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

Correlating Jaw Bone Growth and Nasal Morphology Among Adult Patients With Cleft Lip and Palate: A Retrospective Cephalometric Study

This retrospective cross-sectional study reviewed adult patients with operated cleft lip and/or palate (CL/P) and normal control, and performed comprehensive craniofacial and nasal morphological analyses based on lateral cephalometric radiographs. Pearson or Spearman correlation coefficient assessed intraclass correlation. Seven hundred fifty-seven operated patients with CL/P, and 165 noncleft normal controls were enrolled. Among the normal and CL/P groups, S-N-A angle registered positive correlations with nasal base prominence (S-N'-Sn, degrees). Upper facial height (N-ANS, mm) had positive correlations with nasal dorsum length (N'-Prn, mm) and nasal bone length (N-Na, mm). Although in patients with bilateral cleft lip and palate, there were moderate negative correlations ( r =-0.541, P <0.05) with soft tissue facial profile angle (FH-N'Pog', degree) and nasolabial angle (Cm-Sn-ULA, degree). Correlation exists between the morphology of jaw bones and external nose among patients with CL/P. Maxillary sagittal insufficiency is associated with concave nasal profile, and maxilla height is associated with nasal length.

Scar Outcome in Unilateral Complete Cleft Lip Repair: A Comparative Analysis of Vertical Lip Lengthening Strategies Using the Rotation-Advancement Concept

OBJECTIVE

To assess the differences in scar outcomes between modified rotation-advancement techniques proposed by Drs. Mohler and Noordhoff, designed to address issues such as inadequate vertical lip length and scarring on the upper third of the lip in the original rotation-advancement technique.

DESIGN

Retrospective single-surgeon (RD) study.

PATIENTS

Consecutive non-syndromic children (n = 68) with unilateral complete cleft lip and palate.

INTERVENTIONS

Modified Mohler (columellar backcut reconstructed with C flap; n = 34) and modified Noordhoff (lower, medially-created backcut reconstructed with laterally-based triangular skin flap; n = 34) repairs.

MEAN OUTCOME MEASURES

Using 12-month postoperative frontal photographs, scar evaluations (overall and superior, middle, and inferior portions of the lip) were appraised by an assessment panel composed by independent professional and nonprofessional raters employing four validated qualitative scar assessment scales: Manchester Scar Scale, modified Scar-Rating Scale, Stony Brook Scar Evaluation Scale, and Visual Analog Scale. Quantitative computerized photogrammetric scar widths of the superior, middle, and inferior portions of the upper lip were also measured.

RESULTS

The modified Noordhoff method showed significantly (all P < .001) better scar quality for the overall scar and superior portion of the scar in all four scales compared to the modified Mohler method, with no significant (all P > .05) difference for the middle and lower portions. No significant difference (all P > .05) was observed for photogrammetric scar width measurements.

CONCLUSION

The modified Noordhoff technique provided better qualitative results for unilateral complete cleft lip-related scars compared to the modified Mohler technique.

Measuring the Unilateral Cleft Lip Nasal Deformity: Lateral Deviation of Subnasale Is a Clinical and Morphologic Index of Unrepaired Severity

OBJECTIVE

Objective measurement of pre-operative severity is important to optimize evidence-based practices given that the wide spectrum of presentation likely influences outcomes. The purpose of this study was to determine the correlation of objective measures of form with a subjective standard of cleft severity.

DESIGN

3D images were ranked according to severity of nasal deformity by 7 cleft surgeons so that the mean rank could be used as the severity standard.

PATIENTS

45 patients with unilateral cleft lip and 5 normal control subjects.

INTERVENTIONS

Each image was assessed using traditional anthropometric analysis, 3D landmark displacements, and shape-based analysis to produce 81 indices for each subject.

MAIN OUTCOME

The correlation of objective measurements with the clinical severity standard.

RESULTS

Lateral deviation of subnasale from midline was the best predictor of severity (0.86). Other strongly-correlated anthropometric measurements included columellar angle, nostril width ratio, and lateral lip height ratio (0.72, 0.80, 0.79). Almost all shape-based measurements had tight correlation with the severity standard, however, dorsum deviation and point difference nasolabial symmetry were the most predictive (0.84, 0.82).

