The Asher-McDade Aesthetic Index in Comparison With Two Scoring Systems in Nonsyndromic Complete Unilateral Cleft Lip and Palate Patients

Reliability of the novel cleft lip and palate smile esthetic index (CLP-SEI)

BACKGROUND/OBJECTIVES

The aim of this research was to determine the reliability of a novel index for the assessment of smile esthetics in patients with cleft lip and/or palate (CL ± P) at the end of their multidisciplinary treatment, for use in clinical and academic settings.

MATERIALS AND METHODS

Five orthodontists, five periodontologists, five general practitioners, five dental students, and five laypeople rated the smiles of 10 patients with CL ± P twice at a 2 weeks interval. The rating scale consisted of four main categories: 1. nasolabial esthetics, 2. gingival esthetics, 3. dental esthetics, and 4. overall esthetics. A total of 15 parameters were rated. Intra- and inter-rater agreements were calculated using SPSS.

RESULTS

The inter-rater agreement varied between good and excellent whereby the orthodontists, periodontists, general practitioners, dental students, and laypeople obtained agreement scores of 0.86, 0.92, 0.84, 0.90, and 0.89, respectively. The intra-rater agreement was good with agreement scores of 0.78, 0.84, 0.84, 0.80, and 0.79, respectively.

LIMITATIONS

Smile esthetics were rated on static pictures, not in real life or by video recordings in a young adult population.

CONCLUSIONS/IMPLICATIONS

The cleft lip and palate smile esthetic index is a reliable tool for the assessment of smile esthetics in patients with CL ± P.

Constructing of predictive model for the surgical effect of patients with cleft lip and palate

OBJECTIVE

To explore effective factors of surgical effect for patients with cleft lip and palate, and to construct the predictive model of surgical effect, which provide reference for improving the effect of cleft lip and palate surgery.

METHODS

This study has been ethically reviewed and approved by the Medical Ethics Committee of Guiyang Stomatological Hospital before the study began.A total of 997 cases of cleft lip and palate surgical treatment in Guiyang Stomatological Hospital from 2015 to 2020 were collected. Logistic regression analysis was used to analyze the factors influencing the surgical outcome, and a score system was established by assigning values to the influencing factors using the nomogram. Data of 110 patients were verified, and decision curve analysis was used to evaluate the predicted results.

RESULTS

Logistic regression analysis showed that the number of surgeries, surgical methods, breast milk, prenatal examination, nutrition during pregnancy and labor intensity during pregnancy were independent risk factors for poor surgical results (all P<0.05). The predictive model was built by including the number of surgeries, surgical methods, breast milk, prenatal examination, nutrition and labor intensity during pregnancy into the predictive scoring system. The critical value was 273, the area under ROC curve (AUC) was 0.733(95%CI:0.704~0.76), the sensitivity was 89.57%, and the specificity was 48.14%.When the external validation data of 110 patients were brought into the score, the AUC of poor diagnostic value reached 74.5%, P<0.05, which was close to the modeling accuracy of 73.3%.

CONCLUSION

This study constructed a predictive model of surgical effect for patients with cleft lip and palate, which can be used for the clinical prediction of cleft lip and palate patients in Guizhou Province.

Nasolabial appearance in unilateral cleft lip and palate patients: A comparison of aesthetics using two scoring systems: A cross-sectional study

OBJECTIVE

The objective of the study was to assess nasolabial aesthetics in patients with complete unilateral cleft lip, with or without cleft palate (UCL ± P) using two scoring systems.

DESIGN

A cross-sectional study conducted in a tertiary care government hospital.

PATIENTS

Photographic records of 91 patients with complete UCL ± P from the age group of 5-18 years (mean age = 13.2 ± 3.14 years) were included.

METHOD

A panel of three orthodontists with varying experience in cleft management rated nasolabial aesthetics using two scoring systems, that is Asher Mc-Dade index (AMAI) and Cleft Aesthetic Rating Scale (CARS). Intraclass correlation coefficient, Fleiss' kappa and Cronbach's alpha were used to measure the internal consistency amongst three raters and Spearman-Brown formula was used for measuring overall reliability. Time required for assessment of each photograph was compared with ANOVA.

