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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 93-98

Analysis of preoperative measurements in unilateral cleft lip patients toward the outcome of secondary cleft deformities


Reconstructive Sciences Unit, Hospital Universiti Sains Malaysia, Kelantan, Malaysia

Date of Web Publication7-Aug-2019

Correspondence Address:
Dr. Evelyn Yoke Ling Hoh
Reconstructive Sciences Unit, Hospital Universiti Sains Malaysia, Kelantan
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_1_19

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  Abstract 

Introduction: The purpose of this study is to determine whether the severity of the initial cleft deformity has any effect on the postoperative result of primary lip and palate repair in terms of the presence or severity of secondary deformity. The anthropometric measurements of the cleft side will be measured against the noncleft side as control. Materials and Methods: This was a cross-sectional, noninterventional study conducted for 12 months from March 2017 to March 2018. All children aged 5–12 years old with unilateral cleft lip deformity who underwent cleft lip repair from the year 2005 to 2013 were included in the study with a total of 42 patients. Both preoperative and postoperative lip and nose, anthropometric measurements were taken with a ruler and caliper. Difference between cleft and noncleft sides for philtrum lateral height (PLH), lip height (LH), nostril floor width (NF), and nostril height (NH) were taken to represent asymmetry or the severity of deformity and categorized into a grading system representing initial severity (IS) and postoperative asymmetry (PA). Relationship between the IS and PA were analyzed. Results: All four indices were lesser for the postoperative measurements showing an improved outcome after surgery. There was a significant difference between the IS and PA for PLH (P < 0.001) and NF (P = 0.007), thereby inferring that IS grade is not symmetrical from PA for both indices measured. However, there was no statistically significant difference between the IS and PA for LH (P = 0.055) and NH (P = 0.410). Therefore, the IS and the PA for these two indices are symmetrical. A majority of patients are within the similar grade for both IS and PA for LH; 15 patients for IS and PA Grade 1 and 11 patients for IS and PA Grade 2 (n = 26). As for NH, there were 13 patients with IS and PA Grade 1 and eight patients with IS and PA Grade 2 (n = 21). Conclusion: This study determines a coherent connection between the preoperative and postoperative LH and NH asymmetry. Thus, the postoperative lip and nose height asymmetry was worse in more severe clefts compared to those with a less severe initial cleft deformity.

Keywords: Anthropometric measurement, cleft severity, secondary deformity, unilateral cleft


How to cite this article:
Hoh EY, Sulaiman WA. Analysis of preoperative measurements in unilateral cleft lip patients toward the outcome of secondary cleft deformities. J Cleft Lip Palate Craniofac Anomal 2019;6:93-8

How to cite this URL:
Hoh EY, Sulaiman WA. Analysis of preoperative measurements in unilateral cleft lip patients toward the outcome of secondary cleft deformities. J Cleft Lip Palate Craniofac Anomal [serial online] 2019 [cited 2019 Oct 22];6:93-8. Available from: http://www.jclpca.org/text.asp?2019/6/2/93/264090


  Introduction Top


Orofacial cleft deformities have been managed by plastic surgeons worldwide for decades. The prevalence of cleft lip and/or palate varies between 1.5 and 25/10,000 births,[1] whereas the average occurrence rate is approximately 1 in 700 live births.[2]

Cleft lip and/or palate may present as a unilateral or bilateral deformity and may be associated with a syndrome. The global incidence of unilateral cleft lip is 0.5/1000 births.[3] Local data report an incidence of the cleft anomaly of 1.1/1000 livebirths in which 78% has cleft lip.[4]

It was found that cleft lip and palate deformities were the second-most common organ system involved in isolated birth defects in an epidemiological study conducted locally.[5]

Cleft lip repair is one of the most common corrective surgery of a congenital deformity performed by plastic surgeons.[3] Among the different techniques described, the Millard rotation-advancement technique is used worldwide and has undergone a myriad of modifications and variations.[6]

Even with meticulous planning and technique, secondary deformities are common after cleft lip surgery, with an occurrence rate of 60%–75% and may be due to the intrinsic anomaly itself, or as a consequence of the surgery.[7]

Secondary deformities that are present after cleft lip surgery may affect the lip or nose or both. The secondary lip deformities are irregularities of the vermillion border, deficient vermillion, Cupid's bow deformity, mucosal deficiency, short lip, long lip, tight lip, or wide lip.[8]

The cleft-lip nose is a term coined to describe the residual deformity present after primary lip and/or palate repair.[9] There are many studies describing the nasal deformity postprimary lip repair.

