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Pneumonia remains the primary cause of mortality among children under age 5. Cleft palate (CP) poses various challenges including velopharyngeal disfunction, potentially increasing rates of pneumonia. However, clinical evidence linking pneumonia to defect is lacking. This study aims to assess the prevalence of pneumonia and lower respiratory tract infections (LRTI) among CP patients through a population-based approach. This retrospective cohort study was conducted using medical records from Clalit Health Services in Israel, 2013-2022, encompassing population of 138,261 infants, including 166 with CP. We investigated the prevalence of pneumonia and other infectious diseases before and after palatoplasty, employing Poisson regression models adjusted for multiple demographic and clinical variables. A sibling comparison study was also conducted, analyzing 129 preoperative and 55 postoperative pairs. The preoperative analysis revealed an increased risk of pneumonia (relative risk [RR]: 5.8, 95% confidence interval (CI): 3.93-8.19), lower respiratory tract infections (LRTI) (RR: 1.55, 95% CI: 1.12-2.06), and urinary tract infections (UTI) (RR: 5.27, 95% CI: 3.23-8.03) in children with CP compared to controls. Following surgical repair, a statistically significant but reduced risk for pneumonia persisted up to 5 years (RR: 2.55, 95% CI: 1.59-3.84). Sibling comparison analyses underscored an elevated pneumonia risk compared to CP siblings preoperatively (RR: 7.07, 95% CI: 2.48-29.8). Postoperatively, the RR decreased and was no longer statistically significant (RR: 1.44, 95% CI: 0.49-4.75)., Conclusion: Patients with CP are at higher risk for pneumonia, and the magnitude of risk may be reduced after palatoplasty., What Is Known: • Cleft palate (CP) disrupts the separation of the nasal and oral cavities, leading to food regurgitation into the nasal cavity and theoretically may lead to respiratory tract infections. • The association between CP and respiratory tract infections has yet to be assessed thoroughly., What Is New: • This population-based study has shown that CP is an independent risk factor for pneumonia. • The risk for pneumonia among CP patients is lowered after surgical repair of the defect., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests., (© 2024. The Author(s).)

Objectives: To assess the effect of palatoplasty on growth velocity in undernourished and nourished orally fed children with cleft palate., Methods: A retrospective chart review was conducted using a data query with cleft-associated ICD-10 and ICD-9 codes to identify children who underwent cleft palate repair between 2006 and 2022 at a tertiary pediatric hospital. Data gathered included demographics, admission variables, weight gain, and weight percentile as per the WHO growth chart data. Inclusion was limited to patients with complete growth data and without parenteral feeding support. Nutritional status was defined as undernourished (≤3rd percentile) and nourished (>3rd percentile). Between and within-group comparisons were made using nonparametric tests., Results: A total of 192 patients met the study criteria. Among undernourished patients, the median pre- and postsurgical weekly weight gain was 0.09 kg and 0.05 kg (p = <0.0001), and the median growth percentiles were 0.67% and 1.1%, respectively (p = 0.03). Among nourished patients, the median pre- and postsurgical weekly weight gain was 0.12 kg and 0.07 kg (p = <0.0001), and the median growth percentiles were 25.4% and 29.5%, respectively (p = <0.0001). The postsurgical reduction in weight gain per week was similar across nutritional status (p = 0.43), however, the nourished group demonstrated a larger increase in median growth percentile (3.3% vs. 0.23%; p = 0.03)., Conclusion: This study demonstrates that palatoplasty does not independently improve growth velocity in children who were able to maintain an oral preoperative diet. In the case of undernourished children, there was no clinically significant improvement in postoperative growth percentiles., Level of Evidence: 3 Laryngoscope, 134:5145-5151, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

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., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Apert syndrome (AS) is a rare congenital craniofacial disorder that requires a multidisciplinary approach to treatment and multiple surgeries. Given that cleft palate (CP) is presented in some of these cases, this poses an additional risk of aggravating obstructed airways after closure. The timing and outcome of CP repair in these patients remains disputed and requires additional attention., Design: This retrospective analysis included patients diagnosed with CP and AS, born between 1950 and 2020, and treated at our institution. Data were collected from medical records and evaluated using descriptive statistics., Setting: Data analyses were conducted at Sahlgrenska University Hospital in Gothenburg, Sweden., Patients/participants: A registry of 83 patients with AS resulted in a cohort of 26 patients also presenting with CP., Main Outcome Measures: Postoperative complications, requirement for intensive care, and reoperations following CP repair., Results: CP incidence among all registered patients was 31%. Patients undergoing CP repair at low age (mean: 22.5 months) tended to experience more frequent postoperative complications and requirements for intensive care. Among the evaluated cohort with medical records describing CP repair ( n  = 14), 29% experienced postoperative complications, all of which involved aggravation of obstructed airways., Conclusions: This study highlights the importance of airway assessment before and after CP repair in AS. The findings suggest that surgical outcomes might benefit from postponing CP repair, avoiding combined surgeries, and operating in two stages when indicated. However, additional and larger studies are required., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: We sought to identify differences in 30-day medical and surgical complications in unilateral versus bilateral palatoplasty., Design: The NSQIP-P 2015-2020 database was queried to identify cleft palate repairs using CPT codes. Cases were stratified as unilateral (Veau III) and bilateral (Veau IV) using ICD-9 and -10 codes., Setting: A nationally representative random sample., Patients/participants: A total of 3791 cases were identified with 2608 undergoing unilateral repair and 1183 undergoing bilateral repair., Main Outcomes/measures: The postoperative outcomes of interest included surgical complications (surgical site infections, wound dehiscence), medical complications (pneumonia, urinary tract infection, seizure, cardiac arrest, bleeding/transfusions, systemic sepsis, unplanned intubation), readmission, and reoperation., Results: The bilateral cohort was older (696 days versus 619 days, P  < .001) and had longer operative times (157.3 min versus 144.5 min, P  < .001). The unilateral cohort had more comorbidities including developmental delay, structural CNS abnormalities, need for nutritional support, and bleeding disorders. The bilateral cohort had statistically significant higher occurrences of wound dehiscence (2.1% versus. 1.2%, P  = .03) and readmission (3.2% versus 1.7%, P  = .01). On multivariate analysis, bilateral cleft repair (OR: 1.83, CI: 1.176-2.840, P  = .007) and ASA class 4 (OR: 13.1, CI 2.288- 62.586, P  = .002) were associated with greater odds of readmission., Conclusion: Patients who underwent bilateral cleft repair had a higher proportion of 30-day postoperative complications and a two-fold increased odds of readmission. While palatoplasty is generally regarded as a safe procedure in the pediatric population, identifying factors related to an increased risk of early postoperative complications can help surgical teams better manage high-risk individuals., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

