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

An Objective Evaluation of Cleft Lip Repair Deformities Based on Standardized Photographic Views

BACKGROUND

Several assessment systems of the cleft-related facial deformity have been reported in the medical literature. Assessments have been made from direct clinical evaluations, photographs, on-screen digital images, and 3-dimensional imaging. An evaluation method based on standardized photographic views is developed to evaluate the most common postoperative deformities and to detect the responsible factors for occurrence of these deformities and how to avoid them.

MATERIALS AND METHODS

One hundred forty-five cleft lip cases (105 unilateral and 40 bilateral) were evaluated by using standard sheet and scoring system designed by Operation Smile Inc (Virginia Beach). The scoring system is based on photographic analysis of items including Cupid's bow, nasal symmetry, vermilion contour, white roll continuity, and scar quality.

RESULTS

In the unilateral cleft cases, we found 0.4% excellent, 48.57% good, 38% fair, and 2.85% poor cases. For bilateral clef lip cases, we found 27.5% excellent, 47.5% good, 17.5% fair, and 7.5% poor outcomes. The most common postoperative deformities were nasal asymmetry, scar hypertrophy, deformed Cupid's bow, and vermilion contour asymmetry.

CONCLUSIONS

This objective evaluation system can determine the common cleft lip nasal deformities with detection of the responsible factors. Principles that guide optimum surgical repair have been advocated to avoid the common postoperative deformities. Scar formation is an independent factor that must be managed early and separately to maintain surgical outcomes.

The Role of Nasal Sill Correction in Secondary Cleft Rhinoplasty

BACKGROUND

Evaluating outcomes after cleft rhinoplasty can be challenging because of the lack of objective measures that would lead to a more desirable outcome.

METHODS

This study is a 10-year retrospective review of 30 consecutive patients who underwent secondary unilateral cleft rhinoplasty performed by a single surgeon. Subjective ratings were made using the Unilateral Cleft Lip Surgical Outcomes Evaluation (UCL SOE), which rates 4 components (nose, cupid's bow, lateral lip, and free vermillion) with a score of 0 to 2. Multiple anthropometric measurements (nostril height ratio, width ratio, medial ¼ height ratio, sill ratio, nostril area ratio, columellar angle, tip projection ratio, and nasolabial angle) were taken using a free National Institutes of Health program, ImageJ. Standardized photographs were compared at T0 (preoperatively), T1 (<6 weeks postoperatively), and T2 (>6 weeks postoperatively).

RESULTS

There were 30 patients who met our inclusion criteria: 10 males (66.7%) and 20 females (66.7%). Of these patients, 26 (86.7%) had a complete cleft lip and 4 (13.3%) had an incomplete cleft lip. The patients' average age at time of surgery was 16.2 years with a mean follow-up of 17.9 months. Subjective scores in both nasal and overall UCL SOE ratings improved from T0 to T1, 0.7 to 1.2 (P ≤ 0.001) and 3.6 to 4.7 (P ≤ 0.001), respectively. Visual analog scores in nasal and overall UCL SOE ratings improved between T0 and T2, 0.7 to 0.9 (P = 0.023) and 3.6 to 4.8 (P = 0.002), respectively. Of all the objective measures, nasal sill ratio and cleft height to width ratio correlated with improved subjective ratings across multiple time points.

CONCLUSIONS

Our study shows that objective measures such as nasal sill and nostril shape (cleft height to width ratio) correlate with improved subjective visual analog scale using the UCL SOE. The nasal sill is an often overlooked, yet essential, part of creating an aesthetically pleasing nose during cleft rhinoplasty.

Outcomes at 18 mo of 37 noma (cancrum oris) cases surgically treated at the Noma Children's Hospital, Sokoto, Nigeria

Background

Noma is a rapidly progressing infection of the oral cavity frequently resulting in severe facial disfigurement. We present a case series of noma patients surgically treated in northwest Nigeria.

Methods

A retrospective analysis of routinely collected data (demographics, diagnosis and surgical procedures undergone) and in-person follow-up assessments (anthropometry, mouth opening and quality of life measurements) were conducted with patients who had surgery >6 mo prior to data collection.

Results

Of the 37 patients included, 21 (56.8%) were male and 22 (62.9%) were aged >6 y. The median number of months between last surgery and follow-up was 18 (IQR 13, 25) mo. At admission, the most severely affected anatomical area was the outer cheek (n = 9; 36.0% of patients had lost between 26% and 50%). The most frequent surgical procedures were the deltopectoral flap (n = 16; 43.2%) and trismus release (n = 12; 32.4%). For the eight trismus-release patients where mouth opening was documented at admission, all had a mouth opening of 0–20 mm at follow-up. All patients reported that the surgery had improved their quality of life.

Conclusions

Following their last surgical intervention, noma patients do experience some improvements in their quality of life, but debilitating long-term sequelae persist.

