Use of early hard palate closure using a vomer flap in cleft lip and palate patients

Use of early hard palate closure using a vomer flap in cleft lip and palate patients

Accepted Manuscript Use of early hard palate closure using a vomer flap in cleft lip and palate patients Drs. Bram J.A. Smarius, Dr. Corstiaan C. Breu...

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Accepted Manuscript Use of early hard palate closure using a vomer flap in cleft lip and palate patients Drs. Bram J.A. Smarius, Dr. Corstiaan C. Breugem PII:

S1010-5182(16)30063-4

DOI:

10.1016/j.jcms.2016.05.011

Reference:

YJCMS 2369

To appear in:

Journal of Cranio-Maxillo-Facial Surgery

Received Date: 8 March 2016 Revised Date:

6 April 2016

Accepted Date: 9 May 2016

Please cite this article as: Smarius BJA, Breugem CC, Use of early hard palate closure using a vomer flap in cleft lip and palate patients, Journal of Cranio-Maxillofacial Surgery (2016), doi: 10.1016/ j.jcms.2016.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Use of early hard palate closure using a vomer flap in cleft lip and palate patients Bram J.A. Smarius1, Corstiaan C. Breugem1,2

1.Division of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital, Utrecht, The

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Netherlands

Netherlands

Corresponding author: Drs. B.J.A. Smarius

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2. Division of Plastic Surgery Meander Medical Center, 3813 TZ Amersfoort, The

Division of Pediatric Plastic Surgery, Wilhelmina Children’s Hospital

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P.O. 85090, 3508 AB Utrecht, The Netherlands E-mail address: [email protected]

Dr. C.C. Breugem

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E-mail address: [email protected]

ACCEPTED MANUSCRIPT Introduction Management of children born with a cleft palate deserves special attention because, despite being the most common craniofacial birth defect, there is still no universally accepted treatment approach. The primary objective in the surgical repair of a cleft palate is the

restriction (Phua and de Chalain 2008, Losken et al. 2011).

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development of normal speech, hearing, and feeding with minimal maxillary outgrowth

Numerous approaches for cleft palate repair have been published (Shaw et al. 2001, Agrawal 2009), but each technique has inherent benefits and disadvantages. Pichler introduced the vomer flap for cleft palate repair in 1926, and currently the vomer flap is often used for hard

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palate closure (Agrawal and Panda 2006). In the Eurocleft studies, the patients treated with a vomer flap were associated with the best long-term maxillary outgrowth (Brattstrom et al.

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2005). Previous studies have demonstrated that early hard palate closure using a vomer flap was associated with a significant postoperative reduction of the residual cleft (de Jong and Breugem 2014). A narrower cleft width is associated with a lower incidence of postoperative fistulas (Schultz 1986, Amaratunga 1988, Cohen et al. 1991, Muzaffar et al. 2001, Phua and de Chalain 2008, Parwaz et al. 2009, Landheer et al. 2010, de Agostino Biella Passos et al. 2014). The relationship of performing a vomer flap and the subsequent development of

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fistulas during the later palatal closure as well as the use of releasing incisions during cleft palate closure have not been studied before.

The purpose of this study was to determine the short-term advantages and disadvantage of

patients.

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early hard palate closure using the vomer flap in unilateral and bilateral cleft lip palate

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MATERIAL AND METHODS

Clinical data

Permission for this study was obtained from the Medical Ethical Board (number 12/164; 09/386)

A retrospective review was performed of all consecutive unilateral/bilateral complete cleft lip and palate (Veau III and IV) children who were treated by one surgeon (C.B.) at the Wilhelmina Children’s Hospital and Meander Medical Centre, in the period between July 2007 and August 2015.

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ACCEPTED MANUSCRIPT Data were collected for sex, date of birth, syndrome, adoption, cleft palate type, type of repair, date of cleft repair, cleft width, lateral incisions, fistula and location of fistula. The clefts were classified according to the Veau classification, as follows: Veau III: soft and hard palates and unilateral cleft of the primary palate; Veau IV: soft and hard palates and bilateral clefts of the primary palate.

