Surgical Outcomes Program Reviewer’s Guide Cleft Severity Index Surgical Outcomes Evaluation
Cleft Severity Index In unilateral cleft lip patients, varying degrees of displacement and hypoplasia of the lip, nose, and skeletal base produce a graduated severity of dysmorphology. Increasing degrees deformity and separation of skeletal elements causes increasing malposition of the alar base and septum, resulting in progressive nasal deformity from flattening and elongation of the nostril with downward deflection of the alar cartilage. The nostril width ratio (cleft side-noncleft side) has been shown to vary in a linear fashion with unilateral cleft lip nasal deformity and may serve as an independent and objective indicator of severity. The Cleft Severity Index is based on defined guidelines that evaluate the overall appearance of the deformity, and separates patients into five categories according to the severity of their primary deformity. Grade I through Grade 5 cleft lip/nose deformities are defined according to the progressive degree of lip and nose involvement.
Grade 1 includes the least severe deformities and is characterized by minimal nasal deformity, an indented free mucosal margin, and notched vermillion-cutaneous junction extending upward less than one fourth of labial height. This corresponds to the microform or mini-microform designations.
Grade 2 also describes lesser forms of an incomplete labial cleft. Features include a vermillion notch that extends upward more than one fourth of lip height, a muscular depression above the cutaneous cleft into the sill, an obvious nasal deformity (short hemicolumella, dislocated genu, and displaced alar base).
Grade 3 describes more severe forms of incomplete labial cleft, separated from complete cleft lips by the presence of a band of tissue on the nostril floor, often referred to as Simonart’s band. Features include complete clefting of vermillion and muscle, with worsened nasal deformity (short hemicolumella, dislocated genu, and displaced alar base, and progressive deviation of the columella base to the noncleft side).
Grade 4 describes a complete cleft lip with corresponding increasingly severe nasal deformity. There is complete absence of the nasal floor, marked deviation of the columella toward the noncleft side and tip deviation toward the cleft side. The hemicolumella is very short. The cleft side alar base was more posterior than the noncleft side alar base. Progressive dislocation of the genu results in a worsened slump of the lover lateral cartilage, though some degree of residual anatomic alar curvature is often till present. Nostril width ratio (cleft side to non-cleft side) < 2.
Grade 5 deformities are the most severe. There is wide separation between the medial and lateral elements, and a severe nasal deformity. Large cleft width combined with nasal floor absence often results in a wide passage to the nasopharynx that easily accomidates the tongue or endotracheal tube during surgery. There is an extreme columellar angle and marked septal deviation. The nasal tip is greatly deviated toward the cleft side and the hemicolumella is almost entirely deficient. The cleft side alar base is severely displaced laterally from midline, and markedly more posterior and inferior than the noncleft side alar base. The ala is completely splayed across the cleft, often with complete distortion of normal alar curvature. Nostril width ratio (cleft side to non-cleft side) > 2.
Nostril Width Ratio =
NWR =
Nostril Width (cleft side) Nostril width (noncleft side)
NWC NWNC A caliber can be very helpful
Case #1
Grade 1: “Microform Cleft Lip” § § §
Indented free mucosal margin Vermillion-cutaneous notch < 1/4 labial height Minimal nasal deformity
1
Grade 2: “Incomplete Cleft Lip” § § §
Vermillion-cutaneous notch > 1/4 labial height Muscular depression above cleft Nasal deformity (short hemicolumella, dislocated genu, mildly displaced alar base)
Grade 3: “Simonart’s Band” § § § §
Nearly a complete cleft clip Band of tissue on the nostril floor Complete cleft of vermillion and muscle Nasal deformity (short hemicolumella, dislocated genu, displaced alar base, deviation of columellar base to noncleft side)
Grade 4: “Complete Cleft Lip” § § §
§
Complete cleft of vermillion and muscle Absence of nasal floor Severe nasal deformity (very short hemicolumella, marked columellar deviation, posterior displacement of alar base, tip deviation toward cleft side, progressive dislocation of genu, increase slump LLC) Nostril width ratio (cleft side to non-cleft side) < 2
2
3
4
Grade 5: “Wide Complete Cleft Lip” § § § §
§
Wide separation medial and lateral elements Complete absence of nasal floor Wide cleft accommodates tongue Severe nasal deformity (extreme columellar angle , marked septal deviation, nasal tip is greatly deviated toward cleft side, hemicolumella almost entirely deficient, cleft side alar base severely displaced lateral and posterior, ala splayed across cleft, complete distortion of normal alar curvature) Nostril width ratio (cleft side to non-cleft side) > 2
5
Case #2
Surgical Outcomes Evaluation The aim of the GC4 Surgical Outcomes Program is to continuously evaluate the surgical outcomes of temporary and permanent surgeons at GC4, in order to measure quality while providing valuable follow up and feedback to individual surgeons. The Surgical Outcomes Evaluation system utilizes a standardized scale from 0 to 2 for five different elements of the cleft lip repair, which are added to resulting a total score of 0 to 10.
0 = Unsatisfactory
1 = Satisfactory
2 = Good
Symmetry of the Nose
Asymmetry of alar base, horizontal dimension of nostril, alae
Symmetry of alar base and horizontal dimension nostril; asymmetry of alae
Symmetry of the alar base, nostrils, and alae
Symmetry of Cupid's Bow
Markedly shorter or longer lip creating a major distortion of the cupid´s bow
Mildly shorter or longer lip, minor imbalance in the cupid´s bow
Symmetric and balanced cupid´s bow
1 = Satisfactory
0 = Unsatisfactory
2 = Good
Symmetry of the Lateral Lip
Horizontal and vertical asymmetry between the lateral lip elements on both sides
Horizontal or vertical asymmetry of the lateral lip elements on both sides
Horizontal and vertical symmetry between lateral lip elements on both sides
Symmetry of the Free Vermillion Â
Whistle deformity with major distortion of
Mild asymmetry of the free vermillion
Symmetry of the free vermillion with smooth vermillion margin
Symmetry of Wet/Dry Vermillion (Red Line)
Marked mismatch of the red line
Minimal mismatch of the red line
Good reconstruction of red line