Phenotypic Norms for Unilateral Cleft Lip Pre- and Post-Operatively: A Large-Scale, Multicultural Study of Facial Morphology and Severity
Caroline A. Yao, MD, MS1, Jordan Swanson, MD2, Thomas Imahiyerobo, MD3, Allyn Auslander, MPH1, Jane C. Figueiredo, PhD4, Richard Vanderburg, RN, BSN1, William P. Magee, III, MD, DDS1.
1Division of Plastic and Reconstructive Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA, 2Division of Plastic and Reconstructive Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA, 3Division of Plastic and Reconstructive Surgery, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, NY, USA, 4Institute of Global Health, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
PURPOSE: Unilateral cleft lip has a spectrum of disease, and qualitative assessments of the deformity are often utilized due to a lack of objective data. We define the norms and variability of unilateral cleft lip morphology and surgical results across multiple ethnicities.
METHODS: Anthropometric measurements and standardized photographs were prospectively collected in Morocco, Bolivia, Vietnam and Madagascar during medical missions. Symmetry was analyzed utilizing cleft-side/non-cleft-side ratios of: nostril width, philtral height and horizontal vermillion length. Standardized cleft width was calculated by dividing the pre-operative cleft width by commissure width. Two experienced cleft surgeons and two lay-people subjectively ranked photographs based on degree of deformity.
RESULTS: 149 patients were analyzed. Nasolabial symmetry significantly improved from pre- to post-operatively for all measurements (p<0.001, mean(SD)): columellar angle (65(SD=17) to 87(SD=8 degrees), nostril width ratio (1.7(SD=0.68) to 1.0(SD=0.22), philtral height ratio (0.8(SD=0.14) to 1.0(SD=0.14), lip length ratio (0.9(SD=0.26) to 1.0(SD=0.11)). Mean preoperative cleft width ratio was 0.4(SD=0.12). As pre-operative ratios became more asymmetrical, post-operative results varied more widely. All measurement were normally distributed and did not differ between each country (p>0.05).
Surgeon and lay-person rankings showed high inter-rater reliability (Cronbach-alpha=0.97 and 0.87, pre- and post-operatively). Pre-operatively, multivariate regression showed that cleft width ratio, nostril width ratio and philtral height ratio were predictive of rank (p<0.01, p<0.01, p=0.02). Post-operatively, multivariate regression showed that philtral height ratio was most predictive of rank (p<0.001).
CONCLUSIONS: Unilateral cleft lip deformities have a similar morphology across multiple ethnicities. Post-operative philtral height symmetry best correlated with perceptions of postoperative deformity/outcome.
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