the baseline before applying either FCO2 or local cream, whereas after their applications, it was significantly lower in group 1 (1.92 ± 0.88) in comparison with group 2 (3.70 ± 1.11) and group 3 (4.05 ± 1.29). Regarding scar width assessment, it was significantly lower in group 1 (2.51 ± 0.64) in comparison with groups 2 (3.17 ± 0.54) and 3 (3.27 ± 0.48). The visual analog scale by the participating medical personnel indicated that the FCO2-induced improvement in the lip scar appearance in group 1 more than groups 2 and 3 with a mean score of 44.17 ± 3.45, 36.53 ± 4.43, and 30.40 ± 5.22, respectively. The same assessment by the participating nonmedical personnel was significantly higher in group 1 (43.52 ± 4.20) in comparison with group 2 (37.52 ± 4.73) and group 3 (33.55 ± 4.85).

CONCLUSIONS

We proved that using FCO2 is significantly better than using local creams in the postoperative management of cleft lip scars. More in depth, the early application of this tool is also significantly better than its delayed use.Clinical Trials Registration Name: Assessment of Fractional CO2 Laser in Treatment of Post-surgical Scarring of Cleft LipURL:https://clinicaltrials.gov/ct2/show/NCT03277287?cond=Assessment+of+Fractional+CO2+Laser+in+Treatment+of+Post-surgical+Scarring+of+Cleft+Lip&draw=2&rank=1Clinical Trials ID: NCT03277287Registration Date: June 9, 2017, retrospectively registered.

Preoperative analysis of upper lip in patients with upper cleft lip/palate before lip repair

Background

The postoperative morphological appearances vary widely patients with unilateral cleft lip with or without cleft palate (UCL/P), whether it is complete or incomplete cleft. The main reason of bilateral lip asymmetry after cleft lip surgery lies in the lack of personalized measurement and design before surgery. In this study, we aim to individually investigate areas of the upper lip on cleft and non-cleft sides in patients with unilateral cleft lip with or without cleft palate (UCL/P).

Methods

Ninety-two patients with UCL/P (group 1: <1 year, group 2: 1–2 years) were included in the study. Group 1 included 37 patients with incomplete UCL/P and 29 with complete UCL/P; group 2 included 11 and 15 patients, respectively. The total area of the upper lip on the cleft side (Q8) was divided into Q3, Q4, and Q5 (further divided into a1 and a2), and the upper lip on the non-cleft side (Q7) was divided into Q2 and Q1 (further divided into A1 and A2). Area ratios between the cleft and the non-cleft sides were calculated, and certain parameters were tested for correlations with these ratios.

Results

Values of Q8/Q7 were partially overlapped between patients with complete and incomplete UCL/P. Significant correlations were noted between differences in height of the philtrum column (a–h) and the prolabial area ratio between the cleft and the non-cleft side (Q3/Q2) (P=0.032). Moreover, a significant correlation was noted between a1/A1 and the ratio of the lateral labial area between the cleft and the non-cleft side (Q5/Q1) (P=0.001).

Conclusions

The conventional classification of unilateral cleft lip as incomplete and complete does not completely and accurately reflect individual malformations. Therefore, it is necessary to analyze unilateral cleft lips individually to determine the repair technique and to predict postoperative outcomes.

The Slavcleft: a three-center study of the outcome of treatment of cleft lip and palate. Nasolabial appearance

Background

There is a multitude of protocols of treatment of cleft lip and palate (CLP) worldwide differing in number of operations, surgical techniques, and timings of surgeries. Despite, facial appearance in subjects with CLP is rarely ideal and residual stigmata are easy to notice in many patients irrespective of the protocol. The prospective controlled investigations are optimal for comparing effectiveness of treatment protocols. Because prospective studies are very challenging to perform in CLP field, it is reasonable to retrospectively assess different surgical protocols to identify the promising ones and then to test them in a prospective way.

Methods

Our objective was to assess the nasolabial appearance in a preadolescent Slavic population with unilateral cleft lip and palate (UCLP) by using the 0-200 numeric scale with reference photographs. Patients treated in Warsaw, Poland (n = 32), Prague, Czech Republic (n = 26) and Bratislava, Slovakia (n = 17) were included in this retrospective study. Each cleft center used a unique surgical protocol. Two panels of professional raters (n = 7) and laypeople (n = 10) scored blindly the nasolabial esthetics on cropped frontal and profile images with cropped reference photograph present on the same slide. Intra- and inter-rater agreement was assessed with Cronbach's alpha, intraclass correlation coefficients, t-tests, and Bland-Altman plots. Inter-group differences were evaluated with one-way ANOVA and regression analysis.

