See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/14051795

Evaluation of the Results of Cleft Lip and Palate Surgical Treatment:

Preliminary Report

Article  in  The Cleft Palate-Craniofacial Journal · June 1997

DOI: 10.1597/1545-1569(1997)034<0247:EOTROC>2.3.CO;2 · Source: PubMed

CITATIONS READS

26 425

6 authors, including:

Youri Anastassov Jean-François Kulik

Medical University of Plovdiv Université de Lille
24 PUBLICATIONS   160 CITATIONS    16 PUBLICATIONS   198 CITATIONS   

SEE PROFILE SEE PROFILE

Philippe Pellerin
Centre Hospitalier Régional Universitaire de Lille
235 PUBLICATIONS   1,967 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

sport and AS View project

rare craniomaxillofacial malformations View project

All content following this page was uploaded by Jean-François Kulik on 06 April 2016.

The user has requested enhancement of the downloaded file.

New Diagram for Cleft Lip and Palate Description: The Clock Diagram
Percy Rossell-Perry, M.D.

Objectives: The current classification diagrams for cleft lip and palate are
descriptions of the components involved in the cleft, but they do not consider in
detail the severity of distortion. We sought to establish a new diagram (the
Clock Diagram) for cleft lip and palate, which describes the pathology according
to the severity of distortion of the nose, lip, and primary and secondary palate,
and to apply this classification scheme toward treatment selection.
Methods: The method is based on surgical results obtained from 1043 cleft lip
and palate patients operated by the author between 1996 and 2007, under the
protocol based on our classification. To further illustrate the classification and
diagram method, two types of clefts are described, using the proposed diagram
and compared with Kernahan’s diagram.
Results: This new diagram describes the cleft’s severity using terminology
from our clinic’s classification of cleft severity. In comparison with Kernahan’s
diagram, the Clock Diagram more effectively demonstrates a cleft’s severity. I
have observed a higher incidence of lip and palate revision in severe clefts.
Conclusions: The Outreach Program Lima Clock Diagram classifies the
severity of the cleft and affords an individualized description of cleft
morphology. I have observed a direct relation between cleft severity and the
number of poor outcomes in our patients.

KEY WORDS: classification, cleft lip and palate, diagram, severity

A common question in cleft reconstruction is, Should we ative results. Its disadvantage is that it has been applied only
use the same treatment for any kind of cleft lip and palate? to unilateral clefts and does not consider the width of the
We do believe the answer is no because the morphology of cleft. Smith et al. (1998) described a more comprehensive
clefts varies. There is a need for a new classification and classification, but this is based on Kernahan’s description,
diagram that will allow for the most complete cleft which considers the clefts as complete or incomplete only.
description possible involving the four basic components Ortiz-Posadas et al. (2001) published a new classification
of the cleft: nose, lip, primary palate, and secondary palate. based on cleft severity that included a very good description
The current classifications for cleft lip and palate are of the cleft deformity. However, their scheme is too extensive
descriptions of the components involved in the cleft, but and difficult to remember and did not include a new
they do not consider the severity of its distortion and diagram. In addition, the secondary palate is described in a
diagrams. The Kernahan and Stark’s classification and manner similar to traditional classifications.
diagram is one of the most used around the world. This All these approaches have attempted to characterize
diagram shows us which anatomic segment is involved but many features of cleft lip and palate, but they consider the
not how severely it is affected (Kernahan and Stark, 1958). patient’s anatomy in a limited form or represent a
During recent years, new classifications and diagrams classification that is difficult to remember and apply. In
have been developed that provide more specific cleft addition, most of these new descriptions do not include a
descriptions. Based on the striped Y diagram (Kernahan, new diagram. The severity of the cleft is one of the most
1971), other authors described some modifications, but they important elements to be considered in presurgical plan-
did not develop a new diagram (Friedman et al., 1991; ning. The use of presurgical orthopedics and modifications
Schwartz et al., 1993). Mortier and Martinot (1997) of traditional surgical techniques are examples of individ-
developed a scale that included preoperative and postoper- ualized management of the more severe forms of cleft lip.
This work illustrates the design of a new diagram for cleft
lip and palate that is based on the degree of severity of the
Dr. Rossell-Perry is Medical Director, Interplast Foundation Outreach four basic cleft components: nose, lip, primary palate, and
Surgical Center, Lima, Peru. secondary palate.
Presented at the 10th International Congress on Cleft Lip and Palate and
Related Craniofacial Anomalies, Durban, South Africa, September 2005. METHODS
Submitted August 2008; Accepted October 2008.
Address correspondence to: Percy Rossell-Perry, M.D., Schell Street 120,
Apartment 1503, Miraflores, Lima, Peru. E-mail [email protected]. The method used is based on surgical results obtained
DOI: 10.1597/08-070.1 from 1043 patients with cleft lip and palate who were

