**6. Esthetic outcomes**

While complications following cleft lip repairs are widely reported in the literature, esthetic outcomes are rarely assessed. Furthermore, esthetic outcomes after cleft lip repair in LMICs are rarely, if ever, reported. The goals of any quality improvement initiative are not only to reduce complication rates, but also to help patients achieve the best possible esthetic result from their surgery. To that end, OS started the Surgical Outcomes Program (SOP) which aims to critically evaluate post-operative results after cleft lip repair using validated instruments.

The Unilateral Cleft Lip Severity Index was developed as a tool for analyzing and categorizing unilateral cleft lip deformities according to the amount of lip involved and the degree of nasal asymmetry (**Figure 5**) [31]. The severity index was validated in a study measuring the inter-rater reliability of the tool when used by both surgeon and laypersons. Twenty-five participants (10 surgeons and 15 laypeople) evaluated 25 sets of pre-surgical photographs of unilateral cleft lip patients. Inter-rater reliabilities for both groups were categorized as very good (ICC > 0.8). The severity index is used in conjunction with the Surgical Outcomes Evaluation Scale, which grades the esthetic outcome of a unilateral cleft lip repair based on the symmetry of the nose, cupid's bow, lateral lip, and free vermilion (**Figure 6**) [32]. A similar validation study was performed for the outcomes evaluation scale in which 20 participants (9 surgeons and 12 laypeople) evaluated 25 sets of post-operative photographs. Inter-rater reliabilities were 0.71 for surgeons and 0.82 for laypeople. The validation of these tools for use by non-medical personnel is important as they were designed to be used in resource-limited settings by mission teams composed of a few surgeons and many non-medical personnel.

The Unilateral Cleft Lip Severity Index and Surgical Outcomes Evaluation Scale are now utilized globally and provide feedback regarding outcomes to volunteer surgeons as well as OS administrators with a relatively short turn-around time. In order to aid in the interpretation of results, a retrospective study was performed applying the severity index and outcomes evaluation scale to 1823 patients who had undergone unilateral cleft lip repair by OS during missions in various countries and at GCCCC [33]. The results of this study established a normative bell curve of outcomes for each severity of unilateral cleft lip deformity (**Figure 7**). Based on these normative values, a surgeon can see where his or her results fall in the range of results for a given severity of cleft. Surgeons who fall on the upper end of the spectrum can

#### **Figure 5.**

*Criteria and examples demonstrating each of the 4 grades of the cleft severity index.*

### **Figure 6.**

*Each element is scored on a 3-point scale: 2 (excellent), 1 (mild asymmetry), 0 (unsatisfactory). The scores of the 4 individual components are then summed for a total score of 0 (lowest) to 8 (highest).*

provide coaching to less experienced surgeons, and results that fall below a standard deviation of the average can be investigated for root cause analyses.

The next steps in OS's mission to provide the best quality care to cleft patients in LMICs will be to use the cleft severity index and outcomes evaluation scale to study

**45**

**7. Conclusion**

**Figure 7.**

with a cleft.

*Optimizing Outcomes in Cleft Surgery*

*line represents the maximum possible score.*

*DOI: http://dx.doi.org/10.5772/intechopen.89882*

whether certain interventions or models of care delivery improve esthetic outcomes after cleft lip repair. The routine use of these tools in OS's work around the world provides a means of quality control and ensures that patients in LMICs receive the

*Bell curve of normative surgical outcomes evaluation scores for each of the cleft severities (1 through 4). Dotted* 

Cleft care in LMICs has grown tremendously over the past few decades through the work of charitable organizations and individuals. However, complication rates in this setting have historically been high, and much work is needed to improve the quality of care delivered. Through outcomes analysis and a strong focus on patientcentered care, it is possible to achieve substantial, measurable improvements in the care provided to patients. OS's work over the past decade is evidence that the diagonal model of care delivery can be effective. If charitable foundations are to improve health care equity around the globe, they must work with the intention of building capacity and transferring responsibilities to the local community. By emphasizing research and continuous quality improvement, these organizations will continue to make great strides toward making top-quality care accessible to every child born

same high level of care as patients in the developed world.