Results

The agreement within and between raters was acceptable. We found that patients treated in Warsaw, Prague, and Bratislava showed comparable nasolabial appearance on frontal and profile photographs when judged by both professional raters (p > 0.05) and laypeople (p > 0.05). Regression analysis did not identify influence of gender, group (i.e., Warsaw, Prague, and Bratislava), age at lip repair, surgeon, and age at photographic assessment on esthetic outcome (p > 0.05).

Conclusion

This study showed that none of the surgical protocols showed superiority to produce good nasolabial appearance.

Atypical Outcomes of Nasal and Lip Appearance After Unilateral Cleft Lip Repair: Judgment by Professionals, Patients, and Laypeople

Objective:

To gain more insight into the assessment of “atypical” nasal and lip appearance outcomes compared to “typical” appearance outcomes after unilateral cleft lip and palate (UCLP) repair, when judged by professionals, patients with repaired UCLP, and laypeople.

Design:

An online survey containing 3 series of photographs with various degrees of “typical” and “atypical” nasal and lip appearance outcomes after UCLP repair was sent to 30 professionals, 30 patients with repaired UCLP, and 50 laypeople in 2 countries. Participants were instructed to rank the photographs from excellent to poor based on overall appearance. Mean rank positions of photographs were analyzed and differences in mean rank score between “typical” and “atypical” results were assessed using a T-test. Agreement of ranking between the 3 groups was assessed with an analysis of variance analysis.

Setting:

Amsterdam UMC, location VUmc, Netherlands and Boston Children’s Hospital, Boston, USA.

Patients:

Photographs of 6- to 18-year-old patients with repaired UCLP.

Results:

“Atypical” appearance outcomes were ranked significantly less favorably (small nostril: P = 0.00; low vermillion border: P = 0.02; whistling deformity: P = 0.00) compared to “typical” outcomes. Difference between professionals, patients and laypeople in rank positioning the photographs was not statistically significant (P = 0.89).

Conclusions:

Noses with a smaller nostril and lips containing a whistling deformity were perceived as poorer outcome compared to the “typical” results. Professionals, patients, and laypeople are in agreement when assessing these outcomes.

The Submental Nasal Appearance Scale for the Assessment of Repaired Unilateral Complete Cleft Lip: A Validation Study

Objective:

To reassess reliability and validity of the Submental Nasal Appearance Scale (SNAS) compared to the preliminary pilot study, for assessment of patient photographs with repaired unilateral cleft lip and palate (UCLP). When utilizing the SNAS, 3 nasal features (1. nasal outline; 2. alar base position; 3. nostril axis) must be graded according to symmetry between the cleft and noncleft side using a 5-point scale with reference photographs for each feature. The mean score calculated from the graded features reflects the overall degree of nasal symmetry, which is considered an important goal when repairing UCLP.

Design:

Fifty patient photographs were selected and cropped, displaying the submental view. Six raters assessed these photographs using the SNAS and a separate 5-point scale to assess the overall submental appearance. Interrater reliability was determined for both methods and correlation was calculated between these as an indication of construct validity.

Setting:

Amsterdam UMC, location VUmc, Amsterdam, The Netherlands.

Patients:

Six- to 9-year-old patients with repaired UCLP.

Results:

Interrater reliability of 0.73 and 0.48 was found for the SNAS and overall appearance assessment, respectively, while in the pilot study values of 0.79 and 0.69 were found. Correlation of 0.59 and 0.74 was found in the current and pilot study, respectively, between the SNAS and overall appearance assessment.

Conclusions:

The SNAS is a reliable tool to assess nasal symmetry from the submental perspective. Reliability of the SNAS is higher compared to grading overall appearance, but validity of the SNAS was less well supported.

Facial attractiveness of cleft patients: a direct comparison between artificial-intelligence-based scoring and conventional rater groups

OBJECTIVES

To evaluate facial attractiveness of treated cleft patients and controls by artificial intelligence (AI) and to compare these results with panel ratings performed by laypeople, orthodontists, and oral surgeons.

MATERIALS AND METHODS

Frontal and profile images of 20 treated left-sided cleft patients (10 males, mean age: 20.5 years) and 10 controls (5 males, mean age: 22.1 years) were evaluated for facial attractiveness with dedicated convolutional neural networks trained on >17 million ratings for attractiveness and compared to the assessments of 15 laypeople, 14 orthodontists, and 10 oral surgeons performed on a visual analogue scale (n = 2323 scorings).

