Audit of a multidisciplinary approach to the care of children with unilateral and bilateral cleft lip and palate

Effect of Acellular Dermal Matrix on Long-Term Speech Outcomes in Primary Palatoplasty with Radical Intravelar Veloplasty

OBJECTIVE

This study investigates whether the use of acellular dermal matrix (ADM) affects the long-term speech outcomes in patients undergoing primary palatoplasty with radical intravelar veloplasty.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

A consecutive cohort of 112 patients who underwent primary palatoplasty with radical intravelar veloplasty from August 2014 to March 2018 were included.

MAIN OUTCOME MEASURES

A 2 × 2 cm-sized ADM was incorporated as an interpositional graft between the oral and nasal lining at the soft-hard palate junction. The perceptual analysis of hypernasality and articulation was performed when the age of the patient reached at least 36 months. Cleft-related characteristics and surgical factors affecting the speech outcomes were investigated.

RESULTS

The ADM was applied in 57 patients with a mean follow-up of45.76 months (SD, 10.69), while no ADM was used in 55 patients with a mean follow-up of 48.43 months (SD, 14.98). Regarding the hypernasality outcome, 33.3% (19 of 57 patients) of the ADM group and 27.3% (15 of 55 patients) of the control group showed a greater than mild-to-moderate degree. The distribution of hypernasality and articulation grade showed no significant difference between the two groups. After controlling for potential risk factors that may affect the speech outcomes, the use of ADM showed no significant relationship with velopharyngeal insufficiency.

CONCLUSION

The use of ADM use in primary palatoplasty with radical intravelar veloplasty is not associated with the alteration of speech function in early childhood.

Evidence-Based Practices in Cleft Palate Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications.

SUMMARY

Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.

The Panorama of Cleft Lip and Palate Live Birth in Brazil: Follow-up of a 10-Year Period and Inequalities in the Health System

OBJECTIVE

To provide the prevalence and an overview of cleft lip and palate (CL/P) in the period of 2008 to 2017, as well as the profile of care provided for this condition in Brazil.

DESIGN

Cross-sectional study of epidemiological character.

SETTING

Brazilian government website.

PARTICIPANTS

National Live Birth and Hospital Information System.

INTERVENTION

Organization of the end databases and performance-based statistical analysis.

MAIN OUTCOME MEASURE(S)

Analysis of the prevalence of CL/P in newborns, sociodemographic condition of the mothers, surgical procedures and hospitalizations, and specialized hospitals in Brazil within a 10-year period.

RESULTS

The average prevalence of CL/P in Brazil was ∼52 children per 100 000 live births in the covered period, corresponding to 1 per 1924 newborns. The presence of cleft was associated with preterm birth, being underweight, and the male gender. The highest prevalence was found in the South region, while the lowest was found in the Northeast region, with increasing rates in the North region of Brazil. The states with the highest prevalence were not those with a great number of hospitalizations and surgical procedures for live births with CL/P.

CONCLUSION

In the 10-year study period, the prevalence of CL/P was 0.52 newborns per 1000 live births, a result which differs among the states of Brazil. The need to reinforce the national monitoring of the prevalence and surgical procedures of cleft patients have also emphasized the need to improve public medical care for CL/P subjects.

Vocabulary Growth From 18 to 24 Months of Age in Children With and Without Repaired Cleft Palate

Purpose This study investigated vocabulary growth from 18 to 24 months of age in young children with repaired cleft palate (CP), children with otitis media, and typically developing (TD) children. In addition, the contributions of factors such as hearing level, middle ear status, size of consonant inventory, maternal education level, and gender to the development of expressive vocabulary were explored. Method Vocabulary size of 40 children with repaired CP, 29 children with otitis media, and 25 TD children was measured using the parent report on MacArthur-Bates Communicative Development Inventories: Words and Sentences (Fenson et al., 2007) at 18 and 24 months of age. All participants underwent sound field audiometry at 12 months of age and tympanometry at 18 months of age. A multiple linear regression with and without covariates was used to model vocabulary growth from 18 to 24 months of age across the 3 groups. Results Children with CP produced a significantly smaller number of words at 24 months of age and showed significantly slower rate of vocabulary growth from 18 to 24 months of age when compared to TD children (p < .05). Although middle ear status was found to predict vocabulary growth from 18 to 24 months of age across the 3 groups (p < .05), the confidence interval was large, suggesting the effect should be interpreted with caution. Conclusions Children with CP showed slower expressive vocabulary growth relative to their age-matched TD peers. Middle ear status may be associated with development of vocabulary skills for some children.

