Cleft lip, cleft palate, and velopharyngeal insufficiency

This article provides an introduction to the anatomical and clinical features of the primary deformities associated with unilateral cleft lip-cleft palate, bilateral cleft lip-cleft palate, and cleft palate. The diagnosis and management of secondary velopharyngeal insufficiency are discussed. The accompanying videos demonstrate the features of the cleft lip nasal deformities and reliable surgical techniques for unilateral cleft lip repair, bilateral cleft lip repair, and radical intravelar veloplasty.     

Unilateral cleft lip repair

The marking of the medial lip segment of the Millard rotation advancement procedure for repair of the unilateral cleft lip has been altered in the uppermost portion by utilizing tissue from the columellar base. Once adequate length has been obtained, cutback is utilized at approximately 90 degrees. With adequate full-thickness release of this medial lip segment and subsequent rotation into the proper position, the C flap is advanced into the donor defect of the columellar base and is also used to lengthen the shortened columella on the cleft side. This results in placement of a scar that will closely simulate the "mirror image" of the noninvolved philtral column. Fifty-seven patients with unilateral cleft lip have been repaired utilizing this technique during the past 14 years. Several of these children have required secondary surgeries because of mucosal irregularities or residual nasal deformities, but none has required additional surgery because of inadequate rotation of the medial lip segment or for correction of any donor-site defect at the base of the columella.     

Creating long-term benefits in cleft lip and palate volunteer missions

The authors present their experience with 15 years of organizing cleft lip and palate surgical volunteer missions in Latin America. The history, basic principles, and objectives of Operation San Jose, a volunteer goodwill program from Christus St.Joseph Hospital in Houston, Texas, are covered. This report addresses the different problems encountered and solutions found. Following the principles set by Operation San Jose, CIRPLAST is a Peruvian foundation for plastic surgery that travels to remote areas in Peru, operating on patients with cleft lip and palate deformities. This report highlights the importance of working with local plastic surgeons and their residents, and emphasizes that the program should be organized by and the operations performed by accredited plastic surgeons and with the auspices and support of the national plastic surgery society and the local medical board. Operation San Jose promotes the creation of long-term benefits by offering a program to teach local surgeons cleft lip and palate repair techniques and to set up guidelines to organize local surgeons so that they can continue this effort by treating their own patients in their own countries.     

Onlay cartilage graft of the alar lateral crus for cleft lip nasal deformities

The onlay cartilage grafting technique is described for treatment of unilateral or bilateral cleft lip nasal deformities. The alar cartilage is exposed through rim and intercartilagenous incisions. The cephalic half of the alar cartilage is excised, similar to the technique of traditional tip rhinoplasty. The harvested cartilage is applied to the intact caudal cartilage in layered fashion and secured with absorbable sutures. If necessary, successive layers may be added. These grafts provide a sturdy, yet delicate framework for a more normal appearing alar rim. We have performed this procedure on 16 patients, ages 10 to 41. Follow-up intervals range from 13 to 40 months, with a mean of 19 months. Results have been rated good-to-excellent by patients and surgeons. There has been no recurrence of the deformity. The only complication has been one nasal vestibule synechia.     

Primary definitive nasal correction in patients presenting for late unilateral cleft lip repair

