Three-dimensional analyses of nasolabial forms and upper lip surface symmetry after primary lip repair in patients with complete unilateral cleft lip and palate

Three-dimensional nasal asymmetry analysis between adolescence and adulthood in postoperative patients with unilateral cleft lip and palate using computed tomography

AIM

To investigate the differences of the nasal soft and hard tissue asymmetry in postoperative patients with unilateral cleft lip and palate (UCLP) between adolescence and adulthood, and to explore the correlation of nasal soft and hard tissue asymmetry.

METHODS

CT data from 47 repaired UCLP patients were included and divided into two groups:1. adolescent group: 23 patients (15 males, 8 females; age: 10-12 years old). 2. adult group: 24 patients (16 males, 8 females; age:18-32 years old). The three-dimensional asymmetry in nasal soft and hard tissues was analyzed. Additionally, the correlation between nasal soft and hard tissue asymmetry was also analyzed.

RESULTS

Both the adolescent group and adult group showed asymmetries in nasal soft and hard tissues. Compared to the adolescent group, the adult group had a significantly increased horizontal asymmetry of nasal soft tissues Sbal (P < 0.05). Furthermore, the sagittal asymmetry of soft tissue Glat (P < 0.05), Sbal (P < 0.001), Sni (P < 0.001) and hard tissue LPA (P < 0.05) also increased significantly. In the adult group, there were more landmarks with a correlation between the asymmetry of nasal hard tissue and soft tissue compared to the adolescent group. There were moderate to strong correlations between nasal hard and soft tissue symmetries in the horizontal and sagittal directions (0.444 < r < 764), but no correlation in the vertical direction in the adult group (P > 0.05).

CONCLUSIONS

The asymmetry of nasal soft and hard tissues in patients with repaired UCLP becomes more apparent in the horizontal and sagittal dimensions from adolescence to adulthood. The correlation between the asymmetry of nasal hard tissue and soft tissue becomes stronger in the horizontal and sagittal dimensions. These factors should be taken into account when performing treatment for repaired UCLP patients in adolescence and adulthood.

Enhancing Philtrum Morphology Using Fat Grafting Combined with Percutaneous Rigottomy in Repaired Unilateral Cleft Lip

BACKGROUND

Improving the philtrum morphology of patients with a secondary cleft lip deformity has been a challenge in cleft care. Combining fat grafting with percutaneous rigottomy has been advocated for treatment of volumetric deficiency associated with a scarred recipient site. This study assessed the outcome of synchronous fat grafting and rigottomy for improvement of cleft philtrum morphology.

METHODS

Consecutive young adult patients ( n = 13) with a repaired unilateral cleft lip who underwent fat grafting combined with rigottomy expansion technique for enhancement of philtrum morphology were included. Preoperative and postoperative three-dimensional facial models were used for three-dimensional morphometric analyses including philtrum height, projection, and volume parameters. Lip scar was qualitatively judged by a panel composed by two blinded external plastic surgeons using a 10-point visual analogue scale.

RESULTS

Three-dimensional morphometric analysis revealed a significant (all P < 0.05) postoperative increase of the lip height-related measurements for cleft philtrum height, noncleft philtrum height, and central lip length parameters, with no difference ( P > 0.05) between cleft and noncleft sides. The postoperative three-dimensional projection of the philtral ridges was significantly ( P < 0.001) larger in cleft (1.01 ± 0.43 mm) than in noncleft sides (0.51 ± 0.42 mm). The average philtrum volume change was 1.01 ± 0.68 cm 3 , with an average percentage fat graft retention of 43.36% ± 11.35%. The panel assessment revealed significant ( P < 0.001) postoperative scar enhancement for the qualitative rating scale, with mean preoperative and postoperative scores of 6.69 ± 0.93 and 7.88 ± 1.14, respectively.

CONCLUSION

Synchronous fat grafting and rigottomy improved philtrum length, projection, and volume and lip scar in patients with repaired unilateral cleft lip.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Three-Dimensional Quantification of Postoperative Facial Asymmetry in Patients With Unilateral Cleft lip and Palate Using Facial Symmetry Plane

OBJECTIVE

To quantitatively assess three-dimensional (3D) soft tissue facial asymmetry in patients with unilateral cleft lip and palate (UCLP) who have undergone primary lip repair.

DESIGN

Clinical, retrospective, comparative, methodological study.

PATIENTS/PARTICIPANTS

Twenty patients with UCLP were selected after a review of the records.

INCLUSION CRITERIA

Complete UCLP; surgically treated without secondary repair. An age-matched and sex-matched Control group was employed.

