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van Roey VL, Versnel SL, Heliövaara A, Alaluusua S, Tjoa STH, Wolvius EB, Mink van der Molen AB, Mathijssen IMJ. Comparison of a third surgical protocol for the treatment of unilateral cleft lip and palate: a multidisciplinary systematic review and meta-analysis. Int J Oral Maxillofac Surg 2025:S0901-5027(25)00119-5. [PMID: 40288948 DOI: 10.1016/j.ijom.2025.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2024] [Revised: 04/03/2025] [Accepted: 04/10/2025] [Indexed: 04/29/2025]
Abstract
This systematic review and meta-analysis builds upon our previous publication on the outcomes of patients with unilateral cleft lip and palate (UCLP) treated with Oslo protocols (OP; vomerplasty during lip closure vs delayed hard palate closure protocols (DHPCP), comparing the outcomes of these two protocols with those of one-stage palatoplasty protocols (OSPP). A systematic search of the Embase, MEDLINE/PubMed, Web of Science, Cochrane, and Google Scholar databases was conducted until August 2024. In total, 162 articles (156 study groups) were reviewed, including 4040 UCLP patients following OSPP, 1632 following OP, and 791 following DHPCP. The results suggest that intrinsic maxillofacial growth disturbances are common in UCLP patients, regardless of the timing or type of palatal closure. The incidence of velopharyngeal insufficiency was significantly higher in OP (24%) when compared to DHPCP (9%), with OSPP showing an intermediate incidence (14%). However, these findings are of very low certainty due to evident non-reporting bias and limited data. In contrast, OP and OSPP showed lower oronasal fistula (ONF) rates (7% for OP, 10% for OSPP) compared to DHPCP (20%). Altogether, OSPP and OP are favoured over DHPCP due to the lower incidences of ONF, better overall speech outcomes, and fewer primary surgeries.
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Affiliation(s)
- V L van Roey
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands.
| | - S L Versnel
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - A Heliövaara
- Cleft Palate and Craniofacial Centre, Department of Plastic Surgery, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - S Alaluusua
- Cleft Palate and Craniofacial Centre, Department of Plastic Surgery, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - S T H Tjoa
- Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - E B Wolvius
- Department of Oral and Maxillofacial Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - A B Mink van der Molen
- Department of Plastic and Reconstructive Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - I M J Mathijssen
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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Putri IL, Widiono ES, Liana S, Ruberto S, Dyah Kencono Wungu C. A Systematic Review: Early Simultaneous Vomer Flap with Primary Cleft Lip Repair, Does it Bring More Benefits? Cleft Palate Craniofac J 2024; 61:2038-2048. [PMID: 37525515 DOI: 10.1177/10556656231192295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
INTRODUCTION Vomer flap is a technique to close cleft lip and palate. This technique is a simple procedure that has many benefits. However, the vomer flap's application together with primary lip closure is still questionable. OBJECTIVE To find out whether the vomer flap's application in primary cleft lip repair can provide significant benefits. DESIGN A systematic review was conducted using the PRISMA methodology has been licensed in PROSPERO databases (CRD42023399487). SETTING A comprehensive search was set out, utilizing eight data sources up to March 2023. PARTICIPANTS Both cohort studies and randomized control trials regarding the use of vomer flaps performed concurrently with cleft lip repair in children up to six months old. RESULTS This article involved 8 studies involving 542 patients who met the inclusion criteria, consisting of 6 retrospective cohort studies, 1 RCT study, and 1 prospective cohort study. Vomer flaps provide a reduction in palatal cleft distance of 3-5 mm, a relatively small number of fistulas (0-4%), improvement of velopharyngeal function (nasal tone and nasal emission), maximal development of the maxilla although it is still controversial. CONCLUSION The vomer flap's application in primary cleft lip repair provides many advantages, such as reduced palatal and alveolar clefts, decreased risk of oronasal fistula, increased velopharyngeal function, and increased maxillary growth. It is reliable for the management of cleft lip and palate.
