- Email: [email protected]
Secondary cleft nose rhinoplasty: Subjective and objective outcome evaluation
Accepted Manuscript Secondary cleft nose rhinoplasty: subjective and objective outcome evaluation Volker Gassling, PhD, MD, DMD, Bernd Koos, Falk Birkenfeld, Jörg Wiltfang, Corinna E. Zimmermann PII:
S1010-5182(15)00290-5
DOI:
10.1016/j.jcms.2015.08.012
Reference:
YJCMS 2174
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 25 June 2015 Revised Date:
8 August 2015
Accepted Date: 14 August 2015
Please cite this article as: Gassling V, Koos B, Birkenfeld F, Wiltfang J, Zimmermann CE, Secondary cleft nose rhinoplasty: subjective and objective outcome evaluation, Journal of Cranio-Maxillofacial Surgery (2015), doi: 10.1016/j.jcms.2015.08.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Secondary cleft nose rhinoplasty: subjective and objective
RI PT
outcome evaluation
SC
Volker Gassling1, Bernd Koos2, Falk Birkenfeld1, Jörg Wiltfang1, Corinna E Zimmermann1
Author affiliations:
Department of Oral and Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
2
M AN U
1
Department of Orthodontics, University Hospital of Rostock, Rostock, Germany
Correspondence to:
TE D
Volker Gassling, PhD, MD, DMD
Department of Oral and Maxillofacial Surgery, University Hospital Schleswig-Holstein,
EP
Campus Kiel, Arnold-Heller-Straße 3, Haus 26, 24105 Kiel, Germany Tel.: +49 431 597 2791
AC C
Fax: +49 431 597 4084
Email: [email protected]
Role of the funding source: The present study was financed internally by the author’s institution. The paper has been presented on the 132th Congress of the German Society for Surgery Munich, 2015
ACCEPTED MANUSCRIPT
Secondary cleft nose rhinoplasty: subjective and objective outcome evaluation Abstract
RI PT
Introduction: Secondary rhinoplasty in cleft lip and palate (CLP) is commonly the last step in a set of surgical procedures that result in a variable but typically intensive change in facial appearance. However, there is evidence that the sentiment about the aesthetic and functional
SC
outcomes between patients and surgeons is different. The present study aimed to evaluate the subjective and objective outcomes of secondary rhinoplasty in patients with CLP.
M AN U
Material and methods: Secondary rhinoplasty was performed in 10 patients with repaired unilateral CLP via a standardized open approach. For the subjective evaluation, the patients completed the rhinoplasty outcome evaluation (ROE) questionnaire. Pre- and postoperative photographic documentation served as the basis for the objective evaluation, which included
TE D
the following: (1) assessment by five specialists at craniofacial malformation consultation appointments and by three doctors in continuing education using the Asher-McDade aesthetic
nasolabial angle.
EP
index (AMAI) rating, and (2) metric facial analysis to determine the nasofrontal angle and the
Results: Patient satisfaction was high, based on the evaluation of the ROE questionnaire. The
AC C
analysis of the AMAI rating questionnaire showed no significant differences between the positive ratings of the ‘experienced’ and ‘inexperienced’ doctors. In contrast, there was an obvious and significant difference between the ‘preoperative’ and ‘postoperative’ time points for questions 1 to 3. The metric analysis showed statistically significant improvements of the nasolabial angle and the nasofrontal angle. The subjective and objective outcome evaluations were descriptively congruent. Conclusions: The data suggest that standardized secondary rhinoplasty in CLP leads to both a subjective and a statistically significant objective improvement of facial appearance and thus 1
ACCEPTED MANUSCRIPT may support the psychosocial rehabilitation of affected patients. Furthermore, our results showed that the subjective and objective outcome evaluations of secondary rhinoplasty were largely compatible.
AC C
EP
TE D
M AN U
SC
RI PT
Keywords: cleft lip and palate; cleft nose; outcome; secondary rhinoplasty
2
ACCEPTED MANUSCRIPT Introduction Cleft lip and palate (CLP) represents the most common malformation of the midfacial region worldwide (Dixon et al., 2011). The treatment concept for CLP requires multidisciplinary care and results in a more or less intensive disturbance of the facial appearance, which may
RI PT
lead to particular psychosocial stress in affected individuals. Indeed, psychosocial stress is known as one of the most important risks of physical and mental health hazards in the 21st century (Gee et al., 2004). The psychosocial functioning of children and young adults with
SC
orofacial clefts may be affected, resulting in behavioural problems, depression, and unhappiness with their facial appearance and speech (Hunt et al., 2006). More precisely,
M AN U
dissatisfaction with facial appearance can be localized to the upper lip, the nose and nasal breathing. In a recent comparison of visual face assessments between patients with CLP and a control group, it was found that for patients with CLP there were more initial fixations on the mouth and longer fixations on the mouth and nose regions; in addition, CLP faces were rated
TE D
more negatively overall (Meyer-Marcotty et al., 2010). It is noteworthy, however, that further investigation into psychosocial adjustment difficulties in adolescents with orofacial clefts revealed greater self-satisfaction with several aspects of facial appearance (such as teeth, eyes,
EP
ears, hair, and chin) compared with adolescents without facial disfigurement. However, there was dissatisfaction with lip and nose appearance compared with the control group (Berger et
AC C
al., 2009). These findings illustrate the importance of facial aesthetics (that is the appearance of the nose and the lips) for the psychosocial status of patients with CLP. The nose is located in the centre of the face and plays an essential role in the aesthetic assessment. Nasal deformities, and in particular a cleft nose deformity, not only lead to functional disturbances but also result in psychosocial adjustment difficulties. The unilateral cleft nose is mainly characterized by asymmetry of the nasal tip, deviation of the nasal dorsum, malposition of the lower lateral cartilage and hypoplasia on the cleft side, and septal deviation away from the cleft side. The correction of these complex anomalies by secondary 3
ACCEPTED MANUSCRIPT rhinoplasty is one of the most challenging procedures in facial plastic surgery, and the surgeon has to achieve the best possible aesthetic and functional result for the patient. The disruption of the upper lip, the alveolar process of the maxilla, and the hard and soft palates cause deformation of the bony and cartilaginous structures during the period of growth.
RI PT
Because the soft tissue follows the underlying structures, the newly formed nasal structures must maintain tension within the tissue. Thus, the applied implants or transplants need to fulfil specific requirements. For example, columellar struts must offer high axial and
SC
transversal stability against the soft tissue tension towards the columella and the cleft side nasal base (Byrd et al., 2007). Furthermore, no resorption or rejection of the transplants must
M AN U
occur. The application of cartilaginous transplants from the rib is generally accepted in cleft nose surgery (Chummun et al., 2013, Hafezi et al., 2013, Cao et al., 2014). Unfortunately, up to this point in time, the majority of publications concerning this issue describe the surgeon’s point of view only. However, the surgeon’s assessment of facial
TE D
aesthetics after cleft surgery seems to be of minor relevance and thus emphasizes the role of the social support of affected individuals (Cochrane et al., 1999, Springer et al., 2008 and 2009, Gkantidis et al., 2013, Reddy et al., 2013). Thus, the primary objective of secondary
EP
rhinoplasty should be the highest patient satisfaction. Therefore, the present study aimed to evaluate the objective and subjective assessments of treatment outcomes of standardized
AC C
secondary cleft rhinoplasty. Based on the above-mentioned findings, we hypothesize that: 1. Metric analysis of pre- and postoperative photographs will reveal improvements of the characteristic facial angles; 2. Patients with CLP will show a high degree of satisfaction with secondary rhinoplasty; and 3. The
objective
treatment
outcome
of
secondary
rhinoplasty
assessed
by
interdisciplinary professionals will show an improvement of nasolabial appearance. 4
ACCEPTED MANUSCRIPT Material and methods Study participants Ten patients with a repaired complete, unilateral non-syndromic CLP (median age 21 years, interquartile range (IQR) 2.75) were recruited from craniofacial malformation consultation
RI PT
appointments with the Department of Cranio-Maxillofacial Surgery at the University Hospital of Schleswig-Holstein, Kiel Campus, Kiel, Germany. The age range was 17–24 years, and six men and four women were included (see Table 1). Patients were informed about the course of
SC
the procedure and provided their written consent according to the Helsinki convention before examination began. The study design was approved by the local ethics board (AZ: D 500/14).