MAIN OUTCOME MEASURES

A 3D facial symmetry plane (FSP) was obtained by superimposing the point clouds of the original 3D facial image excluding the surgical site and including lip and nose areas and those of a mirrored facial image using the iterative closest point (ICP) adjustment method. The discrepancies in the depth and angle of the normal vector of the facial surface of each point cloud between right and left sides (cleft and non-cleft sides in the UCLP group, respectively) based on FSP were calculated.

RESULTS

Facial asymmetry in the UCLP group was significantly greater than in the Control group regarding both the discrepancies in the depth (1.34 ± 0.62, 0.73 ± 0.32 pixels, respectively) (P = .0004) and surface angle (18.0 ± 5.88, 12.8 ± 4.0°, respectively) (P = .0024). Biaxial assessment of the discrepancies in the depth and surface angle allowed us to visually extract UCLP patients with greater facial asymmetry.

CONCLUSIONS

Facial asymmetry analysis based on 3D FSP effectively facilitates the facial asymmetry quantification and soft tissue surgical outcome evaluation in patients with UCLP.

Longitudinal Three-Dimensional Stereophotogrammetric Growth Analysis in Infants with Unilateral Cleft Lip and Palate from 3 to 12 Months of Age

This longitudinal study aimed to evaluate facial growth and soft tissue changes in infants with complete unilateral cleft lip, alveolus, and palate (CUCLAP) at ages 3, 9, and 12 months. Using 3D images of 22 CUCLAP infants, average faces and distance maps for the entire face and specific regions were created. Color-coded maps highlighted more significant soft tissue changes from 3 to 9 months than from 9 to 12 months. The first interval showed substantial growth in the entire face, particularly in the forehead, eyes, lower lip, chin, and cheeks (p < 0.001), while the second interval exhibited no significant growth. This study provides insights into facial soft tissue growth in CUCLAP infants during critical developmental stages, emphasizing substantial improvements between 3 and 9 months, mainly in the chin, lower lip, and forehead. However, uneven growth occurred in the upper lip, philtrum, and nostrils throughout both intervals, with an overall decline in growth from 9 to 12 months. These findings underscore the dynamic nature of soft tissue growth in CUCLAP patients, highlighting the need to consider these patterns in treatment planning. Future research should explore the underlying factors and develop customized treatment interventions for enhanced facial aesthetics and function in this population.

Short-term surgical outcomes in patients with unilateral complete cleft lip and palate after presurgical nasoalveolar molding therapy: A three-dimensional anthropometric study

OBJECTIVE

This brief research report aimed to evaluate the short-term efficacy of presurgical nasoalveolar molding (PNAM) therapy on the nasolabial morphology three dimensionally in patients with non-syndromic complete unilateral cleft lip and palate (UCLP).

METHODS

Thirty-six patients with non-syndromic complete unilateral complete cleft lip and palate were enrolled retrospectively and categorized into 2 groups: 18 patients who had received PNAM treatment (PNAM group) and 18 age-matched patients who have not receive PNAM treatment (no PNAM group) from 2017 to 2021. The average starting age for PNAM therapy was 18.33 days, and the average PNAM treatment duration was 99.08 days. Twelve nasolabial parameters were measured to compare the postsurgical outcomes of two groups.

RESULTS

In PNAM groups, cleft width, vertical distance between double Crista philtri and columellar deviation were reduced compared to that in no PNAM group. And nostril height was larger than that in no PNAM group. The differences between two groups were statistically significant (p < .05). There were no statistical differences in columellar length, nostril width and bi-alar width between two groups. However, the nostril width on cleft side in PNAM group was decreased by an average of 1.1 mm.

CONCLUSION

Our result indicated that PNAM therapy decreased cleft width and vertical distance between Crista philtri. It also increased nasal symmetry by decreasing columellar deviation, increasing nostril height.

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.

Three-Dimensional Computed Tomography Reconstruction and Measurement of Nasal End Deformity in Complete Unilateral Cleft Lip and Palate

BACKGROUND

The repair of nasal deformities secondary to cleft lip and palate is complex and requires reliable preoperative nasal 3-dimensional assessment. This study explored nasal end (defined as the lower third of the external nasal and vestibular parts of the nasal cavity) deformities secondary to unilateral complete cleft lip and palate.

METHODS

Three-dimensional nasal end morphometric measurements were obtained from 48 patients who had undergone Millard cleft lip repair and reached skeletal maturity (cleft group) and from 36 age- and ethnicity-matched normal subjects (control group). For the cleft group, paired t tests and 1-way analysis of covariance were used to evaluate the internal and external morphological characteristics of the cleft and noncleft sides of the nasal end, and correlation analysis was done to evaluate the relationship between cleft-side measurements.

