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Unilateral Cleft Lip Severity Affects Aesthetic Outcome
Christopher Haley, BS1, Sebastian Brooke, MD2, Christine Jones, MD2, Ross E. Long, Jr., DMD, MS, PhD3, Thomas Samson, MD2, Donald Mackay, MD2.
1Pennsylvania State University College of Medicine, Hershey, PA, USA, 2Penn State Milton S. Hershey Medical Center, Hershey, PA, USA, 3Lancaster Cleft Palate Clinic, Lancaster, PA, USA.

Background: Pre-surgical nostril width ratio and columellar angle have been shown to independently correlate with the pre-surgical severity of unilateral cleft lip. The Kuijpers- Jagtman version of the Asher-McDade system reliably assesses nasolabial appearance of the repaired unilateral cleft lip. However, the relationship between pre-surgical severity and long-term post-operative outcome has not been determined. The aim of the current study was to determine if there is a correlation between the pre-surgical severity of unilateral cleft lip and post-surgical nasolabial appearance.
Methods: All patients included underwent unilateral cleft lip repair by the same surgeon, had pre-surgical facial casts, and had standard A-P photographs taken 8-9 years post-operatively. To determine cleft severity, nostril width ratio and columellar angle were digitally measured from photographs taken of pre-surgical facial casts. To determine long-term aesthetic outcome, five blinded observers used a modified and validated Kuijpers-Jagtman rating system to assess nasolabial appearance in standard A-P photographs. Correlations between the pre-surgical severity measurements of unilateral cleft lip and post-surgical nasolabial appearance were determined. Inter and intra-rater reliabilities were also calculated.
Results: Thirty one patients were included with a mean age of 2.6 months at time of repair (range 2 to 4 months). There was a statistically significant correlation between pre-surgical nostril width ratio and post-surgical nasal form score (r=.40; p=0.026). There was a statistically significant correlation between pre-surgical columellar angle and post-surgical nasal form score (r=.37; p=0.040). Multivariate regression examining the effect of columellar angle and surgeon experience on nasal form score revealed columellar angle to be an independent predictor of nasal form score (p=0.049). Multivariate regression examining the effect of nostril width ratio and surgeon experience on nasal form score revealed nostril width ratio to be an independent predictor of nasal form score approaching statistical significance (p=0.057). There was not a significant correlation between pre-surgical cleft severity measurements and vermillion border score. There was good inter-rater reliability for nasal form and vermillion border with Cronbach values of 0.91 and 0.79 respectively. The average intra-rater reliability for all 5 observers was 0.87 for nasal form and 0.70 for vermillion border, which also indicates good intra-rater reliability.
Conclusions: This study shows a direct correlation between the pre-surgical severity in unilateral cleft lip deformity and long-term post-surgical nasal appearance. This finding is important because the cleft nasal deformity often carries the greatest stigmata for these patients. In the present setting, where several techniques of primary lip repair with and without cleft nasal repair exist, outcome studies that present and control for pre-surgical severity will render more accurate assessments of these techniques. Ultimately, valid outcome studies will lead to better patient outcomes and possibly establish better practices in cleft surgery.


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