Do cleft lip and palate patients opt for secondary corrective surgery of upper lip and nose, frequently?

Transcription

1 Nkenke et al. Head & Face Medicine 2013, 9:38 HEAD & FACE MEDICINE SHORT REPORT Oen Access Do cleft li and alate atients ot for secondary corrective surgery of uer li and nose, frequently? Emeka Nkenke 1*, Florian Stelzle 1, Elefterios Vairaktaris 2 and Christian Knifer 1 Abstract Purose: This rosective study was aimed at assessing cleft li and alate (CLP) atients oinions and attitudes towards their uer li and nose and the number of secondary corrective surgical interventions electively undertaken to uer li and nose that were carried out during a 2 year follow-u eriod. Materials and methods: During a 2 year follow-u eriod CLP outatients were recruited for the study who attended follow-u examinations at a cleft li and alate craniofacial center and received a recommendation for secondary corrective facial surgery. The articiants filled in a questionnaire that included questions regarding the atients oinions and attitudes towards aearance of li and nose and need for secondary corrective facial surgery. During an additional interval of 2 years the rate of atients who underwent secondary corrective surgery to li and nose was documented. Results: Out of 362 CLP atients 37 (mean age 13.6 ± 7.6 years) received a recommendation for secondary corrective surgery to uer li and/or nose. 22 atients (mean age 12.6 ± 6.3 years) filled in the questionnaire (resonse rate of 62.1%). The satisfaction with the overall facial aearance following the first corrective oeration was statistically significantly better than the satisfaction with the nose ( =.016). The satisfaction with facial symmetry (5.6 ± 2.0) did not differ statistically significantly from the overall satisfaction with the facial aearance (6.2 ± 1.8; =.093). Significantly fewer atients (n = 9) oted for corrective surgery comared to the number of atients who got the recommendation to have secondary corrective surgery done (n = 22, <.0005). Conclusions: The findings of the resent study may reflect a high overall atient satisfaction with the rimary treatment outcome following surgery for CLP. Perceived atient need for secondary oeration for the li/nose may be as low as 5%. Keywords: Cleft li and alate, Uer li, Facial aesthetics, Nose, Secondary corrective surgery Introduction Facial aesthetics is a relevant asect in a erson s general ercetion of life [1]. There is a growing oularity of cosmetic surgery rocedures all around the world. Individual motivations to ot for aesthetic lastic surgery rocedures include the desire to increase self-confidence, self-esteem, and social interactions [2]. One of the major goals of treatment of atients with cleft li and alate malformations aims at a comarable asect: the achievement * Corresondence: Emeka.Nkenke@uk-erlangen.de Equal contributors 1 Deartment of Oral and Maxillofacial Surgery, Erlangen University Hosital, Glueckstr. 11, Erlangen, Germany Full list of author information is available at the end of the article of an unobtrusive facial aearance. By adoting secondary corrective facial surgery efforts are made to achieve sychological and social well-being for the atient as well as his or her family [3]. The different treatment concets that are followed during childhood, adolescence, and adulthood finally converge in the aim of establishing an unobtrusive facial aearance [4]. A number of different studies have evaluated the facial aearance and/or satisfaction of treated cleft li and alate atients [5-14]. The results are conflicting. Some authors reort that there are no significant differences between aesthetic ratings of rofessionals and lay ersons [6]. On the other hand, it has been shown that rofessionals 2013 Nkenke et al.; licensee BioMed Central Ltd. This is an Oen Access article distributed under the terms of the Creative Commons Attribution License (htt://creativecommons.org/licenses/by/2.0), which ermits unrestricted use, distribution, and reroduction in any medium, rovided the original work is roerly cited. The Creative Commons Public Domain Dedication waiver (htt://creativecommons.org/ublicdomain/zero/1.0/) alies to the data made available in this article, unless otherwise stated.