RESULTS

In the cleft group, the cleft side showed significantly smaller nasal vestibular volume and skin area, nostril area, nasal column length, and nostril height and greater nostril base length and nasal alar length than the noncleft side (all P < 0.05). Controlling for sex, there were significant differences in the nasal vestibular volume and skin area, internal nasal valve area, long nostril diameter, nostril base length, columella length, nostril height, and nasal alar length between the cleft and control groups (all P < 0.05). On the cleft side, the area of the skin lining of the nasal vestibule positively correlated with the alar length (r = 0.67, P < 0.05).

CONCLUSIONS

Three-dimensional nasal end reconstruction provides a more detailed preoperative nasal end morphological evaluation than previously available techniques.

LEVEL OF EVIDENCE

Level III, case-control study.

Aesthetic and psychosocial impact of dentofacial appearance after primary rhinoplasty for cleft lip and palate

The primary aim of this study was to demonstrate whether primary rhinoplasty shows aesthetic and psychosocial advantages for children with a complete unilateral cleft lip and palate. The second aim was to determine the satisfaction levels concerning the dentofacial appearance. Group A corresponded to patients from a center specialised in primary cheilo-rhinoplasty with 20 years' experience and Group B to patients who did not benefit from primary rhinoplasty. Children and their parents filled in a custom-designed satisfaction questionnaire on dentofacial appearance and its psychosocial impact. The variables studied were the main criterion (the nose) and secondary criteria (the upper lip, the smile, the profile and the face as a whole). 56 families consented to be involved in the study. The children did not rate statistically differently their social relationships if they had primary rhinoplasty or not. Parents however expressed very different views. They considered the nasal appearance of the children who had primary rhinoplasty as statistically more attractive and evaluated their psychosocial experience as significantly better. For the other parts of the face, in both groups, satisfaction levels of dentofacial appearance and psychosocial comfort were good (scores above 80/100). Yet, 44% of the families would go for further interventions, especially concerning the nose (13% of whom were in Group A and 42% in Group B). Within the limitations of this study, primary rhinoplasty seems to improve the patient's well-being and social life and, therefore, should be considered whenever appropriate.

Morphological Correlations in Nasolabial Formation After Primary Lip Repair for Unilateral Cleft Lip

PURPOSE

We aim to reveal postoperative morphological correlations between the nasolabial components in patients with unilateral cleft lip (UCL). The hypothetical correlations are first, a correlation between the vertical height of the cleft-side alar base and the length of the cleft-side red lip, and second, a correlation between the length of the cleft-side red lip and the vertical position of the cleft-side oral commissure. We explain how these morphological balances are controlled by surgery.

METHODS

Three-dimensional bilateral measurements of the length of the red lip, vertical height of the nasal alar base, and vertical height of the oral commissure were conducted retrospectively on 31 patients with UCL and palate (complete UCL: 26; incomplete UCL: 5) who underwent primary lip plasty at Osaka Women's and Children's Hospital from 2017 to 2019.

RESULTS

We found a statistically significant correlation between the vertical height of the cleft-side alar base and cleft-side red lip length (P = .012, r = 0.45); thus, the longer the red lip, the lower was the nasal alar base. The correlation between the cleft-side red lip length and the vertical height of the cleft-side oral commissure also showed a statistical significance (P = .00074, r = 0.57); thus, the shorter the red lip, the higher was the oral commissure.

CONCLUSIONS

The present results provided objective evidence showing basic morphological relationships between the postoperative nasolabial features of patients with UCL. The results lead to a reasonable approach to define the proposed peak of the Cupid's bow, an unsettled major controversy in cleft lip surgery.

Philtral Ridge Projection in Repaired Unilateral Cleft Lip: Three-Dimensional Anthropometry

BACKGROUND

Cleft surgeons try to construct a philtral ridge during primary repair of a cleft lip, but rarely document the results. The authors used three-dimensional photogrammetry to measure projection of philtral ridges after closure of the common forms of unilateral labial cleft.

METHODS

This is a retrospective study of patients with unilateral complete, incomplete (moderate and severe), and microform cleft lip repaired by one surgeon from 2000 to 2013. Cleft type determined the technique for building a philtral ridge. The relative elevation of the ridge on the cleft versus noncleft side was measured on three-dimensional childhood photographs at two locations along the philtrum: just above the Cupid's bow and at the midlabial level.

