Functional outcomes of cleft lip surgery. Part I: Study design and surgeon ratings of lip disability and need for lip revision.

OBJECTIVE: Children with a cleft of the upper lip exhibit obvious facial disfigurement. Many require multiple lip surgeries for an optimal esthetic result. However, because the decision for lip revision is based on subjective clinical criteria, clinicians may disagree on whether these surgeries should be performed. To establish more reliable, functionally relevant outcome criteria for evaluation and treatment planning, a clinical trial currently is in progress. In this article, the design of the clinical trial is described and results of a study on subjective evaluations of facial form by surgeons for or against the need for lip revision surgery are presented. DESIGN: Parallel, three-group, nonrandomized clinical trial and subjective evaluations/ratings of facial views by surgeons. SUBJECTS: For the clinical trial, children with repaired cleft lip and palate scheduled for a secondary lip revision, children with repaired cleft lip and palate who did not have lip revision, and noncleft children. For the subjective evaluations, surgeons' facial ratings of 21 children with repaired cleft lip. ANALYSIS: Descriptive and Kappa statistics assessing the concordance of surgeons' ratings of (a) repeated facial views and (b) a recommendation of revision on viewing the prerevision and postrevision views. RESULTS: The surgeons' consistency in rating repeated views was moderate to excellent; however, agreement among the surgeons when rating individual participants was low to moderate. CONCLUSIONS: The findings suggest that the agreement among surgeons was poor and support the need for more objective measures to assess the need for revision surgery.

Report of altered sensation in patients with cleft lip.

OBJECTIVE: To determine whether patients with cleft lip have normal perioral sensation. DESIGN: Each subject was carefully questioned about the following: sensation in the face at rest, light touch of different areas, and sensation in natural situations (e.g., exposure to cold weather) that reveal sensory abnormalities. A cotton-tip applicator stick was stroked lightly across the facial skin. The subject's descriptions of the evoked sensations were used to identify and outline areas with abnormal sensation. SETTING: Data were obtained from subjects participating in a longitudinal, university-based study of the functional outcomes of lip revision surgery. PATIENTS: Seventeen patients with cleft lip and 12 control subjects (aged 7 to 22 years, mean 12.9 years) participated. RESULTS: In contrast to control subjects, 9 of 16 patients (56%) reported loss in sensation, described as decreased touch, scratch, tickle, or tingle intensity. Six other patients (38%) reported additional sensation, described as increased scratch, tickle, or tingle intensity. In eight patients, the altered sensation was restricted to the skin area flanking and including the visible scar, encompassing no more than 25% of the total area bound by the inferior nose, nasolabial grooves and inferior vermilion. In seven patients (unilateral cleft), the altered area extended to the contralateral, noncleft side of the upper lip or onto the philtrum. CONCLUSIONS: In contrast to the literature, sensation in the upper lip of many patients with cleft lip is not normal. Loss in sensation is exhibited most commonly and limited largely to the skin overlying tissues traumatized during reconstructive surgery.