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Unilateral Cleft Lip Nasal Deformity: Foundation-Based Approach to Primary Rhinoplasty

Tse, Raymond W. M.D.; Mercan, Ezgi Ph.D.; Fisher, David M. M.D.; Hopper, Richard A. M.D.; Birgfeld, Craig B. M.D.; Gruss, Joseph S. M.D.

Plastic and Reconstructive Surgery: November 2019 - Volume 144 - Issue 5 - p 1138-1149
doi: 10.1097/PRS.0000000000006182
Pediatric/Craniofacial: Original Articles
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Background: Cleft lip results in disruption of the nasal foundation and collapse of tip structures. Most approaches to primary rhinoplasty focus on correction of lower lateral cartilages; however, recurrent deformity is common, and secondary revision is frequently required. The authors describe an alternate approach that focuses on the foundation to “upright the nose,” without any nasal tip dissection. This study assessed changes with surgery and with growth. Secondary goals were to compare methods of sidewall reconstruction and septoplasty and to identify predictors of relapse.

Methods: Consecutive patients undergoing repair (n = 102) were assessed. Images were captured preoperatively, postoperatively, and at 5 years of age (when available) using three-dimensional stereophotogrammetry. Standard anthropometric and contemporary shape-based analysis (volume ratio, dorsal deviation, and alar-cheek definition) was performed to assess longitudinal changes. Images of age-matched normal control subjects were used for comparison.

Results: Significant changes in anthropometric and morphometric measurements occurred following surgery. Postoperative form was similar to controls immediately after surgery and at 5 years. Nasal corrections were satisfactory, and only two patients have elected to undergo revision. When subjects were grouped according to cleft type, we found the same trends. When comparing different methods of nasal sidewall reconstruction or septoplasty, we found no differences. Alveolar cleft width was a significant predictor of worse preoperative and postoperative form.

Conclusions: Significant nasal correction can be achieved by means of reconstruction of nasal foundation, without nasal tip dissection. Preservation of tissue planes may allow for easier secondary revision, if necessary.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Seattle, Wash.; and Toronto, Ontario, Canada

From the Division of Craniofacial and Plastic Surgery, Seattle Children’s Hospital; and the Division of Plastic Surgery, Hospital for Sick Children.

Received for publication May 11, 2018; accepted January 3, 2019.

Presented at the 75th Annual Meeting of the American Cleft Palate–Craniofacial Association, in Pittsburgh, Pennsylvania, April 10 through 14, 2018.

Disclosure:The authors have no financial interest to declare in relation to the content of this article. No funding was received.

Related digital media are available in the full-text version of the article on www.PRSJournal.com.

Raymond W. Tse, M.D., Seattle Children’s Hospital, 4800 Sand Point Way NE, M/S OB.9.527, Seattle, Wash. 98105, raymond.tse@seattlechildrens.org

The unilateral cleft lip nasal deformity results from displacement of underlying base elements1 and consequent collapse of the arch forms that define the nose.2 Although primary rhinoplasty involving nasal tip dissection is often performed, recurrent deformity is common, and secondary correction is undertaken in 35 to 74 percent of patients.3–7 Scar, loss of tissue planes, and anatomical distortion from prior surgery can make later reconstruction more difficult. Similar to building a house, if the roof is constructed before setting a stable and “level” foundation, the house will always remain crooked.

We propose an alternate approach to primary rhinoplasty that emphasizes component reconstruction of the nasal base. By correcting muscle, sill, floor, sidewall, and septum, a stable foundation may be produced. Although nasal tip dissection can be performed at the same time, adequate correction may be achieved by work on the underlying “foundation” alone. In this study, no nasal tip dissection was performed.

Although results of cleft lip repair8–10 have previously been presented, this sequel focuses on the nose with goals to describe an alternate approach to primary rhinoplasty and evaluate surgical changes and stability over time. Secondary goals were to compare different methods of sidewall reconstruction and septoplasty and identify predictors of relapse.

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PATIENTS AND METHODS

Consecutive patients undergoing repair performed by a single surgeon from 2010 to 2013 were reviewed. Images were retrieved from institution database. Prospectively recorded demographic, cleft, and surgical data were retrieved by chart review.