M AN U
Preoperative management
Preoperative planning included a careful medical history with a particular focus on preliminary surgery, accidents, allergy, and nasal breathing disabilities. The clinical examination determined the extent of septal deviation and turbinate bone hyperplasia. During
TE D
the exploration of the outer nose, a particular focus was placed on the nasal projection, the tip of the nose, discrepancies, the skin quality, and the position of the alar bases. The pre- and postoperative photographic documentation was used as the basis for the objective description
EP
of changes in the characteristic facial angles and for the objective assessment of nasolabial appearance by experienced colleagues of the interdisciplinary consultation team and
AC C
inexperienced colleagues using the Asher-McDade aesthetic index (AMAI) rating. For each patient, four photographs were taken (full face frontal view, submental oblique view, right profile view, and left profile view) (Fig. 1). All pictures were taken with a Nikon D200 fullframe imaging sensor (Nikon, Chiyoda, Tokyo, Japan) and a Nikon portrait lens with a focal distance of 60 mm and a lens aperture f20 with manual focus. The exposure time with external lighting was 1/200 second. Each photograph was modified for further assessments (Fig. 2 and 3). Due to the complexity of the intranasal pathology in cases of cleft nose
5
ACCEPTED MANUSCRIPT deformity, a computed tomography (CT) scan in axial and coronal stratification was performed for each patient. Rhinoplasty Secondary rhinoplasty was performed via an open, inverted V approach; osteotomies,
RI PT
septoplasty, domal repositioning, and columellar strut formation from rib cartilage were performed routinely. The operation procedure was divided into two steps. First, ventilation problems were corrected by nasal septum correction and turbinoplasty. Second, correction of
SC
the external nose was achieved by osteotomy of the nasal bone, positioning of the columellar strut, and repositioning of the lower lateral cartilages and nasal tip. At the end of the
M AN U
operation, the result was stabilized using septal splints, nasal tamponades, and a cast. Postoperatively, adequate pain medication (eg, ibuprofen 600 mg on demand), antibiotic prophylaxis (eg, Unacid PD tablets, 3 times a day for 1 week), and cooling (eg, Hilotherm, Argenbühl-Eisenharz, Germany) were considered. The nasal tamponades were typically
TE D
removed 2 days after the operation, the nasal cast was removed after 1 week, and the septum splints were removed after 2 weeks. All procedures were performed by the first author only. Metric facial analysis
EP
Two sets of four photographs (full face frontal view, submental oblique view, right profile view, and left profile view) (Fig. 1) were taken pre- and postoperatively for each patient under
AC C
standardized conditions. The pre- and postoperative photographic documentation served as the basis for the metric analysis, whereby the nasofrontal and nasolabial angles (Graber et al., 1995) were determined (Fig. 2). All pictures for the measurement of the nasolabial and nasofrontal angles were prepared with Adobe Photoshop CS 6 (Adobe Systems, San José, CA USA) and analysed with the integrated angle measurement function in profile view. Rhinoplasty outcome evaluation instrument (ROE) The objective assessment of the postoperative result was performed with the ROE instrument (Alsarraf, 2000), whereby six questions concerning nasal aesthetics and function were asked. 6
ACCEPTED MANUSCRIPT Each question was scored from 0 to 4, with 0 indicating the best score and 4 the worst (see Table 2). The total score was divided by 24 and multiplied by 100. A score above 85 was considered an excellent score and reflected high patient satisfaction. Asher-McDade aesthetic index (AMAI) rating
RI PT
The objective evaluation of the rhinoplasty was performed by the assessment of five specialists at craniofacial malformation consultation appointments and by three doctors with DDS degrees in a continuing postgraduate program; frontal and profile views of the
SC
nasolabial area (Fig. 3) and the AMAI rating (Table 3, Fig. 3) were used (Asher-McDade et al., 1991 and 1992). The nasolabial rating consists of a 5-point ordinal scale assessing the
M AN U
nasal form, the symmetry of the nose, the shape of the vermillion border, and the nasal profile including the upper lip. A score of 1 indicates a ‘very good appearance’; a score of 2 a ‘good appearance’; a score of 3 a ‘fair appearance’; a score of 4 a ‘poor appearance’; and a score 5 a ‘very poor appearance’. The answers for each question (1–4) and patient were used to
TE D
calculate an individual score, which was analysed statistically. All pictures for the assessment were prepared with Adobe Photoshop CS 6 (Adobe Systems, San José, CA USA). In the first step, the frontal and profile view pictures were released according to Asher-McDade et al.
EP
(1991 and 1992). All pictures were scaled to 300 dpi and included in a Microsoft PowerPoint Presentation (Microsoft Power Point: Mac 2011, Microsoft, Redmond, WA, USA) with a
AC C
mapping value of 12 cm height. The presentation and sequence of the pictures were carried out exactly according to the standards of Asher-McDade et al. (1991 and 1992). Data transformation and statistical analysis Metric facial analysis The measured angles were analysed with the statistical software JMP, Version 12 (SAS Institute Inc., Cary, NC, USA). The calculation and graphical presentation were presented as box plots with medians, percentiles and IQR. The statistical correlation between the
7
ACCEPTED MANUSCRIPT preoperative and postoperative time points were analysed using the non-parametric Wilcoxon rank sum test with a level of significance at 0.05. ROE questionnaire The measured scores of the patients were analysed and compared descriptively with the
RI PT
statistical software JMP, Version 12 (SAS Institute Inc., Cary, USA). The analysis and graphical presentation were depicted as box plots with medians, percentiles and IQRs and descriptive comparisons.
SC
AMAI rating questionnaire
The measured scores of the raters were analysed and compared with the statistical software
M AN U
JMP, Version 12 (SAS Institute Inc.). The analysis and graphical presentation were depicted as box plots with medians, percentiles and IQRs. The statistical correlations between the two investigation groups, ‘experienced’ and ‘inexperienced’, and the two time points, ‘preoperative’ and ‘postoperative’, were analysed using the non-parametric Wilcoxon rank
Results
Nasofrontal angle
EP
Metric facial analysis
TE D
sum test with a level of significance at 0.05.
The metric analysis of the pre- and postoperative photographs showed a significant
AC C
improvement of the characteristic facial angles. The nasofrontal angle changed from a median of 143.5° (IQR 16.5) to 135° (IQR 12), and this alteration was statistically significant (p = 0.0309) (Fig. 4).
Nasolabial angle The metric analysis of the pre- and postoperative photographs showed a significant improvement of the characteristic facial angles. The nasolabial angle changed from a median of 76° (IQR 24.5) to 99° (IQR 15), and this alteration was statistically significant (p = 0.0025) (Fig. 4). 8
ACCEPTED MANUSCRIPT ROE questionnaire The return rate of the ROE questionnaires was 90%, and the median score was 87.5% (IQR 17). Overall, the patient satisfaction could be described as high, and the satisfaction of women was higher (median 87.5%, IQR 17) than that among men (median 83.25%, IQR 19) (Fig. 5).
RI PT
AMAI rating questionnaire Comparison of research teams
In the first work stage, the statistical comparison of the ‘experienced’ and ‘inexperienced’
significant differences (Fig. 6).
M AN U
Comparison of preoperative and postoperative scores
SC
research teams was carried out. The scores of the research teams showed no statistically
In the second work stage, statistical comparison of the scores for questions 1 to 5 at the preoperative and postoperative time points was made. Statistically significant differences were found for questions 1 to 3. Question 4 showed a statistical trend with p = 0.0528, thereby
Discussion
TE D
approaching a descriptive difference between the two time points (Fig. 7).