Almost 25 percent of unilateral cleft lip and palate patients present with their deformity in their teens or later years in the developing world. Because more than 80 percent of the world population lives in the developing world, the established protocol for repair of these deformities is not applicable to these patients. Despite the magnitude, there are no significant reports in the literature that deal with this problem. Several issues need to be addressed, but the author limits himself here to the correction of the nasal deformity. The patients at this age are very much concerned with the aesthetic outcome. Procedures described hitherto for primary nasal correction in infants are not successful in restoring nasal shape and symmetry at this late age of presentation. Our experience with radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late prompted us to extend the concept by undertaking a definitive primary correction of the nasal deformity in cleft patients presenting late. Twenty-two patients with unilateral cleft lip deformity (nine male patients and 13 female patients) with ages ranging from 13 to 22 years, presenting between August of 1997 and December of 2000, are included in this study. Of these, 11 patients had a cleft of the lip alone, eight also had a cleft of the alveolus, and three had a cleft of the palate continuous with the cleft lip. All patients showed some maxillary hypoplasia. An external rhinoplasty with lip repair was carried out in all patients. The corrective procedures on the nose included columellar lengthening; augmentation along the pyriform margin, nasal floor, and alveolus using bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; and augmentation of nasal dorsum by bone graft. Clinical follow-up ranged from 4 to 24 months, and the median follow-up period was 13 months. Results have been very good, and much better than results seen earlier with other primary rhinoplasty techniques. While repairing unilateral cleft lip in adolescents, the author thinks it would be most appropriate to address the entire gamut of the deformity in a single stage, provide complete vector reorientation, and augment the hypoplastic elements by autologous tissue. It is not just the fear of poor follow-up, but that merely correcting the lip deformity in these patients without attempting definitive rhinoplasty, in the author's opinion, would be insufficient surgical intervention.     

Pathophysiology of cleft lip muscle

Although attention has been focused for decades on the correction of cleft lip deformities, our knowledge about the etiology of such deformities has remained presumptive. Sixty-six muscle biopsy specimens from cleft lip infants were obtained at the time of primary closure. Histochemical stains, histographic analysis, and electron microscopy were performed. A nonneurogenic muscle atrophy was seen that varied in severity, with muscle fibers near the cleft being the most atrophic and disorganized. Muscle fibers stained with the modified Gomori trichrome technique also demonstrated "ragged red" fibers typical of a mitochondrial myopathy. Electron microscopy confirmed large accumulations of mitochondria distorting the fibrils. These mitochondria also were increased in size and densely packed with cristae. This study thus demonstrates that the muscles in cleft lip deformities are not normal. Instead, they reflect either myopathy in the facial mesenchymal mitochondrion or at least a delay in maturation. We hypothesize that some of the morphologic deformities associated with cleft lip may cause a failure of mesenchymal reinforcement of the facial processes at a critical time in development.     

Radical correction of secondary nasal deformity in unilateral cleft lip patients presenting late

It is universally acknowledged that correction of a cleft lip nasal deformity continues to be a difficult problem. In developing countries, it is common for patients with cleft lip deformities to present in their early or late teens for correction of severe secondary lip and nasal deformities retained after the initial repairs were carried out in infancy or early childhood. Such patients have never had the benefit of primary nasal correction, orthodontic management, or alveolar bone grafting at an appropriate age. Along with a severe nasal deformity, they present with alveolar arch malalignments and anterior fistulae. In the study presented here, a strategy involving a complete single-stage correction of the nasal and secondary lip deformity was used.In this study, 26 patients (nine male and 17 female) ranging in age from 13 to 24 years presented for the first time between June of 1996 and December of 1999 with unilateral cleft lip nasal deformity. Eight patients had an anterior fistula (diameter, 2 to 4 mm) and 12 patients had a secondary lip deformity. An external rhinoplasty approach was used for all patients. The corrective procedures carried out in a single stage in these patients included lip revision; columellar lengthening; repair of anterior fistula; augmentation along the pyriform margin, nasal floor, and alveolus by bone grafts; submucous resection of the nasal septum; repositioning of lower lateral cartilages; fixation of the alar cartilage complex to the septum and the upper lateral cartilages; augmentation of nasal dorsum by bone graft; and alar base wedge resections. Medial and lateral nasal osteotomies were performed only if absolutely indicated. The median follow-up period was 11 months, although it ranged from 5 to 25 months. Overall results have been extremely pleasing, satisfactory, and stable.In this age group (13 years of age or older), it is not fruitful to use a technique for nasal correction that corrects only one facet of the deformity, because no result of nasal correction can be satisfactory until septal deviations and maxillary deficiencies are addressed along with any alar repositioning. The results of complete remodeling of the nasal pyramid are also stable in these patients because the patients' growth was nearly complete, and all the deformities could be corrected at the same time, leaving no active deforming vector. These results would indicate that aesthetically good results are achievable even if no primary nasal correction or orthodontic management had been previously attempted.     

