ORIGINAL ARTICLE Early Effect of Vomerine Flap Closure of the Hard Palate at the Time of Lip Repair on the Alveolar Gap and Other Maxillary Dimensions F. Maggiulli, M.D., N. Hay, M. Mars, E. Worrell, J. Green, B.C. Sommerlad Objective: Comparison of the effects of vomerine flap (VF) closure of the hard palate at the time of lip repair with non-closure of the hard palate in subjects with unilateral cleft lip and palate (UCLP). Design: Retrospective, single-blinded, cohort study. Setting: Study model sets of 40 consecutive, non-syndromic, infants with complete UCLP operated on between 1988 and 1998. Patients: All subjects were operated on by a single consultant plastic surgeon immediately before and after the unit’s change of protocol (1993), when VF closure of the hard palate was incorporated at the time of lip repair. Subjects were divided into two groups: VF ( n ¼ 18) and non- VF (n ¼ 22), which acted as a control group. Each subject had maxillary impressions taken before lip repair at 3 months (VF mean age ¼ 11.7 weeks; non-VF mean age ¼ 13.4 weeks) and before palate repair at 6 months (VF mean age ¼ 22.8 weeks; non-VF mean age ¼ 24.0 weeks). Main Outcome Measures: Seven predetermined landmarks and four maxillary dimensions were computed following single-blinded analysis using a reflex microscope. Results: Repeatability tests showed good measurement precision. The operator measure- ment errors were 0.00018 mm in a horizontal plane (X and Y) and 0.00028 in the vertical plane (Z). The VF group showed significant changes in the alveolar cleft width. There were no statistically significant changes in any arch-form variable between the VF and non-VF groups. Conclusion: The decrease of alveolar arch gap width at palate repair (6 months) in the VF group was significantly more than the decrease observed in the non-VF group, and there was no significant decrease in the, anterior and posterior arch width or anteroposterior length of the hard palate in the VF group compared with the non-VF group. KEY WORDS: maxillary growth, reflex microscope, UCLP, vomerine flap, UCLP Single-layer closure of the hard palate by a vomerine flap (VF) at the time of lip repair was described by Pichler (1934) and popularized by the cleft team in Oslo, Norwar (Bergland et al., 1967). Although is practiced in many parts of the world (Agrawal and Panda, 2006), there is disagreement in the literature as to whether the use of a single-layer VF disturbs maxillary growth; some are in favor (Dahl et al., 1981; Semb, 1991). and some are against (Friede and Johanson, 1974; Friede and Lilja, 1994; Friede and Enmark, 2001). A longitudinal cephalometric study of facial growth in 257 patients with unilateral cleft lip and palate (UCLP) treated by the Oslo CLP team indicated that use of single- layer vomer flap at the time of lip repair was particularly advantageous in terms of maxillary development, early separation of the nasal and oral cavities, low rate of symptomatic fistulae, and acceptable arch form (Bergland et al., 1967). It was also a good foundation for mixed dentition alveolar bone grafting (Semb, 1991). Little has been written about