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A Systematic Review Comparing Furlow Double-Opposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair

Nardini, Gil M.D.; Flores, Roberto L. M.D.

Plastic and Reconstructive Surgery: May 2015 - Volume 135 - Issue 5 - p 927e–928e
doi: 10.1097/PRS.0000000000001185

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,

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We read with great interest the article entitled “A Systematic Review Comparing Furlow Double-Opposing 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.

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.

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The authors have no financial relationships to disclose.

Gil Nardini, M.D.

Roberto L. Flores, M.D.

Department of Plastic Surgery

New York University Langone Medical Center

New York, N.Y.

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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
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 two-flap palatoplasty. Plast Reconstr Surg. 2008;122:1121–1130
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