305
306 Cleft Palate–Craniofacial Journal, May 2009, Vol. 46 No. 3

TABLE 1 Unilateral Cleft Lip Classification of Severity

Outreach Surgical Center, Lima, Peru

Type Nose Primary Palate Lip

A. Mild Mild Cleft less than 5 mm A1. Cupid’s bow less than 30 degrees
A2. Cupid’s bow between 30 and 60 degrees
A3. Cupid’s bow higher than 60 degrees
B. Moderate Moderate Cleft between 5 and 15 mm B1. Cupid’s bow less than 30 degrees
B2. Cupid’s bow between 30 and 60 degrees
B3. Cupid’s bow higher than 60 degrees
C. Severe Severe Cleft wider than 15 mm C1. Cupid’s bow less than 30 degrees
C2. Cupid’s bow between 30 and 60 degrees
C3. Cupid’s bow higher than 60 degrees

TABLE 2 Bilateral Cleft Lip Classification of Severity

Outreach Surgical Center Program, Lima, Peru

Type Nose Primary Palate Lip

A. Mild Columella 1/3 to 2/3 of nasal length Cleft less than 5 mm Prolabium 2/3 or more of lateral segment length
B. Moderate Columella up to 1/3 of nasal length Cleft between 5 and 15 mm Prolabium 1/3 to 2/3 of lateral segment length
C. Severe No nasal columella Cleft wider than 15 mm Prolabium 1/3 or less of lateral segment length

operated by the author, under the protocol guided by our c) Severe: There is horizontal, vertical, and posterior
classification system (Tables 1, 2, and 3), from 1996 to 2007 displacement of the nose.
(Rossell, 2006).
In all cases, we performed a presurgical estimation of the Bilateral Cleft Lip (Fig. 2, above)
measurements (Table 3). I used the Millard technique and a
a) Mild: The columellar length is 2/3 to 1/3 of nasal height.
modification (Reichert-Millard technique) for unilateral
b) Moderate: The columellar length is up to 1/3 of nasal
cleft lip repair, a modified Mulliken technique for bilateral
height.
cleft lip repair, and the Bardach technique for cleft palate
repair (Millard, 1990; Rossell, 2008). c) Severe: There is no visual evidence of the columella.
To further illustrate the classification and diagram
method, two cases with different clefts are described using TABLE 3 Outreach Surgical Center Lima, Protocol
the proposed diagram and are compared with others. For
cleft lip and palate description, I use the four basic Outreach Surgical Center, Lima, Cleft Lip Protocol
components: nose, lip, primary palate, and secondary Type Cleft Morphology Technique Time
palate.
Mild Microform Mulliken 3 months old
Unilateral complete or Reichert-Millard 3 months old
Nose incomplete
Bilateral complete or Mulliken modified 3 months old
incomplete
Changes in nasal components affect mainly the cartilage Alveolar cleft Alveolar bone graft 6–8 years old
structures. One of the most important affected components Moderate Unilateral complete cleft Reichert-Millard 3 months old
Bilateral complete cleft Mulliken modified 3 months old
of the nose is the lower lateral cartilage. This cartilage will Moderate nose deformity Primary rhinoplasty 3 months old
be displaced in three directions in relation to cleft severity, Moderate alveolar cleft Alveolar bone graft 6–8 years old
so we can see three types of nasal deformity in a cleft lip. Severe Unilateral complete cleft Reichert-Millard 3 months old
Bilateral complete cleft Mulliken modified 3 months old
In relation to other components such as the septum and Severe nose deformity Primary rhinoplasty 3 months old
the maxilla, the amount of bony deficiency of the maxilla in Severe alveolar cleft Alveolar bone graft 6–8 years old
particular largely determines the displacement of the nose, Nasoalveolar molding or 1–2 months old
lip adhesion
especially vertically and posteriorly. The deformity of
Outreach Surgical Center Lima, Cleft Palate Protocol
septum and maxilla affects not only nasal morphology
Type Cleft Morphology Technique Time
but also surgical outcomes. Mild Incomplete form Soft palate repair
Index: less than 0.2 Minimal incision 1.5 years old
Unilateral Cleft Lip (Fig. 1, above) Two-flap palatoplasty 1.5 years old
Moderate Index: between 0.2 and 0.4 Two-flap palatoplasty 1.5 years old
Severe Index: greater than 0.4 Soft palate repair 6 months old
a) Mild: There is only horizontal displacement of the nose
Delayed hard palate 1.5 years old
on the cleft side. repair
b) Moderate: There is horizontal and vertical displace- Alveolar molding 1–2 months
old
ment of the nose.
 Rossell-Perry, NEW DIAGRAM FOR CLEFT LIP AND PALATE 307

