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Objective: To compare the symmetry of the lip following Rotation-Advancement cleft lip repair by Millard and Pigott and to investigate the effect on the symmetry of cleft side and gender by using different surgical protocols. Symmetry following cleft surgery was compared to that of non-cleft children. Design: Retrospective study of photographs of children aged 5 years. Setting: Three decades of post-operative photographs of children treated by Millard and Pigott. Patients: Eighty-nine children treated by Millard, 87 by Pigott and 91 non-cleft children. Interventions: Photographs were assessed using the Symnose Computer program, a rapid semi-objective quantitative assessment of lip symmetry. Main Outcome Measures: Asymmetry score for each surgeon, and non-cleft children. Results: There was no significant difference in the median lip % mismatch score of Millard, 36.65% and Pigott, 38.52%. Right-sided clefts showed better symmetry than left-sided clefts for Millard (p<.001). This was reversed for Pigott (P=.0121). There was a difference (P<.001) between the symmetry of the two cleft cohorts and the non-cleft children (asymmetry 19.9%), and between Millard's outcomes following different lip surgical protocols (P < .0001), but no difference between Pigott's outcomes using different palate surgical protocols (P = 0.59). Conclusions: Cleft lip repair by Millard and Pigott resulted in similar lip asymmetry (37% and 39% symmetry mismatch, respectively). Lip surgical protocol and cleft side may affect lip asymmetry. Palate surgery did not affect lip asymmetry. Following cleft surgery, children were more asymmetric than non-cleft children.

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BACKGROUND: While there are internationally validated outcome measures for speech and facial growth in cleft lip and palate patients, there is no such internationally accepted system for assessing outcomes in facial aesthetics. METHOD: A systematic critical review of the scientific literature from the last 30 years using PUBMED, Medline and Google Scholar was conducted in-line with the PRISMA statement recommendations. This encompassed the most relevant manuscripts on aesthetic outcomes in cleft surgery in the English language. RESULTS: Fifty-three articles were reviewed. Four main means of determining outcome measures were found: direct clinical assessment, clinical photograph evaluation, clinical videographic assessment and three-dimensional evaluation. Cropped photographs were more representative than full face. Most techniques were based on a 5-point scale, evolving from the Asher-McDade system. Multiple panel-based assessments compared scores from lay or professional raters, the results of which were not statistically significant. Various reports based on cohorts were poorly matched for gender, age, clinical condition and ethnicity, making their results difficult to reproduce. CONCLUSIONS: The large number of outcome measure rating systems identified, suggests a lack of consensus and confidence as to a reliable, validated and reproducible scoring system for facial aesthetics in cleft patients. Many template and lay panel scoring systems are described, yet never fully validated. Advanced 3D imaging technologies may produce validated outcome measures in the future, but presently there remains a need to develop a robust method of facial aesthetic evaluation based on standardised patient photographs. We make recommendations for the development of such a system.

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OBJECTIVE: To compare growth, speech, and nasal symmetry outcomes of three methods of hard palate repair. PATIENTS: Consecutive available records of children born with unilateral bony complete cleft lip and palate over the period 1972 to 1992. INTERVENTIONS: Identical management of lip, nose, alveolus, and soft palate. Hard palate repair by Cuthbert Veau (CV) from 1972 to 1981, von Langenbeck (vL) from 1982 to 1989, or medial Langenbeck (ML) from 1989 to 1991. OUTCOME MEASURES: For growth: GOSLON yardstick or 5-year model index. For speech: articulation test. Nasal anemometry. For nasal symmetry: Coghlan computer-based assessment. All these measures were developed during the period of data collection but not for this project. RESULTS: There was a strong trend toward more favorable anteroposterior maxillary growth with the change from CV to vL to ML techniques. This fell short of statistical significance because of the small sample size. There was a significant reduction in cleft-related articulation faults (p =.01) considered to be related to improved arch form. In the absence of improved rates of velopharyngeal insufficiency or nasal symmetry, increased surgical experience was discounted as a significant contribution to improved growth and articulation outcomes. CONCLUSIONS: Reduced periosteal undermining and residual exposed palatal shelf from CV to vL to ML improved incisor relationships and articulation.

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The simultaneous recording of nasopharyngoscopy and video fluoroscopy allows a comparison to be made of their reliability under various circumstances. While the monocular view and the number of optical fallacies make measurement from endoscopy impossible, radiological views can also be shown to be fallacious, and all measurements should be treated with caution. However, through clinical observation the variability of the final dimensions of tissues raised to treat velopharyngeal incompetence can be roughly gauged. Indeed, the need for more accurate measurement awaits the arrival of a predictable procedure to allow fine tuning of surgery. Simultaneous recording has permitted improved clarity of interpretation and accuracy of measurement in some cases. The chief gain from investigations over the past 30 years has been in the considerably increased understanding of the range of normal and pathological morphology that must be taken into account in surgical treatment.

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The purpose of this study was to audit the process and outcome in terms of nasal-tip symmetry of the first 20 patients with unilateral complete cleft lip and palate treated by the Pigott alar leapfrog primary nasal correction in the early 1970s and followed for 20 years. Symmetry was assessed using the Coghlan computer-based analysis of frontal and basal views to determine the stability of the correction. The Abyholm technique of alveolar bone grafting was performed in 12 of the 20 patients. Various other secondary procedures have been performed on the nose tip and septum to improve the airway or appearance. Photographs were taken within one year of ages 5, 10, 15 and 20 years, and the lower border of the nose, the alar domes and the nostrils were assessed. To assess the overall change from 5 years to 20 years, both views were available for 17 patients. No significant change was found in the lower border or nostril symmetry, but significant deterioration at the P< 0.01 level was found on the basal view. We assessed the 10, 15 and 20 year views of all 12 patients who had undergone alveolar bone grafting to determine early and late changes. No significant benefit was found from alveolar bone grafting or minor secondary procedures for appearance. Consequently, our criteria for undertaking minor adjustments to improve appearance have become more stringent. We consider that objective reporting of appearance should become essential in peer-reviewed journals.

