Bilateral Cleft Lip Repair Research Articles

Premaxillary Setback in Bilateral Cleft Lip and Palate Repair

It is widely established in the literature that patients with cleft lip and palate (CLP) often display midface dysmorphism. However, there is ongoing debate as to the pathophysiology behind the deficient maxillary growth that leads to this deformity. While some argue that it is a result of hypoplastic tissues inherent to the cleft phenotype, others postulate that it is due to surgical disruption of the maxillary growth centers and postoperative scarring1,2. Bilateral alveolar clefts may render a protruding premaxilla, distorting the soft tissue envelope.

A Systematic Review of Primary Rhinoplasty in Patients With Bilateral Cleft Lip

Primary rhinoplasty (PR)at the time of cleft lip repair is controversial. We previously performed a systematic review that supported PR during unilateral cleft lip repair. We now aim to determine whether the same idea translates to care of patients with bilateral cleft lip. A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement guidelines. PubMed and Embase databases were searched for studies that met our inclusion criteria: (1) English language, (2) human subjects, (3) rhinoplasty at the time of bilateral cleft lip repair, and (4) evaluation of nasal outcome. Studies were excluded in case of: (1) inclusion of a large proportion of syndromic patients, (2) case reports, (3) editorials, (4) letters, (5) reviews, and (6) exclusive to unilateral clefts. Out of 281 studies that showed up on initial search, 12 were included in our review. Research quality and level of evidence rating were determined for each study. Of the 12 included studies, 9 supported PR at the time of bilateral cleft lip repair; 8 studies evaluated nasal growth and found no restriction over time; 4 studies followed 158 patients to an average of 15 years and showed 77% did not need secondary rhinoplasty. Although the available literature supports PR in patients with bilateral cleft lip with respect to subjective and objective outcomes, nasal growth, and reducing the need for secondary/revision rhinoplasty, there are significant limitations, necessitating large volume studies.

Premaxillary Setback With Posterior Vomerine Ostectomy and Complete Bilateral Cleft Lip Repair: Report of a Case With Challenging Anatomy.

Congenital clefts of the lip and/or palate are among the most common craniofacial malformations. Patients with bilateral cleft of the lip often present with projected premaxilla. Premaxillary setback with a vomerine ostectomy posterior to the vomero-premaxillary suture, bilateral cleft lip repair, bilateral gingivoperiosteoplasties, and primary cleft lip rhinoplasty are achieved in a single-stage surgery that provides a valuable alternative to patients, especially in the outreach settings. In this article, we present a case report of a patient born with a bilateral cleft of the lip and a protruded premaxilla. He had collapsed secondary palatine shelves requiring intraoperative manual expansion to ensure access to the vomer bone.

Bilateral Cleft Lip Repair: Lessons from History

After studying this article, the participant should be able to: 1. Describe the bilateral cleft lip and nasal deformity and associated anatomical variations. 2. Understand the history and evolution of the bilateral cleft lip repair. 3. Understand the key principles of the surgical repair. This article describes characteristics of the bilateral cleft lip and nasal deformity and its management, including presurgical orthopedics, operative techniques, and postsurgical care.

A Modified Double Z-Plasty for Bilateral Cleft Lip Repair.

Repairing bilateral cleft lip (BCL) with a modified Z-Plasty technique to overcome many complications encountered with other traditional techniques was attempted in a group of Egyptian subjects at the Department of Oral and Maxillofacial Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt between May 2018 to May 2021. The study included 20 patients suffering from primary BCL of both genders with ages ranging from one week to one year. 60% of the patients were female and 40% were males. The modified Z-Plasty technique was used in all patients. Wound healing in all cases was uneventful. No inflammation, infection or wound dehiscence were reported in this study. Postoperative gummy show improved significantly (p=0.001), and 70% of patients had zero postoperative maxillary ridge show as lip lengths improved significantly. The clinical results of the modified double Z-Plasty technique used for closure of BCL were very interesting and avoid scarifying vermillion tissue in addition to the increase of both philtrum length and lip volume. Key Words: Bilateral cleft left lip, Repair, Z-Plasty.

Implementation of an Ambulatory Cleft Lip Repair Protocol: Surgical Outcomes.

