Influence of Unilateral Cleft Lip Configuration on Long-Term Facial Averageness: A New Three-Dimensional Analysis Approach

Abstract

Background:

Concepts regarding cleft lip and palate care vary widely globally, as there is no international consensus. Consequently, institutional surveillance of cleft concepts is essential. In addition to subjective expert rankings, three-dimensional (3D) photogrammetry of the face has become the gold standard for evaluation and objective assessment of facial structures. We evaluated cleft configuration preoperatively to determine the influence thereof on the long-term facial appearance/averageness of unilateral cleft lip patients.

Methods:

Plaster models of the patient's labio-oral region and nose were made preoperatively, digitized, and cleft configuration assessed (cleft width, cleft-columella angle, nasal projection, heminasal width ratio, transverse lip length, labial height). Between 4 and 12 years after surgery, stereophotogrammetry (3D face scans) were captured to determine the patients' individual facial averageness index (FAI) as a deviation from the population mean, using proportion indices (PIs) of facial landmarks and reference data provided by Farkas and FaceBase.

Results:

Cleft width (r = 0.77) and columella length correlated strongly with long-term facial averageness (r = 0.52). Decreasing FAI was seen with increasing patient age (r = −0.42), indicating increasing facial averageness. Other cleft properties showed weaker correlations. Cleft alveolus did not have any impact on FAI.

Conclusions:

The presented method allows objective measurement of facial appearance/averageness as well as preoperative cleft properties. It might be superior to subjective assessments of facial attractiveness/appearance. Objective cleft measurements are strong predictors for future facial averageness. Increasing averageness with growth and age suggests late corrective surgery.

Get full access to this article

View all access options for this article.

References

Pai

BCJ

, Hung

, Wang

RSH

, Lo

. Outcome of patients with complete unilateral cleft lip and palate: 20-year follow-up of a treatment protocol. Plast Reconstr Surg. 2019; 143(2):359e–367e.

Liao

, Cole

, Mars

. Hard palate repair timing and facial growth in unilateral cleft lip and palate: a longitudinal study. Cleft Palate Craniofacial J. 2006; 43(5):547–556.

Campbell

, Costello

, Ruiz

. Cleft lip and palate surgery: an update of clinical outcomes for primary repair. Oral Maxillofac Surg Clin North Am. 2010; 22(1):43–58.

Shaye

. Update on outcomes research for cleft lip and palate. Curr Opin Otolaryngol Head Neck Surg. 2014; 22(4):255–259.

Randall

, Whitaker

, Larossa

. The importance of muscle reconstruction in primary and secondary cleft lip repair. Plast Reconstr Surg. 1974; 54(3):316–323.

Chowdri

, Darzi

, Ashraf

. A comparative study of surgical results with rotation-advancement and triangular flap techniques in unilateral cleft lip. Br J Plast Surg. 1990; 43(5):551–556.

Holtmann

, Wray

. A randomized comparison of triangular and rotation-advancement unilateral cleft lip repairs. Plast Reconstr Surg. 1983; 71(2):172–178.

Tennison

. The repair of the unilateral cleft lip by the stencil method. Plast Reconstr Surg. 1952; 9(2):115–120.

Hausamen

, Tränkmann

. Planung und Durchführung einer kombinierten kieferorthopädisch-chirurgischen Behandlung in Spätfällen von Lippen-Kiefer-Gaumen-Spalten. Fortschr Kieferorthop. 1986; 47:547–557.

10.

Hood

, Hosey

, Bock

, et al. Facial characterization of infants with cleft lip and palate using a three-dimensional capture technique. Cleft Palate Craniofacial J. 2004; 41(1):27–35.

11.

Hood

, Bock

, Hosey

, Bowman

, Ayoub

. Facial asymmetry—3D assessment of infants with cleft lip & palate. Int J Paediatr Dent. 2003; 13(6):404–410.

12.

Rumsey

, Bull

, Gahagan

. A preliminary study of the potential of social skills for improving the quality of social interaction for the facially disfigured. Soc Behav. 1986; 1(2):143–145.

13.

Adetayo

, Adetayo

, Adeyemo

, James

, Adeyemi

. Unilateral cleft lip: evaluation and comparison of treatment outcome with two surgical techniques based on qualitative (subject/guardian and professional) assessment. J Korean Assoc Oral Maxillofac Surg. 2019; 45(3):141–151.

14.

Kallusky

, Zimmerer

, Tavassol

, et al. Deglutition in patients with hypernasality associated with unilateral cleft lip and palate evaluated with high-resolution manometry. Cleft Palate Craniofacial J. 2020; 57(2):238–244.

15.

Singh

, Levy-Bercowski

, Santiago

. Three-dimensional nasal changes following nasoalveolar molding in patients with unilateral cleft lip and palate: geometric morphometrics. Cleft Palate Craniofacial J. 2005; 42(4):403–409.

16.

van Loon

, Reddy

, van Heerbeek

, et al. 3D stereophotogrammetric analysis of lip and nasal symmetry after primary cheiloseptoplasty in complete unilateral cleft lip repair. Rhinology. 2011; 49(5):546–553.

17.

Seok

, Kwon

G-Y

, Baek

S-H

, Choi

, Kim

. Comparison of the 3D digital photogrammetry and direct anthropometry in unilateral cleft lip patients. Arch Craniofacial Surg. 2013; 14(1):11.