Effect of palatoplasty on speech, dental occlusion issues and upper dental arch in children and adolescents with cleft palate: an integrative literature review

ABSTRACT Purpose: to compile acquired knowledge related to speech, maxillary growth, dental arch and dental occlusion issues of subjects with cleft palate (associated or not with cleft lip), relating them to the found structural and morphological changes, along with time of surgery and surgical technique employed in palatoplasty. Methods: a search was carried out on four databases, namely: PubMed, SciELO, LILACS and MEDLINE, between May and August, 2018. The following descriptors, in Portuguese and in their corresponding terms in English, were used: cleft palate, speech, oral surgery or palatoplasty, teeth or dental arch. Results: altogether, 92 articles were found in the four databases. Eleven articles met the established selection criteria, thus, included in this review. According to the findings, the palatoplasty surgical technique influences speech, maxillary growth and dental occlusal issues; however, it is still unclear which technique is more beneficial to the subjects with cleft palate. Conclusion: results found in these 11 studies are divergent in regard to the surgical technique which most favors the development of speech, dental arches and maxillary growth. Therefore, it is important that new researches be carried out relating the aspects of speech, facial growth, dental occlusion and dental arch in the subjects with cleft palate, to the technique and the time of palatoplasty.

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.

Use of autologous platelet-rich plasma in complete cleft palate repair

OBJECTIVES/HYPOTHESIS

Evaluate the effect of topical application of autologous platelet-rich plasma (PRP) in primary repair of complete cleft palate and then compare the result with another group of patients using the same surgical technique, without application of PRP with regard to the incidence of oronasal fistula, velopharyngeal closure, and grade of nasality.

STUDY DESIGN

Case control study.

METHODS

This study was carried on 44 children with complete cleft palate with age range from 12 to 23 months. The children were divided into two age- and gender-matched groups: All children were subjected to the same technique of V-Y pushback repair of the complete cleft palate. In group A (22 children), the PRP prepared from the patient was topically applied between the nasal and oral mucosa layer during palatoplasty, whereas in group B (22 children) the PRP was not applied.

RESULTS

All cases were recovered smoothly without problems. In group A, no oronasal fistula was reported, whereas in group B three patients (13.6%) had postoperative fistulae and two patients (9.1%) needed revision palatoplasty. At 6 months postoperative assessment, group A (with PRP application) showed significantly better grade of nasality (P = 0.024) and better endoscopic velopharyngeal closure (P = 0.016) than group B.

CONCLUSION

Usage of autologous PRP in complete cleft palate repair is simple; effective; can decrease the incidence of oronasal fistula; and also significantly improves the grade of nasality and velopharyngeal closure, which decreases the need of further surgical intervention in cleft palate patients.

LEVEL OF EVIDENCE

3b. Laryngoscope, 126:1524-1528, 2016.

[The need for clinical guidelines for the comprehensive management of patients with cleft lip and palate]

Objective To identify clinical guidelines for the treatment of cleft lip and / or palate in children under one year of age, published in Colombia and internationally. Method A search was conducted in three databases: PubMed, Lilacs and Scielo with the terms "guideline cleft lip and palate", "protocols cleft lip and palate", "guía clínica labio paladar fisurado", "guía de manejo labio paladar fisurado" and "guía labio paladar hendido". In addition to this, we consulted the websites of all pediatric hospitals in Colombia. Results 190 papers were found, of which 96 were not related to the population or focused on treatment, 84 were disciplinary, 8 interdisciplinary and only two were clinical guidelines. Conclusions There are few published guidelines and there is a lack of unified criteria. This gives rise to numerous forms of intervention and the creation of interdisciplinary teams. Therefore, there is a need to reach a consensus regarding the therapeutic approach in order to create treatment protocols based on evidence with quality standards.