From birth to maturity: a group of patients who have completed their protocol management. Part I. Unilateral cleft lip and palate

The optimal management of the cleft lip and palate patient from birth to completion of treatment presents a formidable challenge to the plastic surgeon and the associated health care system. The multidisciplinary team approach for the management of these patients is widely accepted. However, a paucity of literature exists discussing specific protocol management, interventions, and the long-term outcomes of patients who have completed a strict treatment protocol with a consistent multidisciplinary team. The aim of this study was to present the details of the specific management protocol at the Australian Craniofacial Unit for cleft lip and palate patients and to present a group of patients who have completed this specific protocol and discuss the details of their long-term care. During a 28-year period from 1974 to 2002, the records of 337 patients treated for unilateral cleft lip and palate were evaluated. Of these 337 patients, 22 have completed the same specific protocol management. The same surgeon (David, the senior author) has been responsible for performing all operative interventions and for overseeing the care of each of the 22 patients, ensuring that the treatment protocol has been executed appropriately and without deviation. The interventions and outcomes were analyzed on the basis of speech, hearing, nasal airway, occlusion, psychosocial adjustment, and appearance. Because of the large volume of data and potential differences in outcomes, the authors' intention is to present this as part I of a four-part series beginning with unilateral cleft lip and palate. The results of isolated cleft palate, isolated cleft lip, and bilateral cleft lip and palate will be presented as parts II, III, and IV, respectively. Speech results were assessed as normal speech, mild abnormality, or severe abnormality by objective measures, and intervention for velopharyngeal insufficiency was noted. Seventeen patients were rated as having normal speech. Four patients were rated as having mild speech abnormality, one patient was rated as having severe speech abnormality, and seven patients required surgery for velopharyngeal insufficiency. Hearing results were measured objectively, and good hearing results were obtained in 18 cases. Five patients required tympanoplasty. All patients required alveolar bone grafting. The high Le Fort I osteotomy was performed in six cases. Bimaxillary surgery was performed in one case. Of all the patients assessed from birth to maturity, 13 required between three and five surgical interventions, and nine required six operations or more. Further details and photographs of preoperative and postoperative examples are provided.     

The use of nasal splints in the primary management of unilateral cleft nasal deformity

Primary surgical correction of the cleft lip nasal deformity is routinely performed at the Craniofacial Center at Chang Gung Memorial Hospital. Over time, however, there is a tendency for the lower lateral cartilage to retain its memory and, subsequently, recreate the preoperative nasal deformity. Therefore, it is current practice to use a nostril retainer for a period of at least 6 months to maintain the corrected position of the nose. The aim of this study was to qualitatively assess the benefit of postoperative nasal splinting in the primary management of unilateral cleft nasal deformity. Data from two groups of 30 patients with complete unilateral cleft lips each were retrospectively collected and analyzed. The first group served as a control (no nasal splints), and the second group used the nasal retainer compliantly for at least 6 months postoperatively. All patients had their primary lip repair at 3 months of age. A photographic evaluation of the results when the patients were between 5 and 8 years of age was conducted. The parameters used to assess the nasal outcome were nostril symmetry, alar cartilage slump, alar base level, and columella tilt. The first scores were based on residual nasal deformity, and the second set were based on overall appearance. It was found that the mean scores of residual nasal deformity for all four parameters in patients who used the nasal stent were statistically better than the scores of patients who did not (p values ranged from 0.0001 to 0.005). The overall appearance scores for the four parameters in the patients who used the nasal stent after surgery were also statistically better than the scores for those who did not (p values ranged from 0.0001 to 0.01). The results show that postoperative nasal splinting in the primary management of the unilateral cleft nasal deformity serves to preserve and maintain the corrected position of the nose after primary lip and nasal correction, resulting in a significantly improved aesthetic result. Therefore, it is recommended that all patients undergoing primary correction of complete unilateral cleft deformity use the nasal retainer postoperatively for a period of at least 6 months.     