2 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 2 of 11 rate treated cleft li and alate atients significantly less attractive than lay ersons [5]. A third kind of study reveals that cleft li and alate atients are less satisfied with their facial aearance than rofessionals are [8]. From the conflicting data in the current literature it has been concluded that a better understanding of the differences in facial aesthetics ercetions would be a relevant aid in revisional cleft treatment lanning as far as facial aesthetics are concerned. So far, information is missing on the number of atients suffering from cleft li and alate malformations who finally have secondary corrective facial surgery done. The resent rosective study aimed at assessing. i) cleft li and alate atients oinions on and their attitude towards their facial aearance, and ii) the number of secondary corrective surgical interventions to uer li and/or nose that were carried out during a 2 year follow-u eriod. Material and methods The study was aroved by the institutional ethics committee of the University of Erlangen-Nuremberg, Germany. It included atients with reaired cleft li and alate malformations who were treated at the cleft li and alate craniofacial center of the Erlangen University Hosital, Germany. Particiants were recruited from all consecutive atients who joined a follow-u examination between January 2009 and December The follow-u examinations were carried out by an interdiscilinary team of an oral and maxillofacial surgeon, an oto-rhino-laryngologist and an orthodontist. A checklist that included the items erformed surgical interventions and indication for secondary corrective facial surgery was used to erform the examinations in a standardized fashion. Every atient was asked if he or she felt the need for secondary corrective facial surgery and wanted to get medical advice concerning this asect. If the answer was yes, the Asher-McDade esthetic index was used to score nasolabial aearance [15]. In this index, 4 comonents of the nasolabial area are scored, searately, on frontal and lateral view hotograhs (nasal form, frontal view; deviation of the nose, frontal view; shae of the vermillion border and contour of the uer li, frontal view; nasal rofile including uer li, lateral view) Each feature was rated on a 5- oint scale (1, very good aearance; 2, good aearance; 3, fair aearance; 4, oor aearance; 5, very oor aearance). If a single feature was rated 4 or 5, secondary corrective surgery was recommended. For further statistical analysis only the rating that led to the recommendation of secondary corrective surgery was chosen. Possibilities and limitations of the rosective oeration were exlained to each atient in the light of the individual case. Patients who took secondary corrective surgery to li and/or nose into consideration were eligible for further articiation in the study. Each articiant had to sign an informed consent form. The demograhic data of the included atients were comiled (Tables 1, 2, 3, 4 and 5). A questionnaire was distributed by surface mail to the atients where the indication for secondary corrective facial surgery was seen. The questionnaire was designed to assess the atients oinions on and the attitude towards their facial aearance (Table 3). Patients and their arents were informed in a ersonalized cover letter that articiation in the study was voluntary and that individual resonses would be confidential. A stamed self-addressed return enveloe was included. No ersonal incentive was offered. Patient and/or arent informed consent and articiant assent were obtained. The questionnaire covered the interdiscilinary team s recommendation for secondary corrective surgery uer li and/or nose, the atients satisfaction with the aearance of the face, nose and uer li, and their desire for secondary corrective surgery. 6 items were Table 1 Demograhic data of the 37 atients who were eligible for articiation in the study Patient cohort that received a recommendation for secondary corrective surgery Patient cohort that returned questionnaires Gender distribution Female 17 (46%) 11 (50%) Male 20 (54%) 11 (50%).763 Total 37 (100%) 22 (100%) Age (years) Mean (SD) Female 12.1 (5.7) 11.2 (5.3).906 Male 15.0 (8.8) 14.1 (7.1).867 Total 13.6 (7.6) 12.6 (6.3).882 No. of atients who underwent Female 8 (50%) 5 (56%) secondary corrective surgery Male 8 (50%) 4 (44%).790 Total 16 9 SD, standard deviation.