Incidence of velopharyngeal insufficiency and oronasal fistulae after cleft palate repair: A retrospective study of children referred to Isfahan Cleft Care Team between 2005 and 2009

OBJECTIVE

The purpose of this study is to determine the incidence of velopharyngeal insufficiency (VPI) and fistulae development in patients seen by the Isfahan Cleft Care Team and also determine the association of gender, age at repair, and cleft type with the incidence of each.

METHODS

This retrospective study was completed using records of patients referred to Isfahan Cleft Care Team between 2005 and 2009. One hundred thirty-one patients with a history of cleft palate (with or without cleft lip) who had undergone primary palate repair and were at least 4 years of age at the time of the speech evaluation were included in this review. The main outcome of this study was the incidence of fistulae and hypernasality following palatoplasty. A secondary outcome was the association of gender, age at the time of repair, and cleft type on the incidence of fistulae and hypernasality.

RESULTS

A post-surgical fistula was present in 23.7% of the patients studied. Fistula rates were significantly higher in patients who had undergone repair of bilateral clefts of the lip and palate (40.9%) than for those patients who had undergone repair of a unilateral cleft lip and palate (16.9%) (p=0.02). Presence of a fistula was not associated with gender (p=0.99) or age at time of primary surgical repair (p=0.71). Mild hypernasality was noted in 15.3% of patients. Moderate or severe hypernasality was present in 66.5% of the patients and the remaining cases presented with normal resonance. Severe hypernasality was significantly higher in patients with a Veau IV type cleft as compared to patients with Veau III cleft types (p=0.04). There was a significantly higher incidence of hypernasality in boys than in girls (p<0.001). The association of age at the time of palatal repair and incidence of hypernasality was not significant (r=0.13, p=0.07).

CONCLUSIONS

Overall, post-surgical complications were high in this cohort of patients who had undergone cleft palate repair by Isfahan Cleft Care Team during the study time frame. Therefore, there is a high priority need for increased training of best practices for the surgeons.

Clinical Outcomes of Primary Palatal Surgery in Children with Nonsyndromic Cleft Palate with and without Lip

This study presents clinical outcomes of primary cleft palate surgery, including rate of oronasal fistula development, rate of velopharyngeal insufficiency (VPI) requiring secondary surgery, and speech outcomes. We examined the effect of cleft type on the clinical outcomes. Retrospective analysis was performed using clinical records of all patients who received a primary palatoplasty at the Cleft Palate Clinic at Seoul Asan Medical Center, South Korea, between 2007 and 2012. The study included 292 patients with nonsyndromic overt cleft palate (±cleft lip). The results revealed that the rate of oronasal fistula was 7.9% and the incidence of VPI based on the rate of secondary palatal surgery was 19.2%. The results showed that 50.3% of all the patients had received speech therapy and 28.8% and 51.4% demonstrated significant hypernasality and articulatory deficits, respectively. The results of the rate of VPI and speech outcomes were significantly different in terms of cleft type. Except for the rate of oronasal fistula, patients with cleft palate generally exhibited better clinical outcomes compared to those with bilateral or unilateral cleft lip and palate. This study suggests that several factors, including cleft type, should be identified and comprehensively considered to establish an optimal treatment regimen for patients with cleft palate.

Differences in Velopharyngeal Structure during Speech among Asians Revealed by 3-Tesla Magnetic Resonance Imaging Movie Mode

OBJECTIVE

Different bony structures can affect the function of the velopharyngeal muscles. Asian populations differ morphologically, including the morphologies of their bony structures. The purpose of this study was to compare the velopharyngeal structures during speech in two Asian populations: Japanese and Thai.