The resultant deformity affects the esthetic and facial appearance of the patients. This may cause psychosocial problems; the cleft patients tend to have low self-esteem, a tendency to be depressed, anxious and have problems with interpersonal relationships and in social settings.[10]

Many studies have been conducted to assess the facial esthetic outcomes of cleft lip and palate surgery. Methodology ranges from direct clinical assessment,[9],[11],[12] photographic evaluation,[13],[14] videographic evaluation,[15],[16] and three-dimensional (3D) evaluation.[17],[18] Compared to the other methods, direct anthropometric assessment is the quickest, least invasive, and most cost-effective means of measurement which can be easily performed on patients in a clinical setting.

Both qualitative and quantitative measurement tools have been employed to determine pre- and postoperative appearance of cleft lip and palate patients.[9],[12] However, there is a paucity of research to quantitatively assess and correlate the preoperative cleft severity to the resultant secondary deformity. Mortier et al. developed a dual rating grid to determine the correlation of the initial severity (IS) score and postoperative results score of partial unilateral cleft patients based on a rating given by two surgeons.[19]

The purpose of this research is to determine whether the severity of the initial cleft deformity has any effect on the postoperative result of the primary lip and palate repair in terms of the presence or severity of the secondary deformity. Direct anthropometric measurements are taken from the patients; measurements of the cleft side will be measured against the noncleft side as control, and the difference is used as a measure of severity.


  Materials and Methods Top


This was a cross-sectional, noninterventional study conducted at Hospital Universiti Sains Malaysia (HUSM) for 12 months from March 2017 to March 2018. All children aged 5–12 years old with unilateral cleft lip deformity who underwent cleft lip repair under the Reconstructive Sciences Unit in HUSM from the year 2005 to 2013 and are currently under follow-up were selected from our system. A total of 42 patients agreed to participate in the study. Syndromic patients, patients with bilateral cleft lip deformity or those who have undergone orthodontic treatment or lip scar revision or revision surgery, and those without preoperative measurements were excluded from the study.

The sample size was calculated using G Power application using t-test formula. Effect size was set at 0.5 with α error of 0.05 and power of 0.8. The sample size required was 26 patients. This study was approved by the Human Ethical Committee of the School of Medical Sciences, Universiti Sains Malaysia and is in accordance with the approved guidelines. Informed consent was obtained from all the patients' legal guardians or parents and assent obtained for children aged over 7 years.

Preoperative measurements are obtained from patient's case notes. The measurements are taken at the time of primary cheiloplasty with the patient under general anesthesia by a plastic surgeon or plastic surgery trainee at the center. Postoperative anthropometric measurements are taken during follow-up clinic with the same ruler and caliper by the primary author. Based on the anthropometric landmarks, the mouth width, philtrum lateral height (PLH), philtral width, philtrum medium height, lip height (LH), nose width, nostril height (NH), columella height, and nostril floor width (NF) were measured and recorded [Figure 1] and [Table 1]. Lip gap is only taken preoperatively.
Figure 1: Anthropometric points in Unilateral cleft lip and palate patients (CHR, CHL: commissure, VR, VL: right and left vertical length, CPHR: non-cleft side philtral column, CPHL: cleft side Cupid's bow, IS: central Cupid's bow, CPHL': cleft side philtral column, SBAR, SBAL: right and left base of ala (From Noordhoff MS, Chen YR, Chen KT, et al. The surgical technique for the complete unilateral cleft lip-nasal deformity. Oper Techn Plast Reconstr Surg 1995;2:167-74.)