Palatal growth changes in newborns with unilateral and bilateral cleft lip and palate from birth until 12 months after early neonatal cheiloplasty using morphometric assessment

OBJECTIVES

To compare palatal growth changes in infants with complete unilateral (UCLP) or bilateral (BCLP) cleft lip and palate during the first year of life.

MATERIALS AND METHODS

Upper dental arches of 68 neonates with UCLP and BCLP were evaluated using 2D and 3D morphometry based on dental casts obtained in two age categories (T0 before early neonatal cheiloplasty-UCLP 4 ± 3 days, BCLP 6 ± 5 days; T1 before palatoplasty-UCLP 10 ± 2 months, BCLP 12 ± 3 months).

RESULTS

Intensive palatal growth was manifested in both directions of the palate. Palatal growth in the anterior direction was not restricted, despite the intercanine (CC´) and anterior (LL´) widths being significantly narrowed in the BCLP group (CC´ p = 0.019, LL´ p = 0.009). The posterior dental arches were significantly enlarged (UCLP p ≤ 0.001; BCLP p ≤ 0.001). The negative effect of cleft severity on palatal length was not confirmed (p = 0.802). Variability of the palate was immense mainly in BCLP infants (T0); however, it decreased in both cleft types, confirming the formative effect of palatal growth leading to alveolar cleft closure (UCLP p ≤ 0.001; BCLP p = 0.006 on the right, 0.005 on the left).

CONCLUSIONS

Both analyzed cleft groups (UCLP, BCLP) grew favorably during the first year of life, and the palatal growth was not limited in any direction.

CLINICAL RELEVANCE

Geometric morphometry allowed a comprehensive analysis of the palate, which can contribute to the improvement of surgical methods.

Effect of Cleft Types on Outcome of Unilateral Cleft Lip Repair

Introduction:

It is generally assumed that the major phenotypes of unilateral cleft lip (UCL) represent its extent of severity. There are a few studies on this, but objectivity has been lacking. It was the aim of this study to assess the effect of different phenotypes of UCL on the outcome of surgical repair.

Methodology:

This study was a case series of the effect of phenotypes of cleft on the outcome of repair of UCL. Fifteen subjects each were in three UCL phenotype groups. Surgical outcome was assessed quantitatively with anthropometric measurements recorded from a full frontal face photograph of subjects. The analysis was done using Student's t-test and one-way ANOVA at P = 0.05.

Results:

The mean values of the preoperative horizontal and vertical lip height, and nasal width on the cleft side in the cleft lip (CL) group were closest to those of the noncleft side and control. The postoperative mean values of the horizontal and vertical lip height, and nasal width on the cleft side in the CL group were closest to those of the noncleft side and control, while those of the CL, alveolus and palate group were farthest from those of the noncleft side and the control.

Discussion:

The different phenotypes of UCL have different degrees of tissue distortion and deficiencies. CL group had its measurements closest to that of the noncleft sides and control, suggesting that it has the least distortion.

Conclusion:

The comparison between the three groups did not reveal any difference, suggesting that the skill of the surgeon and the selection of a well proven technique are more important factors in the outcome of repair of unilateral cleft lip.

An Analysis of Aesthetic Refinements in 120 Secondary Cleft Rhinoplasties

BACKGROUND

Secondary cleft nose rhinoplasty remains a challenging procedure. Cartilage memory and scar contraction are problematic factors. The need for more detailed procedures for secondary reconstruction in this patient population has arisen. Contemporary refinements demonstrate a highly structured approach. We conducted a retrospective study evaluating the aesthetic results of cleft patients who underwent secondary rhinoplasty.

METHODS

In a retrospective study, a photometric analysis of cleft patients operated in the period 2003-2011 was conducted. Reconstructive methods were documented. Pre- and postoperative photographs of cleft rhinoplasty patients were evaluated using a standardized protocol. Nostril width ratio, columellar angle, tip projection ratio, and nasolabial angle served as objective instruments. The Unilateral Cleft Lip Surgical Outcomes Evaluation score was chosen for external photometric rating and rated blindly by 2 external individual plastic surgeons as independent nonbiased reviewers. The interrater and intrarater reliabilities were calculated using the Cohen kappa coefficient (κ).

RESULTS

A total of 120 secondary rhinoplasties in 85 uni- and bilateral cleft patients could be included. Mean follow-up was 20 months. A total of 60 (71%) patients needed additional bone grafting (chin/pelvis), and 23 (27%) patients a LeFort I osteotomy. In one third of the secondary rhinoplasties, a medial and/or lateral osteotomy was performed (34%). In one fourth (24%), an external septoplasty was considered necessary. In 55% (47 patients) of the cases, a columellar strut was used. Excluding bone grafts, a total of 173 other grafts (mean of 2 grafts/patient) were applied. Postoperative measurements for nostril width ratio and columellar angle were statistically significant. A structured approach with contemporary refinements is described in detail. Intra- and interrater reliabilities for photometric assessment according to the Unilateral Cleft Lip Surgical Outcomes Evaluation score are shown.