An encouraging outcome was described for the use of modified Furlow small double-opposing Z-plasty (sDOZ) using the medial incision (MIsDOZ) approach in repair of Veau type I cleft palate. This retrospective study assessed early results of using extended indication criterion of MIsDOZ for the management of consecutive non-syndromic patients with Veau II cleft palate treated by a single surgeon. Bardach two-flap plus sDOZ (two-flap approach) or medial incision approach with a tension-driven stepwise application of lateral palatal incisions (soft palate only, von Langenbeck type, or two-flap type) were applied. Surgical (age, cleft width, operative time, hospital stay, and complication)- and auditory-perceptual assessment-related data were collected. Two-flap approach (n = 21) demonstrated a significantly (p < 0.001) increased operative time (132.8 ± 12.2 versus 114.8 ± 19.9 min, respectively) and higher use of lateral incisions (100% versus 44.4%) than medial incision approach (n = 27), with no significant (p > 0.05) difference for age at surgery (13.0 ± 6.1 versus 13.6 ± 5.8 months), cleft width (8.5 ± 4.1 versus 8.7 ± 3.8 mm), hospital stay (1.0 ± 0 versus 1.0 ± 0 day), and complication (0% versus 0%) and hypernasality (9.5% versus 7.4%) rates. In conclusion, the medial incision approach for Veau II cleft repair resulted in reduced need for lateral palatal incision with no increase of complication or hypernasality rates., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: This retrospective study investigated the influence of palatal fistula (PF) formation after double opposing Z-plasty (DOZ) on speech outcomes in patients with cleft palate (CP), focusing on cleft width and palatal length as predictors of velopharyngeal insufficiency (VPI)., Methods: This study included 1117 patients with CP (579 males, 538 females) who underwent DOZ, performed by a single surgeon, between 1988 and 2017. Demographic characteristics, cleft dimensions, history of PF formation, and speech outcomes were investigated. Speech evaluations were performed at a minimum age of five to assess nasal emission, hypernasality, compensatory articulation, intelligibility, necessity for VPI surgery, and speech therapy. Logistic regression analysis was performed., Results: Speech assessments were conducted at the median age of five (interquartile range [IQR], 5-6 years). Overall, 96.5% of patients achieved 'socially acceptable speech' after DOZ. Patients with PF history showed greater cleft width and experienced higher rates of hypernasality, nasal emission, and VPI on videofluoroscopy (VFS) compared to those without PF history (mean, 11.4 mm vs. 7.1 mm; 28.4% vs. 23.6%; 34.8% vs. 14.9%, 38.5% vs. 14.0%, 40.6% vs. 28.3%, respectively; all p < 0.0001). Cleft width was significantly associated with VPI-related speech outcomes in the multivariate logistic regression analysis, affecting both perceptual and VFS-measured outcomes., Conclusions: A wider CP gap significantly increased the risk of VPI-related speech difficulties after DOZ. Cleft width is a more critical predictor of adverse speech outcomes than the presence of small-to-medium-sized PFs. Patients with a history of PF and wider cleft gaps require targeted interventions and intensified follow-up to effectively manage and improve speech outcomes., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Surgical treatment of velopharyngeal insufficiency (VPI) includes a wide array of procedures. The purpose of this study was to develop a classification for VPI procedures and to describe variations in how they are performed. Design/participants/setting/outcomes: We completed an in-depth review of the literature to develop a preliminary schema that encompassed existing VPI procedures. Forty-one cleft surgeons from twelve hospitals across the USA and Canada reviewed the schema and either confirmed that it encompassed all VPI procedures they performed or requested additions. Two surgeons then observed the conduct of the procedures by surgeons at each hospital. Standardized reports were completed with each visit to further explore the literature, refine the schema, and delineate the common and unique aspects of each surgeon's technique., Results: Procedures were divided into three groups: palate-based surgery; pharynx-based surgery; and augmentation. Palate-based operations included straight line mucosal incision with intravelar veloplasty, double-opposing Z-plasty, and palate lengthening with buccal myomucosal flaps. Many surgeons blended maneuvers from these three techniques, so a more descriptive schema was developed classifying the maneuvers employed on the oral mucosa, nasal mucosa, and muscle. Pharynx-based surgery included pharyngeal flap and sphincter pharyngoplasty, with variations in design for each. Augmentation procedures included palate and posterior wall augmentation., Conclusions: A comprehensive schema for VPI procedures was developed incorporating intentional adaptations in technique. There was substantial variation amongst surgeons in how each procedure was performed. The schema may enable more specific evaluations of surgical outcomes and exploration of the mechanisms through which these procedures improve speech., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: After cleft lip and/or palate (CL/P) repair, children may develop velopharyngeal insufficiency (VPI) leading to speech imperfections, necessitating additional speech correcting surgery. This study examines the incidence of VPI and speech correcting surgery after Sommerlad's palatoplasty for CL/P, and its association with various clinical features., Materials and Methods: A retrospective cohort study was performed in the Wilhelmina Children's Hospital in Utrecht and child records from 380 individuals with CL/P registered from 2008 to 2017 were retrospectively reviewed. Inclusion criteria comprised the diagnosis of CL/P, primary palatoplasty according to Sommerlad's technique, and speech assessment at five years or older. Association between cleft type and width, presence of additional genetic disorders and postoperative complications (palatal dehiscence, fistula) were assessed using odds ratios and chi squared tests., Results: A total of 239 patients were included. The VPI rate was 52.7% (n = 126) and in 119 patients (49.8%) a speech correcting surgery was performed. Severe cleft type, as indicated by a higher Veau classification, was associated with a significant higher rate of speech correcting surgeries (p = 0.033). Significantly more speech correcting surgeries were performed in patients with a cleft width >10 mm, compared to patients with a cleft width ≤10 mm (p < 0.001). Patients with oronasal fistula underwent significantly more speech correcting surgeries than those without fistula (p = 0.004). No statistically significant difference was found in the incidence of speech correcting surgery between patients with and without genetic disorders (p = 0.890)., Conclusions/clinical Relevance: Variations in cleft morphology, cleft width and complications like oronasal fistula are associated with different speech outcomes. Future research should focus on creating a multivariable prediction model for speech correcting surgery in CL/P patients., (© 2024. The Author(s).)