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Affiliation(s)
- Indri Lakhsmi Putri
- Department of Plastic Reconstructive and Aesthetic Surgery, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Plastic Reconstructive and Aesthetic Surgery Unit, Airlangga University Hospital, Surabaya, Indonesia
| | | | - Stephanie Liana
- Medical Student, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Sandro Ruberto
- Medical Student, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Citrawati Dyah Kencono Wungu
- Department of Physiology and Medical Biochemistry, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
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van Roey VL, Ombashi S, Pleumeekers MM, Mathijssen IMJ, Mink van der Molen AB, Munill M, Versnel SL. Comparison of two surgical protocols for the treatment of unilateral cleft lip and palate: a multidisciplinary systematic review and meta-analysis. Int J Oral Maxillofac Surg 2024; 53:803-820. [PMID: 38664107 DOI: 10.1016/j.ijom.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 08/27/2024]
Abstract
There is still no unanimous agreement on the optimal surgical protocol(s) for the treatment of unilateral cleft lip and palate (UCLP), and a huge variety of protocols are employed by cleft centres across the world. The aim of this systematic review and meta-analysis was to compare reported patient outcomes of the Oslo protocol (and modifications) (OP) and delayed hard palate closure protocols (DHPCP) from a multidisciplinary perspective. A systematic search of multiple databases was conducted until September 2023. Studies reporting any patient outcomes of these protocols were included. Random-effects meta-analyses were performed for evidence synthesis, including comparisons of results between the types of protocol. The quality of evidence was evaluated using the ROBINS-I tool. In total, 62 articles (42 studies) reporting patients with UCLP were reviewed, involving 1281 patients following the OP and 655 following DHPCP. Equally poor long-term sagittal maxillofacial growth was found, and similar results for velopharyngeal insufficiency and nasolabial appearance. In contrast, OP was associated with a lower rate of oronasal fistulas. Disregarding the scarcity of comparable evidence for some domains, the results of this review, overall, favour OP over DHPCP. However, caution should be taken when interpreting the results on velopharyngeal insufficiency and oronasal fistulas, since the possibility of confounding and other biases remains.
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Affiliation(s)
- V L van Roey
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands.
| | - S Ombashi
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - M M Pleumeekers
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Dutch Craniofacial Centre, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - I M J Mathijssen
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Dutch Craniofacial Centre, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - A B Mink van der Molen
- Department of Plastic and Reconstructive Surgery, UMC Utrecht, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - M Munill
- Department of Maxillofacial Surgery, Hospital Vall d'Hebron, Barcelona, Spain
| | - S L Versnel
- Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands; Dutch Craniofacial Centre, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Menville JE, Spake C, Soliman L, Shinde N, Persad-Paisley EM, Baranwal N, Woo AS. Dehiscence and Fistula Formation Following Anterior Palatal Reconstruction With Vomer Flap. J Craniofac Surg 2024; 35:1101-1104. [PMID: 38727218 DOI: 10.1097/scs.0000000000010267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/04/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND AND PURPOSE Anterior palatal reconstruction using vomer flaps has been described during primary cleft lip repair. In this procedure, the mucoperiosteal tissue of the vomer is elevated to reconstruct the nasal mucosa overlying the cleft of the hard palate. Here the authors, evaluate the efficacy of a technique in which a superiorly based vomer flap is sutured to the lateral nasal mucosa. The authors assess vomer flap dehiscence rates and compare the likelihood of fistula development in this cohort to patients who underwent palatoplasty without vomer flap reconstruction. METHODS A retrospective chart review was conducted of all palatoplasties performed by the senior author at an academic institution during a 7-year period. Medical records were reviewed for demographic variables, operative characteristics, and postoperative complications up to 1 year following surgery. Logistic regression analysis was conducted to assess the effects of vomer flap reconstruction on fistula formation, adjusting for age and sex. RESULTS Fifty-eight (N=58) patients met the inclusion criteria. Of these, 38 patients (control group) underwent cleft palate reconstruction without previous vomer flap placement. The remaining 20 patients underwent cleft lip repair with vomer flap reconstruction before palatoplasty (vomer flap group). When bilateral cases were counted independently, 25 total vomer flap reconstructions were performed. Seventeen of these 25 vomer flap reconstructions (68%) were completely dehisced by the time of cleft palate repair. In the vomer flap group, 3 of the 20 patients (15%) developed fistulas in the anterior hard palate following the subsequent palatoplasty procedure. In the control group, only 1 of the 38 patients (2.6%) developed a fistula in the anterior hard palate. There was no significant association between cohorts and the development of anterior hard palate fistulas [odds ratio=10.88, 95% confidence interval (0.99-297.77) P =0.07], although analysis was limited by low statistical power due to the small sample size. CONCLUSIONS In our patient population, anterior palatal reconstruction using a superiorly based vomer flap technique was associated with complete dehiscence in 68% of cases. Fistula formation in the anterior hard palate was also proportionately higher following initial vomer flap reconstruction (15% versus 2.6%). These results prompted the senior author to adjust his surgical technique to 1 in which the vomer flap overlaps the oral mucosa. While follow-up from these adjusted vomer flap reconstruction cases remains ongoing, early evidence suggests a reduced requirement for surgical revision following implementation of the modified technique.