The current study aimed to examine the subjective and objective treatment outcomes after
EP
secondary rhinoplasty in patients with repaired, complete, unilateral non-syndromic CLP. There were three findings of particular interest. First, the metric facial analysis showed a
AC C
significant improvement of the nasofrontal angles from a median of 143.5° (IQR 16.5) to 135° (IQR 12) and a change in the nasolabial angles from a median of 76° (IQR 24.5) to 99° (IQR 15). Second, patient satisfaction was high based on the evaluation of the ROE questionnaire (median 87.5%, IQR 17). Third, the analysis of the AMAI rating questionnaire showed no
statistically significant differences between the positive ratings of the experienced and inexperienced doctors. In contrast, there was an obvious, significant difference between the preoperative and postoperative time points for AMAI questions 1 to 3.
9
ACCEPTED MANUSCRIPT A literature review revealed that most studies concerning secondary cleft rhinoplasty evaluated only the surgeon’s assessment of treatment outcome. To date, little is known about the patient’s perspective (Hens et al., 2011, Byrne et al., 2014, Roosenboom et al., 2014). Our metric analysis of pre- and postoperative photographs showed a significant improvement
RI PT
in the characteristic facial angles, that is the nasofrontal angle and the nasolabial angle, after secondary rhinoplasty (Fig. 4). In the literature, few studies have assessed the outcome of secondary rhinoplasty by measuring characteristic facial angles (Guyuron, 1988, Graber et
SC
al., 1995), although a comparison of the results of the metric facial analysis with those of the AMAI rating showed that they were descriptively congruent. These findings indicate that
M AN U
facial metric analysis is an appropriate instrument for the assessment of operation outcome after secondary rhinoplasty. In this context, it has been shown that rib cartilage is an appropriate transplant material for secondary rhinoplasty of the cleft nose. The application of rib cartilage transplants as columellar struts offers sufficient axial and transversal stability
TE D
against the soft tissue tension towards the columellar and cleft side nasal base (Kridel et al., 2009, Hafezi et al., 2013, Duron et al., 2014). Moreover, other groups have shown an improvement of postoperative nasal aesthetics through the use of columellar struts in patients
EP
with CLP (Pitak-Arnnop et al., 2011). Indeed, autologous rib cartilage is a sufficient transplant material not only for the columellar strut but also for the reconstruction of the nasal
AC C
dorsum and other parts of the nasal skeleton (Cervelli et al., 2006). The ROE questionnaire results showed a high degree of patient satisfaction with the aesthetic and functional outcome (ROE: 87.5%, IQR 17), and the satisfaction of female patients was higher (median 87.5%, IQR 17) than that of males (median 83.25 %, IQR 19) (Fig. 5). In particular, there was a high degree of satisfaction with the appearance of the nose (Question 1: six responses of 3 – very much; and three responses of 4 – absolutely yes). In addition, most patients believed that people in their social environment liked their nose (Question 3: five responses of 3 – very much; and four responses of 4 – absolutely yes). Furthermore, the 10
ACCEPTED MANUSCRIPT participants did not think that the current appearance of their nose hampers their social or professional activities (Question 4: two responses of 3 – rarely; and seven responses of 4 – never). Further surgery of the nose was not desired (Question 6: three responses of 3 – probably no; and six responses of 4 – certainly no), and only two patients reported complaints
RI PT
with nasal breathing (Question 2: Do you breath well through your nose? Two responses of 3 – more or less; five responses of 3 – very much; and two responses of 4 – absolutely yes) which can be explained by the complex intranasal anomalies of the cleft nose. The above-
SC
mentioned findings are comparable with those of other workgroups (Hens et al., 2011, Byrne et al., 2014, Roosenboom et al., 2014). However, the subjective treatment outcome of the
M AN U
present study was superior to the findings of Roosenboom et al. (17.7; SD, 4.2 (73.75)), Hens et al. (73.10; SD, 2.0), and Byrne et al. (76.1). The results of the ROE questionnaires in the present study are most comparable with those of Byrne et al., in regards to the high satisfaction with the functional and aesthetic outcomes. Similar to the present study, these
TE D
authors could not confirm patient satisfaction from the objective viewpoint in all respects. However, positive assessment of the postoperative outcome was congruent between patients and observers in all cases (Byrne et al., 2014). One possible explanation for the higher
EP
satisfaction among the patients in the present study may be the fact that a single doctor treated all of the patients, and thus the high degree of subjective satisfaction may be explained by
AC C
strong social bonding rather than the operative result. Additionally, the assessment of professionals using the AMAI showed a statistically significant improvement of nasolabial appearance on the frontal and profile view photographs. A statistical comparison of the ‘experienced’ and ‘inexperienced’ research teams was carried out, although the scores of both research teams showed no statistically significant differences (Fig. 6). However, the statistical comparison of the scores of questions 1 to 4 at the preoperative and postoperative time points showed statistically significant differences for questions 1 to 3, and question 4 showed a statistical trend with p = 0.0528 that only 11
ACCEPTED MANUSCRIPT approached a descriptive difference between the two time points (Fig. 7). This result was unexpected because the surgical procedure was limited to the nose and no surgery was performed on the shape of the vermilion border. The lip-supporting effect of the columellar strut may explain the present descriptive improvement following the surgical procedure.
RI PT
However, the international literature reports results of the AMAI rating in very young patients, in whom the results correspond to the preoperative status, or where the patient populations were too different in age to be comparable (Asher-McDade et al., 1992). In terms
SC
of methodology, there is clear evidence that this method is reliable for evaluations between different centres.
M AN U
The objective shortcoming of the AMAI questionnaire is that it lacks evaluation of extranasal symmetry and nostril form which is a major problem in unilateral cleft rhinoplasty. To approach these important complementary items, a prospective study with a newly developed computer-guided protocol assessing the form and surface area of these variations would be
TE D
helpful and is planned by the authors. The findings of these evaluations will be correlated and compared with the results of the AMAI questionnaire to evaluate the objective versus the
Conclusions
EP
subjective assessment.
Our data suggest that standardized secondary rhinoplasty in CLP leads to both a subjective
AC C
and a statistically significant objective improvement of facial appearance and thus may support the psychosocial rehabilitation of affected patients. Furthermore, we found that the subjective and objective outcome evaluation between different observers was largely congruent.
12
ACCEPTED MANUSCRIPT Conflict of interest The authors declare that they have no conflict of interest. Acknowledgements We thank all participating patients for their cooperation. The corresponding author´s
AC C
EP
TE D
M AN U
SC
RI PT
institution financed this study.
13
ACCEPTED MANUSCRIPT Fig. legends Fig. 1 (a) Preoperative and (b) postoperative photographic documentation (full face frontal view, submental oblique view, right profile view, and left profile view). Fig. 2 Metric analysis of the preoperative and postoperative photographic documentation
RI PT
whereby the nasofrontal (a) and nasolabial angles (b) were determined.
Fig. 3 Objective evaluation of rhinoplasty using the (a) frontal view and (b) profile view of the nasolabial area according to the Asher-McDade aesthetic index (AMAI) rating
SC
questionnaire.
Fig. 4 The statistically significant improvement in the two measured angles, the nasofrontal
M AN U
and the nasolabial angle, between the preoperative and postoperative situations is shown as a box plot.
>
Fig. 5 The median, percentile and IQR for the rhinoplasty outcome evaluation (ROE)
TE D
questionnaire for men and women are shown as box plots.
Fig. 6 The scores for questions 1–4 (different column colours) of the AMAI rating for different study groups (experienced vs. inexperienced) are shown as box plots. No statistically
EP
significant differences in the ratings were observed.
AC C
decimal points not decimal commas on the y-axis and for the p-values; and italicize the ‘p’ in the probability values, e.g. p=0.7855 > Fig. 7 The scores for questions 1–4 (different column colours) of the AMAI rating for preand postoperative time points are shown as box plots.
