The Necessity of Nasal Layer Closure in Cleft Palate Repair

Abstract

Sir:FigureWe read with keen interest the article entitled “Is Nasal Mucoperiosteal Closure Necessary in Cleft Palate Repair?” by Steinbacher et al. (Plast Reconstr Surg. 2011;127:768–773). This potentially groundbreaking concept of single-layer closure in the hard palate region offers a theoretical advantage of lesser midfacial growth disturbances. In addition, there is significant reduction in operating time. However, certain questions need to be clarified before incorporating this concept in “standard of care practice” for cleft palate patients. It is important for the authors to explain why they chose to perform single-layer palatal closure in this retrospective study. Was this group of patients having narrower cleft palatal widths to merit single-layer closure? This is pertinent, as the rate of palatal fistula formation does correlate with the cleft width and available palatal shelf width.1–3 The reason we suggest this selection bias is the considerable difference in surgical duration between the two groups (84 minutes for the single-layer closure group and 135 minutes in those with two-layer closure). Nasal mucosal elevation and closure alone in the hard palatal region is unlikely to account for such a disparity in duration in otherwise comparable group 1 patients. Thus, the application of the “null hypothesis” in this retrospective study without excluding the selection bias relating to palatal and cleft dimensions could have confounded the study results. Another issue relates to the management of lateral oronasal communication after mucoperiosteal flap mobilization in patients undergoing single-layer closure. This communication can be of significant dimensions to close spontaneously in the absence of perfect apposition of the undersurface of sutured palatal flaps to the hard palate bone. This situation is likely in the single-layer closure group patients with a wider cleft or vertically oriented palatal shelves. A prospective, randomized, controlled trial can effectively and convincingly answer the apprehensions regarding the concept put forward by the authors. Ramesh Kumar Sharma, M.Ch., D.N.B.(Plast. Surg.) Surinder Singh Makkar, M.Ch.(Plast. Surg.) Atul Parashar, M.Ch.(Plast. Surg.) Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India