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Affiliation(s)
- Jesse E Menville
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
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Kurimori ÉT, Garib D, Graziadei SM, Sathler R, Dalben GDS, Lauris RDCMC, Souza-Brosco TV, Nobrega ESDS, Alonso N, Tonello C, Ozawa TO. Growth Outcomes Audit for Unilateral Cleft Lip and Palate (UCLP) After 2-stage Palate Repair. J Craniofac Surg 2023; 34:1756-1759. [PMID: 37552130 DOI: 10.1097/scs.0000000000009569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 06/27/2023] [Indexed: 08/09/2023] Open
Abstract
PURPOSE To assess the impact of 1 and 2-stage palatoplasty protocol on the dental arch relationships in unilateral cleft lip and palate (UCLP) in a single center. METHODS Our study consisted of 349 individuals divided into 2 groups according to the palatoplasty protocol. Two-stage group comprised 169 subjects with UCLP (mean age: 6.9 y, 110 male and 59 female) who underwent lip, nasal ala, and anterior palate repair with vomer flap from 3 to 6 months (first surgery stage). Soft palate repair occurred from 12 to 18 months (second surgery stage). The one-stage group comprised 180 subjects with UCLP (mean age: 7.2 y, 108 male and 72 female) who underwent 1-stage palatoplasty. Dental models were evaluated by 3 experienced orthodontists applying Goslon Yardstick and the 5-year-old index (FYOI). The influence of the palatoplasty technique and surgeon factor on the interarch relationship was evaluated. The weighted Kappa was used to assess intraexaminer and interexaminer agreements for comparisons of dental arch relationships. Intergroup comparisons were conducted using the χ 2 test ( P <0.05). RESULTS The intraexaminer reliability was very good (0.81 to 0.98) and interexaminer reliability varied from satisfactory to very good (0.56 to 0.83). The mean occlusal index of the 2-stage and 1-stage groups was 2.77 and 3.03, respectively. The variability of the mean index between surgeons varied from 2.38 to 3.2 in the 2-stage group and 2.91 to 3.2 in the 1-stage group. There were significant differences in the frequency of Goslon 5 index ( P =0.002) between groups, with the 2-stage group presenting less cases (1.18%) than the group 1-stage (11.11%). CONCLUSION The interarch relationship was similar for both palate repair protocols. Two-stage palatoplasty showed a decreased prevalence of Goslon index 5.
