Reconstruction of residual cleft nasal deformities in adolescents: Effects on social perceptions

Outcome of Patients with Complete Cleft Lip and Alveolus: 20-Year Follow-Up

BACKGROUND

Patients with cleft have functional and aesthetic impairment, and typically require several interventions as they grow. Long-term evaluation following a treatment protocol is essential, but such reports on patients with complete cleft lip and alveolus (CLA) are sparse in the literature.

METHODS

A retrospective review was conducted of all patients with complete CLA born between January of 1995 and August of 2002 and treated at our center. Patients who received continuous multidisciplinary team care until 20 years of age were included, and patients with cleft palate and syndromic abnormalities were excluded. Facial bone growth was evaluated using cephalometric analysis.

RESULTS

Eighty-seven and 11 patients with unilateral and bilateral CLA, respectively, were included. All patients underwent one-stage cheiloplasty with primary rhinoplasty. Revision lip/nose surgery was performed in 21.8% and 27.3% during growing age, and in 51.7% and 72.7% after skeletal maturity, respectively. Orthognathic surgery was performed in 20.7% and 27.3%, respectively. Compared with unilateral CLA patients, bilateral CLA patients had more operations (3.0 versus 3.7; P = 0.03) and a higher chance of undergoing alveolar bone grafting twice (1.1% versus 36.4%; P < 0.01). Patients with complete CLA had less hypoplastic maxilla, and underwent fewer operations than those with complete cleft lip and palate.

CONCLUSIONS

Complete CLA is a less severe form of cleft, but the patients still require multiple interventions. This review revealed certain suboptimal results, and modifications have been made in the treatment protocol. Longitudinal follow-up and periodic assessment help to establish an ideal therapeutic strategy and improve overall cleft care.

A Cross-Sectional Study Examining Andrews' Analysis in Caucasian and African American Subjects

BACKGROUND

Andrews' analysis is a commonly utilized instrument to aid in esthetic positioning of the anteroposterior position of the maxillomandibular complex; however, there is limited data regarding use in non-Caucasian subjects.

PURPOSE

The purpose of this study was to document laypersons preferences of anteroposterior position of the maxillomandibular complex in relation to Andrews' lateral profile analysis in African American (AA) and Caucasian subjects.

STUDY DESIGN, SETTING, SAMPLE

A cross-sectional study was implemented to evaluate the esthetics of AA and Caucasian subjects. Photographs were taken and simulated with anteroposterior maxillomandibular complex positioning in varying relationships to Andrews' goal anterior line limit. A survey was then designed to select the preferred simulation of the facial profile of each subject.

INDEPENDENT VARIABLE

The independent variable was the race of the study subjects.

MAIN OUTCOME VARIABLE

The main outcome was the layperson's preferred lateral facial profile for each subject.

COVARIATES

The covariates included age, race, sex, education level, income, of the laypersons.

ANALYSES

A proportion test was used to decide which profile was preferred. Logistic regression analyses were conducted to assess the association between the preference and respondent demographics. P < .05 was considered significant.

RESULTS

A total of 264 surveys were distributed, and 250 complete surveys were utilized (response rate = 95%). Respondents were majority male (51.2%), aged 35-44 (37.2%), college-educated (57.2%), earning between $20,000 and $50,000 annually (44%), and identified as Caucasian (77.2%). For the female subjects, the respondents preferred +4 and + 6 mm anterior to goal anterior line limit with 54.2% for the Caucasian and 65.9% for the AA subjects (difference = 11.7%; 95% CI:2.7 to 20.7%; P = .008). For the males, 47.4% of the respondents chose 0 mm and +2 mm for the AA subject, while only 24.9% preferred +2 mm for the Caucasian male (difference = 22.5%; 95% CI: 13.8 to 31.1%; P < .0001). Respondent demographics were not found to influence selection.

CONCLUSION AND RELEVANCE

The preferred facial profile as judged by laypersons differs between Caucasian and AA subjects when defined through Andrews' analysis.

Healthcare use and direct medical costs in a cleft lip and palate population: an analysis of observed and protocolized care and costs

This study was performed to describe observed healthcare utilization and medical costs for patients with a cleft, compare these costs to the expected costs based on the treatment protocol, and explore the additional costs of implementing the International Consortium for Health Outcomes Measurement (ICHOM) Standard Set for Cleft Lip and Palate (CL/P). Forty patients with unilateral CL/P between 0 and 24 years of age, treated between 2012 and 2019 at Erasmus University Medical Center, were included. Healthcare services (consultations, diagnostic and surgical procedures) were counted and costs were calculated. Expected costs based on the treatment protocol were calculated by multiplying healthcare products by the product prices. Correspondingly, the additional expected costs after implementing the ICHOM Standard Set (protocol + ICHOM) were calculated. Observed costs were compared with protocol costs, and the additional expected protocol + ICHOM costs were described. The total mean costs were highest in the first year after birth (€5596), mainly due to surgeries. The mean observed total costs (€40,859) for the complete treatment (0-24 years) were 1.6 times the expected protocol costs (€25,198) due to optional, non-protocolized procedures. Hospital admissions including surgery were the main cost drivers, accounting for 42% of observed costs and 70% of expected protocol costs. Implementing the ICHOM Standard Set increased protocol-based costs by 7%.