Objective: This study investigates the effectiveness of demineralized bone matrix (DBX) to close alveolar clefts in patients previously treated with bone morphogenic protein-2 (BMP-2) who remained with bone nonunion., Design: This is an IRB-approved retrospective, single-center study., Setting: This study was conducted at a tertiary academic center., Patients/participants: We searched for all surgical encounters with the Current Procedural Terminology (CPT) code 42210 from the years 2013-2019. Included patients were diagnosed with cleft alveolus, previous BMP-2 exposure and required revision bone grafting during mixed dentition for persistent alveolar defects., Interventions: 17 patients underwent revision alveolar bone grafting (ABG) with either DBX (n = 10) or autograft (n = 7) to repair persistent bony cleft., Main Outcome Measure(s): The primary study outcome measured was alveolar bone graft revision failure described as continued alveolar nonunion., Results: The median age at revision ABG was 13.1 ± 3.3 years, with a mean follow-up time of 4.9 years (1.1-9.2 years). Patients were 53% male, 47% had a unilateral cleft lip and alveolus. 58.8% of patients were treated with DBX in the cleft, 41.2% treated with autograft from iliac crest. Overall, 11.8% (n = 2) of all revisions failed, requiring a second revision. The average time to reoperation was 2.06 years, and both were re-grafted with autograft. There was no statistically significant difference between the type of bone graft source used and the failure rate obtained ( P  = .1544)., Conclusions: DBX and autologous iliac crest bone grafts achieve similar alveolar union rates during revision ABG in patients treated with previous BMP-2 to the alveolar cleft., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To provide healthcare professional-friendly practical recommendations for early detection of cleft palate-related deformities in newborns and offer an overview of managing these high-prevalent congenital abnormalities., Source of Data: PubMed, SciELO, Lilacs, Cochrane, ScienceDirect, and Scopus databases were reviewed for cleft- and diagnosis-related studies., Summary of the Findings: Unfortunately, the global prevalence of delayed detection of cleft palate-related deformities remains unacceptably high, with over a quarter of cleft palates missed at birth. This delayed identification causes physical and psychological distress for patients and families, including feeding challenges and weight faltering. To improve cleft management, it is essential to adopt routine detailed, in-depth intraoral examination immediately after birth. It is recommended not only to finger-assisted palpate the intraoral structures but also to visually inspect the oral cavity from gingiva to uvula using a wooden tongue depressor and light-assisted examination. With timely diagnosis and referral to specialized care, pediatricians, nurses, speech therapists, and plastic surgeons provide life-changing treatments, including health care maintenance, anticipatory guidance, feeding support, primary surgical reconstruction, and age- and condition-specific protocols., Conclusions: Encouraging neonatologists and pediatricians, who are the first to examine newborns, to actively investigate the intraoral region for cleft palate-related deformities is instrumental in optimizing therapeutic approaches and prioritizing age-phases in treatment. Their crucial role in early detection and referral can lead to transformative outcomes, impacting not only the future of the newborns by facilitating functional integration into society but also yielding positive effects on families and the health system., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2024 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Background: The aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing post-operative complications. This study aimed to compare the long-term outcomes of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center., Methods: A retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included., Results: A total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were included in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% vs. 4.6%, p = 0.01), and the VPI prevalence was not significantly different (9.2% vs. 7.9%, p = 0.62). Patients who developed fistula had a significantly higher likelihood of developing VPI than patients without oronasal fistula (50.0% vs. 7.1%, respectively; p < 0.01), with an odds ratio of 13.0., Conclusion: Both modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension lowered the risk of oronasal fistula., Competing Interests: Conflicts of interest statement No conflicting relationship exists for all authors., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: This study investigates whether the use of acellular dermal matrix (ADM) affects the long-term speech outcomes in patients undergoing primary palatoplasty with radical intravelar veloplasty., Design: Retrospective cohort study., Setting: Tertiary university-affiliated hospital., Participants: A consecutive cohort of 112 patients who underwent primary palatoplasty with radical intravelar veloplasty from August 2014 to March 2018 were included., Main Outcome Measures: A 2 × 2 cm-sized ADM was incorporated as an interpositional graft between the oral and nasal lining at the soft-hard palate junction. The perceptual analysis of hypernasality and articulation was performed when the age of the patient reached at least 36 months. Cleft-related characteristics and surgical factors affecting the speech outcomes were investigated., Results: The ADM was applied in 57 patients with a mean follow-up of45.76 months (SD, 10.69), while no ADM was used in 55 patients with a mean follow-up of 48.43 months (SD, 14.98). Regarding the hypernasality outcome, 33.3% (19 of 57 patients) of the ADM group and 27.3% (15 of 55 patients) of the control group showed a greater than mild-to-moderate degree. The distribution of hypernasality and articulation grade showed no significant difference between the two groups. After controlling for potential risk factors that may affect the speech outcomes, the use of ADM showed no significant relationship with velopharyngeal insufficiency., Conclusion: The use of ADM use in primary palatoplasty with radical intravelar veloplasty is not associated with the alteration of speech function in early childhood., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To compare the effectiveness of short-term ventilation tubes compared to surveillance on conductive hearing loss in children with non-syndromic orofacial clefting involving the muscular palate., Introduction: Chronic otitis media with effusion is a common finding in children with cleft palate. The accepted convention is insertion of short-term ventilation tubes at the time of palate repair, but some centres are choosing conservative management. Each approach has its advantages but there is currently no consensus on the most appropriate management in children with non-syndromic cleft palate., Inclusion Criteria: Children <18 years with cleft lip and palate, or isolated cleft palate, not associated with a genetic syndrome, who have been diagnosed with chronic otitis media with effusion., Methods: A systematic search of MEDLINE, CINAHL, Embase and Scopus databases was conducted. Grey literature searches were conducted through Central Register of Controlled Trials, Clinicaltrials.gov and ProQuest. Two reviewers screened the studies, conducted critical appraisal, assessed the methodological quality, and extracted the data. Where possible, studies were pooled in statistical meta-analysis with heterogeneity being assessed using the standard Chi-squared and I 2 tests., Results: Four studies met the inclusion criteria but were of low quality with a moderate risk of bias. Only data on hearing thresholds could be pooled for analysis which found no statistically significant difference. Other outcomes were presented in narrative form. Certainty of evidence for all outcomes was deemed low to very low using GRADE criteria., Conclusions: No definitive conclusions can be drawn regarding most effective management at improving conductive hearing loss. Missing data and inconsistent reporting of outcomes limited capacity for pooled analysis., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Surgical intervention can contribute to the development of velopharyngeal insufficiency (VPI) leading to hypernasality and regurgitation. In this case, a patient with a history of bilateral buccal flaps used for her primary CP repair presented to clinic with hypernasality and VPI as assessed by speech exam and imaging. She underwent repeat bilateral buccal flap palatal lengthening with division of the pedicles 3 months later. Three months after her division, her hypernasality score improved from moderate to mild and her posterior gap decreased. This study concluded buccal flaps can be used a second time for patients needing palatal revisions for VPI., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Approximately 30% of patients with a history of repaired cleft palate (CP) go on to suffer from velopharyngeal dysfunction (VPD). This study discusses the operative management of VPD and postoperative speech outcomes in a cohort of CP patients., Setting: An academic tertiary pediatric care center., Methods: Retrospective cohort study., Patients: Patients with history of repaired CP (Veau I-IV) who underwent operative management of VPD between January 1st, 2010 and December 31st, 2020. Operative modalities were posterior pharyngeal flap (PPF), sphincter pharyngoplasty (SPP), Furlow palate re-repair, and buccal myomucosal flap palate lengthening (PL)., Outcome Measures: The primary outcome measure is postoperative speech improvement evaluated by the Pittsburgh Weighted Speech Scale (PWSS)., Results: 97 patients met inclusion criteria. 38 patients with previous straight-line primary palatoplasty underwent Furlow re-repair; these patients were significantly younger (7.62 vs 11.14, P  < .001) and were more likely to have severe VPD per PWSS (OR 4.28, P  < .01, 95% CI 1.46-12.56) when compared to VPD patients with previous Furlow repair. 21.1% of these patients required an additional non-revisional VPD procedure. The remaining patients underwent a non-revision procedure (26 PPF, 22 SPP, 11 PL); all experienced significant ( P  < .001 on paired t-test) reductions in PWSS total and subgroup VPD severity scores without difference in improvement between operation types. SPP was statistically associated with all-cause complication (OR 2.79, 95% CI 1.03-7.59, P  < .05) and hyponasality (OR 3.27, 95% CI 1.112-9.630, P  < .05)., Conclusion: Furlow re-repair reduced need for additional VPD operations. Speech outcomes between non-revisional operations are comparable, but increased complications were seen in SPP., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Cleft palate repair is a common reconstructive procedure that can involve significant blood loss. Tranexamic acid (TXA) has been proposed to minimise blood loss during various surgical procedures, but its effectiveness in cleft palate repair remains unclear. This systematic review and meta-analysis aimed to assess the effectiveness of TXA to reduce postoperative blood loss. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search across multiple databases, including PubMed, Cochrane, and Web of Science, to identify relevant studies published up to September 2023. Only randomised controlled trials (RCTs) were included. Primary outcomes measured were total blood loss, transfusion rates, and postoperative complications. We identified four relevant RCTs, which included 275 cleft palate patients with a mean (range) age of 28.7 (6-65) months. The pooled analysis found no significant difference in duration of surgery (MD -18.40 minutes, p = 0.09), preoperative haemoglobin (MD 0.46 g/dl, p = 0.27), or postoperative haemoglobin (MD 0.07 g/dl, p = 0.86) between TXA and control groups. Intraoperative blood loss was lower with TXA, but with TXA, the difference was not statistically significant (MD -16.63 ml, p = 0.15). TXA significantly improved surgical field visibility (p = 0.004). No adverse events occurred with its use. While no significant differences were found in surgical outcomes with TXA, surgical field visibility significantly improved, and TXA showed a promising safety profile. Larger and higher-quality RCTs are still needed to validate these preliminary findings before TXA can be considered as a standard treatment., (Copyright © 2024 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: To present the design and methodology for an actively enrolling comparative effectiveness study of revision palatoplasty versus pharyngoplasty for the treatment of velopharyngeal insufficiency (VPI)., Design: Prospective observational multicenter study., Setting: Twelve hospitals across the United States and Canada., Participants: Individuals who are 3-23 years of age with a history of repaired cleft palate and a diagnosis of VPI, with a total enrollment target of 528 participants., Interventions: Revision palatoplasty and pharyngoplasty (either pharyngeal flap or sphincter pharyngoplasty), as selected for each participant by their treatment team., Main Outcome Measure(s): The primary outcome is resolution of hypernasality, defined as the absence of consistent hypernasality as determined by blinded perceptual assessment of a standard speech sample recorded twelve months after surgery. The secondary outcome is incidence of new onset obstructive sleep apnea. Statistical analyses will use propensity score matching to control for demographics, medical history, preoperative severity of hypernasality, and preoperative imaging findings., Results: Study recruitment began February 2021. As of September 2022, 148 participants are enrolled, and 78 have undergone VPI surgery. Enrollment is projected to continue into 2025. Collection of postoperative evaluations should be completed by the end of 2026, with dissemination of results soon thereafter., Conclusions: Patients with VPI following cleft palate repair are being actively enrolled at sites across the US and Canada into a prospective observational study evaluating surgical outcomes. This study will be the largest and most comprehensive study of VPI surgery outcomes to date., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The objective of this study was to use data from Smile Train's global partner hospital network to identify patient characteristics that increase odds of fistula and postoperative speech outcomes., Design: Multi-institution, retrospective review of Smile Train Express database., Setting: 1110 Smile Train partner hospitals., Patients/participants: 2560 patients., Interventions: N/A., Main Outcome Measure(s): Fistula occurrence, nasal emission, audible nasal emission with amplification (through a straw or tube) only, nasal rustle/turbulence, consistent nasal emission, consistent nasal emission due to velopharyngeal dysfunction, rating of resonance, rating of intelligibility, recommendation for further velopharyngeal dysfunction assessment, and follow-up velopharyngeal dysfunction surgery., Results: The patients were 46.6% female and 27.5% underweight by WHO standards. Average age at palatoplasty was 24.7 ± 0.5 months and at speech assessment was 6.8 ± 0.1 years. Underweight patients had higher incidence of hypernasality and decreased speech intelligibility. Palatoplasty when under 6 months or over 18 months of age had higher rates of affected nasality, intelligibility, and fistula formation. The same findings were seen in Central/South American and African patients, in addition to increased velopharyngeal dysfunction and fistula surgery compared to Asian patients. Palatoplasty technique primarily involved one-stage midline repair., Conclusions: Age and nutrition status were significant predictors of speech outcomes and fistula occurrence following palatoplasty. Outcomes were also significantly impacted by location, demonstrating the need to cultivate longitudinal initiatives to reduce regional disparities. These results underscore the importance of Smile Train's continual expansion of accessible surgical intervention, nutritional support, and speech-language care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: During periods of civil strife, the need for trauma care and lack of sufficient cleft surgeons causes an increase in children left untreated with cleft lip and palate deformities. During the Syrian war, some cleft care was provided through visiting charities, with surgeries performed both in Syria and neighboring countries. There is a need to increase the number of adequately trained cleft surgeons available in such regions so that care can be achieved beyond mission trips., Methodology: Cleft lip and palate repair workshops were delivered to 50 doctors in Syria. Pre-workshop, trainees received supplementary learning material. During the workshop, attendees received didactic teaching followed by 2 simulation sessions. Pre- and post-workshop, attendees completed questionnaires regarding their confidence and ability to perform cleft lip and palate repair., Results: Pre-workshop, 96% of workshop attendees had never independently performed cleft lip repair while 100% of attendees had not previously performed cleft palate repair. The mean pre-workshop confidence score was 2.452. Post-workshop, the mean confidence score was 3.503. Confidence rating scores significantly improved ( P  < .001)., Conclusion: The workshop delivered in Syria, together with this cleft lip and palate simulator provides an effective training tool that may support surgical training globally, particularly those in low-income countries. Further support is needed by charity organizations to ensure the continued delivery of such training., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Using both endoscope and exoscope in cleft soft palate surgery is not widespread, despite the potential advantages related to view magnification, ergonomic posture of the surgeon, and involvement of the surgical team., The aim of the current study is to compare endoscopic (Olympus Visera © ) and exoscopic (Karl-Storz Vitom © ) assistance in cleft soft palate surgery in a preclinical cadaver setting., A formalin fixed specimen was dissected to mimic the anatomical conditions of a cleft soft palate., Ten young surgeons with limited experience in transoral surgery were involved in the exercitation on the specimen., The exercitation consisted of 4 tasks: (1) device setting; (2) identification of muscle plane; (3) muscle suturing; (4) oral mucosa suturing., Participants were timed while performing each task both with exoscope and endoscope and asked to fill in 2 questionnaires related to the visual systems used (NASA Task Load System TLS and VAS 1-10)., All surgeons completed the 4 tasks with both the endoscope and exoscope. The execution times were similar except for faster setting of the exoscope. Participants felt that completing surgical exercises using the exoscope required less physical, intellectual, and temporal efforts compared to the endoscope. The exoscope was also more appreciated for its handling, 3D visualization, and limited encumbrance., Exoscope scored better both at NASA TLS and VAS 1-10 and required a faster setting than endoscope. Further clinical in-vivo studies are required to explore the advantages of these devices in cleft palate repair., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To examine skeletal morphology and dental arch relationships at 8 years of age following early 2-stage palatoplasty, which consists of soft palate plasty at 1 year of age and hard palate closure at 1.5 years of age, and to compare the results with those of conventional pushback palatoplasty., Design: Retrospective., Setting: Single institutional study., Patients: Eighty-six patients with nonsyndromic complete unilateral cleft lip and palate (UCLP) were selected., Intervention: The subjects were divided into 2 groups according to the palatoplasty protocols, as follows: 45 patients, who underwent early 2-stage palatoplasty (ETS group), and 41 patients, who underwent 1-stage pushback palatoplasty (PB group)., Main Outcome Measures: Skeletal morphology was assessed using lateral cephalometric analysis, and dental arch relationships were examined using the GOSLON yardstick., Results: Cephalometric analysis revealed that the anterior-posterior length of the maxilla, measured by PTM-A and PTM-ANS, both projected to the nasal floor (NF) plane, was longer in the ETS group than in the PB group (PTM-A/NF, p  = .04; PTM-ANS/NF, p  = .03, unpaired t -test), although no significant difference was observed in SNA ( p  = .09, unpaired t -test). Upper posterior facial height was shorter in the ETS group than in the PB group ( p  = .02, unpaired t ). Assessments with the GOSLON yardstick showed that the ETS group presented better dental arch relationships than the PB group ( p  = 0.04, Mann-Whitney's U -test)., Conclusions: The present results suggested that the ETS protocol reduced the negative effects of palatal surgery on facial development and dental arch relationships in patients with complete UCLP at 8 years of age., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