Cleft lip repair has traditionally been performed as an inpatient procedure. There has been an interest toward outpatient cleft lip repair to reduce healthcare costs and avoid unnecessary hospital stay. We report surgical outcomes following implementation of an ambulatory cleft lip repair protocol and hypothesize that an ambulatory repair results in comparable safety outcomes to inpatient repair. This is a single-institution, retrospective study. Patients undergoing primary unilateral (UCL) and bilateral (BCL) cleft lip repair from 2012 to 2021 with a minimum 30-day follow-up. A total of 226 patients with UCL and 58 patients with BCL were included. Ambulatory surgery protocol in 2016. Variables include demographics and surgical data including 30-day readmission, 30-day reoperation, and postoperative complications. There were no differences in rates of 30-day readmission, reoperation, wound complications, or postoperative complications between the pre- and post-protocol groups. Following ambulatory protocol implementation, 80% of the UCL group and 56% of the BCL group received ambulatory surgery. Average length of stay dropped from 24 h pre-protocol to 8 h post-protocol. The 20% of the UCL group and 44% of the BCL group chosen for overnight stay had a significantly higher proportion of congenital abnormalities and higher American Society of Anesthesiology (ASA) class. Reasons for overnight stay included cardiac/airway monitoring, prematurity, and monitoring of comorbidities. There were no differences in surgical outcomes between the ambulatory and overnight stay groups. An ambulatory cleft lip repair protocol can significantly reduce average length of stay without adversely affecting surgical outcomes.

Repair of Primary Bilateral cleft Lip

Bilateral cleft lips have traditionally been a challenge to repair and the results have not been very favorable. However, advances in the recent past in the understanding of the nature of the deformity, especially the nasal component have brought a revolutionary change in the approach to these patients, with remarkable improvement in the outcome. The management of the premaxilla and its alignment with the maxillary shelves presurgically is crucial for the optimal treatment of such patients. The treatment protocol and technique followed at our center are described. It is a modification of the Mulliken technique. The philtrum is designed to be small in keeping with its rapid growth potential. The philtral flap is raised and the orbicularis oris muscles from the two sides are mobilized and brought together in the mid-line. Adequate mobilization of the muscles is necessary to avoid closure under tension. The evolution of the concept of primary rhinoplasty is described. The technique of preschool columellar lengthening and open rhinoplasty that is followed at our center is described. Unfavorable results include scarring, dehiscence, and central vermillion deficiency.

Gingivosupraperiosteoplasty following Presurgical Maxillary Orthopedics Is Associated with Normal Midface Growth in Complete Unilateral and Bilateral Cleft Patients at Mixed Dentition.

Passive orthodontic appliances and gingivosupraperiosteoplasty are adjuncts that can be used by surgeons at the time of primary cleft lip repair. These treatments, along with the surgical technique of cleft lip and palate repair, may impact midface growth. The objective of this study was to describe the authors' protocol for unilateral and bilateral cleft lip repair and to evaluate midfacial growth in a cohort of patients at mixed dentition who had undergone presurgical passive orthodontic appliance therapy and gingivosupraperiosteoplasty at the time of unilateral and bilateral cleft lip repair. Fifteen complete unilateral and 15 complete bilateral cleft lip and palate patients underwent passive orthodontic appliance treatment and primary lip repair with gingivosupraperiosteoplasty. Lateral cephalograms were analyzed by three blinded reviewers. Mean cephalometric measurements at mixed dentition were compared to cephalometric values for noncleft patients, unilateral cleft lip and palate patients who did not undergo gingivoperiosteoplasty or presurgical treatment, and unilateral cleft lip and palate patients who underwent gingivoperiosteoplasty/nasoalveolar molding with independent samples t tests. Mean cephalometric values were within age-specific normal values for sella-nasion-A point, sella-nasion-B point, A point-nasion-B point, and facial axis. Eighty-seven (13/15) percent of unilateral cleft lip and palate patients and 93 percent (14/15) of bilateral cleft lip and palate patients did not exhibit skeletal class III malocclusion. There was no significant difference between cephalometric values for our patients and patients who did not receive gingivosupraperiosteoplasty or presurgical treatment or who underwent the gingivoperiosteoplasty/nasoalveolar molding protocol. Presurgical passive orthodontic appliances, combined with gingivosupraperiosteoplasty at the time of lip repair, leads to normal maxillary development in most patients at mixed dentition. Assessment of midface growth at skeletal maturity is required. Therapeutic, IV.

A Guide to Bilateral Cleft Lip Markings: An Anthropometric Study of the Normal Cupid's Bow.