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Cleft palate fistula in our study was defined according Muzzaffar et al. as a failure of healing or a breakdown in the primary surgical repair of the palate (Muzaffar et al. 2001).

Symptomatic fistulas were identified by the presence of hypernasal speech, articulation

problems, or fluid regurgitation from the nose. The primary outcome was measured by the

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incidence of a fistula after cleft palate repair that required secondary surgery.

During palate surgery, cleft width was measured in millimetres at the junction of the hard and soft palate before the first and second operation using a Castroviejo calliper before injection

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of local anaesthetics.

Operation technique

All palate surgeries were performed according to the standard treatment protocol at our department since 2007. All UCLP/BCLP children underwent simultaneous cleft hard palate

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closure with a vomer flap and repair of cleft lip during the first operation. Figure 1 demonstrates how the vomer flap was performed. This “single-layer mucosa” flap closure was performed after the incision was performed on the vomer. The incision extended to the dorsal end of the vomer. It is imperative to realize that a “double-breasted” closure of the mucosa of

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the lesser segment is performed.

Subsequently the rest of the cleft palate was closed during a second intervention using a von Langenbeck technique (and intravelar veloplasty under the operating microscope), preferably

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before the patient age of 12 months (Figure 2). Von Langenbeck palatoplasty could be performed with or without relaxing incisions.

Statistical analysis

Patient characteristics were summarized by descriptive statistics. Cleft width at first and second assessment were normally distributed and therefore the difference in cleft width was evaluated by a two-sided paired sample t-test. The difference in cleft width was considered to be statistically significant at a p-value of ≤ 0.05. All statistical analyses were performed using IBM Statistical Package for Social Science (SPSS) version 22 (SPSS Inc., Chicago, IL, USA).

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ACCEPTED MANUSCRIPT RESULTS

A total of 91 children (62 male, 29 female) were treated by a simultaneous lip and hard palate closure using a vomer flap and soft palate closure during a second intervention. Patient characteristics of the group are listed in Table 1. The mean age at time of lip closure and

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vomer flap was 5.8 months (standard deviation [SD] = 7.1, range = 2.9−49.2 months,) and the mean age at second surgery was 13.6 months (SD = 10.8, range = 6.3−79.9 months).

One patient (bilateral cleft lip/palate) developed a fistula (1.1%) that required secondary

surgery for closure (Table 2). The fistula was located in the middle part of the hard palate.

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Cleft palate width was measured before the first and second operation. We observed a

significant reduction in cleft width after the first stage procedure. The mean cleft width at first assessment was 13.0 mm (range = 7–22 mm) compared to 8.8 mm (range = 4–15 mm) at the

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second assessment (mean difference = 4.6 mm, 95% confidence interval [CI] = 3.93–5.35, p < 0.01). During the Von Langenbeck palatoplasty, 50 patients (55%) required a releasing incision.

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DISCUSSION

The primary objective in the surgical repair of a cleft palate is to achieve an anatomical palatal closure with normal development of speech, hearing and feeding, and minimal or no negative affect on maxillary outgrowth. This study provides new insights into the short-term

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analysis of 91 consecutive children with unilateral/bilateral cleft palate who underwent an early hard palate repair using vomer flap.

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Currently the vomer flap is often used for early hard palate closure. This regional flap is easily accessible and located next to the cleft palate. It is well vascularised and is useful in the majority of cleft palate patients (Kobus 1984). It is a suitable and an effective procedure during cleft palate closure, as demonstrated by other authors (Ferdous et al. 2010, de Jong and Breugem 2014). Deshpande et al. concluded that a failed vomer flap increase the risks of complications in the subsequent palate repair (Deshpande et al. 2015). However, since performing the vomer flap with a “double breasted mucosa” closure, we have never seen a complete dehiscence of the flap. Sometimes a small partial dehiscence of the most dorsal part has been observed, but this is of little clinical consequence. It is of special importance not to perform a vomer flap if the child has a pressure sore on the vomer from an erroneously placed 3

ACCEPTED MANUSCRIPT nipple from the special needs feeder (Habermann feeder). If patients have a pressure sore wound in our institution, we would provide a special orthodontic plate to protect the vomer and subsequently improve healing of the mucosa before performing the vomer flap. An important indicator for a successful cleft palate repair technique is the incidence of palatal fistulas. Studies of the last 15 years show an incidence of fistulas after palatoplasty with a