Correction of secondary cleft lip deformities

Learning Objectives: After studying this article, the practitioner should be able to (1) describe the common secondary deformities of the cleft lip, (2) determine the appropriate timing for surgical intervention to correct the deformities, and (3) determine the best method of addressing each of the individual secondary deformities of the cleft lip. Secondary deformities are common in children born with a cleft lip and palate. Patients with cleft lip deformity will undergo multiple surgical procedures early in life, so it is imperative to prioritize treatment of their secondary deformities and minimize the number of interventions needed. Of the many approaches used to correct these problems, surprisingly few work well consistently. As with all plastic surgery, the timing and procedure should be predicated on the severity of the deformity.     

Lip pressure changes following lip repair in infants with unilateral clefts of the lip and palate

The present study was designed to quantitatively assess lip pressure changes following cleft lip repair in infants with unilateral cleft lip, alveolus, and palate. Lip pressure measurements were taken using an electronic transducer system developed especially for this study. Lip pressure was monitored from 3 months (preoperatively) through 2 years of age in cleft and normal control children. Findings from the present study confirm the hypothesis that lip repair in infants with unilateral cleft lip and palate significantly increases lip pressure and that increased lip pressure remains significantly higher than in normal control children for the 2-year duration of the study. Thus increased lip pressure when the palate is unrepaired has to be considered as a factor modulating subsequent craniofacial growth.     

Growth status of children treated for unilateral cleft lip and palate

Cephalometric distances, angles, and proportions were evaluated for 32 children 5 to 8 years of age treated for unilateral cleft lip and palate. The children were age and sex matched with untreated controls with normal skeletal relationships. The unilateral cleft lip and palate sample was treated by the same surgeon and orthodontist using the same techniques and appliances. Measures of overall facial proportions, facial convexity, and prognathism were not significantly different between the two groups. The primary group differences pertain to the posterior aspect of the maxilla, which is vertically short in the unilateral cleft lip and palate sample. Horizontally, the maxilla of the unilateral cleft lip and palate children was significantly longer, producing a steeper palatal plane. In addition, the zygoma and orbits of unilateral cleft lip and palate children were somewhat retruded; the posterior cranial base and total mandibular length also were longer in the unilateral cleft lip and palate children.     

Upper lip measurements at the time of surgery and follow-up after modified rotation-advancement flap repair in unilateral cleft lip patients

The purpose of this prospective study was to determine whether unilateral cleft lip repaired by the rotation-advancement flap will grow short on the repaired side. This study involved 56 patients with nonsyndromic unilateral cleft lip (31 with complete and 25 with incomplete cleft lip) who underwent a rotation-advancement flap repair by a single surgeon between 1989 and 1997. Eleven patients were lost to follow-up. Forty-five patients have been followed for a varying period of between 8 and 84 months (mean = 37 months). The upper lip was measured immediately after the lip repair and follow-up using calipers. The growth ratios of vertical, horizontal, and nostril sill dimensions were compared between the cleft side and the noncleft side of the same face. Statistical analysis was performed to compare the growths between the cleft and noncleft sides. There was not a significant difference in the growth ratios of vertical (Wilcoxon signed rank test, p = 0.85) and horizontal dimensions (Student's t test, p = 0.18) between the cleft and noncleft sides. There was, however, a statistically significant difference in the growth ratios of nostril sill width between the cleft and noncleft sides (Student's t test, p = 0.02). Our findings indicated that a repaired unilateral cleft retained the vertical and horizontal dimensions determined at the time of the initial repair.     

