Surgical Outcomes Program Reviewer’s Guide  

Cleft Severity Index

Surgical Outcomes Evaluation

 

Bilateral Cleft Severity Index  

In bilateral cleft lip patients, varying degrees of displacement and hypoplasia of the lip, nose, and skeletal base produce a graduated severity of dysmorphology. Increasing degrees of deformity and separation of skeletal elements causes increasing malposition of the premaxilla, alar bases, and septum resulting in progressive nasal deformity from flattening and elongation of the nostril and downward deflection of the alar cartilage. The Cleft Severity Index is based on defined guidelines that evaluate the overall appearance of the deformity, and separates patients into four categories according to the severity of their primary deformity. Grade I through Grade 4 cleft lip/nose deformities are defined according to the progressive degree of lip and nose involvement.

Grade 1 describes the least severe incomplete / incomplete bilateral cleft lip. Features include an incomplete cleft on both sides and relatively a mild nasal deformity (mildly displaced alar bases and widened nasal sills).

Grade 2 describes incomplete / complete bilateral cleft lip, with worsened nasal deformity (short columella, displaced alar bases, and frequent deviation of the columella to one side).

Grade 3 describes the less severe form of complete/complete bilateral cleft lip. The premaxilla is aligned with the maxillary arch or mildly protruded. In the basal view the junction point (*) between de mucosa of the prolabium with the mucosa of the premaxilla is posterior to a line between the alar bases ( ). There is increasingly severe nasal deformity with a very short columella, absence of nasal floor bilaterally, and worsened displacement of both alar bases with slump of the lower lateral cartilages (LLC).

Grade 4 describes the more severe form of complete / complete bilateral cleft lip. There is typically wide separation between the medial and lateral elements, and a severe nasal deformity. There is an extremely short columella and marked septal deviation if the premaxilla is deviated towards one side. The alar bases are severely displaced laterally from midline, and markedly more posterior. The premaxilla is severely protruded and anterior to the lateral lip elements. In the basal view the junction point (*) between de mucosa of the prolabium with the mucosa of the premaxilla is at or anterior to a line between the alar bases ( ).

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Grade 1: “Incomplete/Incomplete” § Bilateral Incomplete Cleft Lip § Mild nasal deformity (short hemicolumella, mildly

displaced alar base)

Grade 2: “Complete/Incomplete” § Complete/Incomplete cleft lip § Asymmetric nasal deformity (short hemicolumella,

dislocated genu, displaced alar base, deviation of columellar base to one side)

Grade 3: “Complete/Complete” § Complete/Complete cleft lip § Absence of nasal floor in both sides § Severe nasal deformity (very short hemicolumella,

posterior displacement of alar base, progressive dislocation of genu, increase slump LLC)

§ In the basal view the junction point (*) between the mucosa of the prolabium with the mucosa of the premaxilla is posterior to a line between the alar bases ( ).

Grade 4: “Severe Complete/Complete” § Premaxilla is severely protruded, being anterior to the

lateral lip elements and often deviated § Wide separation medial and lateral elements § Large clefts accommodate tongue § Bilateral complete absence of nasal floor § Severe nasal deformity (very short columella, marked

septal deviation, nasal tip deviation, alar bases severely displaced lateral and posterior)

§ In the basal view the junction point (*) between the mucosa of the prolabium with the mucosa of the premaxilla is at or anterior to a line between the alar bases ( ).

 

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4  

2  

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Example #2  Example #1  

 

Surgical Outcomes

Nose

-Symmetry of nostrils in horizontal dimension

-Symmetric horizontal alar base insertion

Philtrum -Symmetry of philtral columns

-Philtral Width same or less to colummela witdh

-Precise apposition of white roll

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Lateral Lip -Symmetry of horizontal distances: commissure – cupid bow peak

-Symmetry of vertical fullness / thickness

Free Vermillion

-Symmetric and smooth free vermillion border

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Standardized Evaluation of Four Components of the Bilateral Cleft Lip

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Surgical Outcomes Evaluation  

2 = Excellent

Standardized scale (0, 1, 2) to grade four different elements of the bilateral cleft lip repair. Grades are added for an overall score (0 - 8).

1 = Satisfactory Ideal

Horizontal and vertical asymmetry of lateral lip elements

Horizontal or vertical asymmetry of lateral lip elements

Horizontal and vertical symmetry of lateral lip elements

0 = Unsatisfactory

Nose -Symmetric horizontal dimensions of nostrils

- Symmetric horizontal alar base insertion

Lateral Lip -Symmetric horizontal distances commissure – cupid bow peak

-Symmetric vertical fullness / thickness

Free Vermillion -Symmetric and smooth free vermillion border

Asymmetry one component: alar base, insertion or horizontal dimension

Mild distortion / asymmetry of vermillion margin and/or red line

Symmetry of alar base insertion and horizontal dimension

Symmetric / smooth vermillion margin and red line

Asymmetry of alar base insertion, and Nostril horizontal dimension

Whistle deformity with major distortion of free vermillion and/or red line

Marked difference in vertical height of philtral columns and wide philtrum

Philtrum symmetric and proportional to colummela

Mildly asymmetric filtrum or midly wide philtrum

Philtrum -Symmetric vertical height of philtral columns

- Width of Philtrum

-Even white roll apposition