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Surgical Approach

Nasal Sill

Approximation of nasal sill is incorporated in the lip repair.8,9,11 Creases along the nasal base (ala-lip and columella-lip) and their intersection, x, are identified on the noncleft side (Fig. 1). Corresponding landmarks, x′ and x″, are identified on the cleft side such that manual apposition of the two points corrects the nasal deformity and produces symmetric columella and alar base relationships.

Fig. 1.

Fig. 1.

In the case of complete clefts, the available nasal sill medial and lateral to the cleft are used to create a sill that matches the noncleft side. In the case of complete with band or incomplete clefts (i.e., when nasal floor is intact), urethral sounds are used to measure nostril diameters to calculate the excess cleft side circumference (i.e., difference in nostril diameters × π).11 The designed closure and nasal floor excision (x to x″) is confirmed to be similar to the difference in nostril circumference (but not exceeding it, to avoid creating a micronostril).9 (See Figure, Supplemental Digital Content 1, which shows the nasal sill closure for incomplete cleft, http://links.lww.com/PRS/D757.) Unlike rotation-advancement, the alar base and upper lateral lip are left in continuity to preserve the native contours of nasal sill.

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Muscle

Although skin incisions can involve any design, muscle correction follows a pattern of rotation-advancement (Fig. 2). On the medial side, orbicularis is delaminated from columella and mucosa, and release of muscle from the alveolus allows the lip to drop.

Fig. 2.

Fig. 2.

On the lateral side, orbicularis is separated from mucosa and alar base, with dissection continuing along the nasal vestibule and up to the alveolus. Release of muscle from periosteum continues lateral to the alar base to produce an “empty triangle” devoid of muscle. Adequate dissection is confirmed when advancement of muscle into the dead space under the columella accentuates the alar crease (as the lateral edge of muscle abuts the ala).

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Septum

Repositioning is performed if the septum deviates from the facial midline. The anterior nasal spine is exposed through the medial lip incision.

Previous descriptions12–16 involve a “direct” approach that denudes the cartilage to mobilize it to the facial midline. (See Figure, Supplemental Digital Content 2, which shows the direct approach septoplasty with delamination of cartilage, http://links.lww.com/PRS/D758.) This approach was used during the first year of this study.

An alternate “indirect” approach was subsequently devised to preserve the tissue plane between perichondrium and cartilage (Fig. 3). A horizontal incision is taken through periosteum on the anterior surface of the premaxilla so that a subperiosteal plane can be developed along the nasal floor on either side of the anterior nasal spine. Following release of retaining noncleft nasal floor periosteum and detachment from the spine, the septum is moved en bloc with its enveloping perichondrium and adjacent periosteum to midline. Five tissue layers are then available for suture fixation.

Fig. 3.

Fig. 3.

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Lateral Sidewall

Soft tissues and the accessory chain of cartilage along the alar base and piriform margin are released by means of the lateral lip incision. Additional upper buccal sulcus incision and supraperiosteal dissection over the maxilla is also undertaken if needed.

The points of nasal closure (x′ and x″) are approximated to assess relative anteroposterior relationships. Persistent cleft alar base retrusion is addressed by release, advancement, and reconstruction of the defect between piriform and corrected alar base position using any one of three options.

For lateral wall advancement17 (Fig. 4), mucoperiosteum within the nasal cavity is raised and incision is taken along the cleft margin with a vertical backcut. The flap is advanced en bloc with the alar base so that mucoperiosteum spans the gap between piriform aperture and the new alar base position.

Fig. 4.

Fig. 4.

For turbinate flap,18 vertical release along the piriform aperture is made up to the base of the turbinate so that the anteriorly based flap fills the defect. The L-flap19 is based on mucoperiosteum, with an incision continued along the cleft margin to allow closure of the nasal floor. Flap selection was random and not based on any algorithm. Incision, transposition, and closure for each is as previously illustrated.20

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Nasal Floor

When the nasal floor is open, the flap used for the lateral sidewall is brought across the nasal cavity and inset into the vomer/septal mucosa (Fig. 5). Closure forms a tube and progresses from posterior to anterior, eventually lining up the planned points of nasal closure (x′ and x″).

Fig. 5.

Fig. 5.

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Final Closure

Nasal tip dissection is not performed. Septoplasty, alar advancement, lateral sidewall reconstruction, and floor closure produce the majority of the nasal correction (Figs. 6 and 7).

Fig. 6.

Fig. 6.

Fig. 7.

Fig. 7.