The aim of this study was to define the ratio of the heights of the vermilion between the peaks and trough of the Cupid's bow and hence assist in defining the point of closure on the lateral lip element to achieve a balanced Cupid's bow in bilateral lip repair based on our findings. This study is a retrospective observational study of the anthropometrics of the upper lip's Cupid's bow. Three-dimensional (3D) images of toddlers between 2009 and 2016 were extracted from a normative 3D image database of toddlers at the Royal Children's Hospital, Melbourne. Participants from the normative 3D image database at the age of 1 year were studied. This excluded any patients with prior trauma or surgical intervention of the nasolabial region. Landmarks measured were right and left crista philtri (cphR and cphL), labial superius (ls), stomion (sto), right and left chelion, and labial fissure (lf). Vermilion height of the right peak, trough, and left peak of the Cupid's bow was calculated by analyzing the vertical linear distance between cphR-lf, ls-sto, and cphL-lf. The ratio between the median and paramedian heights were recorded. The paramedian height of the upper lip vermilion is consistently greater than the midline height. There was no significant sexual dysmorphism between ratio of paramedian to midline height on the right (P = .538) and left (P = .410). We describe an anthropometric observation of the vermilion relationship at the Cupid's bow and define a specific lateral lip marking for bilateral cleft lip repair based on our anthropometric findings.

Repair of Asymmetric Bilateral Cleft lip: 1 Stage or 2 Stage.

To verify the advantages and indications of 1-stage and 2-stage repair for asymmetric bilateral cleft lip (BCL). Retrospective study. From January 2004 to December 2016 in our department. Patients with BCL. Over 6 months after the operation, the surgery outcomes were evaluated and graded by 2 experienced surgeons. The result of surgery was evaluated using the scoring method of Mortier et al and Anastassov and Chipkov. Among 133 patients with asymmetric BCL, 61 (45.9%) had 1-stage repair and 72 (54.1%) had 2-stage repair. Sixty-eight (51.1%) patients had complete-incomplete cleft lip (CL), and those who underwent 1-stage repair showed a trend of better outcome (P = .028). Fifty (37.6%) patients with incomplete-microform CL showed no significant difference between the outcomes of 2 surgery plans (P = .253). In 15 (11.3%) patients with complete-microform CL, only one had 1-stage repair with a score of 8.5. The other 14 patients with 2-stage repair were scored 3.68 ± 1.28. Two-stage repair was preferable when the deformity degree was very different on 2 sides, as it could reduce unnecessary scar tissue and extend the nasal columella. One-stage repair could help to achieve the anatomical reduction of the orbicularis oris and a better contour of the vermilion tubercle. One-stage repair is recommended for patients with complete-incomplete CL and incomplete-microform CL. Two-stage repair for patients with complete-microform CL is preferred in our center, but more studies are required to support this conclusion.

Nasolabial appearance of bilateral cleft lip repair at five years of age. Comparing techniques of modified advancement-rotation (Delaire) with Manchester repair: a retrospective cohort study

The techniques used to repair bilateral cleft lip have evolved over time, yet little data exist to compare outcomes using the various techniques. The aim of this study was to retrospectively evaluate and compare the aesthetic outcomes of two types of complete bilateral cleft repair: advancement rotation and a historic cohort repaired with the Manchester technique. A total of 32 consecutive patients who had complete repair of bilateral cleft lips were identified retrospectively from our centre using inpatient records. The first 16 (born between 1994 and 2005) underwent the Manchester repair, the second 16 (born between 2006 and 2010) a Delaire modified advancement rotation technique. Standardised photographs were taken at five years post repair and cropped to isolate the nasolabial component. Appearance outcomes were assessed by 20 members of the cleft and plastic surgery team, who were each asked to rate all 32 images using the Asher-McDade five-point scale. A chi squared test was used to determine whether there was a statistically significant difference in cleft scores between the two approaches. There was a mean (SD) of 2.8 (1.02) in the advancement rotation group and a mean (SD) of 3.1 (1.07) in the Manchester group. There was a statistically significant difference in the distribution of scores in the advancement rotation group compared with the Manchester group, with lower scores (better results) in the advancement rotation group (p=0.003). This study demonstrates that the advancement rotation technique for the repair of bilateral cleft lip defects resulted in a superior nasolabial appearance when directly compared with the Manchester repair at 5 years of age.