There are several factors to consider when planning cleft palate repair. It is important to review the patient's associated comorbidities, as they impact decisions on perioperative management and family counseling. Many comorbidities change the risk of postoperative airway obstruction, velopharyngeal insufficiency, or fistula formation. It is also critical to determine the type of cleft palate to be addressed, as this influences the decision on which technique is most appropriate for optimal patient outcome. Common surgical techniques for palatoplasty are reviewed in detail and outcomes are discussed as it relates to various techniques. Intraoperative photographs are included to detail the procedures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To examine levator veli palatini muscle composition in patients with nonsyndromic cleft palate and investigate the impact of Veau class., Design: Prospective cohort study., Setting: Tertiary care academic hospital., Patients/participants: Thirteen patients with nonsyndromic cleft palate were recruited., Interventions: During primary palatoplasty, a sample of levator veli palatini muscle was excised and prepared for histological analysis., Main Outcome Measures: Fat and collagen content were determined utilizing Oil Red and Sirius red stains, respectively, while muscle fiber cross-sectional areas were calculated from H&E-stained samples, with analysis using histomorphometric methods. Immunofluorescent staining of myosin heavy chain isoforms was performed., Results: Patients underwent repair at 10.8 months of age (interquartile range [IQR] 10.2-12.9). Fat content of the levator veli palatini muscle was low in both groups, ranging from 0% to 5.2%. Collagen content ranged from 8.5% to 39.8%; neither fat nor collagen content showed an association with Veau classes. Mean muscle fiber cross-sectional area decreased with increasing Veau class, from 808 µm 2 (range 692-995 µm 2 ) in Veau II to 651 µm 2 (range 232-750 µm 2 ) in Veau III ( P  = .02). There was also a nonsignificant decrease in proportion of type I muscle fibers with increasing Veau class (44.3% [range 31.4%-84.4%] in Veau II vs 35.3% [range 17.4%-61.3%] in Veau III)., Conclusions: Muscle fiber area in levator veli palatini muscles decreases in Veau III clefts in comparison to Veau II. The impact of these differences in velopharyngeal dysfunction requires further analysis of a larger cohort., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: KBP is a consultant for Stryker CMF.