CONCLUSIONS

Quantitative measures of severity transcend cleft type and can be used to grade clinical severity. Lateral deviation of subnasale was the best measure of severity and may be used as a surrogate of uncoupled premaxillary growth; it should be recorded as an index of pre-operative severity with every cleft lip repair. The correlation of other measures evaluated clarify treatment priorities and could potentially be used to grade outcomes.

Unsupervised anomaly appraisal of cleft faces using a StyleGAN2-based model adaptation technique

A novel machine learning framework that is able to consistently detect, localize, and measure the severity of human congenital cleft lip anomalies is introduced. The ultimate goal is to fill an important clinical void: to provide an objective and clinically feasible method of gauging baseline facial deformity and the change obtained through reconstructive surgical intervention. The proposed method first employs the StyleGAN2 generative adversarial network with model adaptation to produce a normalized transformation of 125 faces, and then uses a pixel-wise subtraction approach to assess the difference between all baseline images and their normalized counterparts (a proxy for severity of deformity). The pipeline of the proposed framework consists of the following steps: image preprocessing, face normalization, color transformation, heat-map generation, morphological erosion, and abnormality scoring. Heatmaps that finely discern anatomic anomalies visually corroborate the generated scores. The proposed framework is validated through computer simulations as well as by comparison of machine-generated versus human ratings of facial images. The anomaly scores yielded by the proposed computer model correlate closely with human ratings, with a calculated Pearson's r score of 0.89. The proposed pixel-wise measurement technique is shown to more closely mirror human ratings of cleft faces than two other existing, state-of-the-art image quality metrics (Learned Perceptual Image Patch Similarity and Structural Similarity Index). The proposed model may represent a new standard for objective, automated, and real-time clinical measurement of faces affected by congenital cleft deformity.

Proposed grading system of unilateral cleft lip to predict surgical challenges

Background

It is a common practice to subjectively categorize cleft lip deformities into narrow and wide cleft. The proposed grading of unilateral cleft lip can serve as a predictive factor of the difficulties to be encountered during repair and the expected outcome of surgery.

Materials and Methods

This was a 5-years retrospective study of the records of 32 patients with unilateral cleft lip that presented to a single surgical unit. We grouped the patients based on the age at surgery. We calculated the alar base width ratios of the cleft to non-cleft sides, and this was used for grading. We graded the clefts using ratio of 1.00-1.50 for mild cleft, 1.51 to 2.00 for moderate cleft, 2.01-3.00 for severe cleft, and >3.00 for extensive cleft lip.

Results

The youngest child was 1 month old, while the oldest was 50 years. Majority of the patients (17) were older than 2 years at the time of surgery. Only nine babies (28.1% of the patients) were able to have their surgery done within the age of 6 months. Those that had extensive unilateral cleft lip were 10 (31.3%). However, a total of 18 (56.3% of the patients) had cleft lips that were either mild or moderate grade.

Conclusion

This grading of unilateral cleft lip helps in objective preoperative assessment of the severity and in predicting the difficulty expected during lip repair. It is also helpful in assigning clefts to trainees and in determining which patients should be referred to an experienced surgeon.

Growth patterns of the nasolabial region following unilateral cleft lip primary repair

Surgical correction is the optimal way of repairing a congenital cleft lip. Patients with this condition often undergo initial surgical treatment at an early age and achieve an acceptable outcome. However, their levels of satisfaction will decrease in later stages of life as facial growth and development will inevitably cause changes in long-term outcomes, especially in the nasolabial region. Therefore, it is important for surgeons to understand nasolabial development after primary treatment and tailor their surgical techniques appropriately. This review focuses on the growth patterns of the nasolabial region after primary repair, so as to provide references for operative strategy.

Achieving midvault symmetry in unilateral cleft nose deformity rhinoplasty

Background

The objective of the study was to provide aesthetic improvement in unilateral cleft nose deformity by reconstructing the midvault of cleft side alone with unilateral osteotomies, simulating symmetry with the normal side, together with tip reconstruction. While most of the literature emphasizes on tip reconstruction, few of them focus on techniques of repositioning the slanting nasal sidewall, which aids in achieving the desired symmetry. We describe a method of repositioning the bony nasal vault to a more lateral and symmetrical orientation by making unilateral osteotomies.