18.

Edler

, Agarwal

, Wertheim

, Greenhill

. The use of anthropometric proportion indices in the measurement of facial attractiveness. Eur J Orthod. 2006; 28(3):274–281.

19.

Edler

, Abd Rahim

, Wertheim

, Greenhill

. The use of facial anthropometrics in aesthetic assessment. Cleft Palate Craniofacial J. 2010; 47(1):48–57.

20.

Wang

, Liao

, Chen

PKT

. Outcome of gingivoperiosteoplasty for the treatment of alveolar clefts in patients with unilateral cleft lip and palate. Br J Oral Maxillofac Surg. 2013; 51(7):650–655.

21.

Sitzman

. Cleft Lip and Palate: Current Surgical Management, an Issue of Clinics in Plastic Surgery. Elsevier Health Sciences; 2014. http://books.google.com/books?id=MuYjAwAAQBAJ&pgis=1. Accessed May 4, 2020.

22.

Farkas

. Anthropometry of the Head and Neck, 2nd ed., Vol. 2. New York: Raven Press;, 1994:79–82.

23.

Brinkley

, Fisher

, Harris

, et al. The FaceBase consortium: a comprehensive resource for craniofacial researchers. Dev. 2016; 143(14):2677–2688.

24.

Cohen

. Statistical Power Analysis for the Behavioural Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.

25.

Stein

, Dunsche

, Gellrich

, Härle

, Jonas

. One- or two-stage palate closure in patients with unilateral cleft lip and palate: comparing cephalometric and occlusal outcomes. Cleft Palate Craniofacial J. 2007; 44(1):13–22.

26.

Campbell

, Restrepo

, Park

, et al. Influence of severity on aesthetic outcomes of unilateral cleft lip repair in 1,823 patients. Plast Reconstr Surg Glob Open. 2019; 7(1):e2083.

27.

Mercan

, Oestreich

, Fisher

, et al. Objective assessment of the unilateral cleft lip nasal deformity using three-dimensional stereophotogrammetry: severity and outcome. Plast Reconstr Surg. 2018; 141(4):547e–558e.

28.

Meltzer

, Vaidya

, Capone

. The cleft-columellar angle: a useful variable to describe the unilateral cleft lip-associated nasal deformity. Cleft Palate Craniofacial J. 2013; 50(1):82–87.

29.

Vathulya

, Jain

. Columellar-frenulum angle—A significant clinical parameter in assessing the degree of severity in unilateral cleft lip. Cleft Palate Craniofacial J. 2016; 53(3):290–297.

30.

Christofides

, Potgieter

, Chait

. A long term subjective and objective assessment of the scar in unilateral cleft lip repairs using the Millard technique without revisional surgery. J Plast Reconstr Aesthetic Surg. 2006; 59(4):380–386.

31.

Campbell

, Restrepo

, Deshpande

, et al. Validation of a unilateral cleft lip surgical outcomes evaluation scale for surgeons and laypersons. Plast Reconstr Surg Glob Open. 2017; 5(9):e1472.

32.

Schwenzer-Zimmerer

, Chaitidis

, Berg-Boerner

, et al. Quantitative 3D soft tissue analysis of symmetry prior to and after unilateral cleft lip repair compared with non-cleft persons (performed in Cambodia). J Cranio Maxillofacial Surg. 2008; 36(8):431–438.

33.

Tobiasen

. Social judgments of facial deformity. Cleft Palate J. 1987; 24(4):323–327.

34.

Tobiasen

, Hiebert

, Boraz

. Development of scales of severity of facial cleft impairment. Cleft Palate Craniofacial J. 1991; 28(4):419–424.

35.

Eliason

, Hardin

, Olin

. Factors that influence ratings of facial appearance for children with cleft lip and palate. Cleft Palate Craniofacial J. 1991; 28(2):190–193.

36.

Roberts-Harry

, Stephens

. Panel perception of facial attractiveness. Br J Orthod. 1991; 18(2):152–153.

37.

Farkas

. Accuracy of anthropometric measurements: past, present, and future. Cleft Palate Craniofacial J. 1996; 33(1):10–18.

38.

Schendel

. Anthropometry of the head and face. Plast Reconstr Surg. 1995; 96(2):480.

39.

Thornhill

, Gangestad

. Human facial beauty—Averageness, symmetry, and parasite resistance. Hum Nat. 1993; 4(3):237–269.

40.

Marentette

. Anthropometric facial proportions in medicine. In: Farkas

, Munro

, ed. Head & Neck Surgery. Vol. 10. Springfield, IL: Charles C Thomas;, 1988:S80–S81.

41.

Farkas

, Posnick

. Growth and development of regional units in the head and face based on anthropometric measurements. Cleft Palate Craniofacial J. 1992; 29(4):301–302.

42.

Hajnis

, Farkas

. Anthropological record for congenital developmental defects of the face (especially clefts). Acta Chir Plast. 1969; 11(4):261–267.

43.

Farkas

, Cheung

. Facial asymmetry in healthy North American Caucasians. An anthropometrical study. Angle Orthod. 1981; 51(1):70–77.

44.

Farkas

, Eiben

, Sivkov

, et al. Anthropometric measurements of the facial framework in adulthood: age-related changes in eight age categories in 600 Healthy White North Americans of European Ancestry from 16 to 90 years of age. J Craniofac Surg. 2004; 15(2):599.