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Affiliation(s)
- Érika Tiemi Kurimori
- Department of Orthodontics, Bauru Dental School, University of São Paulo, Bauru/SP, Brazil
| | - Daniela Garib
- Department of Orthodontics, Bauru Dental School, University of São Paulo, Bauru/SP, Brazil
- Departments of Orthodontics
| | | | | | | | | | | | | | - Nivaldo Alonso
- Craniofacial Surgery, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru/SP, Brazil
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Sert G, Calis M, Suslu AE, Ozgur F. Effect of cleft palate repair with vomer flap on incidence and severity of obstructive sleep apnea. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01818-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Vandenberg K, Castle M, Qeadan F, Kraai T. Oronasal Fistula Incidence Associated With Vomer Flap Repair of Cleft Palate: A Systematic Review and Meta-Analysis. Cleft Palate Craniofac J 2020; 58:957-965. [PMID: 33302724 DOI: 10.1177/1055665620974562] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To determine the incidence of oronasal fistulas (ONF) associated with primary repair of the anterior palate using a single-layered, superiorly based, vomer mucoperiosteal flap. DESIGN A systematic review of MEDLINE, PubMed, Cochrane, and Web of Science databases using the keywords: "vomer flap" and "cleft palate repair" were carried out. A meta-analysis was performed using random effect modeling with stratified analysis by syndromic diagnosis, number of surgeons, and mean age. MAIN OUTCOME MEASURE(S) Incidence of ONFs. RESULTS The meta-analysis included 9 studies with a total of 464 children who met inclusion criteria. The overall ONF rate was 3.0% (95% CI: 1.0-9.0). Fistula rates were not significantly different in studies that included syndromic patients compared to studies that did not, 5.0% (95% CI: 1.0-24.0) versus 3.0% (95% CI: 1.0-6.0), respectively. There was no significant difference between studies in which there was a single surgeon versus multiple surgeons, 3.0% (95% CI: 1.0-13.0) versus 4.0% (95% CI: 1.0-8.0), respectively. Age at the time of cleft repair showed no statistically significant difference in fistula rate when comparing children with a mean age less than 12 months to those greater than 12 months, 3.0% (95% CI: 1.0-5.0) versus 5.0% (95% CI: 1.0-28.0), respectively. CONCLUSIONS The vomer flap technique in cleft palate repair appears to be associated with a low ONF rate unaffected by syndromic diagnosis, number of surgeons, or patient age at time of repair.
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Affiliation(s)
- Katherine Vandenberg
- Department of Surgery, Division of Otolaryngology Head & Neck Surgery, 1104University of New Mexico Health Sciences Centers, Albuquerque, NM, USA
| | - Michael Castle
- 1104University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Fares Qeadan
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | - Tania Kraai
- Department of Surgery, Division of Otolaryngology Head & Neck Surgery, 1104University of New Mexico Health Sciences Centers, Albuquerque, NM, USA
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Baillie L, Sell D. Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique. Cleft Palate Craniofac J 2020; 57:1197-1215. [DOI: 10.1177/1055665620923925] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Objective: To report speech and velopharyngeal function (VPF) outcomes, and surgical characteristics, at age 5 following early complete palate closure using the Sommerlad protocol. Design: A retrospective, descriptive, cross-sectional consecutive series. Setting: A regional twin site center; a district general hospital and tertiary children’s hospital. Participants: Between 1993 and 2006, 877 participants underwent surgery; 712 (81%) were eligible for inclusion; 391 (55%) were included, 321 (45%) excluded. Thirteen percent had bilateral cleft lip and palate (CLP), 40% unilateral CLP, and 47% isolated cleft palate. Intervention: Lip and vomerine flap repair at 3 months of age (BCLP, UCLP) with soft palate closure using radical muscle dissection and retropositioning at a mean age of 6.6 months, range 4 to 23 months, as described and undertaken by Sommerlad. Outcome Measures: Velopharyngeal Composite (VPC) CAPS-A and articulation summary scores derived from analysis using the Cleft Audit Protocol for Speech-Augmented. Results: A VPC-SUM CAPS-A score of “0” was found in 97% reflecting adequate VPF; 73% had no cleft articulation difficulties. The BCLP group had the poorest articulation. Secondary speech surgery rate was 2.6% and 10.7% had fistula repair. Levator muscle quality and degree of retropositioning was associated with speech outcomes related to VPF. 2.6% had current features of VPI. Conclusions: Complete palate closure by around 6 months of age by the surgeon who described the technique led to excellent perceived VPF and very good speech outcomes at age 5, with less speech therapy and secondary speech surgery than commonly reported. These findings serve as a benchmark for the Sommerlad protocol and technique.