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range of 0%−58 % (Table 3). Like our study, other studies using vomer flap for palate closure demonstrate a decreased fistula incidence with a mean of 1.9%. (Table 4). Although not

within the scope of this study, this table also differentiates between one-stage and two-stage palate closure, where a “two-stage” palatoplasty is defined when the soft palate is closed first

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and subsequently the hard palate is closed during a later intervention. One-stage closure

techniques in the literature demonstrate an average incidence of 7.8% for fistulas, while the

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two-stage closure had a 22.0% fistula incidence.

A narrower cleft width provides a lower occurrence of fistulas (Schultz 1986, Amaratunga 1988, Cohen et al. 1991, Muzaffar et al. 2001, Phua and de Chalain 2008, Parwaz et al. 2009, Landheer et al. 2010, de Agostino Biella Passos et al. 2014). This study demonstrated that the

as fistula development.

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use of the vomer flap reduced the cleft width and subsequently the risk of complications such

Fistulas are the result of a mucosal breakdown following primary repair of a palatal cleft. The use of lateral releasing incisions decreases the tension at the site of closure and subsequently

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could reduce the risk of tension causing circulation problems, necrosis, and possible fistula formation (Campbell 1962). Sommerlad attributed his fistulas (15%) to his conservative use

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of lateral releasing incisions (Langenbeck flaps) (20%) (Sommerlad 2003). Becker and Hansson (2013) indicated that the use of lateral releasing incisions (42%) in wider clefts might result a lower fistula rate (5%) (Becker and Hansson 2013). However, there are also possible disadvantages to lateral releasing incisions. Making lateral releasing incisions increases the possibilities of postoperative haemorrhage and pain, while abundant use of the releasing incision could decrease the vascularity of the flaps, possibly increasing of incidence of fistulas (Campbell 1962). None of our patients needed second surgeries because of postoperative bleeding form the donor area. In our study, we used lateral incisions in 55% of the patients. The patient that developed a fistula had lateral releasing incisions. None of our patients had a postoperative haemorrhage or infection. The other disadvantages of the vomer

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ACCEPTED MANUSCRIPT flap include possible bleeding from the donor area. Especially, extending the excision to the adenoid area could result in postoperative bleeding. It is imperative to carefully use diathermia to coagulate all possible bleeding areas.

Although many authors would agree that there are numerous short-term benefits of vomer

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flaps, some surgeons feel that scaring in the donor area could result in long-term maxillary outgrowth restriction. However, Eurocleft and Americleft intercentre studies have reported a favourable effect on long-term maxillary growth with the use of vomer flap (Brattstrom et al. 2005, Daskalogiannakis et al. 2011). Liao et al (2014) also analyzed 334 cephalometric

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radiographs from 95 patients with nonsyndromic complete unilateral cleft lip and palate who underwent hard palate repair by two different techniques (vomer flap versus two-flap) (Liao et al. 2014). The facial morphology was analyzed at age 20 years. The hard palate repair

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technique significantly influenced protrusion of the maxilla (SNA: β = −3.5°, 95 % CI = −5.2 to 1.7; p = 0.001) and the anteroposterior jaw relation (ANB: β = 4.2°, 95 % CI = −6.4 to 1.9; p = 0.001; Wits: β = −5.7 mm, 95% CI = −9.6 to 1.2; p = 0.01) at age 20 years, and their growth rates (SNA: p = 0.001, ANB: p < 0.01, and Wits: p = 0.02). However, the vomer flap repair had a smaller adverse effect than two-flap surgery on the outgrowth of the maxilla. This

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effect on maxillary growth was on the anteroposterior development of the alveolar maxilla and was progressive with age. It is possible that not the vomer flap per se but other factors such as the releasing incisions could influence the maxillary outgrowth more than the vomer flap itself. Only performing a releasing incision in the mucosa is a different procedure when

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compared to performing a releasing incision to the maxilla and to the space of Ernst, as advocated by some authors (Jackson et al. 2004).