RESULTS

AI evaluation of cleft patients (mean score: 4.75 ± 1.27) was comparable to human ratings (laypeople: 4.24 ± 0.81, orthodontists: 4.82 ± 0.94, oral surgeons: 4.74 ± 0.83) and was not statistically different (all Ps ≥ 0.19). Facial attractiveness of controls was rated significantly higher by humans than AI (all Ps ≤ 0.02), which yielded lower scores than in cleft subjects. Variance was considerably large in all human rating groups when considering cases separately, and especially accentuated in the assessment of cleft patients (coefficient of variance-laypeople: 38.73 ± 9.64, orthodontists: 32.56 ± 8.21, oral surgeons: 42.19 ± 9.80).

CONCLUSIONS

AI-based results were comparable with the average scores of cleft patients seen in all three rating groups (with especially strong agreement to both professional panels) but overall lower for control cases. The variance observed in panel ratings revealed a large imprecision based on a problematic absence of unity.

IMPLICATION

Current panel-based evaluations of facial attractiveness suffer from dispersion-related issues and remain practically unavailable for patients. AI could become a helpful tool to describe facial attractiveness, but the present results indicate that important adjustments are needed on AI models, to improve the interpretation of the impact of cleft features on facial attractiveness.

Validity of the combined use of two esthetic rating systems, the infant index and 5-point aesthetic index, for pre- and postsurgical evaluation of cleft lip repair

OBJECTIVE

The present study was designed to investigate the usefulness of combining two different ordinal scaling indices, infant index (I-I) and 5-point aesthetic index (5-PAI), for the assessment and prediction of esthetic outcome of primary lip repair for patients with unilateral cleft lip.

MATERIALS AND METHODS

The nasolabial appearance of the patients was evaluated before primary lip repair and at 5 years of age using cropped facial photographs with frontal and oblique views. The I-I and 5-PAI employ expanded reference photographs and objective esthetic variables for judgment.

RESULTS

The inter- and intrarater Kappa values of both I-I and 5-PAI demonstrated good to very good agreement (range: 0.74-0.84 for I-I and 0.62-0.77 for 5-PAI). Furthermore, both the declination of the columella and the deformity of the alar cartilage in I-I showed a correlation with nasal rating score of 5-PAI and were identified as predictable independent parameters (declination of the columella: Rs = 0.37, P = 0.04; deformity of the alar cartilage: Rs = 0.35, P = 0.02).

CONCLUSION

The combined use of I-I and 5-PAI with expanded reference photographs and objective variables could be useful for obtaining greater accuracy of the esthetic assessment and predicting postsurgical nasolabial esthetics at infancy.

Validating the Asher-McDade score to assess facial aesthetic outcomes in 22 consecutive complete bilateral cleft lip repairs

Most scoring systems used to assess facial aesthetics in cleft patients tend to lack consistency, and the absence of an internationally agreed system makes comparison challenging. The most widely used and validated tool is the five-point Asher-McDade index. We note that there are currently no reports (to our knowledge) of its use for scoring outcomes after bilateral cleft lip repair. To validate it for this use, the aim was to describe the outcomes of 22 consecutive bilateral cleft lip repairs assessed using this scale. A retrospective review was undertaken of 22 consecutive patients with bilateral cleft lip repairs performed at our centre. Each patient underwent bilateral advancement rotation repair with a vomer flap on one side at three months followed by repair of the remaining hard palate and an intravelar veloplasty three months later. Standardised photographs were taken five years after repair and were cropped to isolate the nasolabial component. Eleven members of the cleft multidisciplinary team were asked to rate each image on a five-point Likert scale. Statistical analysis was performed using a two-way ANOVA test and intraclass correlation coefficient to interrogate intraobserver and interobserver variance. A total of 22 consecutive patients with complete bilateral cleft lips were photographed. The overall mean (range) score for the repairs was 3.2 (4.3 - 1.8). Two-way ANOVA demonstrated that inter-rater variability accounted for just over 10% (11.23% of the total variance, p < 0.0001). As predicted, the single biggest factor affecting score variability was the patient's appearance, which accounted for 44.51% of the total variance between scores (p < 0.0001). Intraobserver variance was not found to be significant, accounting for 0.33% of the total variance (p = 0.0006). We demonstrate that the Asher-McDade scoring system is a valid tool to use when assessing bilateral cleft lip repairs. Variance in the patient's score was significantly related to a true difference in appearance, with only a small percentage of differences being due to intraobserver and interobserver variation.

Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology

BACKGROUND

Cleft lip repair is essential to restoring physiologic function and ensuring social and psychological well-being in children with orofacial clefts. It is important to critically study various techniques to understand the elements of the lip and nasal repair that contribute to favorable results. Here, we use eye-tracking technology to evaluate how viewers analyze images of cleft lips repaired by the Fisher, Millard, or Mohler techniques.

METHODS

Thirty viewers were shown 5 images without deformity and 5 images each of unilateral cleft lips repaired by the Fisher, Millard, or Mohler techniques. Viewers assessed the esthetic quality of images on a Likert scale while eye-tracking technology analyzed their gaze patterns.

RESULTS

Of the 3 repair techniques, viewers found Fisher repairs most esthetically pleasing (mean ± standard error, 6.91 ± 0.13). Mohler repairs were next most attractive at (6.47 ± 0.13), followed by Millard repairs at (5.60 ± 0.14). The proportion of time spent in fixed gaze on the nose and upper lip was greatest for Millard repairs (58.3% ± 0.4%) and least for Fisher repairs (51.9% ± 0.5%). Viewers fixated most frequently on the nose and upper lip in Millard repairs (83.2% ± 0.5%) and least frequently in Fisher repairs (75.3% ± 0.5%). When examining the Millard compared with Fisher and Mohler repairs, viewers spent more time and fixations on the ipsilateral lip, nose, and repair scar than on the contralateral lip.

CONCLUSIONS

The esthetics of the Fisher repair appear to be favored as measured by Likert scores and gaze data. Eye-tracking technology may be a useful tool to assess outcomes in plastic surgery.

Autologous Fat Transplantation to Improve Lip Contour in Secondary Cleft Lip Deformity

The insufficient volume of lip is one of the pathological problems of cleft lip, despite that the cleft lip the muscles and skin are repositioned. Autologous fat is an ideal material for soft tissue repair, including correction of contour deformity, restoration of volume insufficient, and even improvement of tissue characteristics. In this study, the authors evaluated the result of fat grafting in improvement of lip contour in secondary cleft lip deformity. The authors performed a retrospective analysis of their series of patients who underwent lip fat grafting. A total of 65 subjects with lip fat grafting for cleft lip revision were recruited for the study. The photographs documented the original malformation and the posttreatment photographs. The authors recruited female and male raters, who were experts in the field or lay persons to form a panel of 12 raters altogether. Symmetry and aesthetics were improved after fat grafting based on vermillion border (P = 0.02), symmetry of lip (P = 0.007), and nasal profile including upper lip (P = 0.04) using a 1- to 5-point scale. After treatment, both sides of the lip are more symmetrical, the thickness of the filling part is significantly increased, the filling area is soft, the appearance is satisfied. Fat grafting is an efficient secondary procedure to improve lip contour after cleft lip repairs.

Perth scoring system for assessment of the cleft lip

Background: Currently, there is no standardised assessment tool to assess facial aesthetics in cleft lip and palate surgery. Inter-centre comparison is hampered by the use of different aesthetic indices with low intra- and inter-rater reliability. Aim: The Perth scoring system is a new assessment tool for unilateral cleft lip which scores four key components of the cleft lip/nose repair: lip length, white roll, alar insertion point and vermillion. The aim of this study was to validate the Perth scoring system as a reliable and useful new assessment tool and to demonstrate the use of the scoring system to measure improvements after cleft lip revision. Method: Nineteen patients who underwent cleft lip revision by the senior author were selected. Pre- and postoperative photos were presented to a panel of raters to score. Scores were analysed to determine the intra-and inter-rater reliability and to compare outcomes. Results: Almost all patients (15/16) had improvement in scores (range 1.09–5.59) after cleft lip revision. Intra raters’ agreement scores from lowest to highest were: lip length (0.65), white roll (0.7), alar insertion point (0.78) and vermillion (0.78). The total intra-class correlation coefficient was 0.96 (0.94–0.98, 95% CI, P<0.000). Conclusion: This new scoring system is a valid and useful tool for assessment of the unilateral cleft lip. The high rate of intra- and inter-rater reliability allow it to serve as a useful tool to compare surgical outcomes both within and between centres. Further field testing with a larger cohort of patients is required.

The Psychosocial Patient-Reported Outcomes of End of Pathway Cleft Surgery: A Systematic Review

OBJECTIVE

To identify and review the literature on the psychosocial patient-reported outcomes (PROs) of surgery at the end of the cleft treatment pathway.

DESIGN

A systematic literature search was performed using electronic databases (Medline, PubMed, EMBASE, PsycInfo, Web of Science, and Science Direct) from database inception to September 2017, to identify studies measuring and reporting the psychosocial PROs of end of pathway cleft surgery.