Objective: An inspiring early result with no oronasal fistula formation was recently described for a modified medial incision small double-opposing Z-plasty (MIsDOZ) for treating Veau type I cleft palate. This study describes an early single-surgeon experience in applying this newly proposed surgical approach., Design: Retrospective single-surgeon study., Patients: Consecutive nonsyndromic patients (n  =  27) with Veau I cleft palate., Interventions: Topographic anatomical-guided MIsDOZ palatoplasty with pyramidal space dissection (releasing of the ligamentous fibers in the greater palatine neurovascular bundle and pyramidal process region, in-fracture of the pterygoid hamulus, and widening of space of Ernst) performed by a novice surgeon (RD)., Mean Outcome Measures: Age at surgery, the presence of cleft lip, palatal cleft width, use of lateral relaxing incision, and 6-month complication rate (bleeding, dehiscence, fistula, and flap necrosis). A published senior surgeon-based outcome dataset (n  =  24) was retrieved for comparison purposes., Results: Twenty-two (81.5%) and 5 (18.5%) patients received the medial incision only technique and lateral incision technique, respectively ( P   =  .002). Age, presence of cleft lip, and cleft width were not associated (all P  > .05) with the use of lateral incision. Comparative analysis between the novice surgeon- and senior surgeon-based datasets revealed no significant differences for sex (females: 74.1% vs 62.5%; P   =  .546), age (10.2  ±  1.7 vs 9.6  ±  1.2 months; P   =  .143), rate of lateral incision (18.5% vs 4.2%; P   =  .195), and postoperative complication rate (0% vs 0%)., Conclusion: This modified DOZ palatoplasty proved to be a reproducible procedure for Veau I cleft palate closure, with reduced need for lateral incision and with no early complication., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This study characterizes the potential loss of velar length in patients with a wide cleft and rescue of this loss of domain by local flap reconstruction, providing anatomic evidence in support of primary lengthening of the soft palate during palatoplasty., Methods: A retrospective review was conducted of all patients with a cleft palate at least 10mm in width, who underwent primary palatoplasty with a buccal flap prior to 18 months of age over a 2-year period. All patients underwent primary palatoplasty with horizontal transection of the nasal mucosa, which was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting palatal lengthening was measured and the mucosal defect was reconstructed with a buccal flap., Results: Of the 22 patients included, 3 (13.6%) had a history of Pierre Robin sequence, and 5 (22.7%) had an associated syndrome. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 had (13.6%) a Veau IV cleft. All patients had a right buccal flap during primary palatoplasty. The mean cleft width at the posterior nasal spine was 10.6  ±  2.82mm, and mean lengthening of the velum after horizontal transection of the nasal mucosa closure was 10.5  ±  2.23mm. There were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission, and no bleeding complications., Conclusions: Patients with a wide cleft palate have a potential loss of 1cm velar length. The buccal flap can rescue the loss of domain in palatal length, and potentially improve palatal excursion., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Children with hypopituitarism (CwHP) can present with orofacial clefting, frequently in the setting of multiple midline anomalies. Hypopituitarism (HP) can complicate medical and surgical care; the perioperative risk in CwHP during the traditionally lower risk cleft lip and/or palate (CL/P) repair is not well described. The objective of this study is to examine the differences in complications and mortality of CL/P repair in CwHP compared to children without hypopituitarism (CwoHP)., Design: A retrospective cross-sectional analysis., Setting: The 1997 to 2019 Kids' Inpatient Databases (KID)., Patients: Children 3 years old and younger who underwent CL/P repair., Main Outcome Measure(s): Complications and mortality., Results: A total of 34 106 weighted cases were analyzed, with 86 having HP. CwHP had a longer length of stay (3.0 days [IQR 2.0-10.0] vs 1.0 day [IQR 1.0-2.0], P  < .001) and higher rates of complications and mortality (12.8% vs 2.9%, P  < .001) compared to CwoHP. Controlling for demographic factors, CwHP had 6.61 higher odds of complications and mortality than CwoHP (95% CI 3.38-12.94, P  < .001)., Conclusions: CwHP can present with a CL/P and other midline defects that can increase the complexity of their care. These data show a significant increase in length of stay, complications, and mortality in CwHP undergoing CL/P repair. Increased multidisciplinary attention and monitoring may be needed for these children peri- and postoperatively, especially if additional comorbidities are present. Further studies on perioperative management in this population are warranted to reduce morbidity and mortality., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: A palatal fistula is an adverse outcome of cleft palate repair. It is unknown if a palatal fistula will influence velopharyngeal closure, even after repair of the fistula. This study determines the effect of a soft palate fistula on the risk of developing velopharyngeal insufficiency., Methods: A retrospective chart review was conducted on patients who underwent primary cleft palate repair between 2000 and 2015, with complete records at 4 years of age. Fistulae involving the secondary palate following primary palatoplasty were classified as the soft or hard palate. A forced-entry multivariate logistic regression model was built to detect predictors of velopharyngeal dysfunction., Results: Records of 329 patients were analyzed with a mean follow-up of 8.7 years. A palatal fistula was identified in 89/329 patients (27%) and 29/329 patients (9%) underwent an independent fistula repair. Of the patients with fistula, 44% were located in the hard palate only and 56% had soft palate involvement. Compared to patients without a fistula, rates of velopharyngeal dysfunction were significantly higher in patients with a fistula involving the soft palate (OR 3.875, CI: 1.964-7.648, P  < .001) but not in patients with a hard palate fistula (OR 1.140, CI: 0.497-2.613, P  = .757). Veau class, age at primary repair, and syndromic status were not significant predictors of VPI (0.128≤ P  ≤ .975)., Conclusions: A palatal fistula involving the soft palate is a significant predictor for development of velopharyngeal dysfunction after primary palatoplasty. Surgical intervention, at the time of fistula repair, to add vascularized tissue may be indicated to prophylactically decrease the risk of velopharyngeal dysfunction., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Palatal fistulae are challenging complications following cleft palate repair. The addition of acellular dermal matrix (ADM) to cleft palate repair has been shown to reduce fistula formation in previous studies. The use of autologous dermal graft has all the structural advantages of ADM, has less rejection and immunogenic potential, and is cost effective., A prospective study., Patients with Group II and III cleft palate (Nagpur Classification) without prior intervention for palatal repair in the Department of Plastic Surgery at PGIMER from January 2020 till June 2021., The addition of autologous dermal graft for palatoplasty., Outcome of the study was fistula development or exposure of dermal graft., Autologous dermal graft was harvested of average dimension of 8.73 cm 2 (range 5.25-18 cm 2 ) from groin region. Sixteen patients were included in the study. Among them, 2 patients (12.5%) developed postoperative fistula (Type III &V Pittsburgh Classification)., Our study showed that the rates of postoperative fistula formation are comparable with prior literature using artificial dermal matrices., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Palate development involves a genetic regulation through a complex molecular mechanism that may be disrupted by environmental factors, resulting in impaired fusion and cleft palate formation. An encounter with a case of cleft palate due to dorsal tongue hamartoma prompted us to perform this systematic review., Objective: To review the clinical profile and management approach for a case with cleft palate and tongue hamartoma., Design: A systematic literature search was conducted using keywords related to cleft palate and tongue hamartoma in PubMed, Scopus, MEDLINE, and Scielo databases through December 2021, with no time or language restrictions., Patients, Participants: Studies reporting patients with cleft palate and tongue hamartoma were included., Main Outcome Measure(s): Information related to clinical profile, diagnostic tests, histopathology, management, and outcomes were extracted., Fourteen relevant publications were identified with 16 cases reported so far. Among them, thirteen patients were females (81.25%), and 3 were males (18.75%). The age of presentation varied from birth to 19 years. Oral-facial-digital syndrome (type II) was the most commonly associated syndrome., Congenital tongue hamartoma with cleft palate is a rare presentation, which can present as an isolated entity or part of a syndrome. Genetic evaluation is warranted, particularly for multiple hamartomatous lesions. The preferred treatment is immediate excision of hamartoma while following a standard timeline for palatoplasty., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To estimate the impact of relaxing incisions on maxillofacial growth following Sommerlad-Furlow modified technique in patients with isolated cleft palate., Study Design: A Retrospective Cohort Study., Methods: A total of 90 participants, 60 patients with non-syndromic isolated soft and hard cleft palate underwent primary palatoplasty (30 patients received the Sommerlad-Furlow modified technique without relaxing incision (S.F -RI group), and 30 received Sommerlad-Furlow modified technique with relaxing (S.F +RI group) with no significant difference found between them regarding the cleft type, cleft width, and age at repair. While the other 30 were healthy noncleft participants with skeletal class I pattern as a Control group. The control group (C group) was matched with the patient groups in number, age, and sex. All participants had lateral cephalometric radiographs at least 5 years old age. The lateral cephalometric radiographs were taken with the same equipment by the same experienced radiologist while the participants were in centric occlusion and a standardized upright position, with the transporionic axis and Frankfort horizontal plane parallel to the surface of the floor. A well-trained assessor (S. Elayah) used DOLPHIN Imaging Software to trace twice to eliminate measurement errors. All the study variables were measured using stable landmarks, including 12 linear and 10 angular variants., Results: The mean age at collection of cephalograms was 6.03 ± 0.80 in the S.F +RI group, 5.96 ± 0.76 in the S.F -RI group, and 5.91 ± 0.87 in the C group. Regarding cranial base, the results showed no statistically significant differences between the three groups in S-N and S-N-Ba. While the S.F +R.I group had a significantly shortest S-Ba than the S.F -R.I & C groups (P = 0.01 & P < 0.01), but there was no statistically significant difference between S.F -R.I & C groups (P = 0.71). Regarding the skeletal maxilla, there was no significant difference between the S.F +R.I and S.F -R.I groups in all linear measurements (N-ANS and S-PM) except Co-A, the S.F +R.I group had significantly shorter Co-A than the S.F -R.I & C groups (P =  < 0.01). While the angular measurement, S.F +R.I group had significantly less SNA angle than the S.F -R.I & C groups (P =  < 0.01). Regarding mandibular bone, there were no statistically significant differences in all linear and angular mandibular measurements between the S.F +R.I and S.F -R.I. groups. Regarding intermaxillary relation, the S.F +R.I group had significant differences in Co-Gn-Co-A and ANB compared to the S.F -R.I & C groups (P =  < 0.01). While there was no statistically significant difference in PP-MP between the three groups., Conclusion: As a preliminary report, the Sommerlad-Furlow modified technique without relaxing incisions was found to have a good maxillary positioning in the face and a satisfactory intermaxillary relationship compared to the Sommerlad-Furlow modified technique with relaxing incisions., (© 2023. The Author(s).)

