Chapter 1eCongenital / 7

factors that contribute to poor academic outcomes in children with clefts are
necessary to understand and address the personal and societal impact.
A. Gosman, MD

Pharyngeal flap versus sphincter pharyngoplasty for the treatment of

velopharyngeal insufficiency: A meta-analysis
Collins J, Cheung K, Farrokhyar F, et al (McMaster Univ, Hamilton, Ontario,
Canada)
J Plast Reconstr Aesthet Surg 65:864-868, 2012

Background.dVelopharyngeal insufficiency (VPI) has been reported in

5e20% of patients following cleft palate repair. Since VPI can limit
communication, determining which operative procedure leads to the great-
est improvement is of utmost importance. Since there is no consensus, this
meta-analysis aims to determine which procedure results in the most signif-
icant resolution of VPI.
Methods.dTwo independent assessors undertook a literature review for
articles that compare procedures aimed at treating VPI. Study quality was
determined using validated scales. Level of agreement was assessed using
intra-class coalition coefficient analysis. The heterogeneity between studies
was evaluated using I2 and Cochrans Q-statistic. Random effect model
analysis and forest plots were used to report a pooled odds ratio (OR)
and 95% confidence intervals (CI) for treatment effect. A p-value of 0.05
was considered for statistical significance.
Results.dTwo randomised controlled trials (RCTs) comparing pharyn-
geal flap to sphincter pharyngoplasty were obtained. A total of 133 patients
were included, with follow-ups at 3e4 months. The pooled OR was deter-
mined to be 2.95 (95% CI: 0.66e13.23) in favour of the pharyngeal flap.
Conclusions.dBased on these RCTs, which currently compose the high-
est quality data that compares pharyngeal flap versus pharyngoplasty, the
pooled treatment effect suggests a possible trend favouring pharyngeal flap.
:

This article examines an important issue that needs to be resolved, although the
results of the meta-analysis, based on an analysis of the pooled data from 2
randomized controlled trials (RCT) reported by these authors, seem to favor the
use of a superiorly based pharyngeal flap rather than a sphincter-based pharyng-
oplasty. However, even the 2 RCTs, 1 being multi-institutional and 1 being from a
single institution, are somewhat flawed in their methodological designs. Clearly a
large RCT multi-institutional study with strict guidelines for inclusion or exclu-
sion, postoperative follow-up, and adequate numbers of patients in each of the
arms of the study would be most welcome to definitively answer which of the
2 techniques is better for ameliorating velopharyngeal incompetence.
S. H. Miller, MD