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Technical Advance

Improving Cleft Palate/Cleft Lip

Antenatal Diagnosis by 3-Dimensional
Sonography
The Flipped Face View
Lawrence D. Platt, MD, Greggory R. DeVore, MD,
Dolores H. Pretorius, MD

Objective. Three-dimensional sonography has enhanced the diagnosis of congenital anomalies in the
early stages of pregnancy. Both cleft lip and palate remain a diagnostic challenge for the sonographer
because of the variable size of the defects as well as their location. Recently, a technique described by
Campbell et al (Ultrasound Obstet Gynecol 2003; 22:552554, 2005; 25:1218) demonstrated an
improved method called the reverse face view, which appears to assist in the diagnosis of clefts
involving the palate. Methods. The fetal face was initially examined with the fetus in the supine position. Using 3-dimensional sonography, a static volume was acquired. Following acquisition of the volume, it was rotated 90 so that the cut plane was directed in a plane from the chin to the nose. The
volume cut plane was then scrolled from the chin to the nose to examine in sequential order the lower
lip, mandible, and alveolar ridge; tongue; upper lip, maxilla, and alveolar ridge; and hard and soft
palates. Results. This approach identified the full length and width of the structures of the mouth and
palates and allows the examiner to identify normal anatomy as well as clefts of the hard and soft
palates. Conclusions. The fetal hard and soft palates of the mouth can be accessed using a new technique, which we call the flipped face maneuver, when an adequate volume of the face can be
obtained. Key words: cleft lip; cleft palate; sonography.

Abbreviations
3D, 3-dimensional; 2D, 2-dimensional

Received March 29, 2006, from the Department of

Obstetrics and Gynecology, David Geffen School
of Medicine, University of California, Los Angeles,
and Center for Fetal Medicine and Womens
Ultrasound, Los Angeles, California USA (L.D.P.);
Fetal Diagnostic Center of Pasadena, Pasadena,
California USA (G.R.D.); and Department of
Radiology, University of California, San Diego, La
Jolla, California USA (D.H.P.). Revision requested
April 6, 2006. Revised manuscript accepted for
publication May 1, 2006.
Address correspondence to Lawrence D. Platt,
MD, Center for Fetal Medicine and Womens
Ultrasound, 6310 San Vicente Blvd, Suite 520, Los
Angeles, CA 90048 USA.
E-mail: lplatt8496@aol.com
Video online at www.jultrasoundmed.org

rofacial clefting, the fourth most common birth

defect in the United States, has an incidence of
1 per 700.1 Recent studies by Campbell et al2,3
reported a novel technique involving a reverse
face view using 3-dimensional (3D) sonography to diagnose cleft lip and palate in the antenatal period. Clefts of
the lip and primary palate can occur independently from
clefts of the secondary palate and vice versa. Both types
of defects result from a failure of the palatine process to
close between days 5 and 8 of embryogenesis (Figure 1).4
While the prenatal diagnosis of cleft lip is readily attainable using conventional 2-dimensional (2D) sonography,
cleft palate is more difficult to identify, especially if it is an
isolated anomaly.517 As the result of the limitations of 2D
sonography, the majority of palatine clefts are diagnosed
in the neonatal period.8

2006 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2006; 25:14231430 0278-4297/06/$3.50

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In prior studies, Campbell et al2,3 described a

technique for examining the hard palate by
obtaining a 3D volume and rendering an image
and viewing the facial features from the inside
out. They termed this imaging approach the
reverse face view. By scrolling the 3D rendered
image from inside out, they examined the hard
palate in cross section (Figure 2) but did not
image the hard palate en face, as illustrated in
Figure 1.
In this Technical Advance, we describe an
approach in which we use the 3D rendered
image to examine the hard and soft palates en
face, looking at their width and length as though
one were examining the palate in the postnatal
period (Figure 1).