Background: Tissue adjunct is non-palatal tissue used to manage tension at the defect site by providing additional coverage. This review aimed to compare outcomes of various adjuncts employed in primary palatoplasty., Methods: A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library with keywords cleft palate, palatoplasty, surgical flaps, and allografts. Data extracted included demographics, cleft severity, primary/adjunctive techniques, outcomes, and follow-up periods. Logistic regression analyses and chi-squared tests were performed to investigate associations among variables., Results: A total of 1332 patients (aged 3 months-5 years) with follow-up of 1 month to 21 years were included. Cleft severity included submucous cleft (1.7%), Veau I/II (33.3%), Veau III (46.3%), and Veau IV (15.1%). Most reported techniques were Furlow (52%) and intravelar veloplasty (14.3%) for soft palate, Bardach (27.2%), and V-Y Pushback (11.1%) for hard palate. Buccal myomucosal flap (BMMF) was performed in 45.4% of cases, followed by buccal fat pad flap/graft (BFP) in 40.8% and acellular dermal matrix (ADM) in 14%. Severe clefts (Veau III/IV) were repaired more frequently with BMMF compared with ADM (p = 0.003) and BFP (p = 0.01). Oronasal fistula occurred in 3.1% of patients, and velopharyngeal insufficiency (VPI) in 4%, both associated with Veau IV (fistula: p = 0.002, VPI: p = 0.0002). No significant differences were found in fistula (p = 0.79) or VPI (p = 0.14) rates between adjuncts. In severe clefts (Veau III/IV), ADM was associated with fistula formation (p = 0.03)., Conclusions: Adjuncts in primary palatoplasty may mitigate unfavorable outcomes associated with severe clefts. BMMF is superior, given its inherent tissue properties, whereas BFP is effective in reducing fistula formation., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Children with cleft palate (CP) are at high risk of developing otitis media with effusion (OME) due to Eustachian tube (ET) dysfunction. Palatoplasty has been reported to decrease the frequency of middle ear disease and improve ET function, and although various techniques have been developed, there is no consensus on the differences in the impact of different techniques on the middle ear. The purpose of this study was to determine the differential effects of palatoplasty on middle ear function and hearing., Methods: We performed a retrospective observational survey of pediatric patients who underwent palatoplasty for CP between June 2010 and October 2018 at Tohoku University Hospital. Cases were divided into three groups depending on the palatoplasty procedures performed: the push-back palatoplasty group, the two-flap palatoplasty group, and the Furlow double-opposing Z-plasty group. We examined the differences in clinical characteristics between patients who underwent each procedure. The primary outcome variable was tympanic membrane (TM) findings, and the secondary outcome was hearing test results., Results: Children who underwent the two-flap palatoplasty had a higher tympanostomy tube (TT) insertion rate and a higher total number of TT insertions than those who underwent the Furlow double-opposing Z-plasty or the push-back palatoplasty. The TM retraction rate tended to be lower in the Furlow double-opposing Z-plasty group than in the push-back palatoplasty group or the two-flap palatoplasty group. The hearing test results at the last visit were not significantly different among the three groups., Conclusions: Children who underwent the two-flap palatoplasty had a higher rate of TT insertions, potentially increasing the risk of TM perforation. In contrast, the Furlow double-opposing Z-plasty group had a lower tendency for TM regression, possibly due to improved ET function and reduced incidence of OME. It is important to understand the advantages and disadvantages of each technique before selecting one suitable for the child's cleft and arch width. Additionally, it is important to conduct regular follow-up of TM findings and hearing test results even after palatoplasty., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: Prior research suggests that children with cleft palate (CP) are at increased risk of obstructive sleep-disordered breathing (SDB). However, few studies differentiate the effects of CP repair on SDB based on syndrome status. The goal of this study was to evaluate differences in SDB after palatoplasty among children with nonsyndromic CP, syndromic CP, and isolated Robin sequence (RS)., Design: Retrospective chart review., Setting: Tertiary academic children's hospital., Patients/participants: A total of 145 children who underwent primary CP repair from 2014 to 2021., Main Outcome Measure: Post-palatoplasty SDB is defined as parent-reported symptoms and/or evidence of obstructive sleep apnea (OSA)., Results: Median age at palatoplasty was 11.1 [IQR 10.2-13.6] months. Most patients (61.4%) had nonsyndromic CP, 26.9% had a syndrome, and 11.7% had RS. Children with syndromic CP and RS had more post-palatoplasty SDB symptoms (56.4% vs 58.8% vs 30.3%, P  = .006) and higher rates of OSA (25.6% vs 29.4% vs 5.6%, P  = .001) compared to children with nonsyndromic CP after palatoplasty. Children with syndromic CP and RS had nearly 3 to 4 higher odds of post-palatoplasty SDB than children with nonsyndromic CP (adjusted odds ratio [aOR] 2.88, 95% CI 1.29-6.47, P  = .010; aOR 3.73, 95% CI 1.19-11.70, P  = .024)., Conclusion: This study showed that children with CP experience higher rates of SDB after palatoplasty than the general pediatric population. Within the cohort, children with syndromic CP and isolated RS were more likely to have obstructive sleep disorders than nonsyndromic children after palatoplasty. Clinicians should counsel caregivers accordingly and closely monitor these groups for SDB after palate repair., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population., Design: A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty., Setting: New York-Presbyterian Hospital., Patients/participants: Patients with cleft palate undergoing primary palatoplasty., Interventions: Meta-analysis of reported patient outcomes in ERAS and control cohorts., Main Outcome Measure(s): Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications., Results: Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls ( P  < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients ( P  < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups ( P  = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses., Conclusions: ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.

Patau syndrome (trisomy 13) is a severe disorder associated with multiple systemic defects. Patau syndrome is commonly associated with ocular abnormalities but rarely associated with congenital glaucoma. To obtain a better surgical view, palatoplasty requires neck extension during surgery. The intraocular pressure (IOP) of patients with Patau syndrome can increase owing to the neck extension position while undergoing palatoplasty, particularly in those with congenital glaucoma. Here, we describe a case with increased IOP measured using a rebound tonometer during palatoplasty in a pediatric patient with Patau syndrome and congenital glaucoma. This case shows that it may be important to reduce the degree of neck extension and shorten the operation time to minimize any increase in the IOP during palatoplasty in pediatric patients with Patau syndrome accompanied by congenital glaucoma.

This study aims to characterize current use, knowledge, and attitude toward ERAS protocols by academic craniofacial surgeons., Craniofacial surgeons were provided with electronic surveys., Electronic survey; Institutional tertiary surgeons., 102 cleft palate surgeons surveyed and 31 completed the survey (30.4%)., None., Respondents rated their knowledge, use, and willingness to implement perioperative interventions modeled after adult ERAS protocols., Majority (67.7%) rated they were knowledgeable about ERAS. However, 61.3% "never use" a standardized protocol for cleft palate surgery. Only 3 ERAS elements are currently implemented by a majority of cleft surgeons: avoiding prolonged perioperative fasting (67.7%), using hypothermia prevention measures (74.2%), and minimizing use of opioids (62.5%). A large majority of respondents noted they never administer bolus (71.0%) or infusion (80.6%) dosing of tranexamic acid; most of these surgeons also indicated that administering tranexamic acid "would not be a valuable addition" (67.7% and 71.0%, respectively). Short-acting sedatives are used by 12.9% and by 16.1% of surgeons in all patients during extubation and postoperative recovery, respectively. By contrast, 22.6% never use such agents during extubation and 48.4% never use it during postoperative recovery. Overall, 67.7% of respondents replied that they would be willing to implement an ERAS protocol for cleft palate repair., Many respondents report using interventions compatible with an ERAS approach and the majority are willing to implement an ERAS protocol for cleft palate repair.

