Comparison of Three Methods of Rating Nasolabial Appearance in Cleft Lip and Palate

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.

Validity of the combined use of two esthetic rating systems, the infant index and 5-point aesthetic index, for pre- and postsurgical evaluation of cleft lip repair

OBJECTIVE

The present study was designed to investigate the usefulness of combining two different ordinal scaling indices, infant index (I-I) and 5-point aesthetic index (5-PAI), for the assessment and prediction of esthetic outcome of primary lip repair for patients with unilateral cleft lip.

MATERIALS AND METHODS

The nasolabial appearance of the patients was evaluated before primary lip repair and at 5 years of age using cropped facial photographs with frontal and oblique views. The I-I and 5-PAI employ expanded reference photographs and objective esthetic variables for judgment.

RESULTS

The inter- and intrarater Kappa values of both I-I and 5-PAI demonstrated good to very good agreement (range: 0.74-0.84 for I-I and 0.62-0.77 for 5-PAI). Furthermore, both the declination of the columella and the deformity of the alar cartilage in I-I showed a correlation with nasal rating score of 5-PAI and were identified as predictable independent parameters (declination of the columella: Rs = 0.37, P = 0.04; deformity of the alar cartilage: Rs = 0.35, P = 0.02).

CONCLUSION

The combined use of I-I and 5-PAI with expanded reference photographs and objective variables could be useful for obtaining greater accuracy of the esthetic assessment and predicting postsurgical nasolabial esthetics at infancy.

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.

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.

Nasolabial Aesthetics Following Cleft Repair: An Objective Evaluation of Subjective Assessment

OBJECTIVE

Assess the weight and contribution of each of the parameters of the Asher-McDade Scale to overall subjective assessment of nasolabial aesthetics following cleft lip repair.

DESIGN

Retrospective cohort evaluation.

SETTING

Cleft and craniofacial center.

PARTICIPANTS

Forty-one patients who underwent unilateral cleft lip repair.

INTERVENTIONS

Unilateral cleft lip repair.

MAIN OUTCOME MEASURES

Nasolabial rating using the Asher-McDade scale and overall subjective assessment of nasolabial aesthetics using a rank score following unilateral cleft lip repair.

RESULTS

Strong interrater reliability was observed between the 3 raters. Significant association was determined on bivariate analysis between nasal form score (β = 27.06; P < .001), nasal symmetry score (β = 26.41; P < .001), nasal profile score (β = 28.75; P < .001), vermilion border score (β = 13.40; P = .012), and the ranking score. Adjusted β coefficients obtained from multivariate regression analysis were used to develop a modified nasolabial appearance score (over 5), that is, weighted for each of the 4 parameters: nasal form (over 8, adjusted β = 14.33), nasal symmetry (over 5, adjusted β = 7.96), nasal profile (over 5, adjusted β = 9.44), and vermilion (over 2, adjusted β = 3.31). Regression analysis between our modified nasolabial appearance score and patient ranking score demonstrated superior goodness of fit when compared to the Asher-McDade overall nasolabial appearance score (R² = .80; P < .001 vs R² = .69; P < .001).

CONCLUSION

The parameters evaluated in the Asher-McDade scale have different weights and contribute differently to overall subjective assessment of nasolabial aesthetic outcomes following cleft lip repair. Adjusting for their weights results in a modified score that demonstrates superior correlation with overall subjective assessment of nasolabial aesthetic outcomes.

Nasolabial outcomes in a nationwide study of orofacial cleft in New Zealand

OBJECTIVES

To (a) assess nasolabial outcomes across four main cleft subgroups, (b) assess agreement using a categorical and a continuous scoring measure and (c) compare outcomes to international studies.

SETTINGS AND SAMPLE POPULATION

Analysis of 470 images of which 218 was unilateral cleft lip and palate (UCLP), 128 unilateral cleft lip (UCL), 90 bilateral cleft lip and palate (BCLP) and 34 bilateral cleft lip (BCL). Images were taken around five (n = 279) and eight-ten (n = 191) years of age.

MATERIALS & METHODS

Cropped images were assessed using the Asher-McDade (AM) and a 100 mm visual analogue scale (VAS) by a panel of six raters. Scoring was undertaken for vermillion border and nasal form, symmetry and profile. Analysis was undertaken for each subscore, a total score with sensitivity analysis using a total score based on the subscores for each patient. AM intra- and inter-rater reliability was assessed using weighted kappa and for the VAS components reliability was assessed using Pearson correlation.

RESULTS

The AM intra-rater reliability was moderate/substantial, whilst inter-rater reliability was fair. The VAS intra-rater correlations were high, and inter-rater correlations were moderate. Better outcomes were found with cleft lip (CL) vs cleft lip and palate (CLP). No differences were found for sex, ethnicity, age and cleft laterality (unilateral). The AM found no difference between unilateral or bilateral. The VAS found bilateral scored worse than unilateral for both CL and CLP.