METHODS

Ten healthy Japanese and Thai females (five each) were evaluated with a 3-Tesla (3 T) magnetic resonance imaging (MRI) scanner while they produced vowel-consonant-vowel syllable (/asa/). A gradient-echo sequence, fast low-angle shot with segmented cine and parallel imaging technique was used to obtain sagittal images of the velopharyngeal structures.

RESULTS

MRI was carried out in real time during speech production, allowing investigations of the time-to-time changes in the velopharyngeal structures. Thai subjects had a significantly longer hard palate and produced shorter consonant than Japanese subjects. The velum of the Thai participants showed significant thickening during consonant production and their retroglossal space was significantly wider at rest, whereas the dimensional change during task performance was similar in the two populations.

CONCLUSIONS

The 3 T MRI movie method can be used to investigate velopharyngeal function and diagnose velopharyngeal insufficiency. The racial differences may include differences in skeletal patterns and soft-tissue morphology that result in functional differences for the affected structures.

Ghost Protocol: Greatest Healing Opportunity for Soft Tissue, a Treatment Paradigm for Complex Sarcoma Reconstruction

Modern sarcoma treatment has created new challenges for plastic surgeons. This study was designed to review the recent experience and practice patterns following complex sarcoma resection at a large sarcoma center. All cases from October 2013 to October 2014 involving rare nonepithelial tumors, a multidisciplinary surgical team, radiation and/or chemotherapy treatments, and plastic surgical reconstruction were included in the analysis. In addition to evaluating clinical outcomes, cases were reviewed to identify factors associated with excellent or poor patient care. Review of these cases formed the basis of the greatest healing opportunity for soft tissue (GHOST) protocol. Our patient population included seven males (64%) and four females (36%). All except one patient was exposed to radiotherapy, chemotherapy, or some combination. Diverse procedures were used for reconstruction. Early complications occurred in two patients (18%), and late complications in four patients (36%). Sarcoma resection was found to be highly morbid in our series. Patients with poor preoperative nutritional status were more likely to experience complications postoperatively. The decision to stage a reconstruction was complex and influenced by several factors. Multimodal sarcoma treatments may involve highly morbid procedures and create complex wounds. The GHOST protocol is a useful reference for plastic surgeons.

Midface fracture in an unoperated adult patient with cleft palate

In western countries, it is hard to find an unoperated cleft palate due to better healthcare services and awareness. Here, we present an unoperated adult case of cleft palate that had midfacial fractures following a road traffic accident. The patient's cleft lip was repaired when he was 2 years old but the palate was not operated because of poor follow-up. We would like to share the difficulties encountered in diagnosis and treatment planning for this rare kind of trauma case. After routine investigations, a palatal acrylic splint was constructed for fixation and an acceptable degree of function and aesthetics was achieved postoperatively.

Statewide multicenter analysis of the incidence of secondary surgeries after isolated cleft palate repair

INTRODUCTION

Previous smaller studies have reported a wide range, 15% to 45%, of secondary palate surgery. The goal of this study was to report the true incidence of secondary surgery derived from a large statewide database as well as study the timing and risk factors for secondary surgery.

METHODS

Retrospective longitudinal analysis was performed of the 1995 to 2010 California Office of Statewide Health Planning and Development patient discharge database, which allows patients to be followed up over time. Patients were included in the study if they had an isolated palate diagnosis in addition to a primary repair code and excluded if they ever carried a cleft lip diagnosis or repair code.

RESULTS

A total of 2616 isolated cleft palate patients were identified with a median follow-up of 8.0 years. At 16 years, the overall rate of second surgery was 13.6% with complete cleft palate patients having a higher rate of second surgery (15.92%) than the incomplete cleft palate patients (12.36%). The risk of second surgery over time showed a bimodal distribution; the first peak was seen in the first postoperative year and the second peak was seen 3 to 5 years postoperative. On multivariate regression, the only independent risk factor of a secondary surgery was uninsured status (HR, 4.55 [1.64-12.64]), whereas incomplete cleft palate (HR, 0.68 [0.46-0.98]) and Hispanic ethnicity (HR, 0.68 [0.50-0.94]) were found to be protective for secondary surgery with the rest of the covariates not showing significant association.