FIGURE 1 Above: Unilateral nasal component severity. Below: Unilateral lip component severity.

Lip b) Moderate: Cupid’s bow rotation between 30 and 60 degrees.

c) Severe: Cupid’s bow rotation greater than 60 degrees.
There is an absolute soft tissue deficiency in a cleft lip.
This involves all of the anatomic components: skin, muscle, Bilateral Cleft Lip (Fig. 2, below)
and mucosa.
a) Mild: Prolabium height is 2/3 of lateral lip segment
Medial Segment height.
b) Moderate: Prolabium is between 2/3 and 1/3 of lateral
For unilateral cleft lips, I use the cupid’s bow rotation to lip segment height.
estimate the tissue deficiency in the lip component. Therefore, c) Severe: Prolabium height is less than 1/3 of lateral lip
high rotation of cupid’s bow leads to more tissue deficiency in segment height.
the medial lip component; whereas, with a low rotation of
cupid’s bow, less tissue deficiency is seen in the lip. Lateral Segment
For bilateral cleft lips, I use the height of the prolabium
in relation to the height of the lateral lip segment. The tissue deficiency observed is less common in the
I consider three degrees of severity for the lip component lateral segment than in the medial segment. To estimate the
in each type of cleft. severity of this deficiency, I use the difference between cleft
and noncleft sides for unilateral clefts and the difference
between both sides for bilateral clefts.
Unilateral Cleft Lip (Fig. 1, below)
I compare the distance from the noncleft cupid’s bow
a) Mild: Cupid’s bow rotation less than 30 degrees. peak to the noncleft commissure and the distance measured
308 Cleft Palate–Craniofacial Journal, May 2009, Vol. 46 No. 3

FIGURE 2 Above: Bilateral nasal component severity. Below: Bilateral lip component severity.

from the point on the lateral segment where the white roll b) Moderate: Cleft width between 5 and 15 mm.
ends to the commissure on that side for a unilateral cleft lip. c) Severe: Cleft width greater than 15 mm.
The difference between these two segments shows the
severity of the cleft in the lateral segment.
Secondary Palate
Unilateral and Bilateral Cleft Lip
Evaluation of this component should be done before
a) Mild: Difference less than 5 mm.
palatoplasty is performed. The initial evaluation of cleft
b) Moderate: Difference between 5 and 10 mm.
palate width changes after lip repair because of the repaired
c) Severe: Difference greater than 10 mm.
orbicularis oris muscle action.
Estimation of the cleft palate is done by comparing the
In incomplete forms, the presence or absence of
cleft’s width (X) versus the width of both palatal segments
Simonart’s band is not relevant because this tissue is not
(Y1 + Y2) (Fig. 4). This distance has been taken at the
used in lip and nose reconstruction and should, in my
posterior border of the palatine bone between the hard and
opinion, be removed. The presence of this band is
soft palate, from the lateral mucosal and gingival union to
represented in the primary palate component (see below)
the posterior nasal spine.
by number 7 (0 to 5 mm) as a mild cleft deformity (0 mm).
X: Cleft width measured at hard palate posterior border level.
Primary Palate
Y: Palatal segment diameter (right and left) measured at the
same level as X.
I use cleft width to determine a severity grade for
Ratio: X/Y1 + Y2
unilateral and bilateral clefts. In bilateral clefts, the type of
cleft is determined by the more severely affected side.
Under this estimation, the classification for the second-
ary palate component is as follows:
Unilateral and Bilateral Cleft Lip (Fig. 3)
a) Mild: Cleft width less than 5 mm. a) Mild: Ratio is less than 0.20.
 Rossell-Perry, NEW DIAGRAM FOR CLEFT LIP AND PALATE 309