CONCLUSIONS

The nasolabial outcomes differ by cleft type. The correlation was relatively high for the VAS whilst the AM had relatively poor reliability.

Reliability of Americleft Yardstick Nasolabial Appearance Assessment With/Without Basal View for Japanese Children With Unilateral Complete Cleft Lip and Palate

OBJECTIVE

There is debate on the reliability of the Americleft Yardstick (AY) global nasolabial appearance assessment method. The objective was to analyze the effect of the additional basal view (BV) feature on the reliability of the AY method for Japanese children with complete cleft lip and palate (CUCLP).

DESIGN

Blind retrospective analysis of clinical records on 43 patients (5- to 7-year-old) with nonsyndromic CUCLP who underwent primary lip repair from 2005 to 2011.

MAIN OUTCOME MEASURE

Color pictures published in AY and Rubin's studies were used as reference pictures. Patients' photographs were cropped and rated on a 5-point scale for the vermilion border (VB), nasolabial frontal (NLF), and nasolabial profile (NLP) according to AY with/without BV assessment by Rubin's methods. Rating was performed twice by 3 oral surgeons. Intra- and inter-rater reliabilities were analyzed using weighted κ, and correlations between BV and other features were analyzed.

RESULTS

Overall average assessment scores were 2.742 (0.573) with AY and 2.702 (0.489) with AY+BV methods (P = .728). Average intra-rater reliabilities were 0.605 and 0.611 and average inter-rater reliabilities were 0.525 and 0.48 with AY and AY+BV, respectively. Inter-rater reliability was the lowest for NLP. ρ scores between BV versus VB, NLF, and NLP were 0.025, 0.659, and 0.092, respectively.

CONCLUSIONS

Present study demonstrates moderate intra- and inter-rater reliabilities obtained with the AY assessment method for Japanese children with CUCLP. Nasolabial profile standard ambiguity may lead to the poor reliability of AY assessment. Addition of the BV feature does not improve overall reliability.

Nasolabial aesthetics of patients with repaired unilateral cleft lip and palate: A comparison of three rating methods in two countries

OBJECTIVES

The study aimed to compare nasolabial aesthetics of patients with unilateral cleft lip and palate (UCLP) treated in Vietnam and Estonia using three rating methods: five-point aesthetic index, a visual analogue scale (VAS), and reference scores method.

METHODS

A total of 56 patients with repaired UCLP (23 from Vietnam and 33 from Estonia) were included in this cross-sectional study. Patients' facial and profile photographs were cropped to reveal the nasolabial region and coded. Five examiners rated nasolabial aesthetics of the patients using three methods: five-point aesthetic index, 100 mm VAS, and reference scores method. Intraclass correlation coefficients were used to evaluate intrarater and interrater reliabilities.

RESULTS

The five-point aesthetic index had a higher reliability than VAS and reference scores method. The least aesthetic feature among Vietnamese and Estonian patients was nasal symmetry and nasolabial profile respectively. No differences in nasolabial aesthetics were found between Vietnamese and Estonian patients regardless of the rating methods (p > 0.05) except for nasal symmetry.

CONCLUSIONS

The five-point aesthetic index seems to produce more reproducible results. There were no significant differences in nasolabial aesthetics between the two countries. Overall average nasolabial appearance results were obtained using different treatment protocols in the two countries.

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.

Rating nasolabial appearance on three-dimensional images in cleft lip and palate: a comparison with standard photographs

BACKGROUND/OBJECTIVE

Judgement of nasolabial aesthetics in cleft lip and palate (CLP) is a vital component of assessment of treatment outcome. It is usually performed based on two-dimensional (2D) facial photographs. An increasing use of three-dimensional (3D) imaging warrants an assessment if 3D images can substitute 2D photographs during aesthetic evaluation. The aim of this study was to compare reliability of rating nasolabial appearance on 3D images and standard 2D photographs in prepubertal children.

METHODS

Forty subjects (age: 8.8-12) with unilateral CLP treated according to a standardized protocol, who had 2D and 3D facial images were selected. Eight lay raters assessed nasal form, nasal deviation, vermilion border, and nasolabial profile on cropped 2D and 3D images using a 100-mm visual analogue scale (VAS). Additionally, raters answer two questions: 1. Do 2D or 3D images provide more information on nasolabial aesthetics? and 2. Is aesthetic evaluation easier on 2D or 3D images?

RESULTS

Intrarater agreement demonstrated a better reliability of ratings performed on 3D images than 2D images (correlation coefficients for 3D images ranged from 0.733 to 0.857; for 2D images from 0.151 to 0.611). The mean scores showed, however, no difference between 2D and 3D formats (>0.05). 3D images were regarded more informative than 2D images (P = 0.001) but probably more difficult to evaluate (P = 0.06).

LIMITATIONS

Basal view of the nose was not assessed.

CONCLUSIONS

3D images seem better than 2D images for rating nasolabial aesthetics but raters should familiarize themselves with them prior to rating.