I read with great interest the study by Li et al. entitled “Cleft relapse and oronasal fistula after Furlow palatoplasty in infants with cleft palate: incidence and risk factors” . The aim of the study was to investigate the risk factors for the development of postoperative cleft relapse and oronasal fistula after Furlow palatoplasty. By using multivariate analysis, they showed that only the width of the cleft had a statistically significant impact on the incidence of cleft relapse and oronasal fistula. Furthermore, the incidence rates of cleft relapse and fistula were positively correlated with the width of the cleft when it exceeded 6.8 mm and 7.5 mm, respectively.

However, I believe that important aspects of the data were missing: the timing of the hard palate closure and the surgical technique used were not mentioned in the paper, and therefore one could only assume that all patients underwent a one-stage palatoplasty with the Furlow palatoplasty, with no prior closure of the hard palate using a vomer flap. This is of clinical significance, as the literature has described the use of early hard palate closure using a vomer flap in cleft lip and palate patients , resulting in a substantial decrease in the cleft width at the time of soft palate closure.

In their study, Li et al. revealed that fifteen patients (24.2%) developed cleft relapse at 1 week postoperative and that six patients (9.7%) developed an oronasal fistula at 3 months postoperative. Subsequently the authors arrived at the conclusion that for cleft palate with a cleft width of >7.5 mm, the Furlow repair was not recommended in view of the significantly increased risk of developing a postoperative fistula.

I find this recommendation intriguing. From experience at our centre, the majority of cleft palate patients have a cleft width wider than 7.5 mm at the time of operation. Since January 2016, we have adopted the use of a single-stage Furlow opposing double Z-plasty with bilateral relaxing incisions for the repair of all patients with cleft palate . While our case number is small and we only have limited follow-up data, the preliminary data show a mean preoperative width of the cleft of 9.41 mm (range 8–13 mm) for patients undergoing the primary one-stage Furlow palatoplasty procedure; the data are based on 19 patients, with a mean body weight of 8.10 kg (range 7–13.8 kg) and a mean age at operation of 12.4 months (range 10–17 months). Therefore, following the author’s recommendation, all of our patients should not have undergone the Furlow palatoplasty at all! Fortunately, thus far, with all of our Furlow palatoplasty procedures performed by a single experienced surgeon and at a mean follow-up of 4.92 months (range 2–10 months), we have yet to see a single case of cleft relapse or oronasal fistula.

I believe that the potential contrast in our preoperative cleft widths could be multifactorial. Firstly, the patients treated in the study by Li et al. were much younger, with a mean age of 8.3 months at the time of palatoplasty. Secondly, there could be potential errors in the measurement of the cleft width in the different centres. Instead of the absolute value of the cleft width, the ratio of the cleft width to the shelves width would probably be a more appropriate measurement, taking into account the heterogeneity of the target population.

Overall, the authors presented some very interesting findings. However I am afraid that their recommendation of not using a Furlow palatoplasty for cleft widths >7.5 mm should remain debatable. I congratulate the authors for their excellent effort in trying to identify the risk factors for postoperative oronasal fistula. However, stating that a cleft width of more than 7.5 mm is a potential risk factor to caution against Furlow palatoplasty would be a little bit premature at this stage. Further studies are required to consolidate their findings.