14
ACCEPTED MANUSCRIPT Table legends Table 1: Demographic characteristics of the cleft lip and palate (CLP) group (n=10). IQR: interquartile range.
RI PT
‘Female’; and ‘m’ with ‘Male’; replace the hyphen with an en-dash in ‘17–24’; and close up the space between the numbers and the % signs, e.g. 40% > Table 2: Rhinoplasty outcome questionnaire (ROE).
as in Table 3>
AC C
EP
TE D
M AN U
Table 3: Asher-McDade aesthetic index (AMAI).
SC
15
ACCEPTED MANUSCRIPT References Alsarraf R: Outcomes research in facial plastic surgery: a review and new directions. Aesthetic Plast Surg 24: 192-7, 2000 Asher-McDade C, Brattstrom V, Dahl E, McWilliam J, Molsted K, Plint DA, et al.: A sixcenter international study of treatment outcome in patients with clefts of the lip and palate: Part 4. Assessment of nasolabial appearance. Cleft Palate Craniofac J 29: 409-12, 1992
RI PT
Asher-McDade C, Roberts C, Shaw WC, Gallager C: Development of a method for rating nasolabial appearance in patients with clefts of the lip and palate. Cleft Palate Craniofac J 28: 385-90; discussion 90-1, 1991 Berger ZE, Dalton LJ: Coping with a cleft: psychosocial adjustment of adolescents with a cleft lip and palate and their parents. Cleft Palate CraniofacJ 46: 435-43, 2009
SC
Byrd HS, El-Musa KA, Yazdani A: Definitive repair of the unilateral cleft lip nasal deformity. PlastReconstrSurg 120: 1348-56, 2007
M AN U
Byrne M, Chan JC, O'Broin E: Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: evaluation by patients versus health professionals. J Craniomaxillofac Surg 42: 1062-70, 2014 Cao W, Xi M, Zhou F, Feng YP, Huang L: Lateral crus graft with autologous rib cartilage for cleft lip nostril asymmetry: a report of 35 cases. J Huazhong Univ Sci Technolog Med Sci 34: 387-92, 2014 Cervelli V, Bottini DJ, Gentile P, Fantozzi L, Arpino A, Cannata C, et al.: Reconstruction of the nasal dorsum with autologous rib cartilage. Ann Plast Surg 56: 256-62, 2006
TE D
Chummun S, McLean NR, Anderson PJ, David DJ: A long-term evaluation of 150 costochondral nasal grafts. J Plast Reconstr Aesthet Surg 66: 1477-81, 2013 Cochrane VM, Slade P: Appraisal and coping in adults with cleft lip: associations with wellbeing and social anxiety. BrJ MedPsychol 72 ( Pt 4): 485-503, 1999 Dixon MJ, Marazita ML, Beaty TH, Murray JC: Cleft lip and palate: understanding genetic and environmental influences. NatRevGenet 12: 167-78, 2011
EP
Duron JB, Aiach G: [Cartilaginous graft in rhinoplasty.]. AnnChir PlastEsthet: 2014
AC C
Gee GC, Payne-Sturges DC: Environmental health disparities: a framework integrating psychosocial and environmental concepts. Environ Health Perspect 112: 1645-53, 2004 Gkantidis N, Papamanou DA, Christou P, Topouzelis N: Aesthetic outcome of cleft lip and palate treatment. Perceptions of patients, families, and health professionals compared to the general public. JCraniomaxillofacSurg 41: e105-e10, 2013 Graber I, Jovanovic S, Berghaus A: [Subjective and objective evaluation of the outcome of rhinoplasty. A retrospective study]. Laryngorhinootologie 74: 495-9, 1995 Guyuron B: Precision rhinoplasty. Part I: The role of life-size photographs and soft-tissue cephalometric analysis. Plast Reconstr Surg 81: 489-99, 1988 Hafezi F, Naghibzadeh B, Ashtiani AK, Mousavi SJ, Nouhi AH, Naghibzadeh G: Correction of cleft lip nose deformity with rib cartilage. AesthetSurgJ 33: 662-73, 2013 Hens G, Picavet VA, Poorten VV, Schoenaers J, Jorissen M, Hellings PW: High patient satisfaction after secondary rhinoplasty in cleft lip patients. Int Forum Allergy Rhinol 1: 167-72, 2011
16
ACCEPTED MANUSCRIPT Hunt O, Burden D, Hepper P, Stevenson M, Johnston C: Self-reports of psychosocial functioning among children and young adults with cleft lip and palate. Cleft Palate CraniofacJ 43: 598-605, 2006 Kridel RW, Ashoori F, Liu ES, Hart CG: Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose. Arch Facial Plast Surg 11: 378-94, 2009 Meyer-Marcotty P, Gerdes AB, Reuther T, Stellzig-Eisenhauer A, Alpers GW: Persons with cleft lip and palate are looked at differently. JDentRes 89: 400-4, 2010
RI PT
Pitak-Arnnop P, Hemprich A, Dhanuthai K, Yildirim V, Pausch NC: Panel and patient perceptions of nasal aesthetics after secondary cleft rhinoplasty with versus without columellar grafting. JCraniomaxillofacSurg 39: 319-25, 2011
SC
Reddy SG, Devarakonda V, Reddy RR: Assessment of nostril symmetry after primary cleft rhinoplasty in patients with complete unilateral cleft lip and palate. J Craniomaxillofac Surg 41: 147-52, 2013
M AN U
Roosenboom J, Hellings PW, Picavet VA, Prokopakis EP, Antonis Y, Schoenaers J, et al.: Secondary cleft rhinoplasty: impact on self-esteem and quality of life. Plast Reconstr Surg 134: 1285-92, 2014 Springer IN, Zernial O, Nolke F, Warnke PH, Wiltfang J, Russo PA, et al.: Gender and nasal shape: measures for rhinoplasty. Plast Reconstr Surg 121: 629-37, 2008
AC C
EP
TE D
Springer IN, Zernial O, Warnke PH, Wiltfang J, Russo PA, Wolfart S: Nasal shape and gender of the observer: implications for rhinoplasty. J Craniomaxillofac Surg 37: 3-7, 2009
17
ACCEPTED MANUSCRIPT Age (years) Median
21
IQR
2.75
Range
17 - 24
RI PT
Gender w
4 (40 %) 6 (60 %)
AC C
EP
TE D
M AN U
SC
m
ACCEPTED MANUSCRIPT Question 1: Do you like how your nose looks?
0 (Absolutely no)
1 (A little)
2 (More or less)
3 (Very much)
4 (Absolutely yes)
0 (Absolutely no)
1 (A little)
2 (More or less)
RI PT
Question 2: Do you breathe well through your nose?
3 (Very much)
4 (Absolutely yes)
Question 3: Do you believe your friends and people who are dear to you like your nose?
1 (A little)
2 (More or less)
3 (Very much)
SC
0 (Absolutely no)
4 (Absolutely yes)
activities?
0 (Always)
1 (Frequently)
M AN U
Question 4: Do you think the current appearance of your nose hampers your social or professional
2 (Sometimes)
3 (Rarely)
4 (Never)
3 (Very much)
4 (Absolutely yes)
Question 5: Do you think your nose looks as good as it could be?
1 (A little)
2 (More or less)
TE D
0 (Absolutely no)
Question 6: Would you undergo surgery to change the appearance of your nose or to improve your
1 (Very likely yes)
AC C
0 (Certainly yes)
EP
breathing?