Background: Intraocular pressure (IOP) can increase with postural changes, which can cause ocular complications. Neck extension is commonly used during palatoplasty to improve surgical angulation. This study evaluates whether neck extension affects IOP during palatoplasty., Methods: In this prospective observational study, IOP was measured using a rebound tonometer at four specific time points: T1, 10 min after anaesthesia while in the supine position; T2, 5 min after neck extension; T3, at completion of palatoplasty with neck extended; and T4, 5 min after returning to the supine position. The primary outcome was the IOP at T2, and the secondary outcomes were the IOPs at T3 and T4. Haemodynamic and respiratory variables were also measured at each time point., Results: Thirty-seven patients were included. IOP at T2 was significantly higher than at T1 (15.8 ± 3.4 mmHg vs 10.5 ± 2.8 mmHg, P < 0.001), and IOPs at T3 and T4 were also significantly higher than at T1 (T3 vs T1: 18.9 ± 3.6 mmHg vs 10.5 ± 2.8 mmHg, P < 0.001; T4 vs T1: 13.3 ± 3.7 mmHg vs 10.5 ± 2.8 mmHg, P < 0.001). However, no significant differences were observed for the haemodynamic and respiratory variables at any time point., Conclusion: Our findings indicate that the intraoperative neck extension position during palatoplasty significantly increases IOP in paediatric cleft palate patients undergoing a palatoplasty., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

While bilateral cleft lip and palate (BCLP) constitutes a clinical challenge for the whole cleft team, the ideal surgical protocol remains obscure. This study presents the long-term burden of care in terms of secondary surgeries, defined as fistula repair and speech-correcting surgeries (SCS), in a single center. Outcomes of two surgical protocols utilized over the years were also compared., A retrospective single-center analysis of 81 non-syndromic children with complete BCLP born between 1990 and 2010. Two surgical protocols comprising single-stage and two-stage (delayed hard palate closure) procedures were compared. Outcome was analyzed at the time of alveolar bone grafting (ABG) and post-ABG., Altogether 54 children (66.7%) had underwent secondary surgery by the time of bilateral ABG. At this point, 38.3% (n = 31) of patients had received SCS and 49.4% (n = 40) had undergone fistula repair. The corresponding incidences at the end of follow-up were 46.9% (n = 38) and 53.1% (n = 43). No significant difference emerged in SCS incidence between the 2 protocols; however, prior to ABG the single-stage protocol had a significantly lower need for fistula repair. Regarding the location of fistulas, some differences were observed, with the single-stage procedure more associated with anterior fistulas., BCLP has a high surgical burden of care in terms of secondary surgeries, defined as SCS and fistula repair. In our experience, the single-stage protocol, particularly the two-flap technique, offers better results in the management of BCLP than the two-stage approach with a short delay in hard palate closure.

Objective: Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance., Design: Cross-sectional survey-based evaluation., Setting: International comprehensive cleft care workshop., Participants: Total of 489 participants., Interventions: Three-day simulation-based hybrid comprehensive cleft care workshop., Main Outcome Measures: Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance., Results: The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 ± 3.08 vs 27.63 ± 3.93; P  = .04) and perceived impact on their clinical practice (22.37 ± 3.42 vs 21.02 ± 3.45 P  = .01)., Conclusion: Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

Objective: To determine the impact of illustrated postoperative instructions on patient-caregiver knowledge and retention., Design: Prospective study with all participants receiving an educational intervention., Setting: Pediatric plastic surgical missions in Guatemala City, Guatemala, between 2019 and 2020., Participants: A total of 63 majority-indigenous Guatemalan caregivers of patients receiving cleft lip and/or palate surgery., Intervention: Illustrated culturally appropriate postoperative care instructions were iteratively developed and given to caregivers who were surveyed on illustration-based and text-based information at preoperative, postoperative, and four-week follow-up time points., Main Outcome Measure: Postoperative care knowledge of illustration-based versus text-based information as determined by the ability to answer 11 illustration- and 8 text-based all-or-nothing questions, as well as retention of knowledge as determined by the same survey given at four weeks follow-up., Results: Scores for illustration-based and text-based information both significantly increased after caregivers received the postoperative instructions (+13.30 ± 3.78 % SE, + 11.26 ± 4.81 % SE; P  < .05). At follow-up, scores were unchanged for illustration-based (-3.42 ± 4.49 % SE, P  > .05), but significantly lower for text-based information (-28.46 ± 6.09 % SE, P  < .01). Retention of text-based information at follow-up correlated positively with education level and Spanish literacy, but not for illustration-based., Conclusions: In the setting of language and cultural barriers on a surgical mission, understanding of illustration-based and text-based information both increased after verbal explanation of illustrated postoperative instructions. Illustration-based information was more likely to be retained by patient caregivers after four weeks than text-based information, the latter of which correlated with increased education and literacy.

Objective: To evaluate and compare the effect of honey or saline mouth bath for wound care on the rate of re-epithelisation of the lateral palatal defects and occurrence of early postoperative complications following palatoplasty., Methodology: This was a prospective randomized study on participants with non-syndromic cleft palate conducted at a tertiary health institution in Lagos, Nigeria. The test group received oral honey drops for post-operative care for an initial period of two weeks post-surgery, while the control group had regular oral toileting using a warm saline solution. The primary outcome was epithelisation of lateral palatal defect at 2- and 4-weeks post repair. Descriptive and comparative statistics were computed, and the p -value was set at <0.05., Results: Fifty participants were recruited into the study, 24 in the Test group and 26 in the Control group. The frequency of occurrence of oronasal fistula in the Test group was 4.0% while in the Control group was 10.0%, however, this was not statistically significant. Complete epithelisation of the lateral palatal defect was clinically observed in 66.7% of the participants in the Test group at 2 weeks post-operation, while only 38.5% of participants in the Control group had clinically observed complete epithelisation at the same time point (β = 1.70, p  = .035, 95% CI 1.122-26.533). At four weeks, all wounds had epithelised irrespective of the study group., Conclusion: The application of honey appears to aid earlier epithelization of palatal surgical wounds following cleft palate repair and reduced the incidence of palatal fistula.

The case series details 2 unusual cases of male newborns with cleft lip and palate (CLP) that later developed formula otorrhea. Both patients underwent bilateral myringotomies with the insertion of pressure equalizing (PE) tubes for chronic otitis media with effusion (OME). Chronic otorrhea associated with feeding occurred post-PE tube insertion and the otorrhea was later confirmed to be due to reflux of formula. Patients were treated with antibiotic ear drops, routine ear cleaning, anti-reflux medication, and reflux precautions. After definite cleft palate repair, formula otorrhea completely resolved. When patients with CLP develop chronic OME or otorrhea following PE tube placement, reflux of formula into the middle ear should be considered and treated accordingly.

To delineate the indications, referral sources and outcomes of radical muscle dissection palate repair in the first 4 years of life for patients with submucous cleft palate (SMCP)., This study presents a retrospective analysis of a single surgeon's management., All children were treated at Great Ormond Street Hospital, United Kingdom., Twenty-three children with nonsyndromic SMCP were included in this study., All participants underwent radical muscle dissection repair before their fourth birthday., Parameters analyzed included: referral sources, indications for referral, extent of anatomical abnormality, and postoperative outcomes., Paediatricians provided the largest proportion of referrals to the cleft lip and palate clinic (39%) due to the presence of cleft lip/palate on prenatal scans or during neonatal examination. Over half (n = 12, 52%) of patients had severe anatomical anomalies being in grade IV (score 8-9), with the classical triad present to some extent in all but 2 of the patients. The main indication for surgery was nasal regurgitation of food and liquid (n = 9, 35%) followed by hypernasality (n = 6, 21%), difficulty feeding (n = 3, 8%), and severe anatomical defect (n = 2; 4%). Postoperatively, the presenting complaint improved in the majority of cases., Nonsyndromic SMCP is often missed, though may present with nasal regurgitation, feeding problems, and/or hypernasality, though may be missed in nonsyndromic children. Early radical muscle dissection repair in the first 4 years of life is safe and effective, facilitating normal speech development.