RESULTS

Overall, both AMAI and CARS showed high reliability and outcome assessment with good inter-rater reliability and internal consistency, when used independently by orthodontists having varied experience. Statistically significant difference was present in time taken for assessment of nasolabial aesthetics with CARS index (8.75 ± 1.65 seconds) as compared to AMAI (18.62 ± 3.49 seconds).

CONCLUSION

Asher Mc-Dade index and CARS are equally reliable and consistent for the assessment of nasolabial aesthetics in patients with UCL ± P. However, considerably less time was taken for the assessment using CARS index as compared to AMAI. The use of CARS index is recommended for the initial assessment and screening of patients by orthodontists using two dimensional photographs.

Long-Term Effects of Nasoalveolar Molding in Patients With Unilateral Cleft Lip and Palate: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to investigate long-term treatment effects of nasoalveolar molding (NAM) in patients with unilateral cleft lip and palate (UCLP).

DESIGN

Included manuscripts met the following criteria: (1) involved patients with UCLP who received NAM; (2) included comparison group(s) who either received non-NAM passive presurgical infant orthopedic appliances (PSIO) or who did not receive any PSIO; (3) reported at least one objective or validated measure of nasolabial, craniofacial, or palatal form; and (4) had patient follow-up beyond 4 years of age.

RESULTS

A total of 12 studies were included in this review. Meta-analyses were possible for Asher-McDade parameters and cephalometric measurements. Compared to patients who did not receive any PSIO, those who underwent NAM therapy were more likely to have good to excellent frontal nasal form (Risk ratio: 2.4, 95% CI: 1.24-3.68) and vermillion border (Risk ratio: 1.8, 95% CI: 1.19-2.71). However, there were no statistically significant differences in cephalometric measurements between these groups. Additionally, there were no statistically significant differences between patients receiving NAM versus non-NAM PSIO. There was insufficient evidence to determine the impact of NAM on dental arch development.

CONCLUSIONS

The preponderance of evidence in this review suggests that NAM produces benefits in nasolabial aesthetic form when compared with no appliance-based presurgical treatment. However, there is insufficient evidence to conclude whether NAM produces such benefits when compared with other passive PSIOs.

The Slavcleft: a three-center study of the outcome of treatment of cleft lip and palate. Nasolabial appearance

Background

There is a multitude of protocols of treatment of cleft lip and palate (CLP) worldwide differing in number of operations, surgical techniques, and timings of surgeries. Despite, facial appearance in subjects with CLP is rarely ideal and residual stigmata are easy to notice in many patients irrespective of the protocol. The prospective controlled investigations are optimal for comparing effectiveness of treatment protocols. Because prospective studies are very challenging to perform in CLP field, it is reasonable to retrospectively assess different surgical protocols to identify the promising ones and then to test them in a prospective way.

Methods

Our objective was to assess the nasolabial appearance in a preadolescent Slavic population with unilateral cleft lip and palate (UCLP) by using the 0-200 numeric scale with reference photographs. Patients treated in Warsaw, Poland (n = 32), Prague, Czech Republic (n = 26) and Bratislava, Slovakia (n = 17) were included in this retrospective study. Each cleft center used a unique surgical protocol. Two panels of professional raters (n = 7) and laypeople (n = 10) scored blindly the nasolabial esthetics on cropped frontal and profile images with cropped reference photograph present on the same slide. Intra- and inter-rater agreement was assessed with Cronbach's alpha, intraclass correlation coefficients, t-tests, and Bland-Altman plots. Inter-group differences were evaluated with one-way ANOVA and regression analysis.

Results

The agreement within and between raters was acceptable. We found that patients treated in Warsaw, Prague, and Bratislava showed comparable nasolabial appearance on frontal and profile photographs when judged by both professional raters (p > 0.05) and laypeople (p > 0.05). Regression analysis did not identify influence of gender, group (i.e., Warsaw, Prague, and Bratislava), age at lip repair, surgeon, and age at photographic assessment on esthetic outcome (p > 0.05).

Conclusion

This study showed that none of the surgical protocols showed superiority to produce good nasolabial appearance.