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Table 1: Definition of anthropometric landmarks

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PLH, LH, NH, and NF for cleft and noncleft sides were taken and the difference calculated to represent asymmetry or severity of the initial and postoperative deformity and divided equally into three categories representing IS and postoperative asymmetry (PA) [Table 2] and [Table 3] with one representing the least difference or asymmetry and three the most severe. The association between the IS and PA was estimated using the extended McNemar test.
Table 2: Grading of preoperative asymmetry using the measured difference between the cleft and noncleft sides to represent initial severity (IS)

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Table 3: Grading of postoperative asymmetry using the measured difference between the cleft and noncleft sides (PA)

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Data were entered and analyzed using the predictive analysis software IBM SPSS® Version 25 (Armonk, NY, IBM Corp).


  Results Top


A total of 42 patients participated in this study, of which 52.4% are female and 47.6% are male. Only 11 (26.2%) of patients have a family history of cleft deformity, whereas 31 patients (73.8%) have no family history of the cleft. A total of 26 patients (61.9%) have left-sided cleft and 16 patients (38.1%) with right-sided cleft deformity. Mean age at primary lip repair is 3.6 months, whereas the mean age at palatal repair is 9.2 months.

The mean, standard deviation, and minimum and maximum values of all pre- and postoperative lip and nose measurements are shown in [Table 4] and [Table 5]. Four indices (PLH, LH, NF, and NH) are measured on both cleft and noncleft sides. Measured difference between cleft and normal sides for these four indices (PLHD, LHD, NFD, and NHD) is shown in [Table 6].
Table 4: Descriptive statistics of preoperative anthropometric measurements

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Table 5: Descriptive statistics of postoperative anthropometric measurements

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Table 6: Descriptive statistics of measured difference between cleft and noncleft sides

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For the preoperative lip measurements, the range of value for PLHD is 2.0–7.0 mm with a mean of 4.095, whereas the range of value for LHD is 0.0–5.0 mm with a mean of 2.405. In comparison to that, the range of value of preoperative nasal measurements was greater than the lip measurements with 0.5–14.5 mm for NFD and 0.0–11.0 mm for NHD and mean values of 7.881 and 3.810, respectively. All four indices were lesser for the postoperative measurements with a range of value of 0.0–6.0 mm and mean of 1.595 (PLHD), 2.119 (LHD), 2.024 (NFD), and 1.976 (NHD).

The association between the IS and PA for all four indices were estimated using the extended McNemar test [Table 7] and [Table 8]. Using the McNemar test, there was a significant difference between the IS and PA for PLH (P< 0.001) and NF (P = 0.007), thereby inferring that IS grade is not symmetrical from PA for both indices measured. However, there was no significant difference between the IS and PA for LH (P = 0.055) and NH (P = 0.410). Therefore, the IS and the PA for these two indices are symmetrical. A majority of patients are within the similar grade for both IS and PA for LH; 15 patients for IS and PA Grade 1 and 11 patients for IS and PA Grade 2 (n = 26). As for NH, there were 13 patients with IS and PA Grade 1 and eight patients with IS and PA Grade 2 (n = 21).
Table 7: Association between the initial severity and postoperative asymmetry for lip measurements

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Table 8: Association between the initial severity and postoperative asymmetry for nasal measurements

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  Discussion Top


Surgical correction of the cleft deformity has been performed by plastic surgeons for decades. The Millard rotation advancement technique is one of the most common methods of lip repair and has undergone many modifications.[6] In this study, all patients underwent Millard rotation advancement as a primary lip repair. Thirty-one patients also had a closed rhinoplasty procedure during the same setting either with the McCombs' procedure or Tajima suspension stitch. Those with cleft palate subsequently underwent a palatoplasty procedure.

Despite various methods and developments in cleft correction, secondary lip and nasal deformities are still present in a significant number of patients.[7],[20] Secondary deformities that present after cleft surgery may affect the lip; such as inadequate upper lip volume or bulk, irregularities of the vermillion border, deficient vermillion, the large or small prolabium segment with a poorly defined Cupid's bow and philtrum, mucosal deficiency, short lip, long lip, tight lip, or wide lip. It may also affect the nasal complex, such as alar deformities, large or narrow nasal sill or columella base, septal deviation, and insufficient or excessive wrapping of the ala.[19]

Secondary deformities may affect the appearance and cause psychosocial problems, especially for children of school going age. They may experience low self-esteem and shy away from their peers. Most cleft patients with residual deformity eventually need revision surgery.