2 (Possibly yes)
3 (Probably no)
4 (Certainly no)
ACCEPTED MANUSCRIPT Question 1: Nasal form (frontal view) 1 (very good appearance)
2 (good appearance)
3 (fair appearance)
4 (poor appearance)
5 (very poor appearance)
3 (fair appearance)
4 (poor appearance)
5 (very poor appearance)
3 (fair appearance)
4 (poor appearance)
1 (very good appearance)
2 (good appearance)
1 (very good appearance)
2 (good appearance)
SC
Question 3: Shape of the vermilion border
Question 4: Nasal profile including upper lip
3 (fair appearance)
EP AC C
4 (poor appearance)
M AN U
2 (good appearance)
TE D
1 (very good appearance)
RI PT
Question 2: Symmetry of the nose
5 (very poor appearance)
5 (very poor appearance)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1010-5182(15)00290-5
DOI:
10.1016/j.jcms.2015.08.012
Reference:
YJCMS 2174
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 25 June 2015 Revised Date:
8 August 2015
Accepted Date: 14 August 2015
Please cite this article as: Gassling V, Koos B, Birkenfeld F, Wiltfang J, Zimmermann CE, Secondary cleft nose rhinoplasty: subjective and objective outcome evaluation, Journal of Cranio-Maxillofacial Surgery (2015), doi: 10.1016/j.jcms.2015.08.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Secondary cleft nose rhinoplasty: subjective and objective
RI PT
outcome evaluation
SC
Volker Gassling1, Bernd Koos2, Falk Birkenfeld1, Jörg Wiltfang1, Corinna E Zimmermann1
Author affiliations:
Department of Oral and Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
2
M AN U
1
Department of Orthodontics, University Hospital of Rostock, Rostock, Germany
Correspondence to:
TE D
Volker Gassling, PhD, MD, DMD
Department of Oral and Maxillofacial Surgery, University Hospital Schleswig-Holstein,
EP
Campus Kiel, Arnold-Heller-Straße 3, Haus 26, 24105 Kiel, Germany Tel.: +49 431 597 2791
AC C
Fax: +49 431 597 4084
Email: [email protected]
Role of the funding source: The present study was financed internally by the author’s institution. The paper has been presented on the 132th Congress of the German Society for Surgery Munich, 2015
ACCEPTED MANUSCRIPT
Secondary cleft nose rhinoplasty: subjective and objective outcome evaluation Abstract
RI PT
Introduction: Secondary rhinoplasty in cleft lip and palate (CLP) is commonly the last step in a set of surgical procedures that result in a variable but typically intensive change in facial appearance. However, there is evidence that the sentiment about the aesthetic and functional
SC
outcomes between patients and surgeons is different. The present study aimed to evaluate the subjective and objective outcomes of secondary rhinoplasty in patients with CLP.
M AN U
Material and methods: Secondary rhinoplasty was performed in 10 patients with repaired unilateral CLP via a standardized open approach. For the subjective evaluation, the patients completed the rhinoplasty outcome evaluation (ROE) questionnaire. Pre- and postoperative photographic documentation served as the basis for the objective evaluation, which included
TE D
the following: (1) assessment by five specialists at craniofacial malformation consultation appointments and by three doctors in continuing education using the Asher-McDade aesthetic
nasolabial angle.
EP
index (AMAI) rating, and (2) metric facial analysis to determine the nasofrontal angle and the
Results: Patient satisfaction was high, based on the evaluation of the ROE questionnaire. The
AC C
analysis of the AMAI rating questionnaire showed no significant differences between the positive ratings of the ‘experienced’ and ‘inexperienced’ doctors. In contrast, there was an obvious and significant difference between the ‘preoperative’ and ‘postoperative’ time points for questions 1 to 3. The metric analysis showed statistically significant improvements of the nasolabial angle and the nasofrontal angle. The subjective and objective outcome evaluations were descriptively congruent. Conclusions: The data suggest that standardized secondary rhinoplasty in CLP leads to both a subjective and a statistically significant objective improvement of facial appearance and thus 1
ACCEPTED MANUSCRIPT may support the psychosocial rehabilitation of affected patients. Furthermore, our results showed that the subjective and objective outcome evaluations of secondary rhinoplasty were largely compatible.
AC C
EP
TE D
M AN U
SC
RI PT
Keywords: cleft lip and palate; cleft nose; outcome; secondary rhinoplasty
2
ACCEPTED MANUSCRIPT Introduction Cleft lip and palate (CLP) represents the most common malformation of the midfacial region worldwide (Dixon et al., 2011). The treatment concept for CLP requires multidisciplinary care and results in a more or less intensive disturbance of the facial appearance, which may
RI PT
lead to particular psychosocial stress in affected individuals. Indeed, psychosocial stress is known as one of the most important risks of physical and mental health hazards in the 21st century (Gee et al., 2004). The psychosocial functioning of children and young adults with
SC
orofacial clefts may be affected, resulting in behavioural problems, depression, and unhappiness with their facial appearance and speech (Hunt et al., 2006). More precisely,
M AN U
dissatisfaction with facial appearance can be localized to the upper lip, the nose and nasal breathing. In a recent comparison of visual face assessments between patients with CLP and a control group, it was found that for patients with CLP there were more initial fixations on the mouth and longer fixations on the mouth and nose regions; in addition, CLP faces were rated
TE D
more negatively overall (Meyer-Marcotty et al., 2010). It is noteworthy, however, that further investigation into psychosocial adjustment difficulties in adolescents with orofacial clefts revealed greater self-satisfaction with several aspects of facial appearance (such as teeth, eyes,
EP
ears, hair, and chin) compared with adolescents without facial disfigurement. However, there was dissatisfaction with lip and nose appearance compared with the control group (Berger et
AC C
al., 2009). These findings illustrate the importance of facial aesthetics (that is the appearance of the nose and the lips) for the psychosocial status of patients with CLP. The nose is located in the centre of the face and plays an essential role in the aesthetic assessment. Nasal deformities, and in particular a cleft nose deformity, not only lead to functional disturbances but also result in psychosocial adjustment difficulties. The unilateral cleft nose is mainly characterized by asymmetry of the nasal tip, deviation of the nasal dorsum, malposition of the lower lateral cartilage and hypoplasia on the cleft side, and septal deviation away from the cleft side. The correction of these complex anomalies by secondary 3
ACCEPTED MANUSCRIPT rhinoplasty is one of the most challenging procedures in facial plastic surgery, and the surgeon has to achieve the best possible aesthetic and functional result for the patient. The disruption of the upper lip, the alveolar process of the maxilla, and the hard and soft palates cause deformation of the bony and cartilaginous structures during the period of growth.
RI PT
Because the soft tissue follows the underlying structures, the newly formed nasal structures must maintain tension within the tissue. Thus, the applied implants or transplants need to fulfil specific requirements. For example, columellar struts must offer high axial and
SC
transversal stability against the soft tissue tension towards the columella and the cleft side nasal base (Byrd et al., 2007). Furthermore, no resorption or rejection of the transplants must
M AN U
occur. The application of cartilaginous transplants from the rib is generally accepted in cleft nose surgery (Chummun et al., 2013, Hafezi et al., 2013, Cao et al., 2014). Unfortunately, up to this point in time, the majority of publications concerning this issue describe the surgeon’s point of view only. However, the surgeon’s assessment of facial
TE D
aesthetics after cleft surgery seems to be of minor relevance and thus emphasizes the role of the social support of affected individuals (Cochrane et al., 1999, Springer et al., 2008 and 2009, Gkantidis et al., 2013, Reddy et al., 2013). Thus, the primary objective of secondary
EP
rhinoplasty should be the highest patient satisfaction. Therefore, the present study aimed to evaluate the objective and subjective assessments of treatment outcomes of standardized
AC C
secondary cleft rhinoplasty. Based on the above-mentioned findings, we hypothesize that: 1. Metric analysis of pre- and postoperative photographs will reveal improvements of the characteristic facial angles; 2. Patients with CLP will show a high degree of satisfaction with secondary rhinoplasty; and 3. The
objective
treatment
outcome
of
secondary
rhinoplasty
assessed
by
interdisciplinary professionals will show an improvement of nasolabial appearance. 4
ACCEPTED MANUSCRIPT Material and methods Study participants Ten patients with a repaired complete, unilateral non-syndromic CLP (median age 21 years, interquartile range (IQR) 2.75) were recruited from craniofacial malformation consultation
RI PT
appointments with the Department of Cranio-Maxillofacial Surgery at the University Hospital of Schleswig-Holstein, Kiel Campus, Kiel, Germany. The age range was 17–24 years, and six men and four women were included (see Table 1). Patients were informed about the course of
SC
the procedure and provided their written consent according to the Helsinki convention before examination began. The study design was approved by the local ethics board (AZ: D 500/14).