CONCLUSIONS

A structured approach for secondary cleft rhinoplasty yields satisfying, reproducible, and stable results.

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.

A Competency Assessment Tool for Unilateral Cleft Lip Repair

Supplemental Digital Content is available in the text.

Objective evaluation of operative performance is increasingly important in surgical training. Evaluation tools include global rating scales of performance and procedure-specific skills checklists. For unilateral cleft lip repair, the numerous techniques make universal evaluation challenging. Thus, we sought to create a unilateral cleft lip evaluation tool agnostic to specific repair technique.

Influence of Unilateral Cleft Lip Configuration on Long-Term Facial Averageness: A New Three-Dimensional Analysis Approach

Background: Concepts regarding cleft lip and palate care vary widely globally, as there is no international consensus. Consequently, institutional surveillance of cleft concepts is essential. In addition to subjective expert rankings, three-dimensional (3D) photogrammetry of the face has become the gold standard for evaluation and objective assessment of facial structures. We evaluated cleft configuration preoperatively to determine the influence thereof on the long-term facial appearance/averageness of unilateral cleft lip patients. Methods: Plaster models of the patient's labio-oral region and nose were made preoperatively, digitized, and cleft configuration assessed (cleft width, cleft-columella angle, nasal projection, heminasal width ratio, transverse lip length, labial height). Between 4 and 12 years after surgery, stereophotogrammetry (3D face scans) were captured to determine the patients' individual facial averageness index (FAI) as a deviation from the population mean, using proportion indices (PIs) of facial landmarks and reference data provided by Farkas and FaceBase. Results: Cleft width (r = 0.77) and columella length correlated strongly with long-term facial averageness (r = 0.52). Decreasing FAI was seen with increasing patient age (r = -0.42), indicating increasing facial averageness. Other cleft properties showed weaker correlations. Cleft alveolus did not have any impact on FAI. Conclusions: The presented method allows objective measurement of facial appearance/averageness as well as preoperative cleft properties. It might be superior to subjective assessments of facial attractiveness/appearance. Objective cleft measurements are strong predictors for future facial averageness. Increasing averageness with growth and age suggests late corrective surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Evaluation of a Digital Protocol for Pre-Surgical Orthopedic Treatment of Cleft Lip and Palate in Newborn Patients: A Pilot Study

The aim of this study was to evaluate the accuracy, invasiveness and impact on clinical results of a digital oral impression protocol in the pre-surgical orthopedic treatment (PSOT) of newborn cleft lip and palate (CLP) patients undergoing primary alveolar surgical repair. Six patients were divided, according to impression technique used, into a digital (intraoral scanner (IOS)) and a non-digital (tray and putty (T&P)) group. Parents considered IOS impressions to be less invasive, compared to T&P impressions. The clinician that took all the impressions considered the IOS to be less stressful compared to the T&P method. In two T&P patients, the impression was repeated because some important anatomical details were missing, in one case due to patient regurgitation during the first attempt. No impression was repeated, and any adverse event was reported in the IOS group. There were no significant differences between these two protocols in pre-surgical alveolar gap reduction and surgical challenge. The study results indicate that this digital protocol can accelerate the production process of the passive molding plate with an instantaneous transmission of the digital impression to the dental lab, maintaining the same accuracy level and clinical outcomes of classical techniques and reducing the invasiveness of impression taking, avoiding any risk of impression material ingestion or inhalation.

Influence of Severity on Aesthetic Outcomes of Unilateral Cleft Lip Repair in 1,823 Patients

Supplemental Digital Content is available in the text.

Background:

Although efforts to improve access to care for patients with cleft lip in the developing world have grown tremendously, there is a dearth of data regarding aesthetic outcomes after cleft lip repairs in this setting. Defining severity-outcome relationships has the potential to improve efficiency of care delivery in resource-limited settings, and to improve overall results. In this study, we investigate the relationship between initial cleft lip severity and early aesthetic outcomes following surgical repair of primary unilateral cleft lip.

Methods:

Using previously validated tools to assess unilateral cleft lip severity and aesthetic outcome after repair, we evaluated 1,823 consecutive patients who underwent primary unilateral cleft lip/nose (UCL/N) repair. Three separate evaluators scored each case for a total of 5,469 total independent evaluations.

Results:

Our results show that with increasing severity of UCL/N deformity, there is a corresponding decrease in early aesthetic outcome scores. Using our results, we established normative early aesthetic outcomes following repair for each severity grade of UCL/N deformity.

Conclusions:

In conclusion, this study has achieved a standardized, timely, and cost-effective evaluation of 1,823 surgical cases of primary UCL/N repair. This data set provides a normal distribution of aesthetic results according to initial cleft severity and defines a standard of “expected” aesthetic results after primary UCL/N repair. Our results also show a clear correlation between initial severity and immediate aesthetic result after surgery, though we also show that excellent results are possible regardless of initial cleft severity.