3 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 3 of 11 Table 2 Distribution of clefts in the cohorts of atients that received a recommendation for secondary corrective facial surgery and that returned the questionnaire Patient cohort that received a recommendation for secondary corrective facial surgery Patient cohort that returned questionnaires Unilateral cleft li and alate Bilateral cleft li and alate Unilateral cleft li and alate Bilateral cleft li and alate Female Male Total included that had to be either by checking the rovided answers or on a 9-oint rating scale. The questionnaire was based on that used by Meyer-Marcotty et al. [16]. When the questionnaire was not returned within 30 days a follow-u letter was sent out. When the questionnaire was not returned after additional 30 days, it was assumed that the resective atients were not willing to articiate in the study. The resonse rate to the questionnaire was calculated. The number of atients who were oerated on for secondary corrective facial surgery within 24 months after the indication had been established or who were willing to be oerated on, and the kind of oeration were documented. Statistical analysis Mean values were given with standard deviations. For comarison of continuous variables in aired samles, the Wilcoxon test was used, while for unaired samles the Mann Whitney-U test was adoted. The χ 2 test was used to test if there was a statistically significant difference in gender distribution, kind of clefts, and decision for or against secondary corrective surgery in the different grous. In order to assess correlations the Pearson correlation coefficient was calculated. P-values less than or equal to.05 were considered significant. Cronbach s α analysis was erformed to assess reliability of the questionnaire. α-values of.7 or higher are in the accetable range recommended by the literature [17]. α-values above.8 reflect a high reliability. All calculations were made using IBM SPSS statistics 20 (IBM, Armonk, NY, U.S.A.). Results A total of 362 atients attended a follow-u examination at the cleft li and alate craniofacial center between January 2009 and December In 37 atients at least 1 feature of the Asher-McDade esthetic index was rated 4 or 5. To these atients secondary corrective surgery was recommended (17 female, 20 male, mean age 13.6 ± 7.6 years, Tables 1 and 2). The recommendations comrised rhinolasty in 19 cases and li revision in 23 cases. To each of the 37 atients a questionnaire was sent out by surface mail. 12 questionnaires were returned within the first 30 days. After that time, the non-resonders received a follow-u letter. Additional 11 questionnaires were returned within the next 30 days. The final resonse rate after 2 months was 62.1%. 1 questionnaire had to be excluded from further analysis because ersonal information of the atient has not been stated by the atient in the resonse letter. Cronbach s α of.792 indicated an accetable reliability of the questionnaire. The 22 returned questionnaires that were suitable for further analysis belonged to 11 female and 11 male atients with an average age of 12.4 ± 6.3 years (Table 1). The mean age of the female and the male atients did not differ statistically significantly ( =.300). In 12 cases secondary corrective surgery to the nose and in 15 cases secondary corrective surgery to the uer li had been recommended by the interdiscilinary team. The results reveal that the cohort of 37 atients who were eligible for the study, did not differ statistically significantly from the atients who finally returned the questionnaire as far as age ( =.882), gender ( =.763), and the kind of cleft malformation ( =.230) were concerned (Tables 1, 2 and 3). Comarable results were found Table 3 Comarison of demograhic data between atients who returned and who did not return the questionnaire Patient cohort that returned questionnaires Patient cohort that did not return questionnaires Age (years) Mean (SD) 15.1 (9.2) 12.6 (6.3).414 Gender Female Male 11 8 Kind of cleft malformation Unilateral Bilateral 5 9 Feature recommended for revision Nose Li 15 8

4 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 4 of 11 Table 4 Demograhic data of atients with unilateral and bilateral cleft li and alate malformations who returned the questionnaire Unilateral CLP Bilateral CLP Gender N Age (years) mean (SD) N Age (years) mean (SD) Female (5.3) (7.0) Male (8.0) (5.0) Total (6.7) (5.2) The difference in mean age between the 17 atients with unilateral cleft li and alate malformations and the 5 atients with bilateral cleft li and alate malformations is not statistically significant ( =.651). when the atients who returned the questionnaire and the atients who did not return the questionnaire, were comared (age, =.414; gender, =.676; kind of cleft malformation, =.220). There was no difference in age when the atients with unilateral cleft li and alate malformations and the atients with bilateral cleft li and alate malformations were comared who had returned the questionnaire ( =.651, Table 4). In the cohort of the resonders the number of recommendations did not differ statistically significantly between nose and uer li ( =.234). During the follow-u eriod 9 of the 22 resonders decided to have secondary corrective facial surgery done (Figures 1, 2, 3, 4, 5, 6, 7 and 8, Table 5). These were significantly less atients than the comlete cohort that had received a recommendation for secondary corrective facial surgery ( <.0005). In the 22 atients who had received a recommendation for corrective surgery there was no statistically significant correlation between Asher-McDade esthetic index ratings and the decision for or against secondary corrective surgery in this grou ( =.085). 