Perth scoring system for assessment of the cleft lip

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Linda Monshizadeh
Vijith Vijayasekaran


outcome assessment, research design, observation variation, surveys and questionnaires


Background: Currently, there is no standardised assessment tool to assess facial aesthetics in cleft lip and palate surgery. Inter-centre comparison is hampered by the use of different aesthetic indices with low intra- and inter-rater reliability.

Aim: The Perth scoring system is a new assessment tool for unilateral cleft lip which scores four key components of the cleft lip/nose repair: lip length, white roll, alar insertion point and vermillion. The aim of this study was to validate the Perth scoring system as a reliable and useful new assessment tool and to demonstrate the use of the scoring system to measure improvements after cleft lip revision.

Method: Nineteen patients who underwent cleft lip revision by the senior author were selected. Pre- and postoperative photos were presented to a panel of raters to score. Scores were analysed to determine the intra-and inter-rater reliability and to compare outcomes.

Results: Almost all patients (15/16) had improvement in scores (range 1.09–5.59) after cleft lip revision. Intra raters’ agreement scores from lowest to highest were: lip length (0.65), white roll (0.7), alar insertion point (0.78) and vermillion (0.78). The total intra-class correlation coefficient was 0.96 (0.94–0.98, 95% CI, P<0.000).

Conclusion: This new scoring system is a valid and useful tool for assessment of the unilateral cleft lip. The high rate of intra- and inter-rater reliability allow it to serve as a useful tool to compare surgical outcomes both within and between centres. Further field testing with a larger cohort of patients is required.


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1. Lonergan AR, Bussey K, Mond J, Brown O, Griffiths S, Murray SB, Mitchison D. Me, my selfie, and I: the relationship between editing and posting selfies and body dissatisfaction in men and women. Body Image. 2019 Mar;28:39–43. PMid:30572289
2. Fardouly J, Rapee RM. The impact of no-makeup selfies on young women's body image. Body Image. 2019 Mar;28:128–134. PMid:30665030
3. Mills JS, Musto S, Williams L, Tiggemann M. ‘Selfie’ harm: effects on mood and body image in young women. Body Image. 2018 Dec;27:86–92.. PMid:30149282
4. Klassen AF, Riff KWW, Longmire NM, Albert A, Allen GC, Aydin MA, Baker SB, Cano SJ, Chan AJ, Courtemanche DJ, Dreise MM, Goldstein JA, Goodacre TEE, Harman KE, Munill M, Mahony AO, Aguilera MP, Peterson P, Pusic AL, Slator R, Stiernman M, Tsangaris E, Tholpady SS, Vargas F, Forrest CR. Psychometric findings and normative values for the CLEFT-Q based on 2434 children and young adult patients with cleft lip and/or palate from 12 countries. Can Med Assoc Jl. 2018;190(15):e455–e462. PMid:29661814 PMCid:PMC5903887
5. Carroll K, Mossey PA. Anatomical variations in clefts of the lip with or without cleft palate. Plast Surg Int. 2012:542078. PMid:23251795 PMCid:PMC3517834
6. Mosmuller DG, Griot JP, Bijnen CL, Niessen FB. Scoring systems of cleft-related facial deformities: a review of literature. Cleft Palate Craniofac J. 2013;50:286–296. PMid:23030761
7. Al-Omari I, Millett DT, Ayoub AF. Methods of assessment of cleft related facial deformity: a review. Cleft Palate Craniofac J. 2005;42:145–156. PMid:15748105
8. Al-Omari I, Millett DT, Ayoub A, Bock M, Ray A, Dunaway D, Crampin L. An appraisal of three methods of rating facial deformity in patients with repaired complete unilateral cleft lip and palate. Cleft Palate Craniofac J. 2003;40:530–537.
9. Sharma VP, Bella H, Cadier MM, Pigott RW, Goodacre TE, Richard BM. Outcomes in facial aesthetics in cleft lip and palate surgery: a systematic review. J Plast Reconstr Aesthet Surg. 2012;65:1233–1245. PMid:22591614
10. Asher-McDade C, Roberts C, Shaw WC, Gallagher C. Development of a method for rating nasolabial appearance in patients with clefts of the lip and palate. Cleft Palate Craniofac J. 1991;28:385–390.
11. Kuijpers-Jagtman AM, Nollet PJ, Semb G, Bronkhorst EM, Shaw WC, Katsaros C. Reference photographs for nasolabial appearance rating in unilateral cleft lip and palate. J Craniofac Surg. 2009;20:1683–1686 PMid:19816333
12. Shaw WC, Asher-McDade C, Brattstrom V, Dahl E, McWilliam J, Molsted K, Plint DA, Prahl-Andersen B, Semb G, The RP. A six-center international study of treatment outcome in patients with clefts of the lip and palate: part 4. Assessment of nasolabial appearance. Cleft Palate Craniofac J. 1992;29:409–412. PMid:1472518
13. Mercado A, Russell K, Hathaway R, Daskalogiannakis J, Sadek H, Long RE Jr, Cohen M, Semb G, Shaw W.The Americleft study: an inter-center study of treatment outcomes for patients with unilateral cleft lip and palate part 4. Nasolabial aesthetics. Cleft Palate Craniofac J. 2011; 48:259–264. PMid:21219227
14. Mosmuller DG, Bijnen CL, Kramer GJ, Disse MA, Prahl C, Kuik DJ, Niessen FB, Don Griot JP. The Asher-McDade aesthetic index in comparison with two scoring systems in nonsyndromic complete unilateral cleft lip and palate patients. J Craniofac Surg. 2015 Jun;26(4):1242–5.. PMid:26080166
15. Asher-McDade C, Roberts C, Shaw WC, Gallager C. Development of a method for rating nasolabial appearance in patients with clefts of the lip and palate. Cleft Palate Craniofac J. 1991;28:385–391.
16. Tobiasen JM, Hiebert JM, Boraz RA. Development of scales of severity of facial impairment. Cleft Palate Craniofac J. 1991;28: 419–424.<0419:DOSOSO>2.3.CO;2 PMid:1742313
17. Campbell A, Restrepo C, Deshpande G, Tredway C, Bernstein SM, Patzer R, Wendby L, Schonmeyr B. Validation of a unilateral cleft lip surgical outcomes evaluation scale for surgeons and laypersons. Plast Reconstr Surg Glob Open. 2017;5(9):e1472. PMid:29062644 PMCid:PMC5640349
18. Howells DJ, Shaw WC. The validity and reliability of ratings of dental and facial attractiveness for epidemiological use. Amer J Orthodontics. 1985;88:402–408.
19. Shaw, WC. Semb G, Nelson P, Brattström V, Mølsted K, Prahl-Andersen B, Gundlach KK. The Eurocleft project 1996–2000: overview. J Cranio Maxillo Surg. 2001(29);131–140, discussion 141–132. PMid:11403549
20. Zhu S, Jayaraman J, Khambay B. Evaluation of facial appearance in patients with cleft lip and palate by laypeople and professionals: a systematic literature review. Cleft Palate Craniofac J. 2016;53(2):187–196. PMid:25650654