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Although not within the scope of this study, there is evidence suggesting that delayed closure of the palate, when the mechanisms for speech development have already been established, is associated with the inability to develop normal speech patterns (Dorf and Curtin 1982, Rohrich et al. 1996, Holland et al. 2007, Lohmander et al. 2012, Pasick et al. 2014). This suggests that early closure should be preferred. However, early hard palate closure is believed to have disadvantageous effects on midfacial growth compared to delayed hard palate closure (Rohrich et al. 2000). The vomer flap procedure leads to an increased operative time in the first operation when the surgeon closed the lip and hard palate. Ferdous et al. (2010) demonstrated that using a vomer

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ACCEPTED MANUSCRIPT flap will lead to a reduction of operating time during the second operation (Ferdous et al. 2010). The mean total operation time (duration of the first operation + second operation) in the Ferdous et al. study was less in the vomer flap group (Ferdous et al. 2010). Also Li et al. (2003) showed that using a vomer flap for cleft palate repair did not prolong the operating

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time (Li et al. 2003).

This study has several limitations. Due to its retrospective nature, there are inherent

weaknesses; however, comparisons to the published literature can be made. It strengths

comparable follow-up and postoperative care.

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CONCLUSION

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include the fact that patients were consecutive cleft patients operated on by one surgeon, with

This study provides new insights in the short-term analysis of children with unilateral/bilateral cleft palate who underwent an early hard palate repair using a vomer flap. It demonstrates that performing a vomer flap is a safe procedure leading to a reduction in cleft width, and

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subsequently is associated with a low fistula rate after cleft palate closure.

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ACCEPTED MANUSCRIPT Conflict of interest No benefits in any form have been received or will be received from a commercial party

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related directly or indirectly to the subject of this article

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ACCEPTED MANUSCRIPT References

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Agrawal K: Cleft palate repair and variations. Indian J Plast Surg 42 Suppl:S102-109, 2009 Agrawal K and Panda K: Use of Vomer flap in palatoplasty: revisited. Cleft Palate-Craniofac Journal 43:30-37, 2006 Amaratunga NA: Occurrence of oronasal fistulas in operated cleft palate patients. J Oral Maxillofac Surg 46:834-838, 1988 Becker M and Hansson E: Low rate of fistula formation after Sommerlad palatoplasty with or without lateral incisions: an analysis of risk factors for formation of fistulas after palatoplasty. J Plast Reconstr Aesthet Surg 66:697-703, 2013 Brattstrom V, Molsted K, Prahl-Andersen B, Semb G and Shaw WC: The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 2: craniofacial form and nasolabial appearance. Cleft Palate Craniofac J 42:69-77, 2005 Campbell DA: Fistulae in the hard palate following cleft palate surgery. Br J Plast Surg 15:377-384, 1962 Cohen SR, Kalinowski J, LaRossa D and Randall P: Cleft palate fistulas: a multivariate statistical analysis of prevalence, etiology, and surgical management. Plast Reconstr Surg 87:1041-1047, 1991 Daskalogiannakis J, Mercado A, Russell K, Hathaway R, Dugas G, Long RE, Jr., Cohen M, Semb G and Shaw W: The Americleft study: an inter-center study of treatment outcomes for patients with unilateral cleft lip and palate part 3. Analysis of craniofacial form. Cleft Palate Craniofac J 48:252-258, 2011 de Agostino Biella Passos V, de Carvalho Carrara CF, da Silva Dalben G, Costa B and Gomide MR: Prevalence, cause, and location of palatal fistula in operated complete unilateral cleft lip and palate: retrospective study. Cleft Palate Craniofac J 51:158-164, 2014 de Jong JP and Breugem CC: Early hard palate closure using a vomer flap in unilateral cleft lip and palate: effects on cleft width. Clin Oral Investig 18:1285-1290, 2014 Deshpande G, Wendby L, Jagtap R and Schonmeyr B: The efficacy of vomer flap for closure of hard palate during primary lip repair. J Plast Reconstr Aesthet Surg 68:940-945, 2015 Dorf DS and Curtin JW: Early cleft palate repair and speech outcome. Plast Reconstr Surg 70:74-81, 1982 Ferdous KM, Salek AJ, Islam MK, Das BK, Khan AR and Karim MS: Repair of cleft lip and simultaneous repair of cleft hard palate with vomer flap in unilateral complete cleft lip and palate: a comparative study. Pediatr Surg Int 26:995-1000, 2010 Holland S, Gabbay JS, Heller JB, O'Hara C, Hurwitz D, Ford MD, Sauder AS and Bradley JP: Delayed closure of the hard palate leads to speech problems and deleterious maxillary growth. Plast Reconstr Surg 119:1302-1310, 2007 Jackson IT, Moreira-Gonzalez AA, Rogers A and Beal BJ: The buccal flap─a useful technique in cleft palate repair? Cleft Palate Craniofac J 41:144-151, 2004 Kobus K: Extended vomer flaps in cleft palate repair: a preliminary report. Plast Reconstr Surg 73:895-903, 1984 Landheer JA, Breugem CC and van der Molen AB: Fistula incidence and predictors of fistula occurrence after cleft palate repair: two-stage closure versus one-stage closure. Cleft Palate Craniofac J 47:623-630, 2010 Li W, Zheng Q and Wei S: Simultaneous repair of cleft lip and closure of cleft hard palate with vomer flaps in patients with unilateral complete cleft lip and palate. Hua Xi Kou Qiang Yi Xue Za Zhi 21:34-35, 47, 2003 Liao YF, Lee YH, Wang R, Huang CS, Chen PK, Lo LJ and Chen YR: Vomer flap for hard palate repair is related to favorable maxillary growth in unilateral cleft lip and palate. Clin Oral Investig 18:1269-1276, 2014