10 cases of rhinolasty (4 unilateral cleft li and alate atients, 6 bilateral cleft li and alate atients) and 8 li revisions (4 unilateral cleft li and alate atients, 4 bilateral cleft li and alate atients) were erformed. The number of female and male atients who were oerated on did statistically not differ on a significant level ( =.886). The atients who underwent corrective surgery were significantly older than the atients who Table 5 Demograhic data of atients who returned the questionnaire distinguishing atients who underwent and who did not undergo secondary corrective facial surgery Corrective surgery No corrective surgery Gender N Age (years) mean (SD) N Age (years) mean (SD) female (1.1) (4.1) male (5.9) (4.9) total (4.4) (4.6) The difference in mean age between the 9 atients who underwent corrective surgery and the 13 atients who did not is statistically significant ( <.0005). Figure 1 8-year old atient scheduled for corrective surgery of the uer li. did not undergo corrective surgery during the observation eriod ( <.0005, Table 5). The results from the questionnaire showed that only 2 male atients were comletely satisfied with their overall facial aearance. 5 male and 6 female atients considered their nose the least satisfying feature of their face, while 4 male and 5 female atients reorted their uer li to be the least satisfying feature (Question 1, Table 6). There was no gender difference for both features ( =.912). All female and 9 male atients stated that they considered a recommended further imrovement of their facial aearance congruent to their ersonal needs (Question 2; Table 5). 15 atients tended to choose an imrovement of the nose, while 5 atients tended to ot for an imrovement of the uer li ( =.007). There was no gender difference for the reference of the correction of the nose or the li ( =.339; Question 3, Table 5). The results of the atients self-reort for satisfaction with overall facial aearance, facial symmetry nose and li can be found in Table 6 (Question 4). There were no statistically significant gender differences. For the comlete cohort of 22 atients the satisfaction with the overall facial aearance was statistically significantly better than the satisfaction with the nose ( =.016). The satisfaction with the overall facial aesthetics did not differ significantly to the uer li ( =.924) as well as to the rating of the facial symmetry ( =.093). The

5 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 5 of 11 Figure 2 Detail of the uer li of the atient in Figure 1 showing a whistling defect. degree of satisfaction did not differ statistically significantly between nose and uer li ( =.593). Nose and uer li ratings did not differ significantly to the selferceived satisfaction with the facial symmetry either ( nose =.436, uer li =.547). 17 atients stated that they would chose secondary corrective surgery within the next two years while 5 Figure 3 Postoerative situation following corrective surgery of the uer li. atients did not want to undergo secondary corrective surgery in the near future. There was no statistically significant difference for this asect between male and female atients (Table 5, Question 5, =.766). Out of the 5 atients who did not want to have secondary corrective facial surgery, 1 male atient was satisfied with his facial aearance and 3 atients felt being too young for secondary corrective surgery and chose to ostone it. 1 atient did not indicate a reason for refraining from secondary corrective surgery. None of the atients resonded that he or she was tired of being oerated on (Question 6; Table 6). 8 out of 17 atients indicated that they would make use of this otion in the future, although they did not during the follow-u eriod (3 female, 5 male, mean age ± 4.72 years). These atients intended to have corrections made of the nose (5 cases) and the uer li (6 cases). When the data of the questionnaire were comared for atients with unilateral and atients with bilateral cleft li and alate malformations, there was a significant difference as far as the reference of the correction of the nose or the li was concerned ( =.030; Question 3, Table 7). In 14 out of 17 cases, the atients with unilateral cleft li and alate malformations indicated that they would choose corrective surgery of the nose. 3 out of 4 atients with bilateral cleft li and alate malformation would choose a correction of the uer li. Although the atients with unilateral cleft li and alate malformations considered their faces to be symmetrical, their ratings were significantly lower than the ratings of the atients with bilateral cleft li and alate malformations ( =.039; Question 4.2, Table 7).