Crowd-Sourced Reliability of an Assessment of Lower Facial Aging Using a Validated Visual Scale

Reliable and valid assessments of the visual endpoints of aesthetic surgery procedures are needed. Currently, most assessments are based on the opinion of patients and their plastic surgeons. The objective of this research was to analyze the reliability of crowdworkers assessing de-identified photographs using a validated scale that depicts lower facial aging.

Nasolabial shape and aesthetics in unilateral cleft lip and palate: an analysis of nasolabial shape using a mean 3D facial template

The aim of this study was to determine the amount of deviation in nasolabial shape in patients with a cleft compared with an average non-cleft face, and to assess whether this difference is related to nasolabial aesthetics. Three-dimensional stereophotogrammetric images of 60 patients with a unilateral cleft were used. To quantify shape differences, four average non-cleft faces were constructed from stereophotogrammetric images of 141 girls and 60 boys. Three-dimensional shape differences were calculated between superimposed cleft faces and the average non-cleft face for the same sex and age group. Nasolabial aesthetics were rated with the modified Asher-McDade Aesthetic Index using a visual analogue scale (VAS). Mean VAS scores ranged from 51.44 to 60.21 for clefts, with lower aesthetic ratings associated with increasing cleft severity. Shape differences were found between cleft faces and the average non-cleft face. No relationship was found for the VAS, age, and sex, except that a lower VAS was related to a higher nose and lip distance between the superimposed cleft and average non-cleft faces for nasal profile (P= 0.02), but the explained variance was low (R²=0.066). In conclusion, except for nasal profile, nasolabial aesthetics were not influenced by the extent of shape differences from the average non-cleft face.

Synchronous correction in secondary cleft deformities: a prospective cohort study

BACKGROUND

Patients with cleft lip and palate deformities undergo multiple surgical procedures from infancy till adolescence. We hypothesized that combining these surgical procedures might offer a better quality of life without compromising on surgical outcomes.

METHODS

A prospective cohort study was conducted at our center including all adult patients who reported to us for the correction of secondary cleft deformities. All patients with secondary deformities associated with cleft lip palate and alveolus were enrolled in the study. Patients with medical issues who are not fit for general anesthesia, Bilateral Cleft deformities, and patients with gross skeletal deformity warranting surgical correction by Le fort I distraction were excluded from the study. All the patients who were included in the study underwent simultaneous lip revision, rhinoplasty and cleft alveolar bone grafting. The outcome lip nose profile was assessed using standardized patient photographs with Ascher Mcdade Scale and Aesthetic outcome index by 2 blinded maxillofacial surgeons and the bone grafting was assessed using Berglands grading system.

RESULTS

Twenty-eight patients were enrolled in the study, 10 patients were excluded based on the exclusion criteria. Thus 18 patients planned for synchronous correction of unilateral secondary cleft deformities were included in the study The Ascher Mcdade Score improved from 15 (13-16), to 4 (4-5) in the post op. All the patients were totally satisfied with the surgical outcome. The aesthetic index showed excellent outcomes in all the lip-nose procedures, except for one case which showed a good outcome. The Bergland Scale showed normal bone height in all cases of alveolar bone grafting, except for one case, which showed less than 3/4^th fill of bone. No complications were associated with any of the procedures.

CONCLUSIONS

Simultaneous correction of multiple secondary cleft lip deformities should be considered when feasible, to improve the psychological benefit and reduce financial burden on these patients. However, careful planning and execution of the techniques is essential to avoid complications associated with vascular compromise.

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 nasolabial aesthetics by different groups in operated unilateral cleft lip and palate

AIM

The aim of this study is to evaluate and to compare the perception of nasolabial aesthetic by experienced professionals, inexperienced professionals, cleft patients and laypersons in children with unilateral cleft lip and palate (UCLP) using the Asher-McDade Scoring System.