Methods
The GE Voluson Expert system (GE Healthcare,
Waukesha, WI) with either a 2- to 5- or 4- to 8MHz volume transducer was used. To use the
flipped face maneuver, the fetal face is imaged
in the sagittal plane to identify facial anatomy

(Figure 3). The 3D static sweep mode is selected

instead of the 4-dimensional mode because the
former provides a higher-resolution image for 3D
rendering. Before the 3D static sweep, the 2D
image contrast is optimized by activating the
harmonic function to enhance the recognition
of differing tissue interfaces. The volume sweep
can be performed by either directing the ultrasound beam from the lateral side of the face to
the lateral side of the face in the sagittal plane or
from the chin to the nose in the transverse plane.
Whichever method is used for the sweep, the
smallest angle is selected to include the full width
of the face. Since the sweep speed is inversely
proportional to image resolution (the faster the
sweep speed, the poorer the image resolution;
the slower the sweep speed, the higher the image
resolution), we selected the slowest sweep speed
possible not associated with fetal movement
during the volume acquisition. Following the volume acquisition, the combined multiplanar and
rendered image format was displayed on the
screen (Figure 4A). The profile of the fetal face
from either the sagittal or transverse sweep is dis-

Figure 1. View of the hard and soft palates looking from the chin toward the nose. The images illustrate various combinations of
clefting of the lip, alveolar ridge, and hard and soft palates.

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played in the acquired image plane (Figure 4A,

image a), and the perpendicular plane of the face
is also shown (Figure 4A, image b). Once the rendering parameters (eg, threshold) were adjusted
to provide the optimized surface image of the
face, the lips were examined, and the view bar
was then scrolled from the surface of the lips to
the alveolar ridges and the hard palate to identify
the presence or absence of a cleft lip (Figure 4A,
image d). After the above was accomplished, the
reference dot was placed in or below the philtrum.
Using the X, Y, and Z controls, the rendered image
(Figure 4A, image d) was rotated to obtain a facial
image that was perpendicular to the transducer
(Figure 4A). Once these corrections were made,
the image in Figure 4A, image a, was rotated until
the green cut plane was directed from the fetal
chin, looking cephalad toward the palate (Figure
4, AD). The boundaries of the rendering box were
changed to decrease the size of the box to maximize resolution of the rendered image. The rendered image was then rotated so that the chin
appeared in the rendered image as though one
were viewing the chin from below (Figure 4, B
and C). Using the scroll button, the rendered
image was viewed in sequential planes from the
chin to just above the orbits (Figure 5, AD).
Using this technique, the mandible, tongue,
maxilla, and hard and soft palates were viewed.
The resolution of these rendered images was
improved by making the rendered box as small
as possible in the anterior-posterior direction. It
is important to note that the boundaries of the
rendering box are not fixed or accepted during
these manipulations because the technique
depends on changes in the rendering box boundaries or location. Figure 6 illustrates a sequence of
images illustrating the technique for rotating the
volume image of the face into the proper plane for
analysis of the hard and soft palates in a fetus with
cleft lip. Figure 7 illustrates the sequential anatomy identified as the rendered image is examined
from the chin toward the nose. Once the images
are obtained, the rendered image can further be
enhanced by selecting different filters that highlight soft tissues, bone, and cartilage (Figure 8).
Recently, we have used this technique in all
cases of suspected cleft palate or where the
palate has not been visible. While this report is
not meant to provide a case series, in the first 50
J Ultrasound Med 2006; 25:14231430

Figure 2. Reverse facial view technique described by Campbell et al2,3 in which the
cut plane (green arrows) is directed from the back of the skull toward the front.
When the 3D volume is rendered, the transverse hard palate can be identified.

cases we examined to evaluate the diagnostic

capabilities using this approach, 100% of the
prenatal anatomy was confirmed after birth. We
have also reviewed other volume images of faces
in which the cleft palate was previously diagnosed. This technique appears to improve upon
the capabilities to identify the lips, mandible,
and maxillary bones with their respective alveolar ridges, as well as the hard and soft palates.
Limitations of this technique are predominantly related to acquisition of an adequate facial volume that does not have shadowing of the palate.
Figure 3. The fetus is in the supine position, and the fetal face is imaged in the
sagittal plane. From this orientation, the 3D static volume is acquired from left side
to right side or vice versa.

