**7. Outcomes assessments repair**

*"It is very difficult to understand the effectiveness of our actions without measurements."*

—Steve Killelea

Most outcome studies for unilateral cleft lip‐nose repair are single‐surgeon experiences with their preferred techniques [39]. Outcomes are measured with postoperative photographs that assess various anatomic landmarks and features. Other studies compare results as surgeon's technique change over time [40, 41].

AmeriCleft, a large, multicenter study in the U.S., validated the use of the Asher‐McDade rating scale, to audit four different institutions each with their own protocols [42]. The Asher‐McDade system stratifies cleft patients on a seven‐point scale in each of the following nasolabial characteristics [43]:

a. Nasal form

**6.7. Hard palate repair at the time of lip repair**

88 Designing Strategies for Cleft Lip and Palate Care

cartilage and its translocation into normal position.

cleft side lower lateral alar cartilages to a symmetrical position.

**6.8. Primary nasal repair**

*6.8.1. McComb's technique*

*6.8.2. Anderl's technique*

and sutured to the anterior nasal spine.

Sommerlad advocates the Oslo Protocol for closure of the hard palate: a single‐layer mucop‐ erichondral flap of the vomarine septum simultaneous with primary cleft lip repair [34]. While the lip is incised and retracted, tissue exposure is optimal to the anterior palate. This tech‐

**Figure 15.** (A) Schematic representation of closure of a cleft repair with the cupid's bow under‐rotated. The incisions for a second, smaller Z‐plasty above the white roll are planned. (B) Schematic representation of the closure of Z‐plasty.

Early nasal reconstruction is important for the patient's self‐esteem from a young age, and eliminates the need for correction of worsening nasal deformities as one matures and grows. The reparative success of cleft nasal deformity is dependent on dissection that frees the alar

McComb's technique lifts the alar cartilage with its vestibular lining to shorten the cleft‐side nose [36]. Dissection in a subcutaneous plane is performed from the upper buccal sulcus and also through the columella to release the medial and lateral crura. The dissection then is extended from the nostril rim to the tip, dorsum, and nasion. The alar lift is achieved with either one or two mattress sutures through the nasal lining at the intercrural angle, raising the

The Anderl technique utilizes the incisions made for cleft lip repair and wide undermining of the nasal skin. The Anderl technique has extensive mobilization by undermining of the nasal dorsum, supraperiosteal dissection on the surface of maxilla from the vestibule to the infraorbital rim and from the piriform aperture to the maxillary tuberosity [37]. This maneuver allows for greater medial excursion of the lateral element during repair of the lip and nose. The cartilaginous septum is also released from its base attachment to the hard palate, straightened

nique seems not to have unfavorable outcome on maxillofacial growth [35].


The EuroCleft, a large multicenter European study, found that physical metrics correlated poorly with satisfaction [44]. Furthermore, there are few studies that examine the functional‐ ity and quality of life of cleft patients postoperatively [45]. Future metric systems should be comprehensive, incorporating all patient‐related outcomes in a cleft population.