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Affiliation(s)
- Lauren Baillie
- Speech and Language Therapy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Debbie Sell
- Centre for Outcomes and Experience Research in Children’s Health, Illness and Disability (ORCHID), Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
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Emami A, Hashemzadeh H. Does Primary Vomer Flap Significantly Affect Maxillary Growth? World J Plast Surg 2020; 9:62-66. [PMID: 32190594 PMCID: PMC7068186 DOI: 10.29252/wjps.9.1.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Cleft lip and palate (CLP) is a common congenital anomaly. Efficient surgical management of CLP is challenging in severe cases with wide clefts. Use of primary vomer flap simultaneous with cleft lip repair is effective in some cases, but remains a challenging topic. METHODS This study evaluated 81 non-syndromic CLP patients with extensive palatal cleft and no other underlying condition. Thirty-nine patients (group A) who were infants over 6 months of age underwent primary vomer flap during lip repair to decrease the size of their extensive palatal cleft. The results in this group were compared with group B (n=42) who did not receive primary vomer flap. RESULTS Comparison of the two groups showed that although maxillary growth impairment and maxillary constriction had a higher frequency in group A, the palatal cleft was smaller among them, which enabled easier and more efficient cleft repair in the next step. The difference in maxillary growth impairment was not significant between the two groups. However, the prevalence of some complications such as velopharyngeal incompetence and maxillary growth impairment was slightly higher in group A compared with group B. CONCLUSION Use of primary vomer flap at the time of lip repair can decrease the size of palatal cleft and enhance its later closure. However, since impairment of the maxillary growth was slightly (but insignificantly) higher in the vomer flap group, it should be performed at ages over 6 months of age, as well as in certain cases.
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Affiliation(s)
- Abolhasan Emami
- Department of Plastic Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Haleh Hashemzadeh
- Department of Orthodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
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The Impact of Facial Growth in Unilateral Cleft Lip and Palate Treated With 2 Different Protocols. Ann Plast Surg 2020; 84:541-544. [PMID: 32091442 DOI: 10.1097/sap.0000000000002232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIM It is well known that palatoplasty can often cause disturbances in maxillary growth. The use of a single-layer vomer flap for the early closure of the hard palate is controversy among surgeons. The aim of this study is to compare the 10-year facial growth of 2 surgical protocols in the treatment of patients with unilateral cleft lip and palate performed by a single surgeon. METHODS This retrospective analysis includes 43 nonsyndromic patients with complete unilateral cleft lip with or without a vomer flap for the closure of the hard palate during cleft-lip repair. Lateral cephalograms were obtained at the age of 5, 7, and 9 years old, and angular measurements were used to assess patient's facial growth. The Mann-Whitney U test was used to compare 2 treatment protocol groups. RESULT A total of 23 patients in protocol 1 group (16 male, 7 female) and 20 patients in protocol 2 group (10 male, 10 female) were included. At the age of 5 and 7, there was no significant difference of maxillary and mandibular growth in both groups. At the age of 9 years, all the angular measurement revealed statistical significance with SNA (P = 0.02), SNB (P = 0.05), ANB (P < 0.01), and SNPg (P = 0.05). CONCLUSIONS The present study has shown that early anterior palate repair for 3-month-old cleft patients have better maxillary growth and less mandibular prognathism.
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Early outcomes of cleft and palatal width following anterior palate repair (vomerine flap) in infants with wide cleft lip and palate. Arch Plast Surg 2019; 46:518-524. [PMID: 31775204 PMCID: PMC6882701 DOI: 10.5999/aps.2019.00227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 09/24/2019] [Indexed: 11/22/2022] Open
Abstract
Background Anterior palatal repair performed during cleft lip repair using a vomerine flap may assist in recruiting additional soft tissue for subsequent completion of palatoplasty, especially in patients with a wide cleft. We present our early results in the hope of triggering a re-evaluation of this technique regarding its advantages for maxillary growth through further studies of patients with a wide cleft. Methods A retrospective analysis of patients with complete unilateral and bilateral cleft lip and palate was performed, including cleft and palatal measurements taken during initial surgery (lip repair together with anterior palate repair) and upon completion of palatoplasty. Results In total, 14 patients were included in this study, of whom nine (63.3%) had unilateral cleft lip and palate and five (37.5%) had bilateral cleft. All patients had a wide cleft palate. Lip and anterior palate repair was done at a median age of 3 months, while completion of palatoplasty was done at a median age of 10.5 months. Measurements taken upon completion of palatoplasty showed significant cleft width reduction in the mid-palate and intertubercle regions; however, the palatal arch distances at nearby landmarks showed non-significant marginal changes. Conclusions Anterior palate repair using a vomerine flap significantly reduced the remaining cleft width, while the palatal width remained. Further research is warranted to explore the long-term effects of this technique in wide cleft patients in terms of facial growth.