Reducing the Cleft Nose Deformity in Bilateral Cleft Lip Repair.

Repair of a bilateral cleft lip and nose deformity remains a challenge. The nose remains the main persisting stigma for patients, deserving an equal amount of attention as the lip during the repair. We share 3 technical principles to help achieve the optimal nasolabial result and minimize cleft nose deformity after bilateral cleft lip repair. Firstly, cephalad rotation of C-flaps from the prolabium is used to define the nasolabial angle. Secondly, the nasal base and contour is set before the lip repair, as the vectors and tension of nasal repair differ from the vector and tension of the orbicularis oris muscle closure. Thirdly, different suspension and shaping stitches are used to define alar shape and position after lower lateral cartilage release, avoiding additional scars.

Bilateral Complete Cleft Lip Repair: A Step-by-Step Video Series.

Surgeons-in-training learning how to perform cleft surgery should not only acquire a broad repertoire of technical details but also master the proper execution of techniques based on the modern principles of bilateral cleft lip repair with synchronous reconstruction of cleft nose deformity. This article describes a bilateral complete cleft lip repair by adopting these principles, plus a modified composition of mucosal flaps for the nasal floor and intraoral linings, including the prolabial mucosal flap, C-flap mucosal flap, inferior turbinate mucosal flap, and lateral nasal mucosal flap. The accompanying four-part video series presents the step-by-step approach for design and execution of this alternative technique.

NYU Nasoalveolar Molding Protocol: From Birth to Adulthood

INTRODUCTION: One of the most actively debated therapies for patients with a cleft is nasoalveolar molding (NAM). Although supporters cite improvements in nasal symmetry, nasal aesthetics, columellar length, cost benefit, and nasal revision rates, one of the most convincing criticisms of NAM is the absence of reports on its effects at facial maturity, the target timepoint of assessment for cleft care interventions. This study reports clinical outcomes of NAM to facial maturity including rates of revision surgery to the lip and nose, incidence of secondary alveolar bone graft (ABG), and orthognathic surgery (OGS), and effects on facial growth. METHODS: A single-institution retrospective review of patients all with a cleft who underwent NAM protocol from 1990 to 2000. Patients were included in the study if they had a diagnosis of unilateral or bilateral cleft lip and alveolus, with or without cleft palate. Patients were excluded if they had a syndromic diagnosis or if medical and/or dental records were incomplete. Lateral cephalogram measurements of patients with unilateral cleft lip and palate was obtained at 17 years or older and before OGS, if patients received OGS. These measurements were then compared with published Eurocleft cephalometric data. RESULTS: One hundred eighty-nine patients were identified, of which 100 met inclusion criteria. Eighteen patients had cleft lip and alveolus only. The average age at last follow-up visit was 20 years (15–26 years). Average age at time of unilateral cleft lip repair was 4 months (3–7 months), bilateral cleft lip repair 6 months (3–10 months), unilateral palate repair 13 months (4–27 months), and bilateral palate repair 13 months (6–17 months). Gingivoperiosteoplasty (GPP) was performed in 86% (86/100) of patients. ABG was performed in 52% (52/100). Of those who underwent GPP, ABG was avoided in 56% (48/86). A total of 23% (19/82) of patients with both cleft lip and palate required secondary surgery for velopharyngeal insufficiency (VPI), and 8% (4/48) of patients who underwent LeFort I advancement also required surgery for VPI. OGS was performed in 49% (49/100), and revisions to lip and/or nose prior to facial maturity were performed in 49% (49/100). At the time of lip and/or nose revision, 74% (36/49) were older than 14 years. Overall, 17% (17/100) required neither ABG, OGS, nor nose or lip revision. Thirty-four patients with unilateral cleft lip had lateral cephalograms available for analysis. There were no significant differences in SNA (P = 0.44), s-n-pg (P = 0.78), NSL/NL (P = 0.76), NSL/ML (P = 0.61), or n-sp/n-gn × 100 (P = 0.79) when compared with data from Eurocleft centers that used presurgical orthopedics. DISCUSSION: Cleft lip and palate reconstruction were not delayed because of NAM. Surgery for VPI and OGS rates were comparable to those reported in the literature. Facial growth analysis at facial maturity revealed no significant difference when compared with Eurocleft centers other than ANB (P = 0.005). These data suggest that NAM does not inhibit midface growth. Furthermore, ABG was avoided in 56% of patients who underwent GPP; lip and nose revision was avoided in 51%; and ABG, OGS, and any soft tissue revision surgery was avoided in 17%.