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Lohmander A, Friede H and Lilja J: Long-term, longitudinal follow-up of individuals with unilateral cleft lip and palate after the Gothenburg primary early veloplasty and delayed hard palate closure protocol: speech outcome. Cleft Palate Craniofac J 49:657-671, 2012 Losken HW, van Aalst JA, Teotia SS, Dean SB, Hultman S and Uhrich KS: Achieving low cleft palate fistula rates: surgical results and techniques. Cleft Palate Craniofac J 48:312-320, 2011 Muzaffar AR, Byrd HS, Rohrich RJ, Johns DF, LeBlanc D, Beran SJ, Anderson C and Papaioannou a AA: Incidence of cleft palate fistula: an institutional experience with two-stage palatal repair. Plast Reconstr Surg 108:1515-1518, 2001 Parwaz MA, Sharma RK, Parashar A, Nanda V, Biswas G and Makkar S: Width of cleft palate and postoperative palatal fistula─do they correlate? J Plast Reconstr Aesthet Surg 62:1559-1563, 2009 Pasick CM, Shay PL, Stransky CA, Solot CB, Cohen MA and Jackson OA: Long term speech outcomes following late cleft palate repair using the modified Furlow technique. Int J Pediatr Otorhinolaryngol 78:2275-2280, 2014 Phua YS and de Chalain T: Incidence of oronasal fistulae and velopharyngeal insufficiency after cleft palate repair: an audit of 211 children born between 1990 and 2004. Cleft Palate Craniofac J 45:172-178, 2008 Rohrich RJ, Love EJ, Byrd HS and Johns DF: Optimal timing of cleft palate closure. Plast Reconstr Surg 106:413-421; quiz 422; discussion 423-415, 2000 Rohrich RJ, Rowsell AR, Johns DF, Drury MA, Grieg G, Watson DJ, Godfrey AM and Poole MD: Timing of hard palatal closure: a critical long-term analysis. Plast Reconstr Surg 98:236246, 1996 Schultz RC: Management and timing of cleft palate fistula repair. Plast Reconstr Surg 78:739747, 1986 Shaw WC, Semb G, Nelson P, Brattstrom V, Molsted K, Prahl-Andersen B and Gundlach KK: The Eurocleft project 1996-2000: overview. J Craniomaxillofac Surg 29:131-140; discussion 141-132, 2001 Sommerlad BC: A technique for cleft palate repair. Plast Reconstr Surg 112:1542-1548, 2003