M AN U
Preoperative management
Preoperative planning included a careful medical history with a particular focus on preliminary surgery, accidents, allergy, and nasal breathing disabilities. The clinical examination determined the extent of septal deviation and turbinate bone hyperplasia. During
TE D
the exploration of the outer nose, a particular focus was placed on the nasal projection, the tip of the nose, discrepancies, the skin quality, and the position of the alar bases. The pre- and postoperative photographic documentation was used as the basis for the objective description
EP
of changes in the characteristic facial angles and for the objective assessment of nasolabial appearance by experienced colleagues of the interdisciplinary consultation team and
AC C
inexperienced colleagues using the Asher-McDade aesthetic index (AMAI) rating. For each patient, four photographs were taken (full face frontal view, submental oblique view, right profile view, and left profile view) (Fig. 1). All pictures were taken with a Nikon D200 fullframe imaging sensor (Nikon, Chiyoda, Tokyo, Japan) and a Nikon portrait lens with a focal distance of 60 mm and a lens aperture f20 with manual focus. The exposure time with external lighting was 1/200 second. Each photograph was modified for further assessments (Fig. 2 and 3). Due to the complexity of the intranasal pathology in cases of cleft nose
5
ACCEPTED MANUSCRIPT deformity, a computed tomography (CT) scan in axial and coronal stratification was performed for each patient. Rhinoplasty Secondary rhinoplasty was performed via an open, inverted V approach; osteotomies,
RI PT
septoplasty, domal repositioning, and columellar strut formation from rib cartilage were performed routinely. The operation procedure was divided into two steps. First, ventilation problems were corrected by nasal septum correction and turbinoplasty. Second, correction of
SC
the external nose was achieved by osteotomy of the nasal bone, positioning of the columellar strut, and repositioning of the lower lateral cartilages and nasal tip. At the end of the
M AN U
operation, the result was stabilized using septal splints, nasal tamponades, and a cast. Postoperatively, adequate pain medication (eg, ibuprofen 600 mg on demand), antibiotic prophylaxis (eg, Unacid PD tablets, 3 times a day for 1 week), and cooling (eg, Hilotherm, Argenbühl-Eisenharz, Germany) were considered. The nasal tamponades were typically
TE D
removed 2 days after the operation, the nasal cast was removed after 1 week, and the septum splints were removed after 2 weeks. All procedures were performed by the first author only. Metric facial analysis
EP
Two sets of four photographs (full face frontal view, submental oblique view, right profile view, and left profile view) (Fig. 1) were taken pre- and postoperatively for each patient under
AC C
standardized conditions. The pre- and postoperative photographic documentation served as the basis for the metric analysis, whereby the nasofrontal and nasolabial angles (Graber et al., 1995) were determined (Fig. 2). All pictures for the measurement of the nasolabial and nasofrontal angles were prepared with Adobe Photoshop CS 6 (Adobe Systems, San José, CA USA) and analysed with the integrated angle measurement function in profile view. Rhinoplasty outcome evaluation instrument (ROE) The objective assessment of the postoperative result was performed with the ROE instrument (Alsarraf, 2000), whereby six questions concerning nasal aesthetics and function were asked. 6
ACCEPTED MANUSCRIPT Each question was scored from 0 to 4, with 0 indicating the best score and 4 the worst (see Table 2). The total score was divided by 24 and multiplied by 100. A score above 85 was considered an excellent score and reflected high patient satisfaction. Asher-McDade aesthetic index (AMAI) rating
RI PT
The objective evaluation of the rhinoplasty was performed by the assessment of five specialists at craniofacial malformation consultation appointments and by three doctors with DDS degrees in a continuing postgraduate program; frontal and profile views of the
SC
nasolabial area (Fig. 3) and the AMAI rating (Table 3, Fig. 3) were used (Asher-McDade et al., 1991 and 1992). The nasolabial rating consists of a 5-point ordinal scale assessing the
M AN U
nasal form, the symmetry of the nose, the shape of the vermillion border, and the nasal profile including the upper lip. A score of 1 indicates a ‘very good appearance’; a score of 2 a ‘good appearance’; a score of 3 a ‘fair appearance’; a score of 4 a ‘poor appearance’; and a score 5 a ‘very poor appearance’. The answers for each question (1–4) and patient were used to
TE D
calculate an individual score, which was analysed statistically. All pictures for the assessment were prepared with Adobe Photoshop CS 6 (Adobe Systems, San José, CA USA). In the first step, the frontal and profile view pictures were released according to Asher-McDade et al.
EP
(1991 and 1992). All pictures were scaled to 300 dpi and included in a Microsoft PowerPoint Presentation (Microsoft Power Point: Mac 2011, Microsoft, Redmond, WA, USA) with a
AC C
mapping value of 12 cm height. The presentation and sequence of the pictures were carried out exactly according to the standards of Asher-McDade et al. (1991 and 1992). Data transformation and statistical analysis Metric facial analysis The measured angles were analysed with the statistical software JMP, Version 12 (SAS Institute Inc., Cary, NC, USA). The calculation and graphical presentation were presented as box plots with medians, percentiles and IQR. The statistical correlation between the
7
ACCEPTED MANUSCRIPT preoperative and postoperative time points were analysed using the non-parametric Wilcoxon rank sum test with a level of significance at 0.05. ROE questionnaire The measured scores of the patients were analysed and compared descriptively with the
RI PT
statistical software JMP, Version 12 (SAS Institute Inc., Cary, USA). The analysis and graphical presentation were depicted as box plots with medians, percentiles and IQRs and descriptive comparisons.
SC
AMAI rating questionnaire
The measured scores of the raters were analysed and compared with the statistical software
M AN U
JMP, Version 12 (SAS Institute Inc.). The analysis and graphical presentation were depicted as box plots with medians, percentiles and IQRs. The statistical correlations between the two investigation groups, ‘experienced’ and ‘inexperienced’, and the two time points, ‘preoperative’ and ‘postoperative’, were analysed using the non-parametric Wilcoxon rank
Results
Nasofrontal angle
EP
Metric facial analysis
TE D
sum test with a level of significance at 0.05.
The metric analysis of the pre- and postoperative photographs showed a significant
AC C
improvement of the characteristic facial angles. The nasofrontal angle changed from a median of 143.5° (IQR 16.5) to 135° (IQR 12), and this alteration was statistically significant (p = 0.0309) (Fig. 4).
Nasolabial angle The metric analysis of the pre- and postoperative photographs showed a significant improvement of the characteristic facial angles. The nasolabial angle changed from a median of 76° (IQR 24.5) to 99° (IQR 15), and this alteration was statistically significant (p = 0.0025) (Fig. 4). 8
ACCEPTED MANUSCRIPT ROE questionnaire The return rate of the ROE questionnaires was 90%, and the median score was 87.5% (IQR 17). Overall, the patient satisfaction could be described as high, and the satisfaction of women was higher (median 87.5%, IQR 17) than that among men (median 83.25%, IQR 19) (Fig. 5).
RI PT
AMAI rating questionnaire Comparison of research teams
In the first work stage, the statistical comparison of the ‘experienced’ and ‘inexperienced’
significant differences (Fig. 6).
M AN U
Comparison of preoperative and postoperative scores
SC
research teams was carried out. The scores of the research teams showed no statistically
In the second work stage, statistical comparison of the scores for questions 1 to 5 at the preoperative and postoperative time points was made. Statistically significant differences were found for questions 1 to 3. Question 4 showed a statistical trend with p = 0.0528, thereby
Discussion
TE D
approaching a descriptive difference between the two time points (Fig. 7).