Thresholds for Safety of Cleft Lip Surgery in Premature Infants.

The purpose of this study was to delineate optimal age to perform unilateral or bilateral cleft lip repair in premature patients. The American College of Surgeons National Surgical Quality Improvement Program Pediatric data set was queried for unilateral and bilateral cleft lip repairs performed between 2012 and 2017. Complications, readmissions, and reoperations were analyzed in the context of prematurity with appropriate statistics. Degree of prematurity was significantly associated with adverse events (p = 0.001, rs = 0.44). Premature patients with unilateral cleft lip had a significantly decreased risk of adverse events when performing cleft lip repair after 150 days of age [OR, 18.1; p = 0.004; before cutoff, n = 10 of 140 (7.1 percent); after cutoff, n = 0 of 112 (0.0 percent)] in the absence of other risk factors. Premature patients with bilateral cleft lip had a significantly decreased risk of adverse events when performing cleft lip repair after 175 days of age (OR, 16.1; p = 0.010; before cutoff, n = 7 of 33 (21.2 percent); after cutoff, n = 0 of 28 (0.0 percent)] in the absence of other risk factors. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Risk, II.

The Method of Surgical Lip Repair Affects Speech Outcomes in Children With Bilateral Cleft Lip and Palate.

It was hypothesized that lip repair protocols in children with bilateral cleft lip and palate (BCLP) would affect development of bilabial consonants /m/ /b/ /p/. This study compared speech outcomes in 2 surgical groups. A retrospective case note investigation. UK Cleft Centre (2000-2009). Forty-nine children with complete BCLP, of whom 26 had a 1-stage and 23 a 2-stage bilateral cleft lip repair. One-stage cleft lip repair versus a 2-staged cleft lip repair. Bilabial consonant production at 18 months, 3 and 5 years of age. Cleft Speech Characteristics (CSCs) at age 5. At age 18 months, 81% of the 1-stage lip repair group and 4% of the 2-stage lip repair group produced bilabial consonants (P <·0001, Fisher test). At age 3 years, 81% of the 1-stage and 26% of the 2-stage lip repair groups produced bilabial consonants (P =·0133, Fisher test). At age 5 years, both groups had similar bilabial consonant production, but children in the 2-stage lip repair group had more frequent and severe CSCs (P = ·0037, χ2). A 1-stage lip repair for children with complete BCLP resulted in better bilabial consonant production at 18 months and 3 years of age than a 2-stage lip repair. At age 5 years both groups had bilabial consonants but children in the 2-stage lip repair group had worse CSCs. The surgical protocol for bilateral cleft lip repair affected speech outcome in children with BCLP.

Validating the Asher-McDade score to assess facial aesthetic outcomes in 22 consecutive complete bilateral cleft lip repairs

Most scoring systems used to assess facial aesthetics in cleft patients tend to lack consistency, and the absence of an internationally agreed system makes comparison challenging. The most widely used and validated tool is the five-point Asher-McDade index. We note that there are currently no reports (to our knowledge) of its use for scoring outcomes after bilateral cleft lip repair. To validate it for this use, the aim was to describe the outcomes of 22 consecutive bilateral cleft lip repairs assessed using this scale. A retrospective review was undertaken of 22 consecutive patients with bilateral cleft lip repairs performed at our centre. Each patient underwent bilateral advancement rotation repair with a vomer flap on one side at three months followed by repair of the remaining hard palate and an intravelar veloplasty three months later. Standardised photographs were taken five years after repair and were cropped to isolate the nasolabial component. Eleven members of the cleft multidisciplinary team were asked to rate each image on a five-point Likert scale. Statistical analysis was performed using a two-way ANOVA test and intraclass correlation coefficient to interrogate intraobserver and interobserver variance. A total of 22 consecutive patients with complete bilateral cleft lips were photographed. The overall mean (range) score for the repairs was 3.2 (4.3 - 1.8). Two-way ANOVA demonstrated that inter-rater variability accounted for just over 10% (11.23% of the total variance, p < 0.0001). As predicted, the single biggest factor affecting score variability was the patient’s appearance, which accounted for 44.51% of the total variance between scores (p < 0.0001). Intraobserver variance was not found to be significant, accounting for 0.33% of the total variance (p = 0.0006). We demonstrate that the Asher-McDade scoring system is a valid tool to use when assessing bilateral cleft lip repairs. Variance in the patient’s score was significantly related to a true difference in appearance, with only a small percentage of differences being due to intraobserver and interobserver variation.

