Nasal asymmetry in unilateral cleft lip and palate
Introduction
Cleft lip and palate (CLP) is the second most common congenital abnormality in the UK, affecting approximately 1 in 650 live births.1 It can occur unilaterally or bilaterally, with unilateral CLP (UCLP) occurring significantly more frequently.2 UCLP is associated with significant physical abnormalities leading to impairments of speech, hearing, and dental and facial development. It is also accompanied by aesthetic anomalies which compound the stigma of the condition and negatively impact upon the psychosocial development of affected individuals.3
Several factors are imperative in determining aesthetic outcome in UCLP. These include asymmetry of the nose and upper lip, scar quality and patient perception of facial attractiveness.4 The proportional relationship between facial symmetry and perception of attractiveness is widely accepted.5, 6 This is particularly important with regards to the nose, as its location on the face makes it very difficult to mask.7 Nasal asymmetry shows minimal improvement following primary UCLP repair, and for many patients is considered a persistent ‘reminder of the cleft deformity’.8
There remains debate over how to best correct the nasal deformity in cleft patients. There is no current gold standard for the surgical management of UCLP in the UK; technique is determined by the personal preference of the surgeon.9 Closure of the lip is typically performed at three months of age, by one of several techniques, and concurrent primary nasal correction may or may not be performed.10, 11 The principal goal of nasal correction is to produce a more symmetrical nasal form and the intention of early intervention is to reduce the stigma that is often experienced during childhood.12 It may also provide a less complicated secondary revision, which is required by many patients in late adolescence.13 Some surgeons may choose to delay surgical intervention until the nose is fully developed, limiting the potential morbidity of repeated procedures. The decision on whether to perform primary nasal correction is not dependent upon degree of asymmetry at three months. Limited research has quantified the impact of early nasal correction on asymmetry during childhood.
Cussons et al. used a panel of assessors to subjectively rank nasal asymmetry and aesthetics from basal (worm's eye) photographs of 10-year-old UCLP patients with and without primary nasal correction and controls (n = 25, 22 and 15, respectively).14 A significant difference was found between all three groups, with the UCLP group who underwent nasal correction demonstrating the best overall symmetry. Although subjective methods remain invaluable tools for assessing facial attractiveness,15 they pose inherent problems when considering routine follow-up. They also introduce observer bias through inability to blind assessors between the control and UCLP groups. For many years the need for more objective methods to assess surgical outcome has been acknowledged.16, 17
Gosla-Reddy et al. objectively compared ratios of five parameters from facial photographs between the cleft and non-cleft side of three-year-old UCLP patients with (n = 76) and without (n = 82) primary nasal correction.18 In four of the five parameters, better nasal symmetry was found in patients with nasal correction compared to those without. However, this study did not look at children past four years of age and therefore does not consider the changes in symmetry which may occur during nasal development.
Previous research has demonstrated that significant variation in nasal symmetry exists within the general population.19 Several studies have objectively compared nasal asymmetry between 10-year-old UCLP patients and controls, and have shown asymmetry to be significantly greater in UCLP patients both with and without primary nasal correction than in controls.20, 21, 22 These findings demonstrate that adequate management of the cleft-nose deformity has not yet been achieved and emphasise the need for further research in this area. The findings also reinforce the importance of including a control group when assessing nasal asymmetry in UCLP.
Previous studies which have objectively measured nasal asymmetry were largely restricted to complicated and/or time consuming methods. These include manual tracing of facial photographs and cephalometric analysis.20, 21 Computer-aided techniques have been shown to have a high degree of reproducibility, suggesting they may be useful for routine evaluation.23 The Symnose program is a simple method of objectively measuring percentage nasal asymmetry using computer-aided tracing of facial photographs. This is the first study to use the Symnose program to measure nasal symmetry and therefore it is important to assess if the measurements are consistent.
In summary, nasal asymmetry negatively impacts the quality of life of UCLP patients. This is the first retrospective study to use this novel method to objectively compare nasal asymmetry in 10-year-old UCLP patients with and without nasal correction and controls, in order to consider the value of nasal correction at the time of primary cleft repair. The study used Symnose, a computer-assisted technique, to objectively measure percentage nasal asymmetry and consider the potential value of the program as a routine research tool.
Section snippets
Objectives
- 1.
Compare nasal asymmetry between three groups of 10-year-olds: UCLP patients with nasal correction; UCLP patients without nasal correction; and non-UCLP controls
- 2.
Establish the repeatability of Symnose measurements
Setting
A retrospective study of patients who underwent primary cleft lip repair by one of two surgeons at the South West Cleft Unit, Frenchay Hospital, Bristol.
Inclusion criteria
All non-syndromic UCLP patients whose primary cleft lip repair (classical Millard with nasal correction or modified Millard without correction) was carried out by one of the participating surgeons and who had reached their 10 year follow-up by January 2012 were screened for inclusion.
The ‘classical’ Millard technique involved a downward
Method
Nasal symmetry was objectively measured using the Symnose computer program. Facial photographs were collected in two views: frontal and basal (worm's eye). The images of each subject were sized, cropped and traced in accordance with guidance from the program's developers.27 Tracing was undertaken using a digitizing pad (Wacom Intuous 3 PTZ930) and an Apple Macintosh with a 27” screen.
Percentage nasal asymmetry was measured for three parameters: front perimeter (FP), base perimeter (BP) and
Results
The participants' demographics are presented in Table 1. There were significantly more males in the control group (93%) and the CM group (93%) compared to the MM group (64%). With regards to the side of the face on which the cleft occurred, there were significantly more patients with a left-sided UCLP in the MM group compared to the CM group (71% v. 57%). All participants were Caucasian, except for two whom were both in the MM group. Of those who were not Caucasian, one was South East Asian and
Discussion
This is the first study to use this simple computer-aided method to compare nasal asymmetry between 10-year-old UCLP patients who have undergone nasal correction, UCLP patients without nasal correction, and non-UCLP controls. In agreement with previous literature using alternative objective measures of asymmetry,20, 21, 22 this study found that percentage nasal asymmetry was significantly greater in UCLP patients than in controls for base perimeter, nostrils and total asymmetry measurements.