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Clearly, shadowing from a portion of the palate that

is anterior to the area of interest or from the nose or
an extremity can lead to a gap in the palate, which
can be misinterpreted as a defect. In addition, if the
fetal face is directed posterior to the ultrasound
beam, this technique cannot be used because of
shadowing from the occipital bones of the skull. It is
important to scroll through the multiplanar images
to verify that shadowing is not a factor. In addition,
we do not believe that the soft palate can be evaluated in all fetuses from our small series but, rather,
that this is an area that deserves further study.

Discussion
The 3D flipped face technique described in this
report is a rapid and highly effective method for
identification of the fetal lips, alveolar ridges, and
hard and soft palates as early as the second
trimester of pregnancy. Following the volume
acquisition, these views were rendered, displayed, and analyzed in less than 2 minutes. As
Campbell et al2,3 pointed out, recognition of the
palate can be difficult to diagnose on 2D imaging.

Figure 4. A, Profile of the fetal face. The acquired image is shown in a. The purple circle illustrates the reference point, which is placed at the level just below
the philtrum. The acquired multiplanar images perpendicular to this point are displayed in b and c. The rendered image of the face is displayed in d. The
white arrows illustrate the direction that the image will be rotated. B, Change in images as the image in a is rotated (white arrows). The rendered chin is
now observed. C, Further rotation in plane a with the rendered image now looking from the chin toward the nose. D, Completion of the rotation with the
green cut plane looking at the level of the tongue. This is the final orientation of the green cut plane used to display the rendered image for evaluation of
the lips, alveolar ridges, mandible, maxilla, and hard and soft palates.

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In a series of 96 fetuses with cleft lip and palate,

Rotten and Levaillant18 found that although they
could identify the soft palate, they had some difficulty identifying it in all cases. In their series,
there were several false-positive and false-negative results in regard to the extent of facial clefting. Lee et al19 also reported a rendered image of
a clefted soft palate with an open mouth that
was tilted up. Although other studies have
reported that craniofacial malformations could
be accurately diagnosed using 2D and 3D
sonography, we believe that the accurate diagnosis of craniofacial malformations can be
enhanced with 3D sonography using the tech-

niques described in this report as well as multiplanar evaluation of the anatomic structures.2,3,1830 We are far from reaching our goal of
100% sensitivity using prenatal diagnostic
sonography to identify all birth defects because
of difficulties with fetal position, increased
maternal adipose tissue, operator experience,
and a variety of other conditions. Although
these may be limiting factors, it is important to
introduce new techniques that will enhance
ones ability to identify a critical diagnosis during the antenatal period. A video clip demonstrating this technique is available online at
www.jultrasoundmed.org.

Figure 5. Sequence of rendered images using the technique described in Figure 4. The image is moved in the direction of the cut plane from the chin
to the nose, while keeping the cut plane stationary. A, Green cut plane that is used for the rendered images in AD. A, Mandible and corresponding
alveolar ridge; B, tongue; C, maxilla and alveolar ridge; and D, hard and soft palates.

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Figure 6. A, Image acquisition similar to that demonstrated in Figure 4. However, the rendered image in this fetus demonstrates a right-sided cleft lip.
B, The image is rotated so that the green cut plane is directed at the level of the chin. The cut plane is now in the proper location to begin the sequential analysis of the mandible, maxilla, alveolar ridges, and hard and soft palates.
Figure 7. After completing the rotation of the image described in Figure 6, the green cut bar is directed from the lower chin toward the nose to identify the cleft lip and cleft palate. A, Mandible and alveolar ridges; B, cleft lip and tongue; C, cleft of the alveolar ridge and lip; and D, continuity between
the cleft of the alveolar ridge and the hard and soft palates.

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Figure 8. Rendered image at the level of the cleft of the alveolar ridge near the maxillary bone using different filters. The surface smooth and surface rendering filters provide the greatest
detailed images of the tissues at this level in the fetal head.

9.

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