A Simple, Prognostic Severity Scale for Unilateral Cleft Lip
Caroline A. Yao, MD, MS1, Jordan Swanson, MD1, Thomas Imahiyerobo, MD2, Allyn Auslander, MPH1, Diego F. De Cardenas, DDS, PhD3, Melinda Costa, MD1, Jane C. Figueiredo, PhD4, Richard Vanderburg, RN, BSN3, William P. Magee, III, MD, DDS1.
1Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA, 2Division of Plastic Surgery, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, NY, USA, 3Operation Smile International, Virginia Beach, VA, USA, 4Institute of Global Health, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
PURPOSE: There is no universally accepted severity scale for unilateral cleft lip that objectively quantifies the spectrum of disease, making it difficult to evaluate post-operative outcomes in the context of pre-operative severity.
METHODS: Anthropometric measurements and photographs were prospectively collected from unilateral cleft lip patients from Morocco, Bolivia, Vietnam and Madagascar during medical missions. The following were obtained pre- and post-operatively: columellar angle, cleft width, nostril width, vertical lip height and horizontal vermillion length. The number of primary cleft lip repairs done in his/her lifetime was recorded for each surgeon.
Our previous study showed vertical lip height symmetry (cupid’s bow to subalare) best predicts how surgeons and lay-persons rank surgical outcomes. Therefore, we defined "unacceptable" post-operative outcome/symmetry as cleft-side/non-cleft-side vertical lip height discrepancy >3mm, as studies show that human eyes detect down to 3mm of asymmetry in the nasolabial region.
RESULTS: Of the 149 patients included, 22 had unacceptable outcomes. Multivariate and stepwise models showed pre-operative cleft width ratio ("CWR", pre-operative cleft width divided by commissure width) was the most significant predictor for unacceptable outcomes, controlling for surgeon experience. CWR was normally distributed. Two severity categories were created: Grade-1: CWR<5, Grade-2: CWR>0.5. Grade-2 patients had a higher likelihood of unacceptable outcomes (OR 2.9, 95%CI[1.1,7.7], p=0.029). The risk of having unacceptable outcomes was higher for Grade-2 (27%) versus Grade-1 (11%). The probability of having acceptable outcomes for Grade-2 individuals was lower versus Grade-1 (PPV=73% versus 89%).
CONCLUSION: Our scale utilizes a simple, intuitive ratio to classify patients into clinically prognostic categories.
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