RESULTS

Of 263 identified papers, 22 studies were eligible for inclusion. Apart from one randomized controlled study, studies were largely observational and adopted a cross-sectional or retrospective design. The majority (n = 16) were small-scale studies. The methodological quality was variable in terms of what, how, and when psychosocial outcomes were measured and reported. None of the studies utilized a psychosocial PRO measure validated in the cleft population, and few studies measured outcomes prospectively. A high proportion of studies utilized bespoke measures of patient satisfaction. Taken together, findings from the included studies are tentative but seem to suggest patients derive some benefit from undergoing end of pathway cleft surgery, in terms of increased satisfaction, quality of life, social interactions, and decreased appearance-related distress.

CONCLUSIONS

Due to methodological challenges and the heterogeneity of what, how, and when outcomes are measured and currently reported, it is difficult to determine the psychosocial PROs of end of pathway cleft surgeries. Consequently, this review advocates the conduct of well-designed, longitudinal studies using cleft-sensitive tool/s to capture the psychosocial PROs of end of pathway cleft surgery at various time points.

Influence of different techniques of secondary cleft lip revision surgery on upper lip projection

Patient dissatisfaction with labial appearance in the adult cleft lip is frequently linked to poor upper lip projection. Other areas of concern include asymmetry and impaired upper lip height. Different surgical techniques are available to address volumetric deficiencies, according to extent and localization. However, data comparing outcomes in these different areas are limited. The main aim of this study was to assess the relative gains in upper lip projection. An evaluation of upper vermilion height and symmetry was also performed. Thirty-seven consecutive patients treated by a single surgeon had their pre- and postoperative results measured using standardized photographs; these were analysed using subjective and objective outcome measures. Seven examiners evaluated anonymized pre- and postoperative side and front views for subjective evaluation. The objective analysis was performed using Adobe Photoshop. Fifteen lip revisions, four Abbe flaps, 12 dermal grafts, and six PermaLip implants were performed. In bilateral cleft lip and palate patients, Abbe flaps showed the most significant improvement in labial projection, followed by PermaLip implants and dermal grafts. In unilateral cleft lip and palate patients, PermaLip implants best addressed impaired lip projection, followed by dermal grafts. Overall, functional lip revisions showed excellent outcomes for upper lip symmetry; however, only minor changes in labial projection were found.

CLEFT-Q: Detecting Differences in Outcomes among 2434 Patients with Varying Cleft Types

BACKGROUND

Measuring the patient perspective is important in evaluating outcomes of cleft care. Understanding how treatment outcomes vary depending on cleft type may allow for better planning of treatments, setting of expectations, and more accurate benchmarking efforts. The CLEFT-Q is a patient-reported outcome measure for patients with cleft lip and/or palate.

METHODS

The 12 CLEFT-Q scales measuring appearance (i.e., face, nose, nostrils, lips, cleft lip scar, teeth, and jaws), function (i.e., speech), and health-related quality of life (i.e., psychological, school, social, and speech-related distress) were field tested in a cross-sectional study in 30 centers in 12 countries. Patients with cleft lip and/or cleft palate aged 8 to 29 years were recruited from clinical settings. Differences in CLEFT-Q scores by cleft subtypes were evaluated using one-way analysis of variance or Kruskal-Wallis H tests, with Tukey or Dunn procedure with Bonferroni corrections post hoc analyses, respectively. Scores are presented using radar charts to visualize all outcomes simultaneously.

RESULTS

The field test included 2434 patients. Scores on all CLEFT-Q scales varied significantly with cleft subtype. Patients with unilateral or bilateral cleft lip and/or palate scored lower on all appearance scales compared with patients with cleft palate or unilateral incomplete cleft lip. Scores on the speech function and speech-related distress scales decreased with each progressive group in the Veau classification. Patients with complete bilateral cleft lip and palate scored lowest on the social, school, and psychological scales.

CONCLUSIONS

Patient-reported outcomes measured with the CLEFT-Q vary significantly with cleft type. Visualizing multiple outcomes simultaneously with radar charts allows for an understanding of a patient's overall status in a single graph.

Conscious Perception of Facial Asymmetry in a Unilateral Cleft Lip Model

OBJECTIVE

Lip asymmetry after a unilateral cleft lip repair can be perceived as an unsatisfactory result. The objective of this study is to determine the degree of upper lip asymmetry and/or nasal alar hooding required for recognition of asymmetry in a simulated model of unilateral cleft lip.

