Volume 135, Number 5 • Letters negative influence on neurologic outcomes. This statement has some support. We all agree that shortening operative time is an appropriate goal for all patients. However, performing a procedure in a shorter period, yet not correcting the irregularity fully, also has potentially deleterious effects. In the recent study,1 even with the longer operative time associated with whole-vault cranioplasty, the net result was a better neurologic outcome than the shorter endoscopic craniectomy procedure. Why? This has yet to be determined fully, but it may be more critical to release the skull extensively, earlier in childhood during the most rapid growth rates of the brain, than to allow reshaping to occur more gradually over the course of many months. The senior author (J.A.P.) previously examined the neurologic outcome in sagittal synostosis patients undergoing strip craniectomy alone,3 because of repeated observations by the patients’ parents that their children were having significant problems with achievement and with behavioral problems/learning disability. With this information in hand, it is unlikely that the more limited release of the craniosynostosis skull deformity by strip craniectomy alone, described by Ridgway et al.,4 would yield an improved outcome compared with more comprehensive procedures. It is even plausible that the neurologic outcomes could be worse, as the added lateral parietal “barrel staves” to the strip craniectomy performed at the University of Pittsburgh are more likely to have allowed even more immediate expansion of skull volume (with or without a cinching stitch) than the strip craniectomy procedure alone. Finally, although we have confidence in the findings of the comparison-of-technique study, no study is perfect. There should be follow-up studies to examine the questions raised by Drs. Wood, Proctor, and Rogers. In fact, shortly after this material was presented at an international craniofacial society meeting 1 year ago, the senior author approached Dr. Proctor about performing additional comparisons of the wholevault technique versus the isolated strip craniotomy approach, which Dr. Proctor and colleagues preferred. By mutual agreement, we set about to get this done. A formal proposal was passed through human investigation committees at both Harvard and Yale. The data collection is set to begin in November of 2014. DOI: 10.1097/PRS.0000000000001179
John A. Persing, M.D. Eric Brooks, YMS Peter Hashim, M.D. Anup Patel, M.D. Jenny Yang, YMS Section of Plastic and Reconstructive Surgery Yale University School of Medicine New Haven, Conn. Correspondence to Dr. Persing Yale Plastic Surgery Yale University School of Medicine
330 Cedar Street, Third Floor New Haven, Conn. 06520 [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Hashim P, Patel A, Yang JF, et al. The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134:491–503. 2. Jane JA, Edgerton MT, Futrell JW, Park TS. Immediate correction of sagittal synostosis. J Neurosurg. 1978;49:705–710. 3. Magge S, Westerveld M, Pruzinsky T, Persing JA. Long term neuropsychological effects of single-suture craniosynostosis on child development. J Craniofac Surg. 2002;13:99–104. 4. Ridgway EB, Berry-Candelario J, Grondin RT, Rogers GF, Proctor MR. The management of sagittal synostosis using endoscopic suturectomy and postoperative helmet therapy. J Neurosurg Pediatr. 2011;7:620–626.
A Systematic Review Comparing Furlow DoubleOpposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair Sir:
W
e read with great interest the article entitled “A Systematic Review Comparing Furlow DoubleOpposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair” by Timbang et al.1 in the November of 2014 issue of the Journal. This study compares, by means of a literature review, speech outcomes and fistula rates in patients with a cleft who underwent Furlow repair and intravelar veloplasty. Among other criteria, this study excluded studies that included syndromic patients, average age at repair younger than 9 months or older than 18 months, and a follow-up before 4 years of age. Their study demonstrated superior speech outcomes in the Furlow group (9.7 percent) compared with the intravelar veloplasty group (16.5 percent). Large-scale analysis of existing literature can provide meaningful insight into the collective results of prior research; however, the results of this form of analysis are highly dependent on the exclusion criteria and definitions. In the case of the report by Timbang et al., the well-intended methodology has produced, in our opinion, significantly skewed results. The Furlow double-opposing Z-plasty has undergone limited modifications since its inception. This is not only a testament to Dr. Furlow’s innovation (which few could improve on) but provides an advantage toward large-scale retrospective reviews, as the technique has remained stable over time. Intravelar veloplasty, in contrast, has undergone an evolution that has not been appropriately represented in this report.