Results

Eighteen patients of unilateral cleft nose deformity underwent rhinoplasty between March 16 and January 20. All patients had prior primary cleft lip repair. Thirteen patients underwent primary rhinoplasty while 5 underwent secondary rhinoplasty having undergone primary rhinoplasty elsewhere. Follow-up was from 1 to 3 years. Results were evaluated using Rhinoplasty Outcome Evaluation [ROE] Questionnaire, and Asher McDade Aesthetic Index [AMAI] Rating. Pre- and post-operative scores were compared.

All patients were subjectively satisfied. The ROE and AMAI scores showed statistically significant improvement from pre-operative scores.

Conclusion

Obtaining symmetry in cleft nose deformity is a surgical challenge even in experienced hands. Using structural grafts only on the cleft side we attempted to create a near normal symmetry and achieve a natural nasal appearance, with satisfactory improvement from both patient’s and surgeons’ perspective.

Level of evidence

Case series- 4

Can surgeons rely on growth-related changes to achieve lip height and width symmetry in unilateral complete cleft lip repair?

Surgeons face difficulties achieving simultaneous lip height and width symmetry while repairing unilateral complete cleft lip, so one is often sacrificed at the expense of the other. The aim of this study was to evaluate the effect of growth on lip height and width symmetry, to guide the surgeon to the best decision. The study patients (N = 105) were divided into two groups based on the treatment method: 42 were treated with the modified rotational advancement technique (MRA group) and 63 with the Millard rotation-advancement technique (RA group). Furthermore, based on lip height and width symmetry at 6 months postoperative, the patients were divided into three groups: 38 with symmetrical lip height and width (SL), 41 with horizontal lip width more symmetrical than lip height (RAW), and 26 with vertical lip height more symmetrical than lip width (RAH). Measurements were taken preoperatively (T0), 6 months (T1) and 5 years (T2) postoperatively. The MRA group had significantly more symmetrical lip height than the RA group at T1 (P = 0.003) and T2 (P = 0.002); however no statistically significant difference in lip width symmetry was observed between the two groups. In relation to the effects of growth, only lip width symmetry in the RAH group improved significantly between T1 and T2 (P = 0.023). In conclusion the improvement in lip width symmetry following 5 years of postoperative growth did not achieve the same symmetry as when lip width symmetry was achieved intraoperatively. Thus, the MRA technique could be used to obtain intraoperative symmetry of lip height and width.

Surgical design and application of alar cartilage positioning and repositioning in correcting cleft lip nose deformity

Correction of nasal deformity is integral to modern cleft lip repair, and high risk of postoperative relapse remains a technical hurdle to overcome. The authors previously presented internal fixation of alar cartilage based on Chinese nasal morphology and lateral columella tissue increment for the correction of unilateral cleft nose deformity. Through the application and review of these techniques, the authors developed a new technique named alar cartilage positioning for primary cleft nose correction, or alar cartilage repositioning for secondary cases. Here, we introduce the theoretical foundation and preliminary experience in using this new technique.

Toward a Universal Measure of Facial Difference Using Two Novel Machine Learning Models

A sensitive, objective, and universally accepted method of measuring facial deformity does not currently exist. Two distinct machine learning methods are described here that produce numerical scores reflecting the level of deformity of a wide variety of facial conditions.

METHODS

The first proposed technique utilizes an object detector based on a cascade function of Haar features. The model was trained using a dataset of 200,000 normal faces, as well as a collection of images devoid of faces. With the model trained to detect normal faces, the face detector confidence score was shown to function as a reliable gauge of facial abnormality. The second technique developed is based on a deep learning architecture of a convolutional autoencoder trained with the same rich dataset of normal faces. Because the convolutional autoencoder regenerates images disposed toward their training dataset (ie, normal faces), we utilized its reconstruction error as an indicator of facial abnormality. Scores generated by both methods were compared with human ratings obtained using a survey of 80 subjects evaluating 60 images depicting a range of facial deformities [rating from 1 (abnormal) to 7 (normal)].

RESULTS

The machine scores were highly correlated to the average human score, with overall Pearson's correlation coefficient exceeding 0.96 (P < 0.00001). Both methods were computationally efficient, reporting results within 3 seconds.

CONCLUSIONS

These models show promise for adaptation into a clinically accessible handheld tool. It is anticipated that ongoing development of this technology will facilitate multicenter collaboration and comparison of outcomes between conditions, techniques, operators, and institutions.

[Application of autologous costal cartilage-based open rhinoplasty in secondary unilateral cleft lip nasal deformity]

Objective

To evaluate the effectiveness of autologous costal cartilage-based open rhinoplasty in the correction of secondary unilateral cleft lip nasal deformity.