A transfixion suture through the “empty triangle” is used to exclude muscle lateral to the ala and to adhere vestibular mucosa to skin along the alar crease. Additional alar transfixion sutures are used to obliterate the vestibular web and accentuate the alar crease. A horizontal mattress suture is placed along the internal nasal valve to position the lower lateral cartilage over top of the upper lateral cartilage. Muscle repair and skin inset produce the final changes to the nose (Figs. 6 and 7).

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Analysis

Three-dimensional images were captured by a professional image technologist using the 3dMD Cranial system (3dMD, Atlanta, Ga.). Anthropometric analysis was performed using 3dMD Vultus. Measurements followed standard anthropometric analysis,18,21–23 which has previously been validated on three-dimensional images22,24 and correlated with subjective expert appraisals.25 (See Figure, Supplemental Digital Content 3, which shows the conventional anthropometric measurements, http://links.lww.com/PRS/D759.) Columellar angle, nostril width ratio, and lateral lip height ratio have been found to be the most important anthropometric indices of the unilateral cleft lip nasal deformity.25 Nostril height ratio and lip-to-nose ratio are less important25 but have been included to provide a complete report. Ratios of anthropometric measures were expressed as cleft-to-noncleft. Shape-based morphometric analysis was also performed using previously described methods.26 These measures characterize nasal tip and alar symmetry, nasal axis deviation, and alar-cheek definition. (See Figure, Supplemental Digital Content 4, which shows the cleft-specific three-dimensional morphometric analysis, http://links.lww.com/PRS/D760.)

Objective measures preoperatively, postoperatively, and at 5 years of age were assessed. To provide a reference of normal form, three-dimensional images of age-matched control subjects without clefts from Craniobank27 (n = 33) and from FaceBase (www.facebase.org) (Accession FB00000491; project U01DE020078)28 (n = 40) were used for comparison.

Potential differences in outcomes were assessed comparing the three methods of lateral sidewall reconstruction and comparing the two approaches to septoplasty. We also examined the predictive value of alveolar cleft width on postoperative outcomes.

The t test was used to assess changes in individual measurements, with a value of p < 0.05 considered significant. Correlations were measured by Pearson correlation, with a value of p < 0.05 considered significant.

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RESULTS

Subjects and Surgical Data

Demographics

Of 102 subjects identified, 56 were male, 46 were female, and four had associated anomalies/syndromes (i.e., constriction band, craniofacial microsomia, midline deficiency, and chromosomal abnormality not yet determined). Forty had complete, 15 had complete with band, 45 had incomplete, and two had microform clefts. Eighty-seven had adequate three-dimensional images for preoperative and postoperative analysis, and 42 had three-dimensional images at late follow-up (mean age, 5 years).

Among patients with complete cleft lip, 32 had complete cleft lip and palate and eight had complete cleft lip and alveolus. Of these, 15 (38 percent) underwent nasoalveolar molding, five (13 percent) used lip taping, and 19 (48 percent) had no preoperative molding.

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Nasal Sill Dimensions and Surgical Design

The discrepancy of nostril circumferences (cleft versus noncleft) and planned sill excisions are summarized in Table 1. In the case of complete clefts, sill remnant widths were similar on both sides of the cleft (Table 1) and repairs could be centered and designed according to the method described.

Table 1. - Component Reconstruction and Anthropometric Analysis*
Complete (%) Complete with Band (%)† Incomplete (%) Microform (%)‡
No, 40 15 45 2
Nasal sill dimensions and surgical design
 Medial sill remnant width, mm
  Mean 3
  Range 2–5
 Lateral sill remnant width, mm
  Mean 4
  Range 2–5
 Noncleft nostril diameter, mm
  Mean 7.4 7.1 8
  Range 6–8 5–10
 Cleft nostril diameter, mm
  Mean 9.6 8.7 9
  Range 8–10 5–11
 Difference in nostril circumference, mm
  Mean 6.6 5.1 3
  Range 4.5–9 3–10.5
 Nasal floor resection, mm
  Mean 5.5 3.4 2.5
  Range 3.5–7 1.5–6 2–3
Components reconstructed
 Primary septoplasty 40 (100) 15 (100) 40 (89) 2 (100)
  Direct approach 4 6 7 0
  Subperiosteal 36 9 33 2
 Nasal sidewall reconstruction 40 (100) 11 (73) 3 (7) 0
  L-flap 9 1 0 0
  Turbinate 19 3 1 0
  Lateral nasal wall flap 12 7 2 0
 Nasal floor closure All All Intact Intact
*
Nostril diameters were measured using urethral sounds. Nostril circumference was calculated as circumference × π.
Complete with band is defined as one in which there is a soft-tissue connection in the presence of a complete cleft of the alveolus.
Microform was defined as one in which the cleft was one-third or less of the height of the lip.