6 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 6 of 11 Figure 4 Detail of the ostoerative situation in Figure 3 with comlete reair of the whistling defect. Figure 5 Frontal view of a 15-year old atient scheduled for rhinolasty. Figure 6 Lateral view of the atient.

7 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 7 of 11 Figure 7 Postoerative frontal view of the atient following rhinolasty. When the data of the questionnaire were comared for atients who underwent secondary corrective facial surgery and the atients who did not undergo secondary corrective surgery during the observation eriod, no statistically significant differences could be found (Table 8). Discussion The resent rosective study aimed at assessing cleft li and alate atients oinions on and the attitude towards their facial aearance, and their tendency to ot for secondary corrective facial surgery. Based on the identification of atients who were eligible for the study clinical data on these ersons were collected and a questionnaire was sent out to comile the relevant data. Although a resonse rate of 23 of 37 invited atients may seem low, it is exactly within the range that can be exected from the current literature. Resonse rates of arox. 58% to questionnaires received by surface mail have to be exected [18]. The comarison between the atients who were eligible for the study and the atients who finally returned the questionnaire revealed that there were no statistically significant differences between the 2 cohorts. Consequently, it can be assumed that the results were not biased in a ronounced way by the ortion of non-resonders. It can be assumed that the Figure 8 Postoerative rofile of the atient. bias resulting from the non-resonders falls within the normal range. With a Cronbach s α of.792 the questionnaire had an accetable reliability revealing that the results obtained in this study are relevant [17]. The interdiscilinary team of the cleft alate craniofacial center recommended secondary corrective facial surgery to aroximately 10% of the atients who attended a follow-u examination during a 2-years eriod (37 out of 362 atients). However, only 4% (16 out of 362) of the atients chose this otion during the follow-u eriod of 24 months. This result is surrising because, historically, cleft li and alate atients have demonstrated a ositive correlation between satisfaction with facial aearance and health related quality of life [9]. Cleft li and alate atients are more concerned with visible defects than with functional roblems. However, keeing in mind that atients with reaired cleft li and alate malformations feel as socially acceted as do eers without such malformations this low number of atients who decided to have corrective surgery is not surrising [19]. In addition, there are studies that show that atients with cleft li and alate malformations seem to be relatively satisfied with their body image [8]. In this context, symmetry is an imortant asect. Symmetrical faces are erceived as being more attractive [20]. Imaired symmetry might cause significant emotional distress due to

8 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 8 of 11 Table 6 Results of the Questionnaire given searately for male and female atients Question 1 Gender N Nose Uer li None, comletely satisfied Which art of your face do you consider the Female /.912 least satisfying? Male Question 2 Gender N yes no Question not Does the recommendation for corrective facial Female / /.220 surgery meet your ersonal needs? Male Question 3 Gender N Nose Uer li Question not If you think about corrective facial surgery, Female which feature of your face should be imroved (nose/uer li)? Male Question 4 Gender N Mean (SD) 4.1 How satisfied are you with your facial Female ± aesthetics? Male ± 2.4 Total ± How symmetrical do you consider your face? Female ± Male ± 1.9 Total ± How satisfied are you with the aearance Female ± of your nose? Male ± 2.2 Total ± How satisfied are you with the aearance Female ± of your uer li? Male ± 1.5 Total ± 1.9 Question 5 Gender N yes no Do you lan to undergo secondary corrective Female facial surgery within the following 2 years? Male Question 6 Gender N I am satisfied with facial aearance If you do not lan to undergo secondary corrective facial surgery, what is the reason? I am tired of being oerated on I feel too young Female 11 / / /.091 Male 11 1 / 3 For Question 4 answers could be given on a 9-oint rating scale (1, maximum satisfaction and symmetry, res.; 9, minimum satisfaction and symmetry, res.). unhainess with facial aearance [7]. However, in the resent study the satisfaction with facial symmetry