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.
TseRBoothLKeysK, et al.Reliability of nasolabial anthropometric measures using three-dimensional stereophotogrammetry in infants with unrepaired unilateral cleft lip. Plast Reconstr Surg. 2014;133(4):530e‐542e. doi:https://doi.org/10.1097/prs.0000000000000014
2.
HoodCAHoseyMTBockMWhiteJRayAAyoubAF. Facial characterization of infants with cleft lip and palate using a three-dimensional capture technique. Cleft Palate-Craniofac J. 2004;41(1):27‐35. doi:https://doi.org/10.1597/02-143
3.
TseRWEttingerRESitzmanTJMercanE.Revisiting the unrepaired unilateral cleft lip and nasal deformity using 3D surface image analysis: a data-driven model and its implications. J Plast Reconstr Aesthetic Surg. 2021;74(10):2694‐2704Published online 2021. doi:https://doi.org/10.1016/j.bjps.2021.03.026
4.
WuJLiangSShapiroLTseR. Measuring symmetry in children with cleft lip. Part 2: quantification of nasolabial symmetry before and after cleft lip repair. J Cranio Maxill Surg. 2016;53(6):705‐713. doi:https://doi.org/10.1016/j.jcms.2003.07.004
5.
LiangSShapiroLTseR. Measuring symmetry in children with cleft lip. Part 3: quantifying nasal symmetry and nasal normalcy before and after unilateral cleft lip repair. Cleft Palate-Craniofac J. 2017;54(5):602‐611. doi:https://doi.org/10.1597/15-220
6.
MercanEMorrisonCSStuhaugEShapiroLGTseRW. Novel computer vision analysis of nasal shape in children with unilateral cleft lip. J Cranio Maxill Surg. 2018;46(1):35‐43. doi:https://doi.org/10.1016/j.jcms.2017.10.018
7.
MercanEOestreichMFisherDM, et al.Objective assessment of the unilateral cleft lip nasal deformity using three-dimensional stereophotogrammetry. Plast Reconstr Surg. 2018;141(4):547e‐558e. doi:https://doi.org/10.1097/prs.0000000000004233
8.
WuJTseRShapiroLG. Automated face extraction and normalization of 3D mesh data. 2014 36th Annual International Conference of the IEEE Engineering in Medicine and Biology Society; 2014:750‐753. doi:https://doi.org/10.1109/embc.2014.6943699
9.
WuJHeikeCBirgfeldC, et al.Measuring symmetry in children with unrepaired cleft lip: defining a standard for the three-dimensional midfacial reference plane. J Craniofac Surg. 2016;53(6):695‐704. doi:https://doi.org/10.1097/00001665-200201000-00014
10.
TseRWKnightROestreichMRosserMMercanE. Unilateral cleft lip nasal deformity: three-dimensional analysis of the primary deformity and longitudinal changes following primary correction of the nasal foundation. Plast Reconstr Surg. 2020;145(1):185‐199. doi:https://doi.org/10.1097/prs.0000000000006389
11.
YuzurihaSMullikenJB. Minor-form, microform, and mini-microform cleft lip: anatomical features, operative techniques, and revisions. Plast Reconstr Surg. 2008;122(5):1485‐1493. doi:https://doi.org/10.1097/prs.0b013e31818820bc
da Silva FilhoOGSantamariaMda Silva DalbenGSembG. Prevalence of a Simonart’s band in patients with complete cleft lip and alveolus and complete cleft lip and palate. Cleft Palate-Craniofac J. 2006;43(4):442‐445. doi:https://doi.org/10.1597/05-0302.1
15.
FilhoOGSCristovâoRMSembG. Prevalence of a soft tissue bridge in a sample of 2014 patients with complete unilateral clefts of the lip and palate. Cleft Palate-Craniofac J. 1994;31(2):122‐124.
16.
FisherDMTseRMarcusJR. Objective measurements for grading the primary unilateral cleft lip nasal deformity. Plast Reconstr Surg. 2008;122(3):874‐880. doi:https://doi.org/10.1097/prs.0b013e3181811a52
17.
LathamRA. The pathogenesis of the skeletal deformity associated with unilateral cleft lip and palate. Cleft Palate-Craniofac J. 1969;6(4):404‐414.
18.
FisherDMMannRJ. A model for the cleft lip nasal deformity. Plast Reconstr Surg.1998;101(6):1448‐1456.
19.
FisherDMLoLJChenYRNoordhoffMS. Three-dimensional computed tomographic analysis of the primary nasal deformity in 3-month-old infants with complete unilateral cleft lip and palate. Plast Reconstr Surg.1999;103(7):1826‐1834. doi:https://doi.org/10.1097/00006534-199906000-00003
20.
NeiswangerKWeinbergSMRogersCR, et al.Orbicularis oris muscle defects as an expanded phenotypic feature in nonsyndromic cleft lip with or without cleft palate. Am J Med Genet A. 2007;143A(11):1143‐1149. doi:https://doi.org/10.1002/ajmg.a.31760
21.
GilliesHDMillardDR. The Principles and Art of Plastic Surgery. Little, Brown and Company; 1957.
22.
RudyHLWakeNYeeJGarfeinESTepperOM. Three-dimensional facial scanning at the fingertips of patients and surgeons: accuracy and precision testing of iPhone X three-dimensional scanner. Plast Reconstr Surg. 2020;146(6):1407‐1417. doi:https://doi.org/10.1097/prs.0000000000007387
23.
SariKPSaputroIDHarianiL. Use of a three-dimensional smartphone scanner in the quantitative analysis of repaired unilateral cleft lip during the coronavirus disease pandemic. Plast Reconstr Surg-Global Open. 2023;11(3):e4895. doi:https://doi.org/10.1097/gox.0000000000004895
24.
YaoCAImahiyeroboTSwansonJ, et al.The smile index: part 1. A large-scale study of phenotypic norms for preoperative and postoperative unilateral cleft lip. Plast Reconstr Surg. 2018;141(1):137‐146. doi:https://doi.org/10.1097/prs.0000000000003931
25.
YaoCAMcCulloughMAuslanderAImahiyeroboTAVanderburgRMageeWP. The smile index: part 2. A simple, prognostic severity scale for unilateral cleft lip. Plast Reconstr Surg. 2019;143(4):790e‐797e. doi:https://doi.org/10.1097/prs.0000000000005432
26.
TseRWOhEGrussJSHopperRABirgfeldCB. Crowdsourcing as a novel method to evaluate aesthetic outcomes of treatment for unilateral cleft lip. Plast Reconstr Surg. 2016;138(4):864‐874. doi:https://doi.org/10.1097/prs.0000000000002545
27.
MillardDR. Extensions of the rotation-advancement principle for wide unilateral cleft lips. Plast Reconstr Surg.1968;42(6):535‐544.
28.
MullikenJBMartínez-PérezD. The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: technical variations and analysis of results. Plast Reconstr Surg.1999;104(5):1247‐1260.
HoganV. The tilted tripod : a theory of unilateral cleft lip nasal deformity.pdf. Proceedings of the Transactions of the fifth International Congress of Plastic and Reconstructive Surgery. Published online1971.
TseRLienS. Unilateral cleft lip repair using the anatomical subunit approximation: modifications and analysis of early results in 100 consecutive cases. Plast Reconstr Surg. 2015;136(1):119‐130. doi:https://doi.org/10.1097/prs.0000000000001369
TseRWFisherDM. State of the art: the unilateral cleft lip and nose deformity and anatomic subunit approximation. Plast Surg-Chir Plas. 2022:229255032211090. Published online 2022. doi:https://doi.org/10.1177/22925503221109069
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