CONCLUSIONS

The incidence rate of secondary surgery (13.6%) at 16 years was less than reported in the literature. Patients who had a complete cleft palate repaired showed a higher incidence rate compared with those who had an incomplete cleft repaired, likely correlating with the complexity and invasiveness of the primary surgery. The first risk peak at which secondary surgeries were performed reflects the short-term complications that needed to be addressed within the first postoperative year. The second peak reflects the longer-term complications diagnosed at the age at which children reach speech milestones.

Application of the International Classification of Functioning, Disability, and Health–Children and Youth Version (ICF-CY) to Cleft Lip and Palate

Objective

In recent health policy discussions, the World Health Organization has urged member states to implement the International Classification of Functioning, Disability, and Health: Children and Youth Version in their clinical practice and research. The purpose of this study was to identify codes from the International Classification of Functioning, Disability, and Health: Children and Youth Version relevant for use among children with cleft lip and/or palate, thereby highlighting the potential value of these codes for interprofessional cleft palate-craniofacial teams.

Design

The scope of recent published research in the area of cleft lip and/or palate was reviewed and compared with meaningful terms identified from the International Classification of Functioning, Disability, and Health: Children and Youth Version. In a five-step procedure, a consensus-based list of terms was developed that was linked separately to International Classification of Functioning, Disability, and Health: Children and Youth Version categories and codes. This provided a first draft of a core set for use in the cleft lip and/or palate field.

Conclusions

Adopting International Classification of Functioning, Disability, and Health: Children and Youth Version domains in cleft lip and/or palate may aid experts in identifying appropriate starting points for assessment, counseling, and therapy. When used as a clinical tool, it encourages health care professionals to go beyond treatment and outcome perspectives that are focused solely on the child and to include the children's environment and their familial/societal context. In order to establish improved, evidence-based interdisciplinary treatments for children with cleft lip and/or palate, more studies are needed that seek to identify all the influencing conditions of activities, children's participation, and barriers/facilitators in their environments.

Use of rotation flap in repair of cleft palate and velopharyngeal insufficiency

Although cleft palate anomaly is frequent, the criterion standards in surgical treatment have not been determined yet. There are a few techniques described for cleft palate repair owing to the limited tissue in the palatal mucosa, the rigid structure of the palatal mucosa, and the limited vascularity of the hard palate. In this study, a novel cleft palate repair technique based on separating the soft palate from the hard palate as a musculomucosal flap and using it as a rotation flap has been described. The operation is evaluated individually for each anomaly because variations occur in the surgical technique according to the extension of the cleft toward the teeth in the palate. This operation was performed on a total of 28 patients (17 girls and 11 boys) aged between 1.5 and 16 years and presented to our clinic. Patients were assessed for speech analysis outcomes, tympanogram values, hearing functions, magnitude of palatal lengthening during the operation, and rate of fistulae. Statistically significant differences in values of the speech analysis and the audiometric assessment were determined between before and 6 months after surgery. Complete recovery of otitis was observed 1 month after surgery without another treatment in 9 (42.8%) of 21 patients who were detected to have serous otitis media preoperatively. Tension-free closure, lower risk of fistula, good restoration of velopharyngeal functions, ability to be performed on all types of cleft palate, ability to provide a good intraoperative exposure, and being a single stage seem to be the most important advantages of this technique.