did not statistically significantly differ from the overall satisfaction with the facial aearance. It reached an average value over 5.6 ± 2.0 on a 9-oint rating scale indicating a tendency towards satisfaction. It seems that the cohort of atients that was analyzed did not identify their facial symmetry as a major roblem. It has been described in the ast that atients with cleft li and alate malformations often consider their nose unsatisfactory [21]. The resent study confirms these findings. Patients were significantly more satisfied with their overall facial aearance than they were with their nose. This fact was esecially true for atients with unilateral cleft li and alate malformations. Consequently, intheresentstudycorrectionsofthenosewerethekind of corrective surgery desired and erformed most often. However, the number of atients who actually chose to havesecondarycorrectivesurgeryofthenosedoneduring the follow-u eriod was low (9 out of 22 resonders to the questionnaire). This finding has also been described reviously. Although atients with cleft li and alate malformations often feel the need for a correction, they often do not have secondary corrective facial surgerydone[12]. The resent study failed to show a correlation between the rofessional rating of esthetics as a basis for the recommendation for secondary corrective surgery and the actual decision of the atients for or against corrective surgery. This roblem has been addressed in the current

9 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 9 of 11 Table 7 Results of the questionnaire given searately for unilateral and bilateral cleft li and alate atients Question 1 Tye of cleft N Nose Uer li None, comletely satisfied Which art of your face do you Unilateral consider the least satisfying? Bilateral / Question 2 Tye of cleft N yes no Question not Does the recommendation for corrective Unilateral /.411 facial surgery meet your ersonal needs? Bilateral 5 4 / 1 Question 3 Tye of cleft N Nose Uer li Question not If you think about corrective facial surgery, Unilateral which feature of your face should be imroved (nose/uer li)? Bilateral Question 4 Tye of cleft N Tye of Cleft 4.1 How satisfied are you with your Unilateral ± facial aesthetics? Bilateral ± 1.9 Total ± How symmetrical do you consider Unilateral ± your face? Bilateral ± 1.9 Total ± How satisfied are you with the aearance Unilateral ± of your nose? Bilateral ± 2.5 Total ± How satisfied are you with the aearance Unilateral ± of your uer li? Bilateral ± 1.7 Total ± 1.9 Question 5 Tye of cleft N yes no Do you lan to undergo secondary corrective Unilateral facial surgery within the following 2 years? Bilateral Question 6 Tye of cleft N I am satisfied with facial aearance If you do not lan to undergo secondary corrective facial surgery, what is the reason? I am tired of being oerated on I feel too young Unilateral 17 1 / Bilateral 5 / / 1 For Question 4 answers could be given on a 9-oint rating scale (1, maximum satisfaction and symmetry, res.; 9, minimum satisfaction and symmetry, res.). literature, reviously [5]. It has been hyothesized that although secondary corrective facial surgery is recommended by rofessionals, the low rate of actual decision for surgery is the consequence of a rolonged treatment course of atients suffering from cleft li and alate malformations. Multile revious oerations make the atients tired of additional interventions [12]. Although the atients in the resent study were exlicitly asked if they refrained from surgery as a consequence of multile revious interventions, none of the atients stated that this asect was an imortant reason for their decision. Therefore, the asect of surgical fatigue seemed to have no relevance in the resent study. The mean age of atients seeking corrective surgery in the resent study around the age of 13 years at the edge of uberty is not surrising. This asect seems to correlate with intensive stigma exeriences during adolescence [22]. Facial aearance exerts strong imact on social interaction and ersonal develoment [23]. Consequently, facial differences are resumed to negatively affect social encounters and to ut individuals at risk for sychological difficulties and imaired quality of life [24]. Research findings confirm that individuals with visible differences are likely to exerience stigmatizing behaviors such as staring, avoiding, teasing, and manifestations of ity [25]. However, it has been stated that facial differences do not necessarily lead to major sychological maladjustment [26]. This asect again might be an exlanation for the low number of atients who chose to be oerated on in the resent study.