DESIGN

A model of unilateral cleft lip was created using digital morphing software to simulate asymmetries in vermilion height and nasal hooding in photographs of children. Volunteers were shown photographs for different time intervals and with varying degrees of asymmetry. Ability to detect facial asymmetry was recorded and analyzed.

SETTING

This study was conducted by surveying layperson volunteers in public community settings.

PARTICIPANTS

108 layperson volunteers were randomly surveyed.

MAIN OUTCOME MEASURES

The primary outcome measure was a reported lip or nose asymmetry by the volunteers. Proportions and corresponding 95% confidence intervals were obtained to estimate the probability of reporting an asymmetry at 3- and 10-second intervals.

RESULTS

After 3- and 10-second exposure, labial asymmetry was perceived by ≥50% of subjects at 2 mm (62%, P = .001) and 1 mm (89%, P < .0001), respectively. Nasal asymmetry was detected by <50% of subjects at 3 seconds, but ≥50% perceived a 3-mm alteration at 10 seconds (64%, P < .0001). Photographs with combined nasal and labial modification did not lower the threshold for asymmetry perception compared to either deformity alone.

CONCLUSIONS

This study is the first to determine a predictable millimeter threshold for perceived asymmetry in cleft lip deformity using a digital model.

Nasolabial outcomes in a nationwide study of orofacial cleft in New Zealand

OBJECTIVES

To (a) assess nasolabial outcomes across four main cleft subgroups, (b) assess agreement using a categorical and a continuous scoring measure and (c) compare outcomes to international studies.

SETTINGS AND SAMPLE POPULATION

Analysis of 470 images of which 218 was unilateral cleft lip and palate (UCLP), 128 unilateral cleft lip (UCL), 90 bilateral cleft lip and palate (BCLP) and 34 bilateral cleft lip (BCL). Images were taken around five (n = 279) and eight-ten (n = 191) years of age.

MATERIALS & METHODS

Cropped images were assessed using the Asher-McDade (AM) and a 100 mm visual analogue scale (VAS) by a panel of six raters. Scoring was undertaken for vermillion border and nasal form, symmetry and profile. Analysis was undertaken for each subscore, a total score with sensitivity analysis using a total score based on the subscores for each patient. AM intra- and inter-rater reliability was assessed using weighted kappa and for the VAS components reliability was assessed using Pearson correlation.

RESULTS

The AM intra-rater reliability was moderate/substantial, whilst inter-rater reliability was fair. The VAS intra-rater correlations were high, and inter-rater correlations were moderate. Better outcomes were found with cleft lip (CL) vs cleft lip and palate (CLP). No differences were found for sex, ethnicity, age and cleft laterality (unilateral). The AM found no difference between unilateral or bilateral. The VAS found bilateral scored worse than unilateral for both CL and CLP.

CONCLUSIONS

The nasolabial outcomes differ by cleft type. The correlation was relatively high for the VAS whilst the AM had relatively poor reliability.

Aesthetics Assessment and Patient Reported Outcome of Nasolabial Aesthetics in 18-Year-Old Patients With Unilateral Cleft Lip

Objective:

To determine if there is a correlation between objective nasolabial aesthetics assessment using the Cleft Aesthetic Rating Scale (CARS) and patient satisfaction.

Design:

Retrospective analysis of a generic satisfaction questionnaire and independent assessment by three cleft surgeons of the nasolabial area of these patients on 2D frontal photographs, using the CARS.

Setting:

The Vrije Universiteit Medical Center and The Academic Center for Dentistry Amsterdam.

Patients:

Thirty-nine 18-year old patients with a repaired complete or incomplete unilateral cleft lip, with or without a cleft palate, and a completed satisfaction questionnaire. Exclusion criteria were an incomplete questionnaire; a history of facial trauma; and congenital syndromes affecting facial appearance.

Main Outcome Measures:

The correlation between surgeon evaluation (on a 5-point Likert scale) and patient satisfaction (not, moderately or very satisfied) on nasolabial appearance was assessed using Spearman rho (ρ).

Results:

There was a negligible correlation between surgeon evaluation and patient satisfaction on nose assessment (ρ = 0.20) and a moderate correlation on lip assessment (ρ = 0.32).

Conclusions:

Most literature supports this discrepancy between different objective aesthetics evaluation methods and subjective patient-reported outcome measures, suggesting there are factors playing a role in patient satisfaction that are impossible to objectify with assessment methods. Therefore, a strong emphasis should remain on clear communication between the physician and patient regarding their expectations, perception, and satisfaction of surgery results.