Methods

Between January 2013 and June 2020, 30 patients with secondary unilateral cleft lip nasal deformity were treated, including 13 males and 17 females; aged 14-41 years, with an average of 21.7 years. Among them, 18 cases were cleft lip, 9 cases were cleft lip and palate, and 3 cases were cleft lip and palate with cleft alveolar. The autologous costal cartilage-based open rhinoplasty was used for the treatment, and the alar annular graft was used to correct the collapsed alar of the affected side. Before operation and at 6-12 months after operation, photos were taken in the anteroposterior position, nasal base position, oblique position, and left and right lateral positions, and the following indicators were measured: rhinofacial angle, nasolabial angle, deviation angle of central axis of columella, nostril height to width ratio, and bilateral nasal symmetry index (including nostril height, nostril width, and nostril height to width ratio).

Results

The incisions healed by first intention after operation, and no complications such as acute infection occurred. All 30 patients were followed up 6 months to 2 years, with an average of 15.2 months. During the follow-up, the patients' nasal shape remained good, the tip of the nose and columella were basically centered, the back of the nose was raised, the collapse of the affected side of nasal alar and the movement of the feet outside the nasal alar were all lessened than preoperatively. The basement was elevated compared to the front, and no cartilage was exposed or infection occurred. None of the patients had obvious cartilage absorption and recurrence of drooping nose. Except for the bilateral nostril width symmetry index before and after operation, there was no significant difference ( t=1.950, P=0.061), the other indexes were significantly improved after operation when compared with preoperatively ( P<0.05). Eleven patients (36.7%) requested revision operation, and the results were satisfactory after revision. The rest of the patients' nasal deformities were greatly improved at one time, and they were satisfied with the effectiveness.

Conclusion

Autologous costal cartilage-based open rhinoplasty with the alar annular graft is a safe and effective treatment for secondary unilateral cleft lip nasal deformity.

The Use of Crowdsourcing Technology to Evaluate Preoperative Severity in Patients With Unilateral Cleft Lip in a Multiethnic Population

ABSTRACT

Crowd sourcing has been used in multiple disciplines to quickly generate large amounts of diverse data. The objective of this study was to use crowdsourcing to grade preoperative severity of unilateral cleft lip phenotype in a multiethnic cohort with the hypothesis that crowdsourcing could efficiently achieve similar rankings compared to expert surgeons. Deidentified preoperative photos were collected for patients with primary, unilateral cleft lip with or without cleft palate (CL ± P). A platform was developed with C-SATS for pairwise comparisons utilizing Elo rankings by crowdsource workers through Amazon Mechanical Turk. Images were independently ranked by 2 senior surgeons for comparison. Seventy-six patients with varying severity of unilateral (CL ± P) phenotype were chosen from Operation Smile missions in Bolivia, Madagascar, Vietnam, and Morocco. Patients were an average of 1.2 years' old, ranging from 3 months to 3.3 years. Each image was compared with 10 others, for a total of 380 unique pairwise comparisons. A total of 4627 total raters participated with a median of 12 raters per pair. Data collection was completed in <20 hours. The crowdsourcing ranking and expert surgeon rankings were highly correlated with Pearson correlation coefficient of R = 0.77 (P = 0.0001). Crowdsourcing provides a rapid and convenient method of obtaining preoperative severity ratings, comparable to expert surgeon assessment, across multiple ethnicities. The method serves as a potential solution to the current lack of rating systems for preoperative severity and overcomes the difficulty of acquiring large-scale assessment from expert surgeons.

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.

Alar Base Augmentation Using Vomerine Bone Graft in Patients With Cleft Lip Nasal Deformity

BACKGROUND

Although many trials have been made to augment the unilateral alar base depression, the ultimate aesthetic satisfaction has proven difficult to achieve. In our study, we present a novel submucosal dissection technique to harvest the vomer bone and use it as an onlay graft to correct the alar base depression.

METHODS

We collected a prospective cohort study of 11 patients with unilateral cleft lip nasal deformity. Using CorelDRAW X7 software, we obtained perioperative clinical photographs to analyze the nostril and lateral lip morphometric measurements on the cleft side. Computed tomography scans were used to assess the required graft's volume and to detect resorption. We performed vomerine ostectomy and placed and fixed the bone graft in with a lag screw over the alar base depression.