The effect of Delaire cheilorhinoplasty on midfacial growth in patients with unilateral cleft lip and palate

The aim of this research was to evaluate the effect of the Delaire surgical technique on the midfacial morphology in a group of subjects with a congenital unilateral cleft of lip and palate (UCLP), prior to orthodontic treatment. Thirty-five UCLP (15 left and 20 right) patients (16 males and 19 females, mean age 7.03+/-0.9 years; age range 8.7-5.0 years), treated for the correction of congenital malformation, were retrospectively selected. Analysis of midfacial growth was undertaken on lateral cephalograms, and the data were compared with reference values (Ricketts analysis). A Mann-Whitney ranked sum test was used to detect significant differences between the findings and reference values. P <or= 0.05 was considered as significant. The results demonstrated a retropositioning of both the maxilla and mandible (SNA and SNB P<0.01) and increased mandibular development (Go-Me distance). Vertically, there was a trend to a posterior rotation of the mandible (P<0.01), resulting in a hyperdivergent profile. This trend was confirmed by the increase in SpA-SpP/Go-Me (P<0.05). In agreement with previous studies, the effects of surgical closure of a cleft lip might be responsible for excessive maxillary retropositioning with a downward rotation.

Incidence of oronasal fistulae and velopharyngeal insufficiency after cleft palate repair: an audit of 211 children born between 1990 and 2004

OBJECTIVE

We present an audit of primary cleft palate surgery at our unit, including rates of oronasal fistula development, speech outcomes, and rates of velopharyngeal insufficiency requiring secondary surgery.

DESIGN

A retrospective study of patients with all cleft palate types, born between January 1990 and December 2004, who underwent primary palatoplasty at Middlemore Hospital, Auckland, New Zealand.

PATIENTS

The study included 211 patients, collectively operated on by five different surgeons.

RESULTS

The overall rate of true fistula development was 12.8% over a mean follow-up period of 4 years 10 months. The incidence of true fistulae that required surgical repair was 8.1%. Fistula rates were higher for more severe degrees of clefting but were not affected by gender or type of surgical repair. Overall, 31.8% of the study population had some degree of hypernasality following primary palatoplasty. Secondary surgery for velopharyngeal insufficiency was required in 13.3% of patients. Following surgical correction of velopharyngeal insufficiency, no patients were reported to have appreciable hypernasality and 21.7% were reported to have mild hypernasality, a result comparable to previously published audits. The requirement for secondary surgery was higher in patients with more severe clefts.

CONCLUSION

Our results are comparable to other recent studies. We believe that highly coordinated cleft care helps ensure such outcomes. These data provide a benchmark against which we can measure future performance in our attempts to improve outcomes of cleft repair.

Delaire's cheilorhinoplasty: unilateral cleft aesthetic outcome scored according to the EUROCLEFT guidelines

OBJECTIVE

The aim of our study is to evaluate, in accordance with EUROCLEFT guidelines, the aesthetics of nasolabial area in a sample of complete unilateral cleft of lip and palate patients (UCLP), after surgical correction with Delaire' technique.

METHODS

Twenty-two UCLP patients (16 males and 6 females, 9 right and 13 left side clefts) were enrolled in this retrospective study. Patients were operated at 7 (mean value) months of age by a single surgeon. Frontal and sub-mental photos for each baby were recorded at 8.5 (mean value) years of age, and evaluated twice, by three independent maxillofacial surgeons. A five-point scale (EUROCLEFT guidelines) was used. Nonparametric analysis (Kruskal-Wallis test) was applied to detect differences in medians obtained in studied groups.

RESULTS

Kruskal-Wallis test showed no statistical significant differences among evaluations of three surgeons and between the first and the second evaluation of the same surgeon. The global appearance of the upper lip and nose was scored with a mean value of 2 (i.e. good). The sample was then divided into two subgroups, according with patient' age; the aesthetics and the symmetry of the nose resulted better in elder patients (i.e. subgroup A, mean period of observation=10.2 years), whereas upper lip achieved better results in younger patients (i.e. subgroup B, mean period of observation=4.9 years).

CONCLUSIONS

EUROCLEFT guidelines are a useful method to evaluate--aesthetically and over time--cleft lip and palate patients, treated with a single surgical procedure. We hypothesize that Delaire technique could progressively improve aesthetics and symmetry of the nose, throughout the growth of the patient.