FIGURE 3 Unilateral and bilateral primary palate component severity.

b) Moderate: Ratio is between 0.20 and 0.40. which represent the three degrees of severity: mild,
c) Severe: Ratio is greater than 0.40. moderate, and severe (Fig. 5).
I assign the clock numbers (1 to 12) to each degree of
severity of the four components as follows:
THE CLOCK DIAGRAM
a) Right superior quadrant (nasal deformity).
This is a circle divided into four areas, one for each cleft Degrees: Mild (1), Moderate (2), Severe (3).
component. Each area is subdivided into three segments, b) Right inferior quadrant (medial segment lip and
prolabium deformity).
Degrees: Mild (4), Moderate (5), Severe (6).
(The lateral segment lip deficiency is less common than
the medial segment deformity, so I include its
description in the cleft code—see below.)
c) Left inferior quadrant (primary palate severity).
Degrees: Mild (7), Moderate (8), Severe (9).
(For bilateral clefts, I describe both sides in the
diagram.)
d) Left superior quadrant (secondary palate severity).
Degrees: Mild (10), Moderate (11), Severe (12).

The Cleft Code

The cleft consists of four numbers, one from each cleft

FIGURE 4 Secondary palate component severity. component described on the cleft diagram. These four digit
310 Cleft Palate–Craniofacial Journal, May 2009, Vol. 46 No. 3

RESULTS

The numbers of patients and the types of clefts are shown

in Tables 4 and 5. I use two different cleft types to illustrate
the classification and diagram method and the differences
with Kernahan’s diagram.

Type 1: Unilateral Cleft Lip (Fig. 6)

Two complete unilateral cleft lips are illustrated.

Kernahan’s diagram for these clefts is the same, even
though the clefts differ in severity.
Using the clock diagram and severity classification, we
have a different description for each cleft, in accordance
with differences in anatomy. Each one has a different code,
which is easy to remember also (Fig. 6). Description of the
cleft’s width and degree of lip tissue deficiency is not
addressed on Kernahan’s diagram. The cleft on the right
side has a short lateral segment, and this condition is
FIGURE 5 The clock diagram. represented on the cleft code with the sign (*) beside the
second number (lip component).
codes are simple to obtain from the clock diagram and
provide an accurate description of the severity of the cleft Type 2: Bilateral Cleft Lip (Fig. 7)
deformity.
The sign (*) beside the second number (lip component) Two complete bilateral cleft lips are illustrated. Kerna-
indicates that the lateral segment is too short (Fig. 6). In han’s diagram for these clefts again is the same. The clock
bilateral cases, the left side is represented beside the second diagram shows a different description for each cleft that
number (lip component) (Fig. 7). provides important information for cleft lip and palate

FIGURE 6 Comparison of Kernahan’s method and clock diagram for unilateral cleft lip cases.
 Rossell-Perry, NEW DIAGRAM FOR CLEFT LIP AND PALATE 311

FIGURE 7 Comparison of Kernahan’s method and clock diagram for bilateral cleft lip cases.

management (Fig. 7). Finally, to simplify and encourage this feature represents the most important difference from
use of the system, a quick ‘‘cheat sheet’’ can be made for the other well-described classifications such as Mortier’s and
surgeon by placing the severity tables at the bottom of the Ortiz-Posadas’s. In addition, there is no correlation
page that contains the clock diagram (Fig. 8). between these classifications and the authors’ management
protocols.
DISCUSSION This severity classification and the clock diagram are
related to our management protocol. Severe forms require
This new diagram offers an estimation of cleft severity presurgical treatment to obtain better results and fewer
based on our clinic’s cleft severity classification and better complications. I have observed a higher incidence of lip and
describes individual cleft deformity in comparison with palate revision in severe clefts, as have other authors
Kernahan’s diagram. The code in Kernahan’s method and (Henkel, 1998). In my patients, 66.6% of all cases that need
in others is binary: The anomaly is described as either major secondary revision are severe forms of unilateral and
present or absent. The degree of severity of a cleft is not
taken into consideration. The use of the same diagram and TABLE 5 Unilateral and Bilateral Types of Cleft
code for each anomaly suggests that all components are Type of Unilateral Cleft n %
equally important.
Mild 192 41.73
In our method, evaluation of each feature is not binary; Moderate 181 39.35
three degrees are available for each cleft component, Severe 87 18.91
providing more detailed information with respect to cleft Total 460 100