RESULTS

The nostril width showed a significant increase, in addition to the height/width ratio. The columellar angle with the lateral lip height increased remarkably, with a general improvement in the nasal tip aesthetics.

CONCLUSIONS

The vomer bone graft has been shown to correct the lateral and inferior disorientation of the alar base and improve the nostril and nasal tip aesthetic measurements. The vomer bone is therefore a sufficient bone source for grafting with high viability and no resorption.

Revisiting the unrepaired unilateral cleft lip and nasal deformity using 3D surface image analysis: A data-driven model and its implications

BACKGROUND

Current descriptions of the unilateral cleft lip and nasal deformity (uCLND) are based upon limited sample sets and subjective observations. While those descriptions are inconsistent and contradictory, theoretical models, including Hogan's "tilted tripod" and Fisher's "nasal arch forms", have never been tested. Given that favorable outcomes of treatment remain elusive, detailed study of the deformity is critical in devising better treatments. The purpose of this study was to develop a data-driven three-dimensional (3D) model of uCLND that spans the spectrum of presentation and involves a pervasive underlying mechanism.

METHODS

We studied 3D images of 100 infants with unrepaired cleft lip at 6 months of age. Objective assessment included the landmark positions, anthropometric dimensions, and shape-based measures. Cleft severity was stratified by the lateral displacement of subnasale, so that a model could be developed using linear regression.

RESULTS

With progressive deviation of subnasale, the non-cleft alar base moved lateral, the cleft alar base was left posterior, and the nasal dorsum followed the caudal septum (deviating towards the non-cleft side). The "twist" resulted in opposing cleft alar dome collapse, non-cleft alar ring constriction (the non-cleft nasal sill narrowed, lateral genu rose, and alar-cheek junction became more acute), and displacement of the philtrum from midline.

CONCLUSIONS

Our study not only supports theoretical models of uCLND but also clarifies vectors of change and reveals significant non-cleft side alterations. On the basis of our findings, the objectives of treatment should involve centralization of the columella and philtrum and rebalancing the nose by untwisting the orthogonal displacement of the alar bases.

Modified Use of Costal Cartilage in Asians for the Correction of Nostril Asymmetry in Unilateral Secondary Cleft Lip Nasal Deformity

BACKGROUND

Weak alar cartilage and lack of soft tissue on the cleft side are considered to be the main critical factors leading to the asymmetry of bilateral nostrils. The costal cartilage can provide strong structural support and can be used to maintain long-term stability of nostril shape after surgical correction. With the advancement in rhinoplasty techniques, the application and understanding of costal cartilage in cleft lip nasal deformity is still on going. Herein, we present our technique of applying costal cartilage to provide nostril support and correct asymmetry in Asian patients with unilateral secondary cleft lip nasal deformity.

METHODS

Ninety-seven patients who underwent nostril asymmetry correction from January 1, 2013, to October 31, 2018, were analyzed retrospectively. Modified integrative alar cartilage strut and diced nostril augmentation with costal cartilage were implemented to improve the collapsed and flat cleft-side nostril. The release and restoration of muscle and bone were also performed when required. Surgical outcomes were analyzed based on the comparison of nostril parameters, the shape and contour, and symmetry of bilateral nostrils after surgery. During postoperative follow-up, the patients' satisfactions with the corrective outcomes were also investigated.

RESULTS

All patients received the corrective operations with complete survival of all implanted cartilages. The nostril width was narrower in postoperative group (P < 0.05). The nostril height and long axis angle were higher postoperatively (P < 0.05). After correction, the proportion of moderate type increased from 13.4% to 80.4%, whereas the proportion of horizontal type decreased from 86.6% to 17.5%. The symmetry score on the nostril parameters manifested the rate of high score (AS >3) in postoperative groups were 84.5%, 93.8%, and 87.6% for width, height, and angle of the long axis, respectively. They were higher compared with those of preoperative group (0%). More than 95% of the patients were satisfied with the overall aesthetic outcome of the surgery.

CONCLUSIONS

Through ameliorating its constructive technology and optimizing its filling form, the modified use of costal cartilage displayed excellent correction effects in the width, height, and long axis angle asymmetry of Asian patients' nostril. Precise and comprehensive rhinoplasty technique is the cornerstone for achieving satisfactory long-term aesthetic outcomes, especially in severe cases, such as secondary cleft lip nasal deformity.