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Table 1. Patient characteristics (N = 91). Patients Characteristic n (%) Sex Male 62 (68) Female 29 (32) Mean age at 13.6 mo cleft palate closure (mo) Cleft type Veau III Left side 39 (43) Right 24 (26) side 28 (31) Veau IV Syndrome Yes 3 (3) No 88 (97) Adoption Yes 7 (8) No 84 (92)

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Table 2. Fistula incidence. Fistula incidence after vomer flap Cleft type Patients Fistulas, n (%) Veau III 63 0 (0) Veau IV 28 1 (3.6) Total 91 1 (1.1)

ACCEPTED MANUSCRIPT Table 3. Studies from 1999 to 2015: Overall fistula incidence after palatoplasty. Type of repair Cleft types Study size One-stage (n) (%) Smarius and Breugem Von Langenback, All 200 4.0 (2015) Furlow, buccal flap, vomer flap Hosseinabad et al. Veau–Wardill– All 131 (2015) Kilner or (V) von Langenbeck techniques. All

292

Yuan et al. (2015)

Two-flap, one-flap, von Langenbeck, Furlow One-flap, two-flap technique Busan modification

All

177

Rossel Perry et al. (2015) Bae et al. (2015)

-

-

23.7

-

7.9

4.52

-

4.52

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Furlow double opposing Z-plasty, two-flap palatoplasty, intravelar veloplasty, or von Langenbeck flaps

Overall fistula (%) 4.0

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Ha et al. (2015)

Two-stage (%) -

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Article

UCLP

240

7.1

-

7.1

HSCP/SCP

100

3.0

-

3.0

Modified two-flap palatoplasty

All

83

17.0

-

17.0

Aslam et al. (2015)

Two-flap technique (Bardach procedure) Von Langenbeck Furlow, two-flap palatoplasty, + alloderm Furlow Two-flap technique plus intravelar veloplasty Von Langenbeck, Veau-WardillKilner, Furlow Straight closure, Von Langenbeck, Vomer flap Furlow, VeauWardill-Kilner, rotation palatoplasty Two-flap technique Technique of flap rotation Langenbeck

UCLP/BCLP

90

5.6

-

5.6

UCLP All

589 70

27 4.3

-

27 4.3

All UCLP

132 152

1.0 8.6

15.2 -

4.5 8.6

All

2100

-

-

0.7

All

136

9.6

-

9.6

All

167

17.7

-

17.7

All Veau II-IV

55 49

9.1 8.6

-

9.1 8.6

All

64

29.8

-

29.8

Furlow, Veau, von Langenbeck, hybrid, “Other” Sommerlad

All

485

0.8

-

0.8

All

175

6.3

-

6.3

Basta et al. (2014) Rossell-Perry et al. (2014)

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Zhang et al. (2014)

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Passos et al. (2014) Winters et al. (2014)

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Lin et al. (2015)

Lithovius (2014)

Kahraman et al (2014)

Sullivan et al. (2014) Black and Gampper (2014) Abdurrazaq et al (2014) Mahoney et al. (2013)

Becker and Hansson.

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Gongorjav et al. (2012) Annigeri et al. (2012) De Buys Roessingh et al. (2012) Lam et al. (2012) Dong et al. (2012) Maine et al. (2012) Williams et al. (2011) Isik et al. (2011)

Agrawal and Panda (2011) Losken et al. (2011)

Saleh (2010) Landheer et al. (2010)

Furlow, Von Langenbeck, VeauWardill-Kilner, Bardach two-flap U-shaped flap One- or two-stage repair Sommerlad Vomerflap Sommerlad Modified two-flap palatoplasty Two-flap palatoplasty Classic/Modified two-flap palatoplasty Von Langenbeck, Veau-Wardil-Kilner Two flap palatoplasty Two-flap palatoplasty Furlow Double-opposing Z-plasty with or with- out

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Lu et al. (2010) Ferdous et al. (2010) Hodges (2010) Shi et al (2009)

Two-flap, furlow, two-stage, new modified technique Veau-WaldillKilner Malek procedure, One- and two-stage Furlow, Furlow + V-Y pushback Furlow, two-flap Not stated Furlow, Von Langenbeck Rotation flap, Von Langenbeck, V-Y pushback One-stage