An Intraoperative Rescue Procedure for the Protruding Premaxilla in the Repair of Complete Bilateral Cleft Lip: Rapid Premaxillary Molding.

Primary reconstruction of complete bilateral cleft lip and palate (BCLP) with protruding premaxilla in one-stage surgery is challenging because of the tension on muscle repair. Such patients are also common in the developing countries. For this condition, we have applied intraoperative "rapid premaxillary molding (RPM)" technique and obtained satisfactory results. We reviewed the data of patients with complete BCLP with protruding premaxilla applying intraoperative RPM including both our institution and cleft missions to developing countries in the past 20 years. Selection criteria were patients receiving either no or insufficient preoperative molding presenting with significant protruding premaxilla, had consecutive follow-ups after surgery. To perform this technique, the surgeon holds the patient's face with both hands and compresses the protruding premaxilla with both thumbs. An intermittent but stable backward pressure is applied to the premaxilla until the segment is gradually flexible. Repeated compression is performed prior to tying the muscle sutures, at which time the premaxilla is retro-positioned and aligned with the lateral maxillary segments. Pre- and postoperative data were evaluated. We have treated a total of 60 patients with complete BCLP with protruding premaxilla applying intraoperative RPM. All patients tolerated the operations and there were no major intra- and postoperative complications including lip dehiscence and vomer fracture. All of them had satisfactory results such as adequate muscle repair and symmetry of the lip and nostrils. The RPM is a reliable and valuable intraoperative adjunct procedure for patients with complete BCLP presenting the protrusive premaxilla.

Two-Stage Repair of Bilateral Cleft Lip: Indications for This Treatment Strategy.

The aesthetic outcomes of a bilateral cleft lip (BCL) are inferior to that of unilateral cases. With this in mind, the authors reviewed our BCL outcomes in patients having a 2-stage repair. Strategies in repair protocols may be employed to improve outcomes in a particular group of patients. All patients who had a 2-stage repair of BCL in the last 17 years were reviewed. This protocol strategy was specifically employed in patients who had a complete cleft lip on one side and an incomplete cleft lip on the opposite side. The complete side was repaired first followed by the incomplete side a minimum of 6 weeks later. The outcomes in patients undergoing the 2-stage repair in this cohort were assessed. There were 25 patients in this group with 15 males and 10 females. The age at the first stage ranged from 3 to 9 months. It was found that the results in this group resulted in better aesthetic outcomes than patients who had a single-stage repair. There was less stigmata of a tension type repair and a more harmonious relationship between the upper and lower lips. It is recommended that a 2-stage strategy be employed in repair of BCL if one side is complete and the other is incomplete.

Validation of the Hubli Grading System for Assessing Unilateral and Bilateral Cleft Lip Outcomes.

When determining whether a cleft lip repair outcome is acceptable, the severity of a patient's cleft at initial presentation must be considered. Currently, there is not a widely agreed upon scale for grading the pre-operative severity or post-operative surgical outcome for patients with unilateral and/or bilateral cleft lip. The aim of this study is to validate the Hubli grading system as a reliable and reproducible system for characterizing cleft lip repair outcomes. Craniofacial surgeon graders independently evaluated 2489 patients from 56 different countries undergoing both unilateral and bilateral cleft lip repair from April 2004 to December 2018. Preoperative severity and postoperative surgical results were assessed, and these grades were combined to determine surgical outcome acceptability based on initial cleft severity. Intrarater and interrater reliability were calculated as percentages of agreement. Intrarater and interrater acceptability scores had an agreement of 94.50% and 87.04%, respectively. These results indicate that using the Hubli grading system, independent raters are able to reliably and reproducibly measure the acceptability of a cleft lip repair. This study validates the use of the Hubli grading system to evaluate the acceptability of unilateral and bilateral cleft lip repairs. This is the largest study to date to evaluate cleft lip severity and repair outcomes, and the Hubli grading system is the only scale to determine the acceptability of surgical outcomes based on initial cleft severity. This system is designed to identify surgeons with sub-optimal outcomes in order to implement timely, individualized training on a global scale.