A 20 year audit of nose-tip symmetry in patients with unilateral cleft lip and palate

Developing a visual rating chart for the esthetic outcome of unilateral cleft lip and palate repair

INTRODUCTION

Aesthetic impairment is a major concern for the cleft lip/palate patient. Thus, auditing of postsurgical esthetic outcome needs to be further explored as till date no universally accepted protocol exists. The study objective was to propose a new visual rating chart (VRC) for the aesthetic outcome of cleft lip and palate (CLP) surgery.

MATERIALS AND METHODS

In a retrospective review of 200 repaired clefts, the common esthetic deficiencies were identified, categorized and ranked in the order of severity. A chart of the illustrative diagram with textual description of the defects was produced and used as a basis for rating outcome by two groups of raters (familiar raters and recruited raters). Intra- and inter-raters reliability was estimated using Cohen's kappa statistics and intra-class correlation coefficient (ICC). Comparison between mean group coefficient was achieved with Kendall's correlation coefficient of concordance.

RESULTS

The intra- and inter-rater reliability for familiar raters was found to be strong with kappa values range of 0.80-0.87 (P < 0.001). Similarly, inter-raters' reliability by recruited judges was very strong using ICC at both single (0.768) and average measures (0.982).

CONCLUSION

The VRC is a reliable tool for assessing the esthetic outcome of CLP repairs.

Quantitative measurement of symmetry from photographs following surgery for unilateral cleft lip and palate

A computer-based program is presented to be used with digitized frontal and basal photographs. SymNose enables the user to quantify asymmetry of the front view of the lip and nose and of the nose from the base view, using the area of mismatch of one side reflected over the other. There is a facility to transfer results to a spreadsheet. The program is simple and quick to use and runs on Apple Macintosh OSX 10.4 or later, power and Intel-based systems. The outline of a feature can be drawn using the mouse or digitizing pad. The program, together with Help files, is available from the authors.

Unilateral cleft lip: principles and practice of surgical management

Management of cleft lip and palate requires a unique understanding of the various dimensions of care to optimize outcomes of surgery. The breadth of treatment spans multiple disciplines and the length of treatment spans infancy to adulthood. Although the focus of reconstruction is on form and function, changes occur with growth and development. This review focuses on the surgical management of the primary cleft lip and nasal deformity. In addition to surgical treatment, the anatomy, clinical spectrum, preoperative care, and postoperative care are discussed. Principles of surgery are emphasized and controversies are highlighted.

Open rhinoplasty using conchal cartilage during childhood to correct unilateral cleft-lip nasal deformities

BACKGROUND

Although many articles have investigated the optimal method for the primary correction of nasal deformities during unilateral cleft lip repair, residual nasal deformities often remain. Such residual deformities are commonly corrected around the age of 5. We have started performing two-stage nasal repair operations for unilateral cleft lip patients. During the first stage, the nasal floor is elevated, and the alar base is brought into the correct position by muscle reconstruction during primary lip repair. During the second stage, the slanting nasal apex and drooping alar rim are corrected at pre-school age. This article describes the methods and results of second-stage open rhinoplasty.

METHODS

Open rhinoplasty is performed. The conchal cartilage is harvested and used as a strut to strengthen and extend the septum. The lower lateral cartilages are sutured to the grafted cartilage and fixed in the correct position. The operative results of 38 patients were evaluated photogrammetrically. The nasal height, nostril height and the columella angle on a basilar view of the nose were measured.

RESULTS

In most patients, the nose was refined and became less distorted. Poorly projecting nasal tips and drooping alar rims were corrected. The reformed configuration was relatively well maintained for many years. Photogrammetric analysis demonstrated increases in both the nasal height to nasal width ratio and the nostril height to nostril width ratio, and improvement of the columella angle.

CONCLUSION

Performing open rhinoplasty using conchal cartilage during childhood effectively improves unilateral cleft-lip nasal deformities.

Three-dimensional assessment of early surgical outcome in repaired unilateral cleft lip and palate: Part 1. Nasal changes

OBJECTIVE

To evaluate three-dimensional nasal morphology following primary reconstruction in children with unilateral cleft lip and palate relative to contemporaneous noncleft data.

DESIGN

Prospective, cross-sectional, controlled study.