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.

A novel approach quantifying the periorbital morphology: A comparison of direct, 2-dimensional, and 3-dimensional technologies

BACKGROUND

The measurement of anatomical structures is critical in plastic and reconstructive surgery. However, few detailed and standardized measurements have been widely used in the periorbital region. This study aimed to evaluate the feasibility of a novel detailed and standardized protocol with 2D and 3D technologies, and explore the relationship between them and direct measurements.

METHODS

Fifty healthy Caucasians (100 eyes) between 20 and 68 years old were recruited and captured for 3D photographs by VECTRA M3 3D Imaging System. Subsequently, 24 landmarks were located on each 3D photographs following a standardized protocol, and then 19 linear and 3 angular periorbital variables were measured. Furthermore, two-dimensional (2D) and direct measurements were conducted on each subject and compared with 3D measurements and one another.

RESULTS

The grand r means across all measurements were 0.77, 0.78, and 0.88 for direct vs. 2D values, direct vs. 3D values, and 3D vs. 2D values, respectively. The mean absolute differences were 1 mm (ranging from 0.2 mm to 3.7 mm) between direct and 3D measurements, 1 mm (ranging from 0.04 mm to 2.4 mm) between direct and 2D measurements, and 1 mm and 6.6° (ranging from 0.04 mm or 0.5° to 3 mm or 12.8°) between 2D and 3D measurements.

CONCLUSIONS

This study verified the feasibility of this detailed and standardized landmark localization protocol for assessing the periorbital morphology with 2D and 3D technologies. This protocol may work as a bridge communicating with all studies involving any of the three technologies in the future.

Personalized quantification of facial normality: a machine learning approach

What is a normal face? A fundamental task for the facial reconstructive surgeon is to answer that question as it pertains to any given individual. Accordingly, it would be important to be able to place the facial appearance of a patient with congenital or acquired deformity numerically along their own continuum of normality, and to measure any surgical changes against such a personalized benchmark. This has not previously been possible. We have solved this problem by designing a computerized model that produces realistic, normalized versions of any given facial image, and objectively measures the perceptual distance between the raw and normalized facial image pair. The model is able to faithfully predict human scoring of facial normality. We believe this work represents a paradigm shift in the assessment of the human face, holding great promise for development as an objective tool for surgical planning, patient education, and as a means for clinical outcome measurement.

The Validation of an Innovative Method for 3D Capture and Analysis of the Nasolabial Region in Cleft Cases

Objective:

To validate a newly developed method for capturing 3-dimensional (3D) images of the nasolabial region for assessing upper lip scarring and asymmetry in surgically managed unilateral cleft lip and palate (UCLP) cases.

Design:

Validation study, single cohort.

Materials and Methods:

Eighteen surgically managed UCLP cases were recruited, the nasolabial region of each face was scanned using an intraoral scanner (IOS) to produce 3D images. The images were manually segmented to allow the calculation of surface area of the scar and upper lip asymmetry. Five professionals and 5 lay assessors subjectively evaluated the same images and graded the upper lip scarring and asymmetry at 2 separate occasions. The relationship between the subjective and objective assessments was evaluated.

Results:

Moderate correlation was found between subjective and objective evaluations of the upper lip scarring and total asymmetry. The captured 3D images were of good quality for the objective measurements of lip asymmetry and residual scarring. Moderate to strong correlations were detected between the 2 panels (T ranging between 0.5 and 0.9) with no significant difference (P > .05) in the mean score of the subjectively evaluated parameters.

Conclusion:

The IOS is a useful tool for the capture of the nasolabial morphology. The captured 3D images are a reliable source for measuring lip asymmetry and scar surface area. The method has sufficient validity for routine clinical use and for objective outcome measures of the surgical repair of cleft lip.

Three-Dimensional Analysis of Bilateral Cleft Lip and Palate Nasal Deformity

OBJECTIVE

This cross-sectional study utilizes 3-dimensional analysis to assess nasal morphology in patients with bilateral cleft lip and palate (BCLP) compared to controls across the timeline of cleft care.

DESIGN

Retrospective comparative cross-sectional study.

SETTING

Tertiary pediatric academic institution.

PATIENTS AND PARTICIPANTS

One hundred and twelve patients with BCLP and an equal number of age and sex-matched control participants.