anatomy. This system is easy to remember and apply, and Type of Bilateral Cleft
Mild 24 19.2
Moderate 36 28.8
TABLE 4 Number of Patients and Type of Cleft Severe 65 52
Total 125 100
Type of Cleft n %
Type of Cleft Palate
Unilateral cleft lip 460 44.1 Mild 50 10.91
Bilateral cleft lip 125 11.9 Moderate 252 55.02
Complete cleft palate 388 37.2 Severe 156 34.06
Incomplete cleft palate 77 7.4 Total 458 100
312 Cleft Palate–Craniofacial Journal, May 2009, Vol. 46 No. 3

FIGURE 8 Cleft description for unilateral cleft lip and palate.

bilateral cleft lip. In addition, severe forms of cleft palate Using our diagram, it is possible to incorporate elements
have a higher incidence of postoperative fistula (73% of that are not considered in other approaches and to describe
fistulas) and of velopharyngeal incompetence (49.52% of all possible clefts. Our method describes unilateral and
VPI cases). bilateral cleft lips and palates, assessing the severity of each
Finally, I must acknowledge that this system has some of the four cleft components. As such, this method provides
shortcomings, such as the absence of lateral segment a very valuable tool for the evaluation of progress in
description on the clock diagram and of other components patient rehabilitation. This severity-based classification and
such as the nasal septum and maxilla. This deficiency clock diagram are directly related to the management
should be improved in the future. protocol used in our clinic (Table 3).

CONCLUSIONS Acknowledgments. I would like to thank Dr. Bill Schneider for his
assistance with native English speaker manuscript revision.

A diagram was developed to characterize clefts according

to their severity. Traditional methods that have been REFERENCES
developed involve diverse cleft characteristics but are
Friedman H, Sayetta R, Coston G, Hussey J. Symbolic representation of
limited in their description or are too cumbersome for cleft lip and palate. Cleft Palate Craniofac J. 1991;28:252–259.
application. In addition, there is no correlation between Henkel K. Incidence of secondary lip surgeries as a function of cleft type
these classifications and management protocols. and severity. Cleft Palate Craniofac J. 1998;35:310–312.
 Rossell-Perry, NEW DIAGRAM FOR CLEFT LIP AND PALATE 313

Kernahan DA, Stark RB. A new classification for cleft lip and palate. Rossell P. New classification of cleft lip and palate’s severity. Acta Medica
Plast Reconstr Surg. 1958;22:435–442. Peruana. 2006;23:59–66.
Kernahan DA. The striped Y: a symbolic classification for cleft lips and Rossell P. Modification of Reichert’s technique based on natural
palate. Plast Reconstr Surg. 1971;47:469–470. landmarks and individual designs for unilateral repair of cleft lip.
Millard DR Jr. Unilateral cleft lip deformity. In: McCarthy JG, ed. Plastic Scand J Plast Reconstr Surg Hand Surg. 2008;42:113–121.
Surgery. Vol. 4. Philadelphia: Saunders; 1990. Schwartz S, Kapala JT, Rajchgot H, Roberts GL. Accurate and systematic
Mortier PD, Martinot VL. Evaluation of the results of cleft lip and palate numerical recording system for the identification of various types of lip
surgical treatment: preliminary report. Cleft Palate Craniofac J. and maxillary clefts. Cleft Palate Craniofac J. 1993;30:330–332.
1997;34:247–255. Smith AW, Khoo AK, Jackson IT. A modification of the Kernahan ‘‘Y’’
Ortiz-Posadas M, Vega-Alvarado L, Maya-Behar J. A new approach to classification in cleft lip and palate deformities. Plast Reconstr Surg.
classify cleft lip and palate. Cleft Palate Craniofac J. 2001;38:545–550. 1998;102:1842–1847.