Sullivan et al. (2009) Koh et al. (2009)

Parwaz et al. (2009) Murthy et al. (2009) Andrades et al (2008) Losee et al. (2008) Bindingnavele et al. (2008)

-

5.2

UCLP/BCLP

178

0.71

-

0.71

UCLP

40

-

27.5

27.5

All All

40 94

4.5

0 -

0.0 4.5

UCLP HSCP/SCP All

50 140 275

5.4

6 -

6 6.3 5.4

All

436

18.0

37.5

18.3

All

30

20

-

20

All

71

-

-

19.7

HSCP/SCP

67

3.0

-

3.0

HSCP/SCP All UCLP

88 510 459

0 18.0

-

0.0 15.1 18.0

Veau I-III

28

7.1

-

7.1

UCLP/BCLP

330

3.6

-

3.6

All

126

1.6

-

1.6

HSCP/SCP All

30 275

0 14.0

27.0

0 21.0

All UCLP UCLP/BCLP HSCP/SCP

176 43 106 30

7.0 4.7 6.5 13.3

-

7.0 4.7 6.5 13.3

All

449

2.9

-

2.9

UCLP

31

0

-

0

All

31

35

-

35

All

332

2.4

-

2.4

All

213

0.9

-

0.9

All All

132 500

0.76 5.0

-

0.76 5.0

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Friede (2012) Patel et al. (2012) Koudoumnakis et al. (2012)

5.2

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Nadjmi et al. (2013) Al-Nawas et al. (2013)

869

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Doucet et al. (2013)

All

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Dec et al. (2013)

Modefied Furlow repair Oxford, Bardach, Von Langenbeck Malek or Talman protocol Modified Furlow Single-step palatal closure Two-stage Not stated Two-flap technique

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(2013) Jackson et al. (2013)

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Helling et al. (2006) Agrawal and Panda (2006) Inman et al. (2005) Bekerecioglu et al. (2005) Savaci et al. (2005) Jackson et al (2004) LaRossa et al. (2004)

Henkel et al. (2004)

Sommerlad (2003) Rosenstein et al (2003) Muzaffar et al. (2001)

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Wilhelmi et al. (2001) Yu et al. (2001)

Wardill-Kilner, Von Langenback Two or four flap technique One-stage and twostage Buccal flap Furlow doubleopposing zpalatoplasty Wave-Line technique and intravelar veloplasty Sommerlad Not stated Von Langenbeck, Wardill-Kilner, “other” Two-flap technique Furlow and von Langenbeck One-stage and twostage One-stage Delaire palatoplasty Levator retropositioning and double-opposing Zplasty

Mackay et al. (1999)

Schendel et al. (1999) Lin et al. (1999)

-

8.1

Secondary palate HSCP/SCP

814

4.0

-

4.0

182

0

-

0

All UCLP

140 41/41

3.6 11

58

3.6 34.5

HSCP/SCP

70

14

All UCLP

57 47

All

31

All

678

All

148

All

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Hassan and Askar (2007) Mak et al. (2006) Richard et al. (2006)

8.1

-

14.0

14.0 -

13

14.0 13

3.2

-

3.2

2.95

-

2.95

4.7

-

4.7

73

7

-

7

UCLP

41

21.1

27.3

24.4

All All

156 261

3.6 6.8

-

3.6 6.8

SCP

24

0

-

0

All UCLP/BCLP All

285 82 103

15 -

8.7

15 29.3 8.7

All HSCP/SCP

119 96

3.4 3.1

-

3.4 3.1

All

374

-

-

11.5

All

95

0

-

0

All

24

12.5

-

12.5

SC

Khosla et al. (2008) Holland et al. (2007)

211

M AN U

Stewart et al. (2008)

All

TE D

Andersson et al. (2008)

islandization Veau, Von Langenbeck, Furlow Von Langenbeck, Sommerlad Modified von Langenbeck Furlow Z-plasty Schwenkendiek repair, Von Langenbeck Wardill-Kilner, Kriens Furlow Von Langenbeck, Vomer flap Furlow technique + AllodermTM Vomer flap

EP

Phua and De Charlain (2008)

ACCEPTED MANUSCRIPT Table 4. Literature: Benefits and disadvantage in vomer flap studies.