Conclusions
Nasal correction at the time of primary lip repair produces a more symmetrical nasal form in UCLP patients at 10 years of age. However, the asymmetry remains significantly greater than in age-matched controls and therefore improvements in surgical management are still required. Further research on a much larger sample and comparing nasal asymmetry following different primary surgical techniques for lip repair may be of value.
Although still in the early stages of development, the Symnose program
Funding
Financial support was gratefully received from the College of Medical and Dental Sciences, University of Birmingham, as part of the intercalated degree program.
Conflict of interest statement
Mr Nigel Mercer is one of the participating surgeons in the study, however, he played no role in data collection or interpretation of data. Dr Lesley Roberts and Miss Alexandra Freeman declare no conflicts of interest.
Acknowledgements
The authors wish to acknowledge Mr Ron Pigott for promptly providing access to the images of his patients, Dr Sayeed Haque for his assistance in determining and performing the appropriate methods of statistical analysis and Naomi Tomlinson for critical comment on the final manuscript. Additional acknowledgement is extended to all of the staff and patients at the South West Cleft Unit for their persistent kindness, involvement and understanding whilst this research was carried out.
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Cited by (22)
Nasal symmetry after different techniques of primary lip repair for unilateral complete cleft lip with or without cleft of the alveolus and palate: A systematic review
2022, Journal of Cranio-Maxillofacial SurgeryFacial and midfacial symmetry in cleft patients: Comparison to non-cleft children and influence of the primary treatment concept
2019, Journal of Cranio-Maxillofacial SurgeryCitation Excerpt :A comparison of controls, MS+ and MS− groups (ANOVA) showed that the differences between controls and both cleft groups were statistically highly significant for all measured symmetry values (all p < 0.001). In the recent literature, several researchers have underlined the importance of an objective assessment of symmetry and aesthetics in patients with cleft lip, alveolus and palate (Freeman et al., 2013; Gkantidis et al., 2013; Ranganathan et al., 2015; Schwenzer-Zimmerer et al., 2008; Sharma et al., 2012; Sitzman et al., 2014). Three-dimensional techniques provide the opportunity to evaluate these aspects without loss of information.
Evaluation of a portable low-budget three-dimensional stereophotogrammetry system for nasal analysis
2018, Journal of Cranio-Maxillofacial SurgeryA novel computer system for the evaluation of nasolabial morphology, symmetry and aesthetics after cleft lip and palate treatment. Part 2: Comparative anthropometric analysis of patients with repaired unilateral complete cleft lip and palate and healthy individuals
2017, Journal of Cranio-Maxillofacial SurgeryCitation Excerpt :According to various authors, between 15% and 80% of cleft patients will require secondary correction of cleft nose deformity at some point in their lifetime (Matsuo and Hirose, 1990; Salyer, 1992; Matukas and Louis, 1993; Mazzola, 1996; Anastassov et al., 1998; Kane et al., 2000; Salyer et al., 2003). Similar to cleft lip and palate treatment protocols, no consensus has been reached regarding a standardized method for the objective assessment of nasolabial esthetics in patients after surgical management of CLP (Tobiasen et al., 1991; Tobiasen and Hiebert, 1994; Ritter et al., 2002; Al-Omari et al., 2003, 2005; Schwenzer-Zimmerer et al., 2008; Paiva and Andre, 2012; Sharma et al., 2012; Freeman et al., 2013; Gkantidis et al., 2013; Sitzman et al., 2014; Ranganathan et al., 2015). Recently, we have developed a computer system, referred to as “Analyse It Doc” (A.I.D.), which is dedicated for a multicentre qualitative and quantitative evaluation of facial aesthetic outcomes after cleft lip and palate treatment.
A novel computer system for the evaluation of nasolabial morphology, symmetry and aesthetics after cleft lip and palate treatment. Part 1: General concept and validation
2017, Journal of Cranio-Maxillofacial SurgeryCitation Excerpt :The lack of an internationally recognized method constitutes an obstacle for reliable comparative analyses of various treatment strategies used in primary cleft defects and residual deformities, such as nasal asymmetry. The need to develop a widely accepted method for the objective assessment of nasolabial aesthetics in patients with CLP has been emphasized for many years (Tobiasen et al., 1991; Tobiasen and Hiebert, 1994; Ritter et al., 2002; Al-Omari et al., 2003, 2005; Schwenzer-Zimmerer et al., 2008; Paiva and Andre, 2012; Sharma et al., 2012; Freeman et al., 2013; Gkantidis et al., 2013; Sitzman et al., 2014; Ranganathan et al., 2015). Therefore, we decided to undertake an attempt to develop a universal system, referred to as ‘Analyse It Doc’ (A.I.D.), which is suitable for the evaluation of nasolabial aesthetics, morphology and symmetry.
The use and reliability of SymNose for quantitative measurement of the nose and lip in unilateral cleft lip and palate patients
2016, Journal of Cranio-Maxillofacial SurgeryCitation Excerpt :In future studies, groups of different ethnic origin should be included to examine whether they need different norm scores, so SymNose can be used for multiple groups with differences in demographics. The accuracy and reliability of SymNose has already been studied by Pigott and Pigott (2010), McKearney et al. (2013), Freeman et al. (2013) and Russell et al. (2014). However, significant variations in the accuracy and reliability of their results were found.