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Component Reconstruction

Component reconstruction of the nose is summarized in Table 1. Septoplasty was performed in all but five cases in which there was no deviation on intranasal examination. Flaps for nasal sidewall reconstruction were needed in all patients with complete clefts and the majority (79 percent) of patients with complete with band. They were seldom needed in the case of incomplete cleft lip (7 percent).

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Changes with Repair

Anthropometric

Analysis is summarized in Figure 8. Columellar angle changed significantly (p < 0.02) and normalized to within 10 degrees. Variability of columellar angle was similar to that of age-matched controls postoperatively and at 5-year follow-up.

Fig. 8.

Fig. 8.

Nostril width ratio and lateral lip height ratio also changed significantly following surgery (p < 0.02) and normalized to approximate a ratio of 1. Variation in each ratio was similar to that of age-matched controls postoperatively and at 5-year follow-up.

Although the change in alar height ratio across surgery was small and preoperative nostril height ratio could not be measured in subjects with complete clefts (because of absence of a nostril floor), both ratios normalized to approximate a ratio of 1 following surgery, with values similar to that of age-matched controls (Fig. 8). There was no change in lip-to-nose width ratio across surgery; however, it increased at 5-year follow-up. All findings persisted when subjects were grouped by cleft type. (See Table, Supplemental Digital Content 5, which shows the conventional anthropometric measurements grouped by cleft type, http://links.lww.com/PRS/D761.)

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Morphometric

Nasal tip volume ratio, dorsal deviation, and alar-cheek curvature changed significantly with repair and normalized to values similar to those of age-matched controls postoperatively and at 5 years (Fig. 9). All of the findings persisted when subjects were grouped by cleft type (see Table, Supplemental Digital Content 5, http://links.lww.com/PRS/D761).

Fig. 9.

Fig. 9.

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Revisions

Among 102 patients aged 5 years or older, one has undergone tip rhinoplasty to correct progressive nasal deformity and one has undergone revision to correct alar base vertical malposition.

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Predictive Factors

When subjects were examined as a single group, we found no difference in nasal anthropometric measurements with each of the three flaps used for nasal sidewall reconstruction or with either of the two approaches to septoplasty. Given the potential bias of cleft type and severity, we performed subgroup analysis that focused on subjects with complete clefts, in which nasal sidewall reconstruction and septoplasty are universally performed and the greatest apparent nasal changes occur.

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Turbinate versus L-Flap versus Lateral Wall Advancement

Among patients with complete clefts that had 5-year follow-up, five, eight, and four underwent L-flap, turbinate flap, and lateral wall advancement, respectively. (See Table, Supplemental Digital Content 6, which shows an anthropometric analysis for different methods of lateral sidewall reconstruction, http://links.lww.com/PRS/D762.) Early postoperatively, there were differences in lateral lip height and alar height ratio. In the late postoperative period, L-flap was associated with better columellar angle, whereas lateral nasal flap was associated with better lateral lip height ratio. None of the flap types was associated with consistent differences across multiple measures of nasal proportion or form.

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Direct Subperichondrial versus Indirect Subperiosteal Septoplasty

Among patients with complete clefts with 5-year follow-up, four underwent direct septoplasty and 13 underwent indirect subperiosteal septoplasty. There were no differences in measures except for better alar height ratio with subperiosteal septoplasty. That difference disappeared at late follow-up, and neither approach was associated with consistent differences across multiple measures of nasal proportion or form. (See Table, Supplemental Digital Content 7, which shows an anthropometric analysis for different approaches to septoplasty, http://links.lww.com/PRS/D763.)

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Alveolar Cleft Width

Among patients with alveolar clefts, increasing bony width was associated with worse columellar angle, nostril height ratio, and nostril width ratio before surgery (0.61, 0.70, and 0.34, respectively). Following surgery, the association persisted immediately postoperatively (0.31) and at later follow-up (0.59).