Binderoid complete cleft lip/palate

A small subset of infants with complete cleft lip/palate look different because they have nasolabiomaxillary hypoplasia and orbital hypotelorism. The authors' purpose was to define the clinical and radiographic features of these patients and to comment on operative management, classification, and terminology. The authors reviewed 695 patients with all forms of incomplete and complete cleft lip/palate and identified 15 patients with nasolabiomaxillary hypoplasia and orbital hypotelorism. All 15 patients had complete labial clefting (5 percent of 320 patients with complete cleft lip/palate), equally divided between bilateral and unilateral forms. The female-to-male ratio was 2:1. Of the seven infants with unilateral complete cleft lip/palate, one had an intact secondary palate and all had a hypoplastic septum, small alar cartilages, narrow basilar columella, underdeveloped contralateral philtral ridge, ill-defined Cupid's bow, thin vermilion-mucosa on both sides of the cleft, and a diminutive premaxilla. Of the eight infants with bilateral complete cleft lip, one had an intact secondary palate. The features were the same as in patients with unilateral cleft, but with a more severely hypoplastic nasal tip, conical columella, tiny prolabium, underdeveloped lateral labial elements, and small/mobile premaxilla. Central midfacial hypoplasia and hypotelorism did not change during childhood and adolescence. Intermedial canthal measurements remained 1.5 SD below normal age-matched controls. Skeletal analysis (mean age, 10 years; range, 4 months to 19 years) documented maxillary retrusion (mean sagittal maxillomandibular discrepancy, 13.7 mm; range, 3 to 17 mm), absent anterior nasal spine, and a class III relationship. The mean sella nasion A point (S-N-A) angle of 74 degrees (range, 65 to 79 degrees) and sella nasion B point (S-N-B) angle of 81 degrees (range, 71 to 90 degrees) were significantly different from age-matched norms ( = 0.0007 and = 0.004, respectively). The ipsilateral central and lateral incisors were absent in all children with unilateral cleft, whereas a single-toothed premaxilla was typically found in the bilateral patients. Several modifications were necessary during primary nasolabial repair because of the diminutive bony and soft-tissue elements. All adolescent patients had Le Fort I maxillary advancement and construction of an adult nasal framework with costochondral or cranial graft. Other often-used procedures were bony augmentation of the anterior maxilla; cartilage grafts to the nasal tip and columella; and dermal grafting to the median tubercle, philtral ridge, and basal columella. Infants with complete unilateral or bilateral cleft lip/palate in association with nasolabiomaxillary hypoplasia and orbital hypotelorism do not belong on the holoprosencephalic spectrum because they have normal head circumference, stature, and intelligence, nor should they be referred to as having Binder anomaly. The authors propose the term cleft lip/palate for these children. Early recognition of this entity is important for counseling parents and because alterations in standard operative methods and orthodontic protocols are necessary.     

Morphology of the orbital region in adults following the cleft lip-palate repair in childhood

Four measurements and two qualitative signs related to the orbits of 145 adult Caucasian cleft lip/palate patients operated on in childhood were compared with similar data on 100 normal Caucasian Canadians. The average interorbital distance in male patients with unilateral and bilateral cleft lip/palate was greater than in controls, while the interorbital distance in both male and female patients with isolated cleft palate was the same as that in controls. A hypertelorism increased interorbital distance of greater than 2 S.D. above the normal was recorded in 10 cleft patients out of 145, the maximum in male cleft patients being 48 mm and in female cleft patients 38 mm. Orbital eye fissure length asymmetry was seen only in the cleft study group while a dislocation of the eye fissure levels in the frontal plane was found both in patients with clefts and in controls. No direct relationship was found between the extent of the cleft and the incidence of hypertelorism, nor between the site of the cleft and eye fissure asymmetry in unilateral cleft lip/palate patients. The epicanthic fold was significantly more frequent in cleft lip/palate patients (28/145) than in controls (10/100). Anti-mongoloid eye fissure type was recorded only in patients with cleft but mongoloid eye fissure was present both in patients with clefts and controls.     

Primary correction of the unilateral cleft lip nose: a 15-year experience

This paper reviews a 15-year personal experience based on 400 unilateral cleft nasal deformities that were reconstructed using a method that repositions the alar cartilage by freeing it from the skin and lining and shifts it to a new position. The rotation-advancement lip procedure facilitates the exposure and approach to the nasal reconstruction. The nasal soft tissues are transected from the skeletal base, reshaped, repositioned, and secured by using temporary stent sutures that readapt the alar cartilage, skin, and lining. The nasal floor is closed and the ala base is positioned to match the normal side. Good subsequent growth with maintenance of the reconstruction has been noted in this series. The repair does not directly expose or suture the alar cartilage. Improvement in the cleft nasal deformity is noted in 80 percent of the cases. Twenty percent require additional techniques to achieve the desired symmetry. This method has been used by the author as his primary unilateral cleft nasal repair and has been taught to residents and fellows under his direction with good results. This technique eliminates the severe cleft nasal deformity seen in many secondary cases.     