MAIN OUTCOME MEASURE(S)

Nasolabial angle, nasal length, nasal protrusion, columella length, columella width, nasal tip width, alar width, and alar base width were collected at each time point. The measurements were collected pre-nasoalveolar molding (NAM) therapy, post-NAM therapy, post-primary cleft rhinoplasty, 1 year, 5 years, 10 years, and 15 years of age.

RESULTS

Nasolabial angle and nasal tip width were significantly different from controls from pre-NAM through 15 years of age time points. Nasal length was not significantly different at any time point. Alar width and alar base width were significantly different from pre-NAM through 10 years of age time points. Nasal protrusion, columella length, and columella width were significantly different from pre-NAM through 5 years of age time points.

CONCLUSIONS

This study demonstrates that three-dimensional photogrammetry is effective in assessing the changes in nasal morphology that occur throughout the course of care in patients with BCLP from before cleft lip repair to the completion of nasal growth.

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.

Primary Rhinoplasty Does Not Interfere with Nasal Growth: A Long-Term Three-Dimensional Morphometric Outcome Study in Patients with Unilateral Cleft

BACKGROUND

Primary rhinoplasty has not been universally adopted because the potential for nasal growth impairment remains an unsolved issue in cleft care. This study's purpose was to assess the long-term effects of primary rhinoplasty performed by a single surgeon in a cohort of patients with a unilateral cleft lip nose deformity.

METHODS

Three-dimensional nasal morphometric measurements (linear, angular, proportional, surface area, and volume) were collected from consecutive patients (cleft group, n = 52; mean age, 19 ± 1 year) who had undergone primary rhinoplasty with the use of the Noordhoff approach between 1995 and 2002 and reached skeletal maturity. Normal age-, sex-, and ethnicity-matched subjects (control group, n = 52) were identified for comparative analyses.

RESULTS

No significant differences (all p > 0.05) were observed for most measures, including nasal height, alar width, nasal dorsum angle, columellar angle, columellar-labial angle, nasal tip/height ratio, nasal index, alar width/intercanthal distance ratio, nasal surface area, and nasal volume. The cleft group displayed significantly (all p < 0.05) lower nasal bridge length and nasal tip projection, and greater nasal protrusion, tip/midline deviation, nasal tip angle, nasal tip protrusion width index, and alar width/mouth ratio values than the control group.

CONCLUSIONS

Primary rhinoplasty does not interfere with nasal growth as measured by three-dimensional photogrammetric analysis. Further imaging studies are required for the assessment of development in other anatomical nasal structures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Unilateral Cleft Lip Nasal Deformity: Foundation-Based Approach to Primary Rhinoplasty

BACKGROUND

Cleft lip results in disruption of the nasal foundation and collapse of tip structures. Most approaches to primary rhinoplasty focus on correction of lower lateral cartilages; however, recurrent deformity is common, and secondary revision is frequently required. The authors describe an alternate approach that focuses on the foundation to "upright the nose," without any nasal tip dissection. This study assessed changes with surgery and with growth. Secondary goals were to compare methods of sidewall reconstruction and septoplasty and to identify predictors of relapse.

METHODS

Consecutive patients undergoing repair (n = 102) were assessed. Images were captured preoperatively, postoperatively, and at 5 years of age (when available) using three-dimensional stereophotogrammetry. Standard anthropometric and contemporary shape-based analysis (volume ratio, dorsal deviation, and alar-cheek definition) was performed to assess longitudinal changes. Images of age-matched normal control subjects were used for comparison.

RESULTS

Significant changes in anthropometric and morphometric measurements occurred following surgery. Postoperative form was similar to controls immediately after surgery and at 5 years. Nasal corrections were satisfactory, and only two patients have elected to undergo revision. When subjects were grouped according to cleft type, we found the same trends. When comparing different methods of nasal sidewall reconstruction or septoplasty, we found no differences. Alveolar cleft width was a significant predictor of worse preoperative and postoperative form.