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DISCUSSION

Whereas primary rhinoplasty generally entails nasal tip dissection with or without suturing of tip cartilages, we describe an alternate approach that focuses on the foundation to correct the nose. It follows principles of wide surgical release, component reconstruction, and attention to anatomical subunits. Similar to cosmetic rhinoplasty or reconstruction of thumb hypoplasia, each component and tissue type deserves assessment and correction if deemed necessary. As such, the cutaneous nasal sill, muscle, septum, floor, sidewall, and tip cartilages should be considered individually. The presented approach is not a personal one but rather that of our centers. The reason the analysis involved a single surgeon was so that differences in septoplasty and lateral nasal wall reconstruction could be assessed. It also provided an opportunity to determine nasal changes produced by correcting the foundation, without nasal tip correction. As demonstrated in Figures 5 and 6 and measured on three-dimensional analysis, considerable correction of nasal form can be achieved by means of septum, floor, and sidewall correction, before muscle and skin closure, and without any dissection of the tip.

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Septoplasty

Preferential growth of the premaxilla results in shift, rotation, and twist of the anterior nasal spine away from the cleft, with consequent deviation of the caudal septum that follows the spine. Septal deviation was almost universal (even for incomplete clefts), and septal repositioning produced considerable changes.

In contrast to previous reports of primary septoplasty,12,13,15,16,29,30 we did not perform any nasal tip dissection. Our study thus provides unique insights regarding changes produced by septoplasty (without confounding tip procedures). We also described an alternate “indirect” subperiosteal approach that avoids delamination of the cartilage. Based on our study, this new approach seems to be similar in efficacy to previously described direct approaches. However, the intact tissue layers (periosteum-perichondrium-cartilage-perichondrium-periosteum) reduce suture pull-through when fixing the septum to its new position and preserve tissue planes in case future septorhinoplasty is undertaken.

We made two observations when converting to “indirect” subperiosteal septoplasty. The first was that the anterior nasal spine is often bifid and that the height of the spines decreases and space between the spines increases with worsening cleft severity. The embryologic significance of this is unclear; however, awareness can help when trying to identify the anterior nasal spines through the limited medial lip exposure, especially with wide complete clefts. (See Figure, Supplemental Digital Content 8, which shows a bifid anterior nasal spine and relationship with caudal septum, http://links.lww.com/PRS/D764.) The second was that the caudal septum is invariably found between the two bony spines. There is a notion that the caudal septum can dislocate onto the noncleft side31 and that septal reposition reduces the dislocation.12 A direct approach to the septum typically involves only exposing the spine on the cleft side and thus the septum would seem dislocated (see Figure, Supplemental Digital Content 8, http://links.lww.com/PRS/D764). The “indirect” subperiosteal approach involves additional dissection along the noncleft side nostril floor and reveals the noncleft side spine. With this approach, the septum has invariably been found between the two spines. The concept that septal repositioning relocates the septum is not true. Rather, septoplasty “dislocates” the septum and places it in a nonanatomical position, at the midline of the face. The long-term consequences of this surgical dislocation is unknown; however, studies thus far suggest that there is no impact on growth.12,15,29,30,32 Further study is needed to determine the long-term effects on growth.

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Lateral Sidewall

Correction of the retruded cleft alar base leaves a defect along the lateral nasal sidewall that risks collapse if left unaddressed. We used three different methods of reconstruction. As expected, we did not find any to be superior with respect to nose morphology, but we did find that each had unique characteristics.

The turbinate flap provides broad robust tissue, and removal of the underlying bone potentially alleviates obstruction of a narrowed nasal airway. However, the flap is difficult to access if there is no cleft in the palate through which instruments can pass to make the posterior incision. In addition, because of its base along the piriform margin, the posterior extent of nasal floor closure is limited to a level anterior to the lesser segment alveolus.

The L-flap is always available, regardless of cleft type, and can provide a continuous layer of closure with additional elevation of nasal mucoperiosteum. However, the flap can be narrow and does not replace “like-with-like” tissues.

Lateral wall advancement provides broad robust tissue, avoids obliteration of normal anatomy, and replaces tissues in kind. Perhaps the greatest advantage is that it allows continuous posterior nasal floor closure beyond the alveolar ridge. This leaves no residual opening/fistula through the alveolus, facilitates later cleft palate repair (in which the far anterior nasal closure is difficult), and simplifies secondary alveolar bone graft (because the nasal side has already been closed). For these reasons, it has become the first author’s (R.T.) preferred method.