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Plastic and Reconstructive Surgery • May 2015 As noted in the Discussion section, radical intravelar veloplasty has been reported independently by Cutting et al.2 and Sommerlad.3 Transection of the tensor veli palatini followed by radical medial rotation of the levator muscle is at the heart of their surgical technique. In their reports, follow-up was at least 4 years, but they did not stratify their results by cleft type, and their studies were not exclusive of syndromic patients. This may have led to their omission from the study by Timbang et al. despite their demonstration of impressively low failure rates (Cutting et al., 6 percent; and Sommerlad, 5 percent in the last 10 years of the study). The reports of Cutting et al. and Sommerlad, published over 10 years ago, were corroborated by Salyer et al.,4 who demonstrated at 6 percent failure rate using radical intravelar veloplasty. More recently, a report by Andrades et al.5 demonstrated a statistical improvement in speech outcomes when performing radical intravelar veloplasty (7 percent failure) versus “traditional” intravelar veloplasty, further demonstrating benefit to radical rotation of the levator muscle. These four quality and high-volume studies (1148 patients total) have provided consistent scientific evidence that radical intravelar veloplasty is the proper means of performing the “straight-line” repair. In light of these known reports on the evolution of intravelar veloplasty, it is surprising that Timbang et al. did not seize the opportunity to compare the modern technique of intravelar veloplasty to the Furlow repair. If the four studies reporting on surgical outcomes with radical intravelar veloplasty are compared to the four Furlow studies cited by Timbang et al., the surgical outcomes are equivalent between the two repairs, with the radical intravelar veloplasty demonstrating slightly superior speech outcomes. DOI: 10.1097/PRS.0000000000001185
Gil Nardini, M.D. Roberto L. Flores, M.D. Department of Plastic Surgery New York University Langone Medical Center New York, N.Y. Correspondence to Dr. Flores Department of Plastic Surgery New York University Langone Medical Center 307 East 33rd Street Lower Level New York, N.Y. 10016 [email protected]
disclosure The authors have no financial relationships to disclose. references 1. Timbang MR, Gharb BB, Rampazzo A, Papay F, Zins J, Doumit G. A systematic review comparing Furlow double-opposing Z-plasty and straight-line intravelar veloplasty methods of cleft palate repair. Plast Reconstr Surg. 2014;134:1014–1022.
928e
2. Cutting CB, Rosenbaum J, Rovati L. The technique of muscle repair in the cleft soft palate. Oper Tech Plast Reconstr Surg. 1995;2:215–222. 3. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg. 2003;112:1542–1548. 4. Salyer KE, Sng KW, Sperry EE. Two-flap palatoplasty: 20-year experience and evolution of surgical technique. Plast Reconstr Surg. 2006;118:193–204. 5. Andrades P, Espinosa-de-los-Monteros A, Shell DH IV, et al. The importance of radical intravelar veloplasty during twoflap palatoplasty. Plast Reconstr Surg. 2008;122:1121–1130.