Ferdo us et al. (2010)

n = 43 UCLP

-

-

-

n = 81 Veau I−IV

-

-

Vomer flap has a smaller adverse effect than two-flap on growth of maxilla

Simultaneous repair of cleft lip and cleft hard palate with vomer flap vs. separate repair of cleft lip and cleft palate repair Outcome: Alveolar gap reduced bleeding, fistula, operation time

-

Effective and safe procedure Easy to close the soft palate later because of reduction of the alveolar gap Decreased change oronasal fistula Reduced total operation time Better velopharyngeal motility and closure (not significant) Lower nasalance scores (not significant)

Two-flap palatoplasty with standard vomer flap vs. two-flap palatoplasty with extended vomer flap vs two-flap palatoplasty without vomer flap Outcome: Speech function Early simultaneous repair of cleft lip and cleft hard palate with vomer flap vs. one-stage (Sommerlad) Outcome: facial growth age 5 years

AC C

EP

Calis et al (2014)

Vomer flap vs. two-flap Outcome: Maxillary growth age 20 years

-

Xu et al. (2014)

n = 40 UCLP Nonsyndromic

-

-

-

Disadvantage vomer flap

-

Fistula incidence vomer flap 6%

RI PT

n = 95 UCLP Nonsyndromic

Benefits vomer flap

Longer operation time for first operation

0%

SC

Liao et al (2013)

Study design

M AN U

Patients (n)

-

-

-

TE D

Authors

-

-

-

-

Inhibited maxillary growth Delayed hard palate repair less effect on maxillary growth compared to early hard palate repair (age 5 years)

-

ACCEPTED MANUSCRIPT

Deshpan de et al. (2015)

n = 101 UCLP Nonsyndromic

-

-

Agrawal and Panda (2006)

-

-

n = 47 UCLP Nonsyndromic

-

Use of vomer flap in palatoplasty Outcome: A new comprehensive and simple classification of vomerine flaps for palatoplasty

Simultaneous repair of cleft lip and cleft hard palate with vomer flap vs. only cleft lip repair Outcome: Prognosis of vomer flap Simultaneous repair of the cleft lip and cleft hard palate with vomer flap vs. two-flap technique Outcome: growth and speech outcome

Ganesh et al. (2015)

AC C

-

n = 200 UCLP Nonsyndromic

-

-

0%

Significant reduction of residual cleft

-

-

-

-

-

-

EP

Li et al. (2003)

n = 678 UCLP/BC LP

-

RI PT

-

Early simultaneous repair of cleft lip and cleft hard palate with vomer flap vs. separate repair of cleft lip and cleft palate repair Outcome: effects on cleft width Simultaneous repair of cleft lip and cleft hard palate with vomer flap Outcome: efficacy of vomer flap

Vomer flap increased risk of complicati ons in subsequent palate repair.

SC

-

M AN U

N = 47 UCLP Nonsyndromic

TE D

De Jong and Breugem (2014)

-

2% fistula, 1% partial flap necrosis and 4% dehiscen ce

Raising of vomerine flap is simple and safe It can be used for closure of nasal and oral defects

2.95%

Safe procedure Did not prolong operating time

0%

Marginal better growth outcome in vomer flap group

-

Better speech outcome in two-flap group

- 2.5%

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

Figure 1. Design of the vomerplasty technique at which only a “single-layer mucosa” closure is performed. A shows a left cleft of the lip and palate. In B the incision line (dotted line) extended to the dorsal end of the vomer and close to the adenoids. C and D: “double breasted” closure of the mucosa of the lesser segment. (Adapted from de Jong and Breugem, 2014)

ACCEPTED MANUSCRIPT Figure 2. A: UCLP patient. B: The result 6 weeks postoperatively after vomerplasty and lip closure. C: UCLP before operation (a mirror placed inside the mouth). D: The result 6 weeks postoperatively after vomerplasty and lip closure (a mirror placed inside the mouth).

B

CA

SC

RI PT

A

AC C

EP

TE D

M AN U

D