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Anatomical Nasal Lining Flaps for Closure of the Nasal Floor in Unilateral and Bilateral Cleft Lip Repairs Reduce Fistulas at the Alveolus. Plast Reconstr Surg 2019; 142:1549-1556. [PMID: 30188474 DOI: 10.1097/prs.0000000000004986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Techniques vary for addressing the nasal floor during cleft lip repair in patients with a cleft lip and palate. Sometimes, no closure is performed, leaving a symptomatic alveolar fistula until the time of alveolar bone grafting. Often, medial and lateral skin flaps are used, but these are often thin and unreliable. Anatomical nasal lining flaps are used to improve closure with robust, well-vascularized flaps that anatomically close the nasal floor. METHODS A retrospective chart review was performed to identify patients with a unilateral or bilateral cleft lip and palate who underwent primary cleft lip repair with nasal lining flaps or with medial and lateral flaps. The primary outcome was presence of a symptomatic and/or visible oronasal fistula. RESULTS Sixty-four patients were included. Thirty-seven underwent closure with nasal lining flaps, whereas 27 underwent closure using Millard medial and lateral flaps. The rate of symptomatic/visible fistulas after cleft palate repair was 19 percent (seven of 37) for patients with nasal lining flaps and 44 percent (12 of 27) for patients with medial and lateral flaps (p = 0.0509, Fisher's exact test). The alveolar fistula rate was 3 percent (one of 37) for patients with nasal lining flaps and 30 percent (eight of 27) for patients with medial and lateral flaps (p = 0.0032, Fisher's exact test). CONCLUSIONS Nasal lining flaps at the time of cleft lip repair effectively close the anterior nasal floor in patients with a unilateral or bilateral cleft lip and palate. Decreasing the presence of alveolar fistulas after cleft palate repair improves the quality of life for patients with cleft deformities. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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The efficacy of vomer flap for closure of hard palate during primary lip repair. J Plast Reconstr Aesthet Surg 2015; 68:940-5. [PMID: 25971415 DOI: 10.1016/j.bjps.2015.03.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 03/22/2015] [Accepted: 03/30/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIM This study presents the institutional experience of the use of vomer flap for early closure of hard palate during unilateral complete cleft-lip repair. The purpose of this study was to determine the survival rate of the vomer flap and to investigate its effect on the subsequent palatoplasty. PATIENTS AND METHODS This retrospective analysis includes 101 non-syndromic patients with complete unilateral cleft lip who received a vomer flap for the closure of the hard palate during cleft-lip repair. Patients were aged 6 months to 28 years (median 1 year). Success rates of the vomer flaps were assessed clinically and through pre-operative photographs taken at the time of subsequent palate repair. Ninety-two patients returned for second-stage palate repair, and 74 patients with adequate post-operative follow-up information were statistically analysed. RESULTS Of the 101 patients who were operated with primary lip repair and simultaneous vomer flap, only 54 (52.4%) vomer flaps healed completely. Out of 92 patients who returned for subsequent palatoplasty, 71 (77.2%) were operated with the two-flap technique, and 19 (20.7%) received von Langenbeck repairs. Seven (9.1%) patients had a surgical complication. The failure of previous vomer repair and von Langenbeck surgical technique were identified as factors associated with post-operative complications. CONCLUSIONS We conclude that failed vomer flaps increased the risks of complications in the subsequent palate repair. Furthermore, efforts to use von Langenbeck technique rather than the two-flap technique also resulted in increased surgical complications. As a result, we have abandoned the use of the vomer flap with primary lip repair.
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Swan MC, Fisher DM. Cleft lip. Plast Reconstr Surg 2015. [DOI: 10.1002/9781118655412.ch17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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