The objective of this study is to determine an association between the IS of the cleft deformity and the resultant secondary deformity. In the clinical setting, this would be useful to educate parents and patients on what to expect after surgery and may also assist in the planning of further interventions that might be necessary such as a revision procedure or early referral to the orthodontic team.

Many studies have been done to assess the facial aesthetic outcomes of cleft lip and palate surgery. Methodology ranges from direct clinical assessment, photographic evaluation, video graphics evaluation and 3D evaluation.[9],[11],[12],[13],[14],[15],[16],[17],[18] Both qualitative and quantitative measurement tools have been employed to determine pre- and postoperative appearance of cleft lip and palate patients.[7],[9],[12] However, most of these methods are time-consuming, require the use of bulky assessment tools, are not cost-effective or feasible in a clinical setting. Therefore, we have decided to obtain simple anthropometric measurements by direct clinical assessment because it is easily reproducible and can be performed and taught to any physician in an outpatient setting and is also easily accepted by parents and patients alike.

The measured difference of the four indices (PLH, LH, NF, and NH) of the cleft side against the noncleft side show a wider range of value in the nose measurements compared to the lip. After cleft repair, all four indices show an improvement in measured difference and an improved symmetry with a range of value of 0.0–6.0 mm. Therefore, there is an improved outcome in symmetry postoperatively.

Using the McNemar test, the IS and PA grade for PLH and NF is not symmetrical. Margulis et al.,[3] in their study, also found that there was still a significant difference in length of the philtral column between cleft and noncleft sides (P = 0.003) after cleft lip surgery.

There was no significant difference between the IS and PA for LH (P = 0.055) and NH (P = 0.410). It may be inferred that the IS and PA for these two indices are similar. Therefore, patients with a larger asymmetry for LH and NH preoperatively is most likely to present with a more severe discrepancy between the cleft and noncleft side lip and nose height postoperatively.

Furthermore, 26 patients show a larger PA grade compared to the IS. PA grade for nasal indices was larger for 16 patients compared to 14 patients for the lip indices. The larger PA grade for the nasal indices may be due to a few factors; nasal asymmetry preoperatively was more severe compared to lip asymmetry. Therefore, one might expect the residual deformity to be worse in the nasal complex. Furthermore, all of the patients underwent primary lip repair without an open rhinoplasty procedure. Lip surgery has a large effect on the nose,[21] and a closed rhinoplasty or a simple suspension stitch may not be sufficient to address the initial deformity adequately. Conversely, it might even cause an even worse asymmetry postoperatively.

Nevertheless, this study has a few limitations. Larger sample size and inclusion of other measurements or parameters, including cephalometric measurements would be useful to further determine an association between initial cleft severity and severity of postoperative secondary deformity. Furthermore, studying patients within a homogenous age group may eliminate confounding factors such as different rate of growth between younger and older patients.

This study determines a coherent connection between the preoperative and postoperative LH and NH asymmetry. The results obtained conformed to the expected results; that the postoperative grade (PA) in the more severe clefts were worse than those of the least serious clefts in terms of lip and nose height measurement. However, PLH and NF are not suitable to be used as a determinant of postoperative severity. This conclusion may be applicable to centers with a similar treatment protocol. However, in centers which advocate a primary open rhinoplasty, variation in the timing of primary cheiloplasty and adjunctive measures such as presurgical orthopedics, the results may differ.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mossey PA, Modell B. Epidemiology of oral clefts 2012: An international perspective. Front Oral Biol 2012;16:1-8.  Back to cited text no. 1
    
2.
Bell JC, Raynes-Greenow C, Bower C, Turner RM, Roberts CL, Nassar N. Descriptive epidemiology of cleft lip and cleft palate in Western Australia. Birth Defects Res A Clin Mol Teratol 2013;97:101-8.  Back to cited text no. 2
    
3.
Margulis A, Alperson E, Billig A. Cephalometric evaluation of upper lip symmetry after functional unilateral cleft lip repair with the Kernahan and Bauer technique and primary cleft rhinoplasty. Isr Med Assoc J 2014;16:693-6.  Back to cited text no. 3
    