The current study aimed to examine the subjective and objective treatment outcomes after
EP
secondary rhinoplasty in patients with repaired, complete, unilateral non-syndromic CLP. There were three findings of particular interest. First, the metric facial analysis showed a
AC C
significant improvement of the nasofrontal angles from a median of 143.5° (IQR 16.5) to 135° (IQR 12) and a change in the nasolabial angles from a median of 76° (IQR 24.5) to 99° (IQR 15). Second, patient satisfaction was high based on the evaluation of the ROE questionnaire (median 87.5%, IQR 17). Third, the analysis of the AMAI rating questionnaire showed no
statistically significant differences between the positive ratings of the experienced and inexperienced doctors. In contrast, there was an obvious, significant difference between the preoperative and postoperative time points for AMAI questions 1 to 3.
9
ACCEPTED MANUSCRIPT A literature review revealed that most studies concerning secondary cleft rhinoplasty evaluated only the surgeon’s assessment of treatment outcome. To date, little is known about the patient’s perspective (Hens et al., 2011, Byrne et al., 2014, Roosenboom et al., 2014). Our metric analysis of pre- and postoperative photographs showed a significant improvement
RI PT
in the characteristic facial angles, that is the nasofrontal angle and the nasolabial angle, after secondary rhinoplasty (Fig. 4). In the literature, few studies have assessed the outcome of secondary rhinoplasty by measuring characteristic facial angles (Guyuron, 1988, Graber et
SC
al., 1995), although a comparison of the results of the metric facial analysis with those of the AMAI rating showed that they were descriptively congruent. These findings indicate that
M AN U
facial metric analysis is an appropriate instrument for the assessment of operation outcome after secondary rhinoplasty. In this context, it has been shown that rib cartilage is an appropriate transplant material for secondary rhinoplasty of the cleft nose. The application of rib cartilage transplants as columellar struts offers sufficient axial and transversal stability
TE D
against the soft tissue tension towards the columellar and cleft side nasal base (Kridel et al., 2009, Hafezi et al., 2013, Duron et al., 2014). Moreover, other groups have shown an improvement of postoperative nasal aesthetics through the use of columellar struts in patients
EP
with CLP (Pitak-Arnnop et al., 2011). Indeed, autologous rib cartilage is a sufficient transplant material not only for the columellar strut but also for the reconstruction of the nasal
AC C
dorsum and other parts of the nasal skeleton (Cervelli et al., 2006). The ROE questionnaire results showed a high degree of patient satisfaction with the aesthetic and functional outcome (ROE: 87.5%, IQR 17), and the satisfaction of female patients was higher (median 87.5%, IQR 17) than that of males (median 83.25 %, IQR 19) (Fig. 5). In particular, there was a high degree of satisfaction with the appearance of the nose (Question 1: six responses of 3 – very much; and three responses of 4 – absolutely yes). In addition, most patients believed that people in their social environment liked their nose (Question 3: five responses of 3 – very much; and four responses of 4 – absolutely yes). Furthermore, the 10
ACCEPTED MANUSCRIPT participants did not think that the current appearance of their nose hampers their social or professional activities (Question 4: two responses of 3 – rarely; and seven responses of 4 – never). Further surgery of the nose was not desired (Question 6: three responses of 3 – probably no; and six responses of 4 – certainly no), and only two patients reported complaints
RI PT
with nasal breathing (Question 2: Do you breath well through your nose? Two responses of 3 – more or less; five responses of 3 – very much; and two responses of 4 – absolutely yes) which can be explained by the complex intranasal anomalies of the cleft nose. The above-
SC
mentioned findings are comparable with those of other workgroups (Hens et al., 2011, Byrne et al., 2014, Roosenboom et al., 2014). However, the subjective treatment outcome of the
M AN U
present study was superior to the findings of Roosenboom et al. (17.7; SD, 4.2 (73.75)), Hens et al. (73.10; SD, 2.0), and Byrne et al. (76.1). The results of the ROE questionnaires in the present study are most comparable with those of Byrne et al., in regards to the high satisfaction with the functional and aesthetic outcomes. Similar to the present study, these
TE D
authors could not confirm patient satisfaction from the objective viewpoint in all respects. However, positive assessment of the postoperative outcome was congruent between patients and observers in all cases (Byrne et al., 2014). One possible explanation for the higher
EP
satisfaction among the patients in the present study may be the fact that a single doctor treated all of the patients, and thus the high degree of subjective satisfaction may be explained by
AC C
strong social bonding rather than the operative result. Additionally, the assessment of professionals using the AMAI showed a statistically significant improvement of nasolabial appearance on the frontal and profile view photographs. A statistical comparison of the ‘experienced’ and ‘inexperienced’ research teams was carried out, although the scores of both research teams showed no statistically significant differences (Fig. 6). However, the statistical comparison of the scores of questions 1 to 4 at the preoperative and postoperative time points showed statistically significant differences for questions 1 to 3, and question 4 showed a statistical trend with p = 0.0528 that only 11
ACCEPTED MANUSCRIPT approached a descriptive difference between the two time points (Fig. 7). This result was unexpected because the surgical procedure was limited to the nose and no surgery was performed on the shape of the vermilion border. The lip-supporting effect of the columellar strut may explain the present descriptive improvement following the surgical procedure.
RI PT
However, the international literature reports results of the AMAI rating in very young patients, in whom the results correspond to the preoperative status, or where the patient populations were too different in age to be comparable (Asher-McDade et al., 1992). In terms
SC
of methodology, there is clear evidence that this method is reliable for evaluations between different centres.
M AN U
The objective shortcoming of the AMAI questionnaire is that it lacks evaluation of extranasal symmetry and nostril form which is a major problem in unilateral cleft rhinoplasty. To approach these important complementary items, a prospective study with a newly developed computer-guided protocol assessing the form and surface area of these variations would be
TE D
helpful and is planned by the authors. The findings of these evaluations will be correlated and compared with the results of the AMAI questionnaire to evaluate the objective versus the
Conclusions
EP
subjective assessment.
Our data suggest that standardized secondary rhinoplasty in CLP leads to both a subjective
AC C
and a statistically significant objective improvement of facial appearance and thus may support the psychosocial rehabilitation of affected patients. Furthermore, we found that the subjective and objective outcome evaluation between different observers was largely congruent.
12
ACCEPTED MANUSCRIPT Conflict of interest The authors declare that they have no conflict of interest. Acknowledgements We thank all participating patients for their cooperation. The corresponding author´s
AC C
EP
TE D
M AN U
SC
RI PT
institution financed this study.
13
ACCEPTED MANUSCRIPT Fig. legends Fig. 1 (a) Preoperative and (b) postoperative photographic documentation (full face frontal view, submental oblique view, right profile view, and left profile view). Fig. 2 Metric analysis of the preoperative and postoperative photographic documentation
RI PT
whereby the nasofrontal (a) and nasolabial angles (b) were determined.
Fig. 3 Objective evaluation of rhinoplasty using the (a) frontal view and (b) profile view of the nasolabial area according to the Asher-McDade aesthetic index (AMAI) rating
SC
questionnaire.
Fig. 4 The statistically significant improvement in the two measured angles, the nasofrontal
M AN U
and the nasolabial angle, between the preoperative and postoperative situations is shown as a box plot.
>
Fig. 5 The median, percentile and IQR for the rhinoplasty outcome evaluation (ROE)
TE D
questionnaire for men and women are shown as box plots.
EP
significant differences in the ratings were observed.
AC C
decimal points not decimal commas on the y-axis and for the p-values; and italicize the ‘p’ in the probability values, e.g. p=0.7855 > Fig. 7 The scores for questions 1–4 (different column colours) of the AMAI rating for preand postoperative time points are shown as box plots.
14
ACCEPTED MANUSCRIPT Table legends Table 1: Demographic characteristics of the cleft lip and palate (CLP) group (n=10). IQR: interquartile range.
RI PT
‘Female’; and ‘m’ with ‘Male’; replace the hyphen with an en-dash in ‘17–24’; and close up the space between the numbers and the % signs, e.g. 40% > Table 2: Rhinoplasty outcome questionnaire (ROE).
as in Table 3>
AC C
EP
TE D
M AN U
Table 3: Asher-McDade aesthetic index (AMAI).