CONCLUSIONS

Significant nasal correction can be achieved by means of reconstruction of nasal foundation, without nasal tip dissection. Preservation of tissue planes may allow for easier secondary revision, if necessary.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Identifying Three-Dimensional Facial Fluctuating Asymmetry in Normal Pediatric Individuals: A Panel Assessment Outcome Study of Clinicians and Observers

This study measured three-dimensional facial fluctuating asymmetry in 600 normal and healthy Taiwanese individuals (6 to 12 years old) and assessed the perceptions of increasing levels of facial fluctuating asymmetric severity by using a panel composed of 20 clinicians (surgical professionals), as well as 20 adult and 40 pre-adolescent observers. On average, this normal cohort presented a facial fluctuating asymmetry of 0.96 ± 0.52 mm, with 0.52 ± 0.05, 0.67 ± 0.09, 1.01 ± 0.10, and 1.71 ± 0.36 mm for levels I, II, III, and IV of severity, respectively. For all categories of raters, significant differences in the average symmetry-asymmetry scale values were observed, with level I < level II < level III = level IV (all p < 0.01, except for level III vs. IV comparisons with p > 0.05). For level I, pre-adolescent observers presented a significantly (p < 0.05) higher symmetry-asymmetry scale value than adult observers, with no significant (all p > 0.05) differences for other comparisons. For overall facial asymmetry and levels II, III, and IV, no significant (all p > 0.05) differences were observed. This study reveals that the normal pediatric face is asymmetric and the panel assessment of facial fluctuating asymmetry was influenced by the level of severity and the category of raters and contributes to the literature by revealing that pre-adolescent raters present a similar or higher perception of facial asymmetry than adult raters.

Association between three-dimensional measurements of the unilateral cleft lip nasal deformity and maxillary alveolar morphology: A retrospective study

BACKGROUND

It is debatable whether rhinoplasty is necessary during a primary operation for cleft lip. However, many surgeons believe that rhinoplasty should be performed simultaneously for severe deformities. We investigated whether alveolar cleft severity is involved in nasal deformity.

METHODS

Forty-three patients were assessed for alveolar cleft severity using maxillary plaster models prepared during primary cheiloplasty. We conducted morphological assessments of nasal deformities using three-dimensional photogrammetry. Patients were divided into two groups according to alveolar cleft severity: group A, overlap of the alveolar segments; group B, nonoverlap of the alveolar segments. Nasal asymmetry was assessed by measuring distances between landmarks around the nostrils and the columellar angle. These measurements were compared between the groups. The correlations between the columellar angle and the ratios of the five cleft side/non-cleft side distances and the correlation of each ratio were analyzed.

RESULTS

Groups A and B included 21 and 22 patients, respectively. Group A demonstrated superior deviation of the alar base on the non-cleft side than that of the alar base on the cleft side (p < 0.05). No other statistically significant differences were observed. Group A had more severe nasal deformity. Columellar angle and nostril base width demonstrated correlation.

CONCLUSION

In an uncorrected, unoperated unilateral cleft lip nasal deformity, alar base deformity is affected by deformity of the alveolar segments.

Three-Dimensional Assessment of Morphological Changes Following Nasoalveolar Molding Therapy in Cleft Lip and Palate Patients: A Case Report

The applications of computer-guided technologies for three-dimensional image analysis provide a unique opportunity to quantify the morphological dimensional changes of the face in a practical and convenient way. Symmetry of the nasolabial area is one of the main factors of facial attractiveness as well as being the main objective of the treatment of cleft lip and palate (CLP). Technological advances in computer-guided visualization modes and their applications to three-dimensional stereophotogrammetry provide more practical opportunities and alternatives for facial analysis. Each study, however, uses different protocols for the acquisition and analysis of three-dimensional images. In addition, each study identifies different anthropometric points and calculates linear and angular measurements with overlapping protocols. Therefore, it is appropriate to define a standardization of the three-dimensional analysis of CLP patients to compare the studies of different research centers. The aim of this report is to propose a protocol to standardize the acquisition and analysis of three-dimensional images to evaluate the three-dimensional changes in the nasolabial area in cleft lip and palate patients undergoing pre-surgical nasoalveolar molding (PNAM).

Associations Between Genetic Data and Quantitative Assessment of Normal Facial Asymmetry

Human facial asymmetry is due to a complex interaction of genetic and environmental factors. To identify genetic influences on facial asymmetry, we developed a method for automated scoring that summarizes local morphology features and their spatial distribution. A genome-wide association study using asymmetry scores from two local symmetry features was conducted and significant genetic associations were identified for one asymmetry feature, including genes thought to play a role in craniofacial disorders and development: NFATC1, SOX5, NBAS, and TCF7L1. These results provide evidence that normal variation in facial asymmetry may be impacted by common genetic variants and further motivate the development of automated summaries of complex phenotypes.