Outcomes in facial aesthetics in cleft lip and palate surgery: A systematic review

Birmingham Institute of Paediatric Plastic Surgery at Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 NH, UK.
Journal of Plastic Reconstructive & Aesthetic Surgery (Impact Factor: 1.42). 05/2012; 65(9):1233-45. DOI: 10.1016/j.bjps.2012.04.001
Source: PubMed


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.
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.
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.
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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    • "Four methods have been used to evaluate full facial appearance following cleft lip and palate repair (Sharma et al., 2012): direct clinical assessment (Al-Omari et al., 2003), 2D photography (Eichenberger et al., 2014), 3D imaging (Meyer-Marcotty and Stellzig-Eisenhauer, 2009), and video-graphic assessment (Morrant and Shaw, 1996). Only one study reported on the equivalency of rating facial appearance outcome by direct clinical assessment, 2D photography, and 3D imaging by professionals and laypeople (Al-Omari et al., 2003). "
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    ABSTRACT: Objective : To identify whether laypeople and professionals rate the facial appearance of patients with cleft lip and palate (CLP) similarly based on viewing full facial images. Design : Several electronic databases were searched. A hand search was performed among reference lists and relevant journals. Studies that assessed the full facial appearance of patients with CLP based on two-dimensional (2D) photographs, 3D images, or clinical examination by laypeople and professionals using a visual analog scale (VAS) or a categorical rating scale were included. Two authors independently assessed articles using methodologic-quality scoring protocol. Results : Eleven articles were included in qualitative synthesis, including four high-level and seven moderate-level papers. Three studies found that laypeople were more critical than professionals, three found there was no significant difference between laypeople and professionals, and five reported that professionals were more critical than laypeople when assessing facial appearance of patients with CLP. Conclusions : It still remains unknown whether laypeople are more or less critical than professionals when rating facial appearance of patients with repaired CLP. Professionals are more familiar with the esthetic outcomes and difficulties of treating patients. The opposite maybe true for laypeople; this disparity between what is achievable by professionals and what is expected by laypeople may be a source of dissatisfaction in facial appearance outcome. Further well-designed studies should be carried out to address this question and the clinical significance of the difference in rating scores for patients with CLP.
    Full-text · Article · Feb 2015 · The Cleft Palate-Craniofacial Journal
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    • "Our results showed high reliability and reproducibility in the assessment scale applied by healthcare professionals with and without experience in treating children with clefts. Sharma et al. [13] found that some techniques used to evaluate facial esthetics in cleft patients proved to be inefficient because of problems inherent in their design and methodology. According to Alley and Hildebrandt [14], however, human judgment can act as a reliable tool in the assessment of facial attractiveness. "
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    ABSTRACT: Esthetic evaluation of cleft lip and palate rehabilitation outcomes may assist in the determination of new surgical interventions and aid in reevaluation of treatment protocols. Our objective was to compare esthetics assessments of the nasolabial region in children with a unilateral cleft lip and palate between healthcare professionals who were experienced in the treatment of cleft lip and palate and those who were inexperienced. The study group included 55 patients between 6 and 12 years of age who had already undergone primary reconstructive surgery for unilateral cleft lip. Standardized digital photographs were obtained, and the esthetic features of the nose, lip, and nasolabial region were evaluated. We used only cropped photographic images in the assessments of healthcare professionals with and without experience in cleft lip and palate. Interrater analysis revealed highly reliable assessments made by both the experienced and inexperienced professionals. There was no statistically significant difference in the esthetic attractiveness of the lip and nose between the experienced and inexperienced professionals. Compared with the inexperienced professionals, the experienced professional evaluators showed higher satisfaction with the esthetic appearance of the nasolabial region; however, no difference was observed in the analysis of the lip or nose alone.
    Full-text · Article · Jul 2014 · BioMed Research International
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    • "It is central to many aspects of social interaction and the visual perception of the face is influenced by a complex combination of various factors such as appearance, expression, and symmetry. Earlier reports [2, 3] have shown that there is a proportional relationship between symmetry and attractiveness, and symmetrical faces are generally perceived as more attractive. "
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    ABSTRACT: Background. The upper lip-nose complex contributes significantly to the concept of symmetry and proportion of the face. A study of the morphology and aesthetic preferences of the lip-nose complex will provide a database that will serve as a guide for reconstruction. Subjects and Methods. Hundred Nigerian children participated in this study. Demographic data and standard photographs of the philtral column and nostrils were obtained. Sixty volunteers were recruited to evaluate the photographs. Each volunteer was asked to rank the photographs based on their aesthetic preference. Results. The morphology of the philtral columns was classified into four groups: (1) triangular, (2) concave, (3) flat, and (4) parallel. The nostril shape was also classified into four groups: (1) triangular, (2) round, (3) teardrop, and (4) rectangular. In both genders, the triangular shape of philtral column was the most common. There are significant age differences in the aesthetic rankings of philtral columns and nostril shapes. Conclusion. Our study establishes the basal values for the morphometric and aesthetic parameters of the lip-nose complex of 5- and 6-year-old children in Nigeria. We hope our results and reconstructive surgery will intersect at a point to treat disfigurements of the philtrum and nostrils successfully.
    Full-text · Article · Jun 2013
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