10 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 10 of 11 Table 8 Results of the questionnaire given searately for atients who underwent secondary corrective facial surgery and who did not Question 1 Corrective surgery N Nose Uer li None, comletely satisfied Which art of your face do you consider Yes the least satisfying? No Question 2 Corrective surgery N yes no Question not Does the recommendation for corrective facial Yes 9 8 / /.784 surgery meet your ersonal needs? No Question 3 Corrective surgery N Nose Uer li Question not If you think about corrective facial surgery, Yes which feature of your face should be imroved (nose/uer li)? No Question 4 Corrective surgery N Tye of Cleft 4.1 How satisfied are you with your facial Yes ± aesthetics? No ± 1.3 Total ± How symmetrical do you consider your face? Yes ± No ± 1.7 Total ± How satisfied are you with the aearance Yes ± of your nose? No ± 1.9 Total ± How satisfied are you with the aearance Yes ± of your uer li? No ± 1.6 Total ± 1.8 Question 5 Corrective surgery N yes no Do you lan to undergo secondary corrective Yes facial surgery within the following 2 years? No Question 6 Corrective surgery N I am satisfied with facial aearance If you do not lan to undergo secondary corrective facial surgery, what is the reason? I am tired of being oerated on I feel too young Yes 9 / / No 13 1 / 2 For Question 4 answers could be given on a 9-oint rating scale (1, maximum satisfaction and symmetry, res.; 9, minimum satisfaction and symmetry, res.). In the ast, there have been conflicting results as far as a gender difference in the need for secondary corrective facial surgery is concerned. There have been authors who described that female atients with cleft li and alate malformations deemed corrective surgery significantly less necessary than male atients [5]. On the other hand, it has been shown that female cleft li and alate atients wished to have corrective surgery twice as often as male atients [12]. In the resent study an even distribution between male and female atients was found. There was no gender difference as far as the need for secondary corrective facial surgery was concerned. The resent study adds information on the need of cleft li and alate atients to undergo secondary corrective facial surgery to the current literature. The major limitation of the study is the low demand for secondary corrective facial surgery that led to low case numbers. There is a chance that the study failed to demonstrate statistical significance for some asects which might have shown this significance with larger case numbers. Consequently, the study is continued in order to increase the number of included atients allowing a final comrehensive statistical analysis. Conclusions The results of the resent study reveal that the need for secondary corrective surgery to uer li and/or nose is low in the described cohort of atients with cleft li and

11 Nkenke et al. Head & Face Medicine 2013, 9:38 Page 11 of 11 alate malformations. Significantly fewer atients ot for corrective surgery comared to the number of atients who got the recommendation to have secondary corrective facial surgery done. These findings might reflect the good overall atient satisfaction with the outcome of rimary surgical treatment of cleft li and alate malformations. Consent statement All atients and arents, res., included in the study were asked to sign an informed consent form in accordance with Helsinki Declaration. Abbreviations CLP: Cleft li and alate; SD: Standard deviation. Cometing interests The authors declare that they have no cometing interests. Authors contributions EN, FS, EV and CK conceived of the study, articiated in its design and coordination, collected the data, wrote and draft the manuscrit. CK erformed the statistical analysis. All authors read and aroved the final manuscrit. Author details 1 Deartment of Oral and Maxillofacial Surgery, Erlangen University Hosital, Glueckstr. 11, Erlangen, Germany. 2 Deartment of Oral and Maxillofacial Surgery, University of Athens Medical School, Attikon Hosital, Athens, Greece. Received: 8 Setember 2013 Acceted: 3 December 2013 Published: 9 December 2013 References 1. Harris DL, Carr AT: Prevalence of concern about hysical aearance in the general oulation. Br J Plast Surg 2001, 54: Wildgoose P, Scott A, Pusic AL, Cano S, Klassen AF: Psychological screening measures for cosmetic lastic surgery atients: a systematic review. Aesthet Surg J 2013, 33: Klassen AF, Tsangaris E, Forrest CR, Wong KW, Pusic AL, Cano SJ, Syed I, Dua M, Kainth S, Johnson J, Goodacre T: Quality of life of children treated for cleft li and/or alate: a systematic review. 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