Ear Reconstruction Simulation: From Handcrafting to 3D Printing

Microtia is a congenital malformation affecting one in 5000 individuals and is characterized by physical deformity or absence of the outer ear. Nowadays, surgical reconstruction with autologous tissue is the most common clinical practice. The procedure requires a high level of manual and artistic techniques of a surgeon in carving and sculpting of harvested costal cartilage of the patient to recreate an auricular framework to insert within a skin pocket obtained at the malformed ear region. The aesthetic outcomes of the surgery are highly dependent on the experience of the surgeon performing the surgery. For this reason, surgeons need simulators to acquire adequate technical skills out of the surgery room without compromising the aesthetic appearance of the patient. The current paper aims to describe and analyze the different materials and methods adopted during the history of autologous ear reconstruction (AER) simulation to train surgeons by practice on geometrically and mechanically accurate physical replicas. Recent advances in 3D modelling software and manufacturing technologies to increase the effectiveness of AER simulators are particularly described to provide more recent outcomes.

Facial and midfacial symmetry in cleft patients: Comparison to non-cleft children and influence of the primary treatment concept

PURPOSE

Patients with cleft lip, alveolus and palate (CLAP) may suffer from marked asymmetry with an impact on attractiveness and psychosocial aspects. The aim of this study was to assess symmetry in CLAP patients compared to non-cleft controls of similar age with regard to cleft type and treatment concept.

MATERIALS AND METHODS

In CLAP patients with different cleft forms and in healthy non-cleft subjects (control group) a three-dimensional stereophotogrammetric face scan was performed and an objective 3D asymmetry index (AI) was calculated for the whole face, the midface, the upper lip and the nose.

RESULTS

In total, 305 patients were included: 140 CLAP patients (90 male, 50 female, mean age 9.9 ± 3.6 years) and 165 controls (87 male, 78 female, mean age 8.7 ± 2.1 years). In general, CLAP patients showed significantly higher asymmetry than controls, with the most severe asymmetry found in unilateral complete CLAP. Patients treated according to an actual concept considering reconstruction of all affected muscular systems had a significant lower and more favourable AI than patients not treated according to this concept (p < 0.05).

CONCLUSION

An adequate treatment concept is essential to achieve better results concerning symmetry in CLAP, but symmetry values of healthy non-cleft controls are not reached.

Two Methods of Cleft Palate Repair in Patients With Complete Unilateral Cleft Lip and Palate

OBJECTIVE

The objective of this study was to compare the surgical outcome between 2 patient groups with complete unilateral cleft lip and palate who underwent different types of palatoplasty.

METHODS

This is a cohort study between 2 groups of patients with complete unilateral cleft lip and palate who were operated using different surgical techniques from 2008 to 2011. About 28 patients were operated using a primary lip nose repair with vomer flap for hard palate single-layer closure and delayed soft palate repair (modified Oslo protocol) and 32 patients were operated using our protocol in Lima. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency and evaluation of dental arch relationships (scored using the 5-year-olds' index).

RESULTS

Our comparative study observed statistically significant differences between the 2 groups regarding the presence of oronasal fistulas and velopharyngeal insufficiency in favor of our palatoplasty technique. A statistically significant difference was not found in functional vestibular oronasal fistula development between the studied techniques for unilateral cleft palate repair. This comparative study did not observe significant differences in dental arch relationships between the studied techniques.

CONCLUSION

In this study, better surgical outcome than modified Oslo protocol regarding oronasal fistulas and velopharyngeal insufficiency on patients with complete unilateral cleft lip and palate was observed. The results arising from this study do not provide evidence that one technique is enough to obtain better functional closure of the alveolar cleft and dental arch relationship at 5 years.

Development of the Submental Nasal Appearance Scale for the Assessment of Repaired Unilateral Complete Cleft Lip: A Pilot Study

Objective:

To develop the “Submental Nasal Appearance Scale” (SNAS), which is an easy-to-use objectified tool to represent a cleft surgeon’s standard for assessment of the nasal appearance from the submental perspective.

Design:

Eighty-five photographs of patients with unilateral complete cleft lip and palate were selected and cropped, displaying the submental view. Sixty-one photographs were used to develop 5 sets of reference photographs. Three cleft surgeons graded 24 photographs with these sets and subjectively graded the overall nasal appearance as well. Internal agreement for both methods was calculated, as well as correlation between them. The SNAS was created, by only using the combination of sets that showed the highest reliability and correlation.

Setting:

Boston Children’s Hospital, Boston, Massachusetts.

Patients:

Six- to 9-year-old patients with unilateral complete cleft lip and palate.

Results:

The intrarater and interrater reliability was 0.84 and 0.79, respectively, for the SNAS and 0.76 and 0.62, respectively, for the overall appearance assessment. The correlation was 0.74 between the methods.