Comparing definitive unilateral cleft rhinoplasty with and without diced-cartilage alar-base augmentation: A retrospective cohort study

This retrospective cohort study aimed to compare the long-term aesthetic outcomes and satisfaction of patients who underwent two techniques of definitive unilateral cleft rhinoplasty. The two cohorts, comprising patients with mature unilateral cleft deformity, were managed with definitive rhinoplasty, either with or without diced-cartilage alar-base and peri-alar augmentation (ABPA). Thirty patients were included in each cohort. Anthropometric measurements, complications, patient satisfaction scores, and third-party surgeon assessment scores were reviewed. In both cohorts, anthropometric parameters improved. Rhinoplasty with ABPA was the superior cohort in terms of columellar length (10.3 ± 1.0 in the cohort with ABPA, compared with 7.9 ± 0.6 in the cohort without ABPA; p < 0.001), alar-base angle (0.2 ± 0.2, compared with 4.3 ± 0.3; p < 0.001), and columellar deviation (2.5 ± 1.4, compared with 10.3 ± 2.1; p < 0.001). This cohort also had more symmetry in nostril height and nostril width (p < 0.001), a lower recurrence rate (one case compared with 22 cases; p < 0.001), a higher patient satisfaction score (p = 0.002), and a higher surgeon assessment score (p < 0.001, Cronbach's alpha = 0.706, Kendall's coefficient of concordance = 0.787). Within the limitations of this study, it appears that the described technique for augmenting the alar-base and peri-alar maxillary area is manageable, and yields consistent long-term results.

Validation of Andrews Analysis in the Virtual Environment

BACKGROUND

Andrews analysis is a tool to establish the aesthetic anteroposterior position of the maxilla. Andrews analysis has not been evaluated through computer-aided surgical simulation (CASS).

PURPOSE

The purpose of this study was to evaluate the accuracy of Andrews profile analysis when performed in the virtual environment.

STUDY DESIGN, SETTING, SAMPLE

A retrospective cohort study was implemented with consecutive patients undergoing orthognathic surgery between February 2020 and February 2022 at the University of Alabama, Birmingham. Traditional Andrews analysis with lateral smiling photographs were taken during the presurgical appointment in adjusted natural head position (aNHP). The standard cone-beam CT obtained for CASS and archived on the KLS Martin (Jacksonville, Florida) database was accessed for retrospective measurement. Lateral facial photographs in aNHP were imported into the virtual environment and the three dimensional (3D) composite model was then oriented into aNHP. The software engineer, blinded to the traditional measurements, then performed the Andrews analysis in the virtual environment by placing a vertical glabella line on the 3D composite model in aNHP. The linear horizontal distance of the maxillary central incisor perpendicular to the vertical glabella line was recorded.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

Method of Andrews analysis measurement (traditional photographic evaluation vs CASS) MAIN OUTCOME VARIABLE: Linear Andrews analysis measurement.

COVARIATES

Additional covariates evaluated were sex, age at surgery, and dentofacial deformity diagnosis.

ANALYSES

Descriptive statistics were computed to compare photographic analysis versus CASS analysis. A P value of <.05 was considered statistically significant.

RESULTS

The average age was 25.7 years old and 54% of patients were female. For the photographic analysis, the mean incisor-goal anterior limit line distance was -0.44 ± 7.12 mm (95% CI, -1.13 to 0.37 mm; P = .46). For the virtual analysis, the mean incisor-goal anterior limit line distance was 0.13 ± 7.21 (95% CI, -0.004 to 0.30; P = .89). The Pearson correlation coefficients between the photograph and 3D analysis were very strong (0.93). The root mean square deviation between the photographic and 3D analysis cohorts was 2.7 mm.

CONCLUSION AND RELEVANCE

Given the high correlation coefficients between all demographics, CASS can be utilized for Andrews analysis to determine ideal anteroposterior maxillary position to streamline data collection and the planning process.

Sociodemographic Disparities in Access to Cleft Rhinoplasty

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Aesthetic and psychosocial impact of dentofacial appearance after primary rhinoplasty for cleft lip and palate

The primary aim of this study was to demonstrate whether primary rhinoplasty shows aesthetic and psychosocial advantages for children with a complete unilateral cleft lip and palate. The second aim was to determine the satisfaction levels concerning the dentofacial appearance. Group A corresponded to patients from a center specialised in primary cheilo-rhinoplasty with 20 years' experience and Group B to patients who did not benefit from primary rhinoplasty. Children and their parents filled in a custom-designed satisfaction questionnaire on dentofacial appearance and its psychosocial impact. The variables studied were the main criterion (the nose) and secondary criteria (the upper lip, the smile, the profile and the face as a whole). 56 families consented to be involved in the study. The children did not rate statistically differently their social relationships if they had primary rhinoplasty or not. Parents however expressed very different views. They considered the nasal appearance of the children who had primary rhinoplasty as statistically more attractive and evaluated their psychosocial experience as significantly better. For the other parts of the face, in both groups, satisfaction levels of dentofacial appearance and psychosocial comfort were good (scores above 80/100). Yet, 44% of the families would go for further interventions, especially concerning the nose (13% of whom were in Group A and 42% in Group B). Within the limitations of this study, primary rhinoplasty seems to improve the patient's well-being and social life and, therefore, should be considered whenever appropriate.