Reply: A Systematic Review Comparing Furlow Double-Opposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair Sir:
I thank Nardini and Flores for their commentary on the recently published article, “A Systematic Review Comparing Furlow Double-Opposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair.” The commentary raised important questions on the evolution of intravelar veloplasty and on the exclusion criteria of the published article.1 As Nardini and Flores pointed out, there was an evolution over time by some cleft surgeons on how the levator veli palatini muscles are dissected and repositioned in intravelar veloplasty. In the present systematic review, the evolution of intravelar veloplasty was accounted for, as most studies (all studies except one) were published at least two and half decades after the initial description by Kriens.2 Furthermore, despite its evolution, intravelar veloplasty remains operator dependent, and there is great variability among surgeons. The large variations in the outcomes of intravelar veloplasty could be secondary to improper identification, mishandling, or incomplete posterior repositioning of the levator veli palatini muscles.3 The exclusion criteria in the review included syndromic patients, average age at repair younger than 9 months or older than 18 months, and a follow-up before 4 years of age. These exclusion criteria in the systematic review sought to control for confounding variables and to capture a population of patients whose age at repair and protocol of palate repair were more consistent with the nationally accepted standards of care. Data were stratified by cleft type (isolated cleft palate or unilateral cleft lip and palate), as previous studies has demonstrated that persistent velopharyngeal insufficiency was associated with Veau classification and the patient’s age at palatoplasty.4,5 The age of 4 years was chosen, as children with velopharyngeal sufficiency at this age are highly unlikely to develop subsequent velopharyngeal insufficiency.6 Publications with excellent and poor speech outcomes in both groups (intravelar veloplasty, Furlow Z-plasty) were excluded from the systematic review, as they did not meet the inclusion criteria. By adhering to a strict protocol, my colleagues and I sought to control
John A. Persing, M.D. Eric Brooks, YMS Peter Hashim, M.D. Anup Patel, M.D. Jenny Yang, YMS Section of Plastic and Reconstructive Surgery Yale University School of Medicine New Haven, Conn. Correspondence to Dr. Persing Yale Plastic Surgery Yale University School of Medicine
330 Cedar Street, Third Floor New Haven, Conn. 06520 [email protected]
disclosure The authors have no financial interest to declare in relation to the content of this communication. references 1. Hashim P, Patel A, Yang JF, et al. The effects of whole-vault cranioplasty versus strip craniectomy on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134:491–503. 2. Jane JA, Edgerton MT, Futrell JW, Park TS. Immediate correction of sagittal synostosis. J Neurosurg. 1978;49:705–710. 3. Magge S, Westerveld M, Pruzinsky T, Persing JA. Long term neuropsychological effects of single-suture craniosynostosis on child development. J Craniofac Surg. 2002;13:99–104. 4. Ridgway EB, Berry-Candelario J, Grondin RT, Rogers GF, Proctor MR. The management of sagittal synostosis using endoscopic suturectomy and postoperative helmet therapy. J Neurosurg Pediatr. 2011;7:620–626.
A Systematic Review Comparing Furlow DoubleOpposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair Sir:
W
e read with great interest the article entitled “A Systematic Review Comparing Furlow DoubleOpposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair” by Timbang et al.1 in the November of 2014 issue of the Journal. This study compares, by means of a literature review, speech outcomes and fistula rates in patients with a cleft who underwent Furlow repair and intravelar veloplasty. Among other criteria, this study excluded studies that included syndromic patients, average age at repair younger than 9 months or older than 18 months, and a follow-up before 4 years of age. Their study demonstrated superior speech outcomes in the Furlow group (9.7 percent) compared with the intravelar veloplasty group (16.5 percent). Large-scale analysis of existing literature can provide meaningful insight into the collective results of prior research; however, the results of this form of analysis are highly dependent on the exclusion criteria and definitions. In the case of the report by Timbang et al., the well-intended methodology has produced, in our opinion, significantly skewed results. The Furlow double-opposing Z-plasty has undergone limited modifications since its inception. This is not only a testament to Dr. Furlow’s innovation (which few could improve on) but provides an advantage toward large-scale retrospective reviews, as the technique has remained stable over time. Intravelar veloplasty, in contrast, has undergone an evolution that has not been appropriately represented in this report.