MATERIALS AND METHODS

In this retrospective study, 75 patients who applied to Ege University, Faculty of Dentistry, Department of Orthodontics and whose primary surgery operations were completed in Ege University, Faculty of Medicine Department of Plastic and Reconstructive Surgery, were evaluated from the extra-oral and profile photographs. All photographs were arranged according to Asher-McDade Scoring System and evaluated by 4 different groups. 5 people were evaluated in each group consisting of experienced professionals, inexperienced professionals, cleft patients and the laypersons. Nasal form, nasal deviation, vermilion border and nasal profile were evaluated in 5 different categories according to Asher-McDade Scoring System. Statistical analyzes were performed using STATA 11 and MEDCALC software. G Power, Fleiss Kappa, Weighted Kappa and Friedman statistical analyzes were performed for determination of number of individuals, interobserver and intraobserver reliability and comparison of scoring between groups, respectively.

RESULTS

In this study, the interobserver agreement was found to be between 0.75 and 0.80 that shows a high degree of reliability. In the comparision made between the groups; experienced professionals and inexperienced professionals; there was moderate agreement in nasal profile scoring (WK 0.2857) (-0.9673/0.6596). There was agreement between experienced professionals and cleft patients in mostly vermilion border (WK 0.5454) (-0.1643/1.0000). There was no agreement between vermilion border between inexperienced professionals and cleft patients (WK 0.9230) (-1.0000/-0.2878), and compliance with the nasal profile mostly (WK 0.5454) (-0.1643/1.0000). There was a similar insignificant agreement between experienced and inexperienced professionals, cleft patients among the laypersons, at all values (WK 0,0000) (-0.0000/0.0000). According to the scoring results of the photographs for experienced professionals; nasal form, nasal deviation, vermilion border and nasal profile were evaluated as bad and close the bad (4.00±0.00, 3.80±0.44, 3.80±0.44, 3.60±0.54); it was found fair and near the bad for inexperienced professionals (3.00±0.00, 3.00±0.00, 3.40±0.54 3.20±0.44) and close the bad for cleft patients (3.60±0.54, 3.80±0.44, 3.80±0.44, 3.40±0.54). But it was found to be acceptable and good for laypersons (2.00±0.00, 2.00±0.00, 2.40±0.54, 1.40±0.54). Laypersons showed statistically significant difference in the evaluation of nasal form, nasal deviation and nasal profile from the cleft patients (P<0.05), while they showed statistically significant difference in all the score from the experienced professionals (P<0.05, P<0.01).

CONCLUSION

The aesthetic appearance of nasolabial region is one of the important tools to evaluate the success of the treatment in patients with CLP. The success of primary surgery has one of the most important effects for nasolabial aesthetics on patients with clefts. As a result of the study, the evaluation of cleft patients was found to be similar to that of experienced professionals and lower than that of inexperienced professionals and the laypersons. This result shows us that patients with CLP have higher awareness of self-perception, but these patients may have psychosocial problems ranging from low self-esteem to social isolation risk.

Is There a Correlation Between Nasolabial Appearance and Dentoalveolar Relationships in Patients With Repaired Unilateral Cleft Lip and Palate?

OBJECTIVE

To determine whether a relationship exists between the aesthetic scores given to photographic records of the nasolabial region of patients with repaired unilateral cleft lip and palate (UCLP) and the 5-Year Olds' Index scores of study models for the same participants.

DESIGN

Retrospective study.

SETTING

University of Bristol Dental Hospital, United Kingdom.

PARTICIPANTS

Patients with nonsyndromic UCLP previously enrolled in the Cleft Care UK (CCUK) Study.

METHODS

The CCUK participants, who had both study models and photographs (frontal and worm's eye view), were identified and their records retrieved. These were rated by 2 consultants and 2 senior registrars in orthodontics. The 5-Year Olds' Index was used to score the study models, and at a separate sitting, a 5-point Likert scale was used to score the cropped frontal and worm's eye view photographs of the same children. The results were analyzed using intraclass correlation coefficients and Cohen κ.

MAIN OUTCOME MEASURES

Correlation between the aesthetic scores of the photographic views and the concordant 5-Year Olds' Index scores of the study models.

RESULTS

The intraclass correlation coefficient scores showed very poor agreement between the photographic views and their concordant study models. The level of inter- and intra-rater reliability was strongest when scoring the study models.