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Surgeons and orthodontists are still challenged to achieve 'better' noses for children with a unilateral cleft or lip, alveoulus and palate (UCLP). Various aspects are discussed: infant anatomy and later changes, developmental mechanics, cleft syndrome in animals with surgically produced facial clefts, untreated patients with congenital clefts, the radical primary correction of the UCLP nose, the unsolved problems in secondary rhinoplasty and suggestions for scientific communication.

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The aim of this study was to measure on photographs the protrusion of the upper and lower lips and demonstrate their relationships to each other, to measure the width of the mouth, and to compare these findings within complete and incomplete cleft groups and with normal controls at the ages of 5 and 10 years. It was found that the lower lip was more protrusive and the mouth width was narrower in 5-year-old children with complete clefts prior to maxillary collapse than in the control children. It is concluded that there is a lack of tissue in the cleft lip leading to less distensibility and increased lip pressure and that this may be one of the factors causing maxillary retrusion.

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The results of 132 consecutive endoscopically selected pharyngoplasties were assessed. Depending on the size and shape of the velopharyngeal defect on attempted closure, patients had been allocated to one of four pharyngoplasties: (1) a superiorly based pharyngeal flap combined with a V-Y pushback of the soft palate (Honig), (2) a modified Hynes approach, (3) a superiorly based pharyngeal flap, or (4) a fish flap. Patients were categorized according to etiology as having cleft palate, submucous cleft palate, disproportion, or neurologic origin. Acceptable nasal resonance was found after 81 percent of the Honig operations, 81 percent of the Hynes operations, and 63 percent of the superiorly based flap operations, vindicating the selection criteria based on palatal and pharyngeal wall movement. The fish flap operation was successful in only 50 percent and is not recommended. The cleft, submucous cleft, disproportion, and neurologic categories were equally well corrected by the Honig and Hynes operations. Side effects were common, with catarrh or snoring in 51 percent, difficulty breathing through the nose in 27 percent, and 9 percent requiring revision of their pharyngoplasty (6 of 53 Honig and 5 of 63 Hynes operations). The higher median age for those patients requiring pharyngoplasty revision (17 versus 10 years) suggests more cautious use in the older patient.

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A retrospective study of morbidity due to primary radical nasal correction was undertaken on 33 consecutive cases of complete unilateral cleft lip and palate within one year of their 10th birthday. Primary surgery was performed by one surgeon (RWP) using the Alar Leapfrog technique. Morbidity was assessed by the number of manoeuvres required for revisional surgery up to the age of 10 and was derived from the case notes. A total of 12 patients required no revision. The number of revisional manoeuvres was 39 in 27 anaesthetic sessions. Cleft lip noses treated by a technique of primary radical nasal correction (Alar Leapfrog) required a significant number of secondary manoeuvres to produce an acceptable result. This must be balanced against reduced teasing due to improved symmetry over this period.

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A computer-based system of assessing asymmetry was used to compare standardised photographs of primarily corrected cleft noses, uncorrected cleft noses and control (normal) noses. A significant difference was found between control and cleft groups for both upper nasal perimeter (p < 0.001) and nostril outline (p = 0.001), and between uncorrected and corrected noses for upper nasal perimeter (p = 0.03) but not for nostril outline (p = 0.99). Comparing the results achieved by panel assessment (Cussons et al., 1992) with this of the same patients revealed some discordance related to the influence of extraneous factors on panel decisions. Panel assessment is needed in the evaluation of overall appearance, whilst the computer method is able to assess the results of different techniques, and from different centres, on specific features where symmetry is a major objective of surgical technique.

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There is a need to be able to assess the overall result in a significant series of cases of a method of management of the cleft lip and nose deformity in order to avoid "best case" reporting often used to introduce new techniques. The present study was performed by a panel placing standardised base view photographs in rank order. The photographs were of 10-year-old subjects of whom 15 were normal controls, 22 were from the Rikshospitalet, Oslo, all of whom had no primary nasal correction and 25 from Frenchay Hospital, Bristol, who all had radical primary nasal correction. Ranking was performed for upper nasal perimeter symmetry, nostril outline symmetry and for overall aesthetic appearance. Analysis of the results showed a significant difference between the three groups, with the corrected noses showing better symmetry. Inter and intraobserver correlations were very close. The limitations of a ranking and marking method of panel assessment are discussed, and a computerised method is presented in subsequent papers.

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Objective assessment of the results of cleft lip and nose surgery is necessary to quantify differences between alternative surgical techniques. A previously described method of measuring facial asymmetry has been modified to allow a comparison of differently treated cleft noses (radical nasal correction versus no nasal correction). Standardised, inferior view photographs of 10-year-olds were obtained from patient records. These were projected, traced, digitised and analysed using a BBC microcomputer. A method of excluding the ill-defined nasal baseline by obtaining a mirror-image of the upper nasal perimeter is described. The method has a high degree of inter and intra observer reproducibility.

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Early experience of a modified Von Langenbeck repair of cleft palate is reported. In each case the traditional method of repair has been adopted, but with the relieving incision placed medial to the greater palatine artery. Out of a total of 40 patients over a 2-year period 8 were noted to have a fistula, of which 4 closed spontaneously, leaving 4 (10%) potentially requiring further surgery. The modified oral layer closure was conceived with muscle repair directed at restoring normal anatomy and concentrating on construction of a median dorsal convexity.

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