RESULTS

Thirty-four patients were evaluated at a mean age of 9.25 years. All cleft types exhibited greater projection at the philtral midlabial level compared with the Cupid's bow level. The authors found a trend toward a more prominent cleft side philtral ridge in microforms. In incomplete cleft lips, there was slightly greater philtral ridge projection in severe forms repaired after a preliminary nasolabial adhesion compared with those repaired in a single stage. There was similar projection of the cleft side ridge in two-stage complete and single-stage repaired incomplete lips.

CONCLUSIONS

It is possible to construct a philtral ridge that is as prominent as the noncleft side in all types of unilateral cleft lip. Increased muscle thickness may explain the slightly increased philtral ridge projection in patients with an incomplete cleft repaired in two stages compared to one-stage closure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Modeling and measuring average nasal asymmetry by dorsum midline and nose tip lateral deviation

In rhinoplasty and nasal reconstruction, achieving symmetry is critical for optimal patient outcomes and reducing re-operation rates. Assessing nasal asymmetry is challenging, both pre- and intra-operatively, if based on only a surgeons' visual perception to assess and adjust the small distances important to cosmesis (<2-3 mm). To measure nasal symmetry, we first developed an algorithm to analyze lateral nasal deviation on facial three-dimensional (3D) scans captured by external surface scanning. In this, nasal deviation is measured by first registering a 3D facial scan to orthogonal axes in order to remove tilt. The lateral position of the nasal midline is then found across transverse planes along the dorsum and nasal tip regions by probing midpoints 1 and 2 mm back from the local maximum projection. The nasal deviation measurement algorithm was validated on a simulated asymmetrical nose model with known nasal deviation. Simulated deviations were applied to the symmetrical average nose using an exponential twist away from the face, with control of the maximum deviation and degree of curvature. Modeled deviations were evaluated with the algorithm at clinically negligible (0.02-0.06 mm) average differences and for small lateral deviations (1-5 mm). Nasal deviation using the algorithms was then measured for the 100 multi-ethnic subjects in the Binghamton University 3D Facial Expression database. Average values for maximum lateral deviation, deviation across the whole nose, and deviation at the nose tip were measured to provide context to deviation measurements in surgical planning. This research presents a new nasal assessment tool that can be useful in improving symmetry in rhinoplasty and reconstruction.

Measurement accuracy of 3-Dimensional mapping technologies versus standard goniometry for angle assessment

BACKGROUND

A specific aspect of the hypospadias phenotype that may contribute to long-term outcomes is the presence of ventral penile curvature and the adequacy of its surgical correction. The current gold standard to assess this angle is intraoperative goniometry of an erect penis. 3-dimensional (3D) mapping technologies may overcome the limitations of these traditional methods through their combination of digital image and geometric replication to produce consistent 3D digital forms of a physical structure. The aim of this study is to evaluate the measurement accuracy and reliability of handheld 3D mapping technologies versus standard goniometry for angle assessment in a laboratory setting.

METHODS

Blocks with specified angles (10-45°) were printed using a Zortrax M200 3D printer (±0.2% accuracy). Following the completion of standardized training, blinded participants measured each block angle using a baseline digit goniometer. Additionally, complete digital models of the blocks were created using 3D mapping technologies. Structured light scanning was completed using an Artec Space Spider and Artec Studio 13. Traditional photogrammetry was completed using a Canon Eos Rebel T5i DSLR camera and Agisoft Metashape Pro. Photogrammetry with a 3D camera was completed using the VECTRA H1 and VECTRA Analysis Module. All 3D models were imported into the software Autodesk Inventor in which automated angle measurements through the central plane were obtained. Statistical analysis was performed to determine the accuracy, precision and reliability of each modality using SAS 9.4 software. The reliability of goniometry and each mapping technology was evaluated using two-way random effect models with absolute agreement.

RESULTS

Six 3D printed blocks were evaluated. 5 digital models per block were created using each of the 3 mapping technologies. Inter-rater reliability of goniometry was moderate (ICC 0.76, 95% CI 0.46, 0.92), whereas all mapping technologies demonstrated excellent test-retest reliability: structured light scanning (ICC 0.99; 95% CI 0.999, 0.999); traditional photogrammetry (0.99; 0.99, 0.99); 3D camera (0.99; 0.99, 0.99). Mean angle measurements and standard error for each angle and modality are provided in the table.

CONCLUSIONS

This study demonstrated excellent accuracy, precision and reliability of off-the-shelf, handheld 3D mapping technologies and moderate reliability for goniometry when applied to measurements of angulation in a laboratory setting. The described methods developed in the laboratory for optimization of angle analysis from 3D models are an important step toward reliable, reproducible phenotypic analysis of congenital genitourinary conditions in future intraoperative and database development applications.