Formation of philtral column using vertical interdigitation of orbicularis oris muscle flaps in secondary cleft lip

The philtrum in the lip has an important aesthetic significance and is a mark of individual distinction. For patients who have undergone cleft lip surgery, the construction of the philtrum is crucial for restoring a normal appearance to the upper lip. A total of 13 patients with unilateral cleft lip nose deformities were treated for the creation of a philtral column between January of 1998 and February of 1999. Eight of the patients were male and five were female with an age range of 10 to 40 years old. The scar on the philtral column is excised and a full-thickness incision is made down to the orbicularis oris muscle and mucosa. The medial and lateral muscle flaps are then exposed and split into two leaves. The two leaves of each muscle flap are sutured together to create a vertical interdigitation. Any excess skin is not excised but rather closed with 7-0 nylon. The follow-up period ranged from 6 to 15 months, with an average of 10 months. Ten of 13 patients were satisfied with their good surgical results. Two had fair results. One patient experienced a widening of the scar and no improvement in the philtral column. A possible cause for this lack of improvement was a partial disruption of the interdigitated muscle flaps due to the early active movement of the muscle before wound healing. In conclusion, the advantages of this procedure include the creation of an anatomically natural philtrum through preserving the continuity and function of the muscle, sufficient augmentation of the philtral column by the vertical interdigitation of the muscle, relief of skin tension, and no donor-site morbidity.     

A comparison of the effects of the Latham-Millard procedure with those of a conservative treatment approach for dental occlusion and facial aesthetics in unilateral and bilateral complete cleft lip and palate: part I. Dental occlusion

The purpose of this study was to compare the effect of the Latham-Millard presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion protocol with conservative treatment (nonpresurgical orthopedics without gingivoperiosteoplasty) for palatal and dental occlusion in complete bilateral and complete unilateral cleft lip and palate. All patients were from the South Florida Cleft Palate Clinic. A retrospective dental occlusal study was conducted using serial dental casts that had been taken of patients from birth to 12 years of age. All surgical procedures, except for the secondary alveolar bone grafts in the conservative, nonpresurgical orthopedics group, were performed by D. Ralph Millard, Jr. Ralph Latham supervised the presurgical orthopedics cases. Samuel Berkowitz collected and analyzed all the serial records from 1960 to 1996. Among the patients with complete unilateral cleft lip and palate, 30 patients were treated with presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (the Latham-Millard protocol) and 51 patients were treated conservatively (i.e., nonpresurgical orthopedics without gingivoperiosteoplasty). Among the patients with complete bilateral cleft lip and palate, 21 patients were treated with the Latham-Millard protocol and 49 patients were treated conservatively. Conservative treatment was performed between 1960 and 1980. In patients with bilateral cleft lip and palate, a head bonnet with an elastic strip was used to ventroflex the protruding premaxilla. In all patients (unilateral and bilateral cleft), lip adhesion was performed at 3 months followed by definitive lip surgery at 6 to 8 months and palatal cleft closure between 18 and 24 months of age, in most cases. The Latham-Millard procedure was performed from 1980 to 1996; in bilateral cleft patients, it involved the use of a fixed palatal orthopedic appliance to bodily retract the protruding premaxilla and align it within the alveolar segments soon after birth. In all patients (unilateral and bilateral cleft), palatal alignment was also followed by gingivoperiosteoplasty and lip adhesion. Definitive lip surgery was performed between 6 and 8 months of age, and palatal closure was performed between 8 and 24 months of age using the von Langenbeck procedure with a modified vomer flap. All of the study participants had cleft lips and palates of either the unilateral or bilateral type; the unilateral and bilateral groups were further subdivided based on whether they had received the Latham-Millard protocol or the conservative treatment. It was then determined how many in each of these four basic groups had either anterior or buccal crossbites at four different age levels, when they were approximately 3, 6, 9, and 12 years of age. Although several children entered the study at or just before age 6, every patient in the 9-year-old and 12-year-old sample groups had been in the 6-year-old group and all of the 12-year-olds had been included in the immediate preceding age sample. Two-by-two chi-square tests were carried out within each cleft type (unilateral or bilateral) at each of the four age levels separately, to test whether the treatment groups (protocol versus conservative) differed in the frequency of cases with a given kind of crossbite (rather than not having that kind of crossbite). At every age level, a greater percentage of patients treated with the Latham-Millard protocol developed crossbites than did those treated more conservatively. This difference existed for both the anterior and buccal crossbites and for both unilateral and bilateral clefts. Chi-square tests of the treatment differences in crossbite frequency showed that in three quarters of the Latham-Millard protocol versus conservative treatment comparisons (12 out of 16), a significantly greater frequency of crossbite cases occurred after the Latham-Millard protocol treatment as compared with after the conservative procedure. The chi-square values for the differences in outcome between the two kinds of treatment procedures were greater for the anterior crossbites than for the buccal crossbites, suggesting that the Latham-Millard protocol, relative to the conservative method, was more likely to have an adverse effect on the anterior crossbites than on the buccal crossbites. For those patients born with a bilateral cleft, the differences in crossbite frequency between the protocol and the conservative treatment were statistically significant for patients with an anterior crossbite but not for patients with a buccal crossbite. The analysis shows that in complete bilateral and unilateral cleft lip and palate, the frequency of the anterior crossbite and (except for ages 3 and 12) the buccal crossbite is significantly higher with the Latham-Millard presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion protocol compared with the conservative, nonpresurgical orthopedics without gingivoperiosteoplasty treatment. The exception in the bilateral buccal case may be attributed to the small experimental sample size, which brings down the confidence level.     