4.
Cheah I, Neoh SH for the MNNR. Report of Malaysian National Neonatal Registry 2006, Kuala Lumpur MNNR 2008.  Back to cited text no. 4
    
5.
Thong MK, Ho JJ, Khatijah NN. A population-based study of birth defects in Malaysia. Ann Hum Biol 2005;32:180-7.  Back to cited text no. 5
    
6.
Mulliken JB, Martínez-Pérez D. 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;104:1247-60.  Back to cited text no. 6
    
7.
Losee JE, Selber JC, Arkoulakis N, Serletti JM. The cleft lateral lip element: Do traditional markings result in secondary deformities? Ann Plast Surg 2003;50:594-600.  Back to cited text no. 7
    
8.
Stal S, Hollier L. Correction of secondary cleft lip deformities. Plast Reconstr Surg 2002;109:1672-81.  Back to cited text no. 8
    
9.
Farkas LG, Hajnis K, Posnick JC. Anthropometric and anthroposcopic findings of the nasal and facial region in cleft patients before and after primary lip and palate repair. Cleft Palate Craniofac J 1993;30:1-2.  Back to cited text no. 9
    
10.
Noor SN, Musa S. Assessment of patients' level of satisfaction with cleft treatment using the cleft evaluation profile. Cleft Palate Craniofac J 2007;44:292-303.  Back to cited text no. 10
    
11.
Assuncao AG. The V.L.S. classification for secondary deformities in the unilateral cleft lip: Clinical application. Br J Plast Surg 1992;45:293-6.  Back to cited text no. 11
    
12.
Friede H, Lilja J, Johanson B. Lip-nose morphology and symmetry in unilateral celft lip and palate patients following a two-stage lip closure. Scand J Plast Reconstr Surg 1980;14:55-64.  Back to cited text no. 12
    
13.
Asher-McDade C, Roberts C, Shaw WC, Gallager C. Development of a method for rating nasolabial appearance in patients with clefts of the lip and palate. Cleft Palate Craniofac J 1991;28:385-90.  Back to cited text no. 13
    
14.
Edler R, Rahim MA, Wertheim D, Greenhill D. The use of facial anthropometrics in aesthetic assessment. Cleft Palate Craniofac J 2010;47:48-57.  Back to cited text no. 14
    
15.
Morrant DG, Shaw WC. Use of standardized video recordings to assess cleft surgery outcome. Cleft Palate Craniofac J 1996;33:134-42.  Back to cited text no. 15
    
16.
Trotman CA, Faraway JJ, Essick GK. Three-dimensional nasolabial displacement during movement in repaired cleft lip and palate patients. Plast Reconstr Surg 2000;105:1273-83.  Back to cited text no. 16
    
17.
Meyer-Marcotty P, Alpers GW, Gerdes AB, Stellzig-Eisenhauer A. Impact of facial asymmetry in visual perception: A 3-dimensional data analysis. Am J Orthod Dentofacial Orthop 2010;137:168.e1-8.  Back to cited text no. 17
    
18.
Al-Omari I, Millett DT, Ayoub A, Bock M, Ray A, Dunaway D, et al. An appraisal of three methods of rating facial deformity in patients with repaired complete unilateral cleft lip and palate. Cleft Palate Craniofac J 2003;40:530-7.  Back to cited text no. 18
    
19.
Mortier PB, Martinot VL, Anastassov Y, Kulik JF, Duhamel A, Pellerin PN. Evaluation of the results of cleft lip and palate surgical treatment: Preliminary report. Cleft Palate Craniofac J 1997;34:247-55.  Back to cited text no. 19
    
20.
Grewal NS, Kawamoto HK, Kumar AR, Correa B, Desrosiers AE 3rd, Bradley JP. Correction of secondary cleft lip deformity: The whistle flap procedure. Plast Reconstr Surg 2009;124:1590-8.  Back to cited text no. 20
    
21.
Henry C, Samson T, Mackay D. Evidence-based medicine: The cleft lip nasal deformity. Plast Reconstr Surg 2014;133:1276-88.  Back to cited text no. 21
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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