CONCLUSIONS

There was no agreement between the scores given to various photographic views and their corresponding study models. Scoring the study models using the 5-Year Olds' Index was the most reliable outcome measure for this age-group.

Personal technique for definite repair of complete unilateral cleft lip: modified Millard technique

Background

Millard’s rotation-advancement repair, which is used by many surgeons, can make a natural philtral column, but most surgeons use a modification of the rotation-advancement flap. The purpose of this article is to introduce a modification utilized by the authors and to provide detailed surgical procedure.

Methods

We retrospectively reviewed 82 patients’ medical records and presented surgical technique and outcomes. The main features of the authors’ strategy are emphasizing horizontal length of the lip, orbicularis oris muscle duplication for improving the definition of the philtral column, overcorrection of domal portion than the non-cleft side in order to compensate for the recurrence during growth. Two judges rated two times the appearance of the patients’ nose and lip using Asher-McDade aesthetic index. Intra- and interobserver reliabilities were determined using Cohen’s kappa statistics.

Results

All patients recovered eventually after surgery; however, two patients have a minor complications (wound infection in one patient, wound disruption due to trauma in the other patient). The improvement of the aesthetic results can be achieved with this modified Millard technique. Total mean scores of the Asher-McDade index was 2.08, fair to good appearance. The intraobserver reliabilities were substantial to almost perfect agreement and the interobserver reliabilities were moderate to almost perfect agreement.

Conclusion

We modified Millard method for repair of complete unilateral cleft lip. The surgical outcomes were favorable in long-term follow-up. We hope our technique will serve as a guide for those new to the procedure.

The Cleft Aesthetic Rating Scale for 18-Year-Old Unilateral Cleft Lip and Palate Patients: A Tool for Nasolabial Aesthetics Assessment

OBJECTIVE

To develop a reliable and easy-to-use method to assess the nasolabial appearance of 18-year-old patients with unilateral cleft lip and palate (CLP).

DESIGN

Retrospective analysis of nasolabial aesthetics using a 5-point ordinal scale and newly developed photographic reference scale: the Cleft Aesthetic Rating Scale (CARS). Three cleft surgeons and 20 medical students scored the nasolabial appearance on standardized frontal photographs.

SETTING

VU University Medical Center, Amsterdam.

PATIENTS

Inclusion criteria: 18-year-old patients, unilateral cleft lip and palate, available photograph of the frontal view.

EXCLUSION CRITERIA

history of facial trauma, congenital syndromes affecting facial appearance. Eighty photographs were available for scoring.

MAIN OUTCOME MEASURES

The interobserver and intraobserver reliability of the CARS for 18-year-old patients when used by cleft surgeons and medical students.

RESULTS

The interobserver reliability for the nose and lip together was 0.64 for the cleft surgeons and 0.61 for the medical students. There was an intraobserver reliability of 0.75 and 0.78 from the surgeons and students, respectively, on the nose and lip together. No significant difference was found between the cleft surgeons and medical students in the way they scored the nose ( P = 0.22) and lip ( P = 0.72).

CONCLUSIONS

The Cleft Aesthetic Rating Scale for 18-year-old patients has a substantial overall estimated reliability when the average score is taken from three or more cleft surgeons or medical students assessing the nasolabial aesthetics of CLP patients.

[Cosmetic technique application on the modification of lip deformity after cleft lip surgery]

OBJECTIVE

This study aims to explore the effect of cosmetic technique on the modification of lip deformity after cleft lip surgery.

METHODS

A total of 35 patients with postoperative cleft lip and who needed two-stage repair due to the nasolabial deformity were selected. Cosmetic technique was used to modify their lip deformities prior to the surgery. Front photos of the patients were taken before and after modification of their lip deformities. These photos were subsequently assessed by both the patients and the medical staff. The visual analogue method, Asher-McDade aesthetic index, and Mortier PB scale were used by patients and medical staff to evaluate changes in the lip shape by the cosmetic technique.

