ORIGINAL ARTICLE The Americleft Project: A Proposed Expanded Nasolabial Appearance Yardstick for 5- to 7-Year-Old Patients With Complete Unilateral Cleft Lip and Palate (CUCLP) A.M. Mercado, D.M.D., Ph.D., K.A. Russell, D.D.S., M.Sc., J. Daskalogiannakis, D.D.S., M.Sc., F.R.C.D(C), R.R. Hathaway, D.D.S., M.S., G. Semb, D.D.S., Ph.D., T. Ozawa, D.D.S., A. Smith, D.D.S., A.Y. Lin, M.D., R.E. Long Jr., D.M.D., M.S., Ph.D. Objective: To develop a yardstick of reference photographs for nasolabial appearance assessments of 5- to 7-year-old patients with complete unilateral cleft lip and palate (CUCLP). Design: Blind retrospective analysis of clinical records and comparison to historical controls. Patients: Subjects were two groups of 6- to 12-year-olds (n ¼ 124 and n ¼ 135) and one group of 5- to 7-year-olds (n ¼ 149) with nonsyndromic CUCLP from three previous Americleft studies, including cohorts from seven different cleft/craniofacial centers. Interventions: All patients received the infant management protocols of their respective centers. Eleven trained and calibrated judges (five participated in all three studies) did blind ratings of nasolabial appearance using the Asher-McDade method. Main Outcome Measures: Patients receiving the most consistent ratings between judges, selected first from the groups of 6- to 12-year-olds, were used to create a pilot yardstick for eventual use in the third study of 5- to 7-year-olds. For each of the Asher-McDade categories, 8 of the 5- to 7-year-old patients receiving the most consistent scores between raters were ranked by 10 judges for a final elimination to leave three per category. Results: Using this method of successive changes in rating methods, a new reference yardstick for nasolabial appearance rating was established and linked to the original Asher- McDade method as well as the single examples in a previously published yardstick for patients with CUCLP. Pilot testing using the yardstick improved reliabilities. Conclusions: Use of an expanded nasolabial yardstick of reference photographs represen- tative of the range of possibilities of each of the five Asher-McDade categories is now available to see if reliability of these ratings can be improved. KEY WORDS: CUCLP, nasolabial appearance, yardstick Intercenter outcome comparisons have increased value if the outcomes being compared are identical and a common benchmark is used. For outcomes using ordinal scales for ratings, the Goslon Yardstick for dental arch relationships in patients with complete unilateral cleft lip and palate (CUCLP) (Mars et al., 1987) represents one of the best examples of this concept. Used most notably in the original Eurocleft study (Mars et al., 1982), the availability of a reference set of dental models representative of the five rating categories of dental arch relationship (1 ¼ best to 5 ¼ worst) contributed to the very high inter- and intra- reliability of the ratings. Furthermore, with the countless additional intercenter comparisons of dental arch relation- ship that followed, using the same reference yardstick has enabled valid comparison of results between studies (Hathaway et al., 2013). Dr. Mercado is Clinical Assistant Professor of Orthodontics, Division of Orthodontics, The Ohio State University, Columbus, Ohio. Dr. Russell is Professor and Head, Department of Ortho- dontics and Cleft Palate Team, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia, Canada. Dr. Daskalogiannakis is Staff Orthodontist, SickKids Hospital, and Associate Professor, Department of Orthodontics, University of Toronto, Toronto, Ontario, Canada. Dr. Hathaway is Professor, Division of Cranio- facial Plastic Surgery, Cincinnati Children’s Hospital, Cincinnati, Ohio. Dr. Semb is Professor, University of Manchester, Man- chester, United Kingdom. Dr. Ozawa is Orthodontist, Hospital de Reabilita¸ca˜ o de Anomalias Craniofaciais Universidade de Sa˜ o Paulo, Bauru, Brazil. Dr. Smith is Clinical Director and Maxillo- facial Prosthodontist, Lancaster Cleft Palate Clinic, Lancaster, Pennsylvania. Dr. Lin is Director, St. Louis Cleft-Craniofacial Center, SSM Cardinal Glennon Children’s Medical Center, St. Louis University, St. Louis, Missouri. Dr. Long is Executive Director, Lancaster Cleft Palate Clinic, Lancaster, Pennsylvania. Presented at the 12th International Congress on Cleft Lip/Palate and Related Craniofacial Anomalies, Orlando, Florida, May 5–10, 2013. Submitted February 2014; Revised September 2014; Accepted September 2014. Address correspondence to: Dr. Ross E. Long Jr., Lancaster Cleft Palate Clinic, 223 North Lime Street, Lancaster, PA 17602. E-mail rlong@cleftclinic.org. DOI: 10.1597/14-017 30 The Cleft Palate–Craniofacial Journal 53(1) pp. 30–37 January 2016 Ó Copyright 2016 American Cleft Palate–Craniofacial Association