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Aesthetic Outcomes Of Patients With Unilateral Cleft Lip And Palate Following Nasoalveolar Molding Therapy In An Outreach Setting
Serena Kassam, DMD1, Elie P. Ramly, MD2, Emma T. Azurin, BS3, Nicholas Toomey, BS3, Allyson Alfonso, BS2, Rami Kantar, MD2, Adam Johnson, MD,PhD4, Barry Grayson, DMD2, Usama Hamdan, MD, FACS1.
1Global Smile Foundation, Norwood, MA, USA, 2New York University Langone Medical Center, New York, NY, USA, 3Tuft University School of Medicine, Boston, MA, USA, 4Arkansas Children's Hospital, Little Rock, AR, USA.

PURPOSE:
Global Smile Foundation (GSF) is a not for profit foundation whose founders and volunteers have been providing cleft care to underserved communities around the world for 32 years. In 2012, GSF incorporated nasoalveolar molding (NAM) into its treatment model in Guayaquil, Ecuador. We present an evaluation of nasolabial aesthetic outcomes and scarring in patients treated with NAM prior to primary cleft lip repair versus patients who were not in similar outreach settings. Methods: The Cleft Aesthetic Rating Scale (CARS) used frontal photographs taken at least 1-year post primary cleft lip repair to assess the nose: tip, nostrils (symmetry, size, flaring) and upper lip (vermillion symmetry and continuity and length of the philtrum), ranging from 1 (very good) to 5 (very poor). Photos were standardized to reveal only the nasolabial area and excluded any time points after any additional surgical revision to the nasolabial area. Each NAM time point was matched to a control time point based on their age at primary cleft lip repair (maximum of 3 months) and their time post-op from primary cleft lift repair (maximum of 6 months). All included NAM and control patients had Unilateral Cleft Lip and Palate, and were from Ecuador. Patients with congenital syndromes other than cleft lip and palate (CLCP) affecting facial appearance were excluded. Twelve independent raters including three surgeons, three orthodontist, three pediatric dentists and three medical students rated the photographs. As a modification to CARS, raters were also asked to assess scar quality utilizing a previously developed scar subtype scoring system. Results: Of the 189 patients treated with NAM in Guayaquil since 2012, 96 patients had long term follow up, and 27 patients with 34 photographic time points qualified for inclusion, 15 (55.56%) male, 12 (44.44%) female. The average time post primary cleft lip repair was 2.19 1.65 months (range: 0.98-7.37 months). Matched to the patients who had received NAM were 31 control patients with 34 photographic time points, 26 (83.87%) male, 5 (16.13%) female with an average time post primary cleft lip repair of 2.19 1.63 months (range: 0.93-6.98 months) The average rating of Nasal aesthetics was significantly lower in patients who had received NAM compared to nasal controls (2.60 1.05 vs 2.82 1.12 (p <0.01).The average rating for lip aesthetics showed similar differences between patients who had received NAM and matched controls (2.23 0.96 vs 2.56 1.07, (p < 0.01). Similarly, the average rating of scar quality was significantly lower among patients who had received NAM (1.82 0.93 vs 2.03 0.89), (p < 0.01). Conclusion: Using the CARS and a modified scar rating scale, patients who had received NAM were found to have superior nose and lip aesthetic outcomes in comparison to non-NAM controls. This suggests that NAM is not only feasible in an outreach setting, but it is also associated with improved lip, nose and scar outcomes.


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