SETTING

Glasgow Dental Hospital and School, Faculty of Medicine, Glasgow University.

PATIENTS AND PARTICIPANTS

Two groups of 3-year-old children (21 with unilateral cleft lip and palate and 96 controls) with facial images taken using a three-dimensional, vision-based capture technique.

METHODS

Three-dimensional images of the face were reflected so the cleft was on the left side to create a homogeneous group for statistical analysis. Three-dimensional coordinates of anthropometric landmarks were extracted from facial images by a single operator. A set of linear measurements was used to compare cleft and control subjects on right and left sides, adjusting for sex differences.

RESULTS

The mean nasal base width and the width of the nostril floor on right and left sides differed significantly between control and unilateral cleft lip and palate groups. The measurements were greater in children with unilateral cleft lip and palate. The differences in the mean nasal height and mean nasal projection between the groups were not statistically significant. Mean columellar lengths were different between the left and right sides in children with unilateral cleft lip and palate.

CONCLUSIONS

There were significant nasal deformities following the surgical repair of unilateral cleft lip and palate.

Quantitative use of photography in orthognathic outcome assessment

This study reports an independent audit of two aspects of orthognathic surgery, namely control of inter-alar width and mandibular outline asymmetry. Measurements were taken from standardized photographs of a consecutive series of 27 patients, using an on-screen digitizing program (IPTool). All patients had undergone bimaxillary osteotomies involving maxillary impaction and/or advancement, by one surgeon, using a cinch suture for nasal width control. Nine-twelve months after surgery, inter-alar width had increased by just 0.08 cm mean (SD 0.3). Four patients showed an increase of just over 2mm, whilst six showed a small reduction. Based on ratios of size (area) and shape (compactness) of the right and left mandibular segments, there was a small overall improvement in mandibular symmetry (0.019 and 0.005 respectively). Whilst in most of the patients the need for surgery was primarily the correction of antero-posterior and vertical discrepancies, five patients with demonstrable asymmetry showed a clear improvement. In three patients whose asymmetry scores were very mild pre-treatment, there was a small, measured increase in asymmetry, but not to a degree that would be clinically noticeable. At a time when 3D imaging is still unavailable to many clinicians, the results of this study suggest that appropriate measurements taken from carefully standardized conventional photographs can provide a valid and objective means of assessing treatment outcome.

Outcome measurement in the correction of mandibular asymmetry

This study related clinical assessments of the severity of mandibular asymmetry with computerized measurements, obtained by digitizing mandibular outlines from standardized facial photographs. Four ratios were calculated: area (size), compactness (shape), perimeter (length of outline), and moment (center of area). When comparing clinical severity with computer assessment, significant correlations were observed; those for area and compactness were the highest. Sixteen patients subsequently underwent corrective surgery, and their ratios were used to relate the degree of improvement to the original severity of the asymmetry. The posttreatment ratios were also used to audit the outcome, comparing the patients' scores as a group with results previously obtained from patients with normal symmetry and mild asymmetry. Posttreatment outcomes were significantly different from the normal outline group but were comparable with outcomes of patients with mild mandibular asymmetry. The system provided a sensitive, noninvasive method of assessing treatment change and could be useful in providing an objective means of quantifying treatment outcomes.

Comparison of radiographic and photographic measurement of mandibular asymmetry

This study compared measurement of mandibular asymmetry by digitization of mandibular outlines from standardized facial photographs and posteroanterior cephalometric radiographs. Four ratios were used in calculating asymmetry: area (relative size of right and left mandibular segments), perimeter or length of outlines, compactness (shape), and moment. The records of 28 patients with varying degrees of asymmetry were used. A significant relationship was found for 3 of the ratios (area, compactness, and moment) between measurements from photographs and radiographs. A further comparison showed that measurements from the radiographs correlated more closely with those from photographs when the mastoid processes were used as a baseline, rather than latero-orbitale. Repeatability of mandibular outline digitization proved satisfactory. Although digitization from standardized photographs is the preferred approach, the results indicated that posteroanterior cephalometric radiographs can be used similarly. Unlike other cephalometric analyses for mandibular asymmetry, this method avoids problems of landmark identification, thus presenting a clinically useful method of quantifying asymmetry, eg, in auditing the surgical-orthodontic correction of asymmetry or monitoring change over time.