Objective: To analyze graft success rates and hearing outcomes in patients with a history of cleft palate (CP) repair undergoing tympanoplasty., Data Sources: PubMed, Scopus, and CINAHL., Review Methods: Per PRISMA guidelines, the databases were searched from date of inception through December 14, 2021. Studies of patients with previous CP repair who underwent tympanoplasty were included. Meta-analysis of proportions, continuous measures, odds ratios (ORs), and meta-regression were used to analyze graft success and hearing outcomes after tympanoplasty., Results: A total of 323 patients with CP repair and 1169 controls were included. The proportion of graft success was 86.7% (95% CI, 76.1%-94.5%) in patients with CP repair and 88.8% (95% CI, 76.9-96.8) in controls. There was no difference in odds of graft success between patients with CP repair and controls (OR, 1.0 [95% CI, 0.5-1.8]; P = .870). Age was not a significant moderator of graft success in patients with CP repair (r = 0.1 [95% CI, -0.2 to 0.3]; P = .689) or controls (r = -0.0 [95% CI, -0.1 to 0.1]; P = .952). Comparing mean differences between pre- and postoperative air-bone gap was not statistically significant in patients with CP repair and controls (0.2 dB [95% CI, -3.1 to 3.4]; P = .930). Odds of functional success (postoperative air-bone gap <20 dB) were not different between the groups (OR, 0.8 [95% CI, 0.5-1.4]; P = .450)., Conclusion: This meta-analysis does not endorse anatomic or functional differences between patients with CP repair and controls after tympanoplasty. However, there is a paucity of evidence for younger children. Further studies are warranted to elucidate specific risk factors for tympanoplasty outcomes in young patients with previous CP repair., (© 2022 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: To determine how race and ethnicity affect palatoplasty 30-day outcomes., Design: Retrospective review., Patients/setting: The 2012 to 2019 National Surgical Quality Improvement Program (NSQIP) Pediatric database was used to identify patients ≤ 2 years who underwent primary palatoplasty. We compared demographics, comorbidities, and 30-day outcomes among different racial and ethnic groups. Logistic regression was used to determine independent risk factors for adverse events., Main Outcome Measures: Increased risk for adverse events and postoperative surgical outcomes, including complications, readmission, and prolonged length of stay., Results: A total of 8537 patients were identified in the database. African-American patients had the highest proportion of premature infants and infants with a BMI < 15% at the time of repair. Asian patients underwent palatoplasty at a later age compared to other races (12.7 months vs 11.7-12.1 months). Postoperatively, the odds of a complication were significantly higher in Asian patients (aOR = 1.73, 95% CI: 1.17-2.57) and other/unknown patients (aOR = 1.40, 95% CI: 1.05-1.86), but not among African American (aOR = 1.02, 95% CI: 0.70-1.47) or Hispanic (aOR = 0.93, 95% CI: 0.69-1.26) patients. Other/unknown patients were more likely to require postoperative ventilation (aOR = 2.34, 95% CI: 1.38-3.95). The odds of readmission were highest in Asian and other/unknown patients. African American, Hispanic, and other/unknown patients were more likely than Caucasian patients to be hospitalized > 2 days postoperatively., Conclusion: This study highlights ethnic differences in presentation and 30-day outcomes following palatoplasty. Further evaluation of disparities in cleft care should be performed to improve healthcare access and surgical outcomes.

Objective: To examine the safety and efficacy of hyperdry amniotic membrane (HDAM) for wound closure after palatoplasty in cleft palate patients., Methods: HDAMs were prepared by washing and drying under infrared rays and microwaves at temperatures less than 60°C using a hyperdrying device. A total of 16 cleft palate patients (8 males, 8 females), aged 1 to 3 years (mean age 1 year 9 months), received one-stage pushback palatoplasty. The remaining raw wound after surgery was covered by an HDAM and a plastic cover plate. The cover plate was removed 1 week after surgery and parameters including temperature, feeding, allergic reactions, postoperative bleeding, re-epithelialization, wound dehiscence, and infection were monitored during the follow-up period of 31.2 months., Results: All patients could adequately ingest at 5 days postoperation and after removal of the cover plate. None of the patients had a persistent fever or allergic reactions. Ingestion was feasible immediately in all patients, and no postoperative bleeding was observed during ingestion. No secondary hemorrhages were observed during follow-up. No postoperative wound dehiscence on the midline of the palate was observed. No infections were observed after the removal of the cover plate. No patients suffered from severe scar formation or contracture of the wound in the follow-up period. Hemorrhage, undue epithelialization, and scar contracture did not occur in any patient. The mean evaluation score was 7.75 points., Conclusion: HDAM can be used safely and effectively for wound closure following palatoplasty in cleft palate infants. Future studies testing the safety of patient's own amnion for palatoplasty, are required.

A national survey of cleft teams was undertaken to evaluate the current standard of care for patients with cleft lip and palate (CLP) in India as a part of Cleft Care India study., This was a cross-sectional questionnaire-based study., Cleft teams across India attending the 19th Annual Conference of the Indian Society of Cleft Lip and Palate were invited to complete the questionnaire. The questionnaire consisted of 18 questions that included demographics, institutional details, patient protocols, surgical technique, rehabilitation facilities, and accessibility. The data are descriptively reported., A total of 112 centers completed the survey. Nongovernment organizations funded 87% of the cleft centers and 8% did not receive any funding. Only 39% of the centers had centralized cleft services providing multidisciplinary care. Speech therapy was provided either onsite or through referral at 90% of the centers, whereas audiology was provided only at 4% of centers. Feeding advice was routinely provided in 52% of centers. Millard technique was the most preferred technique for unilateral cleft lip repair (66%). The 2-flap technique (37%) and pharyngeal flap (48%) were the most common surgeries for cleft palate and pharyngoplasty, respectively. Although 54% of centers reported their patients to be interested in comprehensive care, 43% reported that their patients only wanted surgical correction., There is wide diversity in access to cleft care and clinical practices across centers in India. Further work is needed to evaluate the quality of care by assessing outcomes of centers treating patients with CLP.

The purpose of this study was to introduce the surgical process of Sommerlad-Furlow modified (S-F) palatoplasty and compare its surgical and functional outcomes with conventional Sommerlad (S) palatoplasty. Patients with non-syndromic cleft palate who had undergone either S-F palatoplasty or S palatoplasty were retrospectively reviewed. Data on the outcomes of velopharyngeal function and postsurgical palatal fistula incidence were collected for all patients. Data for preselected factors, including gender, age at palatoplasty, and cleft type, were also collected. Chi-square tests were conducted. 1254 patients were included. The postsurgical velopharyngeal competence (VPC) rate after S-F palatoplasty was significantly higher than after S palatoplasty (total, 70.5% vs 57.9%, p < 0.0001; age ≤ 1, 87.0% vs 69.2%, p < 0.0001; 1 < age ≤ 2, 78.3% vs 69.3%, p = 0.0479). With regard to different types of cleft palate, the postsurgical VPC rates after S-F palatoplasty were all significantly higher than for S palatoplasty in all patients younger than 2 years of age (complete cleft palate, 78.7% vs 62.4%, p = 0.0016; hard and soft palate cleft, 84.4% vs 74.8%, p = 0.0172; submucosal cleft and soft palate cleft, 96.6% vs 68.4%, p = 0.0114). The postoperative fistula rate after S-F palatoplasty was 4.3%. This modified palatoplasty technique provided adequate cleft palate closure, with satisfactory speech outcomes and low fistula rates, while older age at palatoplasty may affect the postsurgical outcomes. Within the limitations of the study it seems that the Sommerlad-Furlow modified technique is an option for cleft palate repair., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Pedicled buccal fat flaps have been adopted in primary Furlow double-opposing Z-plasty palatoplasty to reduce oronasal fistula formation or to attenuate maxillary growth disturbance. We combined both goals in a single intervention. This study describes a series of 33 modified Furlow small double-opposing Z-plasty palatoplasties reinforced with a middle layer of pedicled buccal fat flaps between the oral and nasal layers for full coverage of the dissected palatal surfaces, with rapid mucosalization of lateral relaxing incisions and no dehiscence or fistula formation.