RESULTS

Prior to the cosmetic technique application, the mean self-score of the patients and the mean scores of the medical staff were 56±13 and 3.22±1.11 points, respectively. After the cosmetic technique application, the mean self-score of the patients and the mean scores of the medical staff were 67±12 and 2.85±1.03 points, respectively. The differences were statistically significant for both the patients and the medical staff (P<0.05).

CONCLUSIONS

Appropriate use of the cosmetic technique can modify the lip deformity after the cleft lip surgery to a certain degree. The use of this technique exerts evident effects in restoring the symmetry
of lip peak and the continuity of the labial arch and in highlighting the philtrum column.

Rating Nasolabial Aesthetics in Unilateral Cleft Lip and Palate Patients: Cropped Versus Full-Face Images

OBJECTIVE

To determine if cropping facial images affects nasolabial aesthetics assessments in unilateral cleft lip patients and to evaluate the effect of facial attractiveness on nasolabial evaluation.

DESIGN

Two cleft surgeons and one cleft orthodontist assessed standardized frontal photographs 4 times; nasolabial aesthetics were rated on cropped and full-face images using the Cleft Aesthetic Rating Scale, and total facial attractiveness was rated on full-face images with and without the nasolabial area blurred using a 5-point Likert scale.

SETTING

Cleft Palate Craniofacial Unit of a University Medical Center.

PATIENTS

Inclusion criteria: nonsyndromic unilateral cleft lip and an available frontal view photograph around 10 years of age.

EXCLUSION CRITERIA

a history of facial trauma and an incomplete cleft. Eighty-one photographs were available for assessment.

MAIN OUTCOME MEASURES

Differences in mean CARS scores between cropped versus full-face photographs and attractive versus unattractive rated patients were evaluated by paired t test.

RESULTS

Nasolabial aesthetics are scored more negatively on full-face photographs compared to cropped photographs, regardless of facial attractiveness. (Mean CARS score, nose: cropped = 2.8, full-face = 3.0, P < .001; lip: cropped = 2.4, full-face = 2.7, P < .001; nose and lip: cropped = 2.6, full-face = 2.8, P < .001).

CONCLUSION

Aesthetic outcomes of the nasolabial area are assessed significantly more positively when using cropped images compared to full-face images. For this reason, cropping images, revealing the nasolabial area only, is recommended for aesthetical assessments.

Facial Aesthetics in Young Adults after Cleft Lip and Palate Treatment over Five Decades

Cleft Lip and Palate (CLP) - a common facial malformation in newborns - is typically corrected by surgical intervention to allow for normal speech development, psychosocial adjustment, and facial attractiveness. The long term treatment outcome can be evaluated after a number of years, possibly in adulthood. We investigated the aesthetics of the nasolabial region by subjective ratings. To compare various surgical approaches we recruited 12 raters to evaluate 429 patients. Expert and lay raters judged photographs from patients, who have completed treatment with one of three different surgical strategies performed in our institution over 50 years. Facial photographs were cropped, presented to the raters in a randomized sequence, and judged by the raters on a 5 point Likert scale. The subjective ratings between the raters revealed a fair to substantial inter-rater reliability. The average ratings of the surgical outcome improved continuously over the investigated 5 decades. Despite possible differences between raters and rater groups this overall result was consistently seen in the gender groups (male/female), or expertise related groups (expert/lay). Our analysis revealed that patients with bilateral CLP scored worse than patients with unilateral CLP when treated in the fifties; more recently treated patients of both groups scored similarly.

Crowdsourcing as a Novel Method to Evaluate Aesthetic Outcomes of Treatment for Unilateral Cleft Lip

BACKGROUND

Lack of convenient and reliable methods to grade aesthetic outcomes limits the ability to study results and optimize treatment of unilateral cleft lip. Crowdsourcing methods solicit contributions from a large group to achieve a greater task. The authors hypothesized that crowdsourcing could be used to reliably grade aesthetic outcomes of unilateral cleft lip.

METHODS

Fifty deidentified photographs of 8- to 10-year-old subjects (46 with unilateral cleft lip and four controls) were assembled. Outcomes were assessed using multiple pairwise comparisons that produced a rank order (Elo rank) of nasal appearance and, on a separate survey, by Asher-McDade ratings. Both surveys were repeated to assess reliability. A group of expert surgeons repeated the same tasks on a smaller subset of photographs.