Assessment of bilateral cleft lip nose deformity: a comparison of results as judged by cleft surgeons and laypersons

Reconstruction of bilateral cleft lip nose deformity is difficult and the outcome is inconsistent. This study was conducted to evaluate the gross outcome and the difference in the assessment of nasal appearance as judged by two groups of raters, cleft surgeons and laypersons. Sixty-four patients with bilateral cleft lip were selected for review. The patients' ages ranged from 5 to 30 years. All patients had undergone primary cleft lip repair and secondary nasal reconstruction, and had been followed for at least 6 months. One image for each patient, which included a digitized frontal, lateral, and worm's-eye view, was projected for evaluation by the raters. The raters included five cleft surgeons and five laypersons. A rating scheme was used in which a score of 3 was given for a good, close to normal nasal appearance, 2 for an average result that needed minor revision, and 1 for a poor result that needed major reconstruction. The scores were averaged for each patient in each group and for each group as a whole. The final outcome was judged as good, fair, or poor on the basis of the mean score for each patient. Statistical analysis was performed. The mean score for all patients was 2.08 as assessed by the laypersons and 2.18 as assessed by the cleft surgeon group. There was no statistically significant difference between the two groups. Comparisons on rating scores among different raters revealed a fair agreement on the ratings within each of the two groups. The results were found to be good in 29.7 percent, fair in 64.1 percent, and poor in 6.3 percent of patients when evaluated by the surgeons. When rated by the laypersons, the nasal appearance was found to be good in 26.6 percent, fair in 60.9 percent, and poor in 12.5 percent of patients. This difference in distribution between the two groups was not statistically significant. When comparing the results given by the two groups of assessors, there was agreement on the nasal appearance in 65.6 percent of patients, and a difference in grading in the rest. For the patients who received different grading, the surgeons rated them one grade higher in 63.6 percent and one grade lower in 36.4 percent. There was no difference in grading between any of the evaluators that reflected a two-grade discrepancy in evaluation of results. This study shows that the surgical outcome of bilateral cleft lip nose deformity repair, at the authors' institution, is less than optimal. When assessing bilateral cleft lip nose appearance, the judgment of results by cleft surgeons was similar to that of the laypersons. However, different rating of results existed within each of the two groups, supporting the importance of clearly assessing patient/parent expectations and defining realistic surgical goals.