927e
Plastic and Reconstructive Surgery • May 2015 As noted in the Discussion section, radical intravelar veloplasty has been reported independently by Cutting et al.2 and Sommerlad.3 Transection of the tensor veli palatini followed by radical medial rotation of the levator muscle is at the heart of their surgical technique. In their reports, follow-up was at least 4 years, but they did not stratify their results by cleft type, and their studies were not exclusive of syndromic patients. This may have led to their omission from the study by Timbang et al. despite their demonstration of impressively low failure rates (Cutting et al., 6 percent; and Sommerlad, 5 percent in the last 10 years of the study). The reports of Cutting et al. and Sommerlad, published over 10 years ago, were corroborated by Salyer et al.,4 who demonstrated at 6 percent failure rate using radical intravelar veloplasty. More recently, a report by Andrades et al.5 demonstrated a statistical improvement in speech outcomes when performing radical intravelar veloplasty (7 percent failure) versus “traditional” intravelar veloplasty, further demonstrating benefit to radical rotation of the levator muscle. These four quality and high-volume studies (1148 patients total) have provided consistent scientific evidence that radical intravelar veloplasty is the proper means of performing the “straight-line” repair. In light of these known reports on the evolution of intravelar veloplasty, it is surprising that Timbang et al. did not seize the opportunity to compare the modern technique of intravelar veloplasty to the Furlow repair. If the four studies reporting on surgical outcomes with radical intravelar veloplasty are compared to the four Furlow studies cited by Timbang et al., the surgical outcomes are equivalent between the two repairs, with the radical intravelar veloplasty demonstrating slightly superior speech outcomes. DOI: 10.1097/PRS.0000000000001185
Gil Nardini, M.D. Roberto L. Flores, M.D. Department of Plastic Surgery New York University Langone Medical Center New York, N.Y. Correspondence to Dr. Flores Department of Plastic Surgery New York University Langone Medical Center 307 East 33rd Street Lower Level New York, N.Y. 10016 [email protected]
disclosure The authors have no financial relationships to disclose. references 1. Timbang MR, Gharb BB, Rampazzo A, Papay F, Zins J, Doumit G. A systematic review comparing Furlow double-opposing Z-plasty and straight-line intravelar veloplasty methods of cleft palate repair. Plast Reconstr Surg. 2014;134:1014–1022.
928e
2. Cutting CB, Rosenbaum J, Rovati L. The technique of muscle repair in the cleft soft palate. Oper Tech Plast Reconstr Surg. 1995;2:215–222. 3. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg. 2003;112:1542–1548. 4. Salyer KE, Sng KW, Sperry EE. Two-flap palatoplasty: 20-year experience and evolution of surgical technique. Plast Reconstr Surg. 2006;118:193–204. 5. Andrades P, Espinosa-de-los-Monteros A, Shell DH IV, et al. The importance of radical intravelar veloplasty during twoflap palatoplasty. Plast Reconstr Surg. 2008;122:1121–1130.
Reply: A Systematic Review Comparing Furlow Double-Opposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair Sir:
I thank Nardini and Flores for their commentary on the recently published article, “A Systematic Review Comparing Furlow Double-Opposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair.” The commentary raised important questions on the evolution of intravelar veloplasty and on the exclusion criteria of the published article.1 As Nardini and Flores pointed out, there was an evolution over time by some cleft surgeons on how the levator veli palatini muscles are dissected and repositioned in intravelar veloplasty. In the present systematic review, the evolution of intravelar veloplasty was accounted for, as most studies (all studies except one) were published at least two and half decades after the initial description by Kriens.2 Furthermore, despite its evolution, intravelar veloplasty remains operator dependent, and there is great variability among surgeons. The large variations in the outcomes of intravelar veloplasty could be secondary to improper identification, mishandling, or incomplete posterior repositioning of the levator veli palatini muscles.3 The exclusion criteria in the review included syndromic patients, average age at repair younger than 9 months or older than 18 months, and a follow-up before 4 years of age. These exclusion criteria in the systematic review sought to control for confounding variables and to capture a population of patients whose age at repair and protocol of palate repair were more consistent with the nationally accepted standards of care. Data were stratified by cleft type (isolated cleft palate or unilateral cleft lip and palate), as previous studies has demonstrated that persistent velopharyngeal insufficiency was associated with Veau classification and the patient’s age at palatoplasty.4,5 The age of 4 years was chosen, as children with velopharyngeal sufficiency at this age are highly unlikely to develop subsequent velopharyngeal insufficiency.6 Publications with excellent and poor speech outcomes in both groups (intravelar veloplasty, Furlow Z-plasty) were excluded from the systematic review, as they did not meet the inclusion criteria. By adhering to a strict protocol, my colleagues and I sought to control