RESULTS

The authors obtained 2500 and 1900 anonymous, layperson evaluations by means of crowdsourcing on each Elo rank and Asher-McDade survey, respectively. Elo rank and Asher-McDade scores were highly reproducible (correlation coefficients, 0.87 and 0.98), and crowd evaluations agreed with those by expert surgeons (0.980 and 0.96 for Elo rank and Asher-McDade score, respectively). Crowdsourcing surveys were completed within 9 hours, whereas the expert surgeons required 3 months. On further analysis of their cleft subject sample set, the authors found that greater initial cleft severity was associated with worse aesthetic outcome.

CONCLUSIONS

Outcomes assessed by crowds were reliable and correlated well with expert assessments. Crowdsourcing allows acquisition of massive numbers of layperson assessments on an unprecedented scale, and is a convenient, rapid, and reliable means of assessing aesthetic outcome of treatment for unilateral cleft lip.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Comparison of two- and three-dimensional assessment methods of nasolabial appearance in cleft lip and palate patients: Do the assessment methods measure the same outcome?

OBJECTIVE

For the assessment of the nasolabial appearance in cleft patients, a widely accepted, reliable scoring system is not available. In this study four different methods of assessment are compared, including 2D and 3D asymmetry and aesthetic assessments.

METHODS

The data and ratings from an earlier study using the Asher-McDade aesthetic index on 3D photographs and the outcomes of 3D facial distance mapping were compared to a 2D aesthetic assessment, the Cleft Aesthetic Rating Scale, and to SymNose, a computerized 2D asymmetry assessment technique. The reliability and correlation between the four assessment techniques were tested using a sample of 79 patients.

RESULTS

The 3D asymmetry assessment had the highest reliability and could be performed by just one observer (Intraclass correlation coefficient (ICC): 0.99). The 2D asymmetry assessment of the nose was highly reliable when performed by just one observer (ICC: 0.89). However, for the 2D asymmetry assessment of the lip more observers were needed. For the 2D aesthetic assessments 3 observers were needed. The 3D aesthetic assessment had the lowest single-observer reliability (ICC: 0.38-0.56) of all four techniques. The agreement between the different assessment methods is poor to very poor. The highest correlation (R: 0.48) was found between 2D and 3D aesthetic assessments. Remarkably, the lowest correlations were found between 2D and 3D asymmetry assessments (0.08-0.17).

CONCLUSION

Different assessment methods are not in agreement and seem to measure different nasolabial aspects. More research is needed to establish exactly what each assessment technique measures and which measurements or outcomes are relevant for the patients.

The Development of the Cleft Aesthetic Rating Scale: A New Rating Scale for the Assessment of Nasolabial Appearance in Complete Unilateral Cleft Lip and Palate Patients

OBJECTIVE

The development of the Cleft Aesthetic Rating Scale, a simple and reliable photographic reference scale for the assessment of nasolabial appearance in complete unilateral cleft lip and palate patients.

DESIGN

A blind retrospective analysis of photographs of cleft lip and palate patients was performed with this new rating scale.

SETTING

VU Medical Center Amsterdam and the Academic Center for Dentistry of Amsterdam.

PATIENTS

Complete unilateral cleft lip and palate patients at the age of 6 years.

MAIN OUTCOME MEASURES

Photographs that showed the highest interobserver agreement in earlier assessments were selected for the photographic reference scale. Rules were attached to the rating scale to provide a guideline for the assessment and improve interobserver reliability. Cropped photographs revealing only the nasolabial area were assessed by six observers using this new Cleft Aesthetic Rating Scale in two different sessions.

RESULTS

Photographs of 62 children (6 years of age, 44 boys and 18 girls) were assessed. The interobserver reliability for the nose and lip together was 0.62, obtained with the intraclass correlation coefficient. To measure the internal consistency, a Cronbach alpha of .91 was calculated. The estimated reliability for three observers was .84, obtained with the Spearman Brown formula.

CONCLUSION

A new, easy to use, and reliable scoring system with a photographic reference scale is presented in this study.