Conclusions:

The SNAS is a reliable tool that reflects a cleft surgeon’s standard and could be used independently or in combination with existing rating scales using the frontal and/or lateral view, for assessment after cleft lip repair.

Defining the Aesthetic Range of Normal Symmetry for Lip and Nose Features in 5-Year-Old Children Using the Computer-Based Program SymNose

Objective:

To provide a normal comparison group against which to judge symmetry results after cleft surgery and to introduce the thin lip correction (TLC) feature in SymNose. A lip–aspect ratio algorithm has been added to the latest version of SymNose to compensate for the higher degree of overlap in thicker lips when compared to thin lips.

Design:

Retrospective analysis of symmetry in healthy participants, using the computer-based program SymNose on both anteroposterior (AP) and base view images. Photographs of 91 noncleft children were traced twice by 3 independent investigators experienced with SymNose.

Participants:

Five-year-old healthy participants from a local state school in Tavistock (West Devon, United Kingdom).

Main Outcome Measure:

Asymmetry expressed as the perimeter mismatch percentage for nose and lip features on AP view images and for nose features on base view images.

Results:

The perimeter mismatch reference range for the nose (AP view) was 2.65% to 30.91%, for the lip 2.13% to 15.44%, for the nose (base view) 1.69% to 14.84%, for the nostrils 4.68% to 26.6%, and for the width–height ratio 1.15% to 1.80%. The perimeter mismatch percentage for the lip without TLC was significantly higher compared to the perimeter mismatch percentage with TLC (P < .001).

Conclusion:

This article provides a noncleft reference range for all perimeters drawn from SymNose against which to compare results after cleft surgery at 5 years of age. Furthermore, it shows the importance of correcting for variance in lip volume per child.

Longitudinal Follow-up of Individuals With Cleft Lip Using Three-Dimensional Stereophotogrammetry

The usefulness of three-dimensional (3D) stereophotogrammetry for treating cleft lip (CL) has been well documented. However, there are only a few reliable anthropometric analyses in infants with CL because at this age they cannot assume a resting facial position. Since 2014, we have used a handheld 3D imaging system in the operating room to obtain optimal images of infants with CL and palate under general anesthesia. Currently, 168 infants with a unilateral cleft, 50 infants with bilateral clefts, and 47 infants with an isolated cleft palate are being followed up in this way for a maximum of 30 months. Most patients ≥3 years of age are cooperative and allow staff to obtain 3D images without sedation. We plan to follow them until adulthood, obtaining 3D images at every intervention. Each year, >150 infants can be added to this ongoing longitudinal study. Using an archive of these digital images, various retrospective studies can be attempted in the future, which include comparisons of the long-term outcomes of various surgical techniques and interventions at different time intervals. This is the first 2-year preliminary report of a 20-year longitudinal study.

Objective Assessment of the Unilateral Cleft Lip Nasal Deformity Using Three-Dimensional Stereophotogrammetry: Severity and Outcome

BACKGROUND

Optimization of care to correct the unilateral cleft lip nasal deformity is hampered by lack of objective measures to quantify preoperative severity and outcome. The purpose of this study was to develop a consensus standard of nasal appearance using three-dimensional stereophotogrammetry; determine whether anthropometric measurements could be used to quantify severity and outcome; and determine whether preoperative severity predicts postoperative outcome.

METHODS

The authors collected facial three-dimensional images of 100 subjects in three groups: 45 infants before cleft lip repair; the same 45 infants after cleft lip repair; and 45 children aged 8 to 10 years with previous repairs. Five additional age-matched unaffected control subjects were included in each group. Seven expert surgeons ranked images in each group according to nasal appearance. The rank sum score was used as consensus standard. Anthropometric analysis was performed on each image and compared to the rank sum score. Preoperative rank and anthropometric measurements were compared to postoperative rank.

RESULTS

Interrater and intrarater reliability was excellent (intraclass correlation coefficient, >0.76; Pearson correlation, >0.75) on each of the three image sets. Columellar angle, nostril width ratio, and lateral lip height ratio were highly correlated with preoperative severity and moderately correlated with postoperative nasal appearance. Postoperative outcome was associated with preoperative severity (rank and anthropometric measurement).

CONCLUSIONS

Consensus ranking of preoperative severity and postoperative outcome can be achieved on three-dimensional images. Preoperative severity predicts postoperative outcomes. Columellar angle, nostril width ratio, and lateral lip height ratio are objective measures that correlate with consensus ratings by surgeons at multiple ages.