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Nasal Floor

The meaning of “nasal floor closure” can be confusing given variations in the extent a cleft can reach and what the “nasal floor” entails. In the case of any cleft lip or cleft lip and alveolus, we closed nasal mucoperiosteum along the full extent of the cleft. In the case of cleft lip and palate, the extent of posterior closure varied with the method of nasal sidewall reconstruction. Closure with a turbinate flap extended beyond the greater segment alveolus but no farther than lesser segment alveolus. Closure with L-flap or lateral nasal wall flap extended beyond the greater and lesser segment alveolus to approximately half the length of the hard palate. In addition to supporting the alar base, we found that nasal floor closure helped to reposition the released septum to midline.

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Nasal Tip

Lower lateral cartilage dissection is often considered the sine qua non of primary cleft rhinoplasty. Our report is unique in that none of the subjects underwent such dissection. Although deformity of the lower lateral cartilages is the most visible abnormality of the cleft lip nasal deformity, malposition of those cartilages is the effect and not cause of the deformity. Our approach focuses on addressing the base elements of the nose with the premise that by addressing the foundation, nasal tip dissection may not be necessary and asymmetries could improve immediately or with time and growth. Only two subjects have undergone nasal revision thus far. Even with primary nasal tip dissection, secondary correction is undertaken in 35 to 70 percent of patients,3–7 as there is a “perverse tendency for the genu to slump with time.”4,33 Scarification of the nasal tip can make secondary surgery more difficult and limit potential aesthetic and airway improvements.3,34 Although previous reports based on observations claim that tip correction has no adverse effect on growth,7,35 recent cephalometric analysis suggests otherwise.36 By preserving tissue planes of the nasal tip, surgery may be facilitated, and the ultimate outcome may be improved. Future assessment at maturity is paramount.

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Lip and Alar Base Changes

We were surprised that the lip-to-nose width ratio did not change with surgical correction. On reexamination of images, we found that both alar base and lip commissures changed with surgery and thus the ratio did not change. Over the course of several years, the commissures widen and the ratio increases.

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Limitations

Whereas most technical descriptions of primary cleft surgery present few or no objective data (and instead, rely on selected example photographs), we have provided objective three-dimensional analysis preoperatively, postoperatively, and at 5 years and used age-matched controls for comparison. Although the data presented are comprehensive, there is currently no consensus on the best way to assess outcome of nasal reconstruction. We used traditional anthropometric measurements so that comparison can be made to other studies. We also used novel shape-based measurements that may be clinically more meaningful. Ultimately, the objective analysis may not fully account for the ideal aesthetic and does not make direct comparison to other surgical approaches. Further study is needed to determine the relative benefits of our approach with additional tip dissection, or of tip correction alone.

In addition, we cannot fully eliminate the effects of molding from the changes produced from surgery. Of 102 patients, five underwent lip taping and 15 underwent nasoalveolar molding. The effects of these interventions are partially accounted for by preoperative images that are captured following any type of presurgical molding. Future study to determine long-term effects of molding would be of great interest.

Finally, although our study is the first to compare different flaps for nasal sidewall reconstruction and different approaches to primary septoplasty, those comparisons were secondary objectives of this study. Although we found no obvious differences, the subgroup analysis involved small numbers, and definitive study may require a larger scale study.

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CONCLUSIONS

Significant correction of the unilateral cleft lip nasal deformity can be achieved by correction of septum, floor, and sidewall, without nasal tip dissection. Changes in objective measures of three-dimensional form approached those of age-matched controls and persisted at 5 years of age. Preservation of tissue planes may allow for easier or better secondary revision, if necessary. In this study, changes produced by different methods of septoplasty and of sidewall reconstruction were similar. Further, longer term assessment and comparative studies are needed.

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ACKNOWLEDGMENTS

Special thanks to Jemere Ruby for illustrating Figures 3, 4, and SDC 2, and Gail Rudakewich for illustrating Figure 2. We wish to thank Alex Kane, M.D., and Rami Hallac, Ph.D., of the University of Texas Southwestern/Children’s Medical Center Analytic Imaging and Modeling Center for access to Craniobank images. We would like to acknowledge FaceBase for access to normative images. The FaceBase Data Management Hub and the FaceBase Consortium are funded by the National Institute of Dental and Craniofacial Research. Thanks also to Chad Purnell, M.D., and Russell Ettinger, M.D., for assistance with manuscript review.

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