SC
15
ACCEPTED MANUSCRIPT References Alsarraf R: Outcomes research in facial plastic surgery: a review and new directions. Aesthetic Plast Surg 24: 192-7, 2000 Asher-McDade C, Brattstrom V, Dahl E, McWilliam J, Molsted K, Plint DA, et al.: A sixcenter international study of treatment outcome in patients with clefts of the lip and palate: Part 4. Assessment of nasolabial appearance. Cleft Palate Craniofac J 29: 409-12, 1992
RI PT
Asher-McDade C, Roberts C, Shaw WC, Gallager C: Development of a method for rating nasolabial appearance in patients with clefts of the lip and palate. Cleft Palate Craniofac J 28: 385-90; discussion 90-1, 1991 Berger ZE, Dalton LJ: Coping with a cleft: psychosocial adjustment of adolescents with a cleft lip and palate and their parents. Cleft Palate CraniofacJ 46: 435-43, 2009
SC
Byrd HS, El-Musa KA, Yazdani A: Definitive repair of the unilateral cleft lip nasal deformity. PlastReconstrSurg 120: 1348-56, 2007
M AN U
Byrne M, Chan JC, O'Broin E: Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: evaluation by patients versus health professionals. J Craniomaxillofac Surg 42: 1062-70, 2014 Cao W, Xi M, Zhou F, Feng YP, Huang L: Lateral crus graft with autologous rib cartilage for cleft lip nostril asymmetry: a report of 35 cases. J Huazhong Univ Sci Technolog Med Sci 34: 387-92, 2014 Cervelli V, Bottini DJ, Gentile P, Fantozzi L, Arpino A, Cannata C, et al.: Reconstruction of the nasal dorsum with autologous rib cartilage. Ann Plast Surg 56: 256-62, 2006
TE D
Chummun S, McLean NR, Anderson PJ, David DJ: A long-term evaluation of 150 costochondral nasal grafts. J Plast Reconstr Aesthet Surg 66: 1477-81, 2013 Cochrane VM, Slade P: Appraisal and coping in adults with cleft lip: associations with wellbeing and social anxiety. BrJ MedPsychol 72 ( Pt 4): 485-503, 1999 Dixon MJ, Marazita ML, Beaty TH, Murray JC: Cleft lip and palate: understanding genetic and environmental influences. NatRevGenet 12: 167-78, 2011
EP
Duron JB, Aiach G: [Cartilaginous graft in rhinoplasty.]. AnnChir PlastEsthet: 2014
AC C
Gee GC, Payne-Sturges DC: Environmental health disparities: a framework integrating psychosocial and environmental concepts. Environ Health Perspect 112: 1645-53, 2004 Gkantidis N, Papamanou DA, Christou P, Topouzelis N: Aesthetic outcome of cleft lip and palate treatment. Perceptions of patients, families, and health professionals compared to the general public. JCraniomaxillofacSurg 41: e105-e10, 2013 Graber I, Jovanovic S, Berghaus A: [Subjective and objective evaluation of the outcome of rhinoplasty. A retrospective study]. Laryngorhinootologie 74: 495-9, 1995 Guyuron B: Precision rhinoplasty. Part I: The role of life-size photographs and soft-tissue cephalometric analysis. Plast Reconstr Surg 81: 489-99, 1988 Hafezi F, Naghibzadeh B, Ashtiani AK, Mousavi SJ, Nouhi AH, Naghibzadeh G: Correction of cleft lip nose deformity with rib cartilage. AesthetSurgJ 33: 662-73, 2013 Hens G, Picavet VA, Poorten VV, Schoenaers J, Jorissen M, Hellings PW: High patient satisfaction after secondary rhinoplasty in cleft lip patients. Int Forum Allergy Rhinol 1: 167-72, 2011
16
ACCEPTED MANUSCRIPT Hunt O, Burden D, Hepper P, Stevenson M, Johnston C: Self-reports of psychosocial functioning among children and young adults with cleft lip and palate. Cleft Palate CraniofacJ 43: 598-605, 2006 Kridel RW, Ashoori F, Liu ES, Hart CG: Long-term use and follow-up of irradiated homologous costal cartilage grafts in the nose. Arch Facial Plast Surg 11: 378-94, 2009 Meyer-Marcotty P, Gerdes AB, Reuther T, Stellzig-Eisenhauer A, Alpers GW: Persons with cleft lip and palate are looked at differently. JDentRes 89: 400-4, 2010
RI PT
Pitak-Arnnop P, Hemprich A, Dhanuthai K, Yildirim V, Pausch NC: Panel and patient perceptions of nasal aesthetics after secondary cleft rhinoplasty with versus without columellar grafting. JCraniomaxillofacSurg 39: 319-25, 2011
SC
Reddy SG, Devarakonda V, Reddy RR: Assessment of nostril symmetry after primary cleft rhinoplasty in patients with complete unilateral cleft lip and palate. J Craniomaxillofac Surg 41: 147-52, 2013
M AN U
Roosenboom J, Hellings PW, Picavet VA, Prokopakis EP, Antonis Y, Schoenaers J, et al.: Secondary cleft rhinoplasty: impact on self-esteem and quality of life. Plast Reconstr Surg 134: 1285-92, 2014 Springer IN, Zernial O, Nolke F, Warnke PH, Wiltfang J, Russo PA, et al.: Gender and nasal shape: measures for rhinoplasty. Plast Reconstr Surg 121: 629-37, 2008
AC C
EP
TE D
Springer IN, Zernial O, Warnke PH, Wiltfang J, Russo PA, Wolfart S: Nasal shape and gender of the observer: implications for rhinoplasty. J Craniomaxillofac Surg 37: 3-7, 2009
17
ACCEPTED MANUSCRIPT Age (years) Median
21
IQR
2.75
Range
17 - 24
RI PT
Gender w
4 (40 %) 6 (60 %)
AC C
EP
TE D
M AN U
SC
m
ACCEPTED MANUSCRIPT Question 1: Do you like how your nose looks?
0 (Absolutely no)
1 (A little)
2 (More or less)
3 (Very much)
4 (Absolutely yes)
0 (Absolutely no)
1 (A little)
2 (More or less)
RI PT
Question 2: Do you breathe well through your nose?
3 (Very much)
4 (Absolutely yes)
Question 3: Do you believe your friends and people who are dear to you like your nose?
1 (A little)
2 (More or less)
3 (Very much)
SC
0 (Absolutely no)
4 (Absolutely yes)
activities?
0 (Always)
1 (Frequently)
M AN U
Question 4: Do you think the current appearance of your nose hampers your social or professional
2 (Sometimes)
3 (Rarely)
4 (Never)
3 (Very much)
4 (Absolutely yes)
Question 5: Do you think your nose looks as good as it could be?
1 (A little)
2 (More or less)
TE D
0 (Absolutely no)
Question 6: Would you undergo surgery to change the appearance of your nose or to improve your
1 (Very likely yes)
AC C
0 (Certainly yes)
EP
breathing?
2 (Possibly yes)
3 (Probably no)
4 (Certainly no)
ACCEPTED MANUSCRIPT Question 1: Nasal form (frontal view) 1 (very good appearance)
2 (good appearance)
3 (fair appearance)
4 (poor appearance)
5 (very poor appearance)
3 (fair appearance)
4 (poor appearance)
5 (very poor appearance)
3 (fair appearance)
4 (poor appearance)
1 (very good appearance)
2 (good appearance)
1 (very good appearance)
2 (good appearance)
SC
Question 3: Shape of the vermilion border
Question 4: Nasal profile including upper lip
3 (fair appearance)
EP AC C
4 (poor appearance)
M AN U
2 (good appearance)
TE D
1 (very good appearance)
RI PT
Question 2: Symmetry of the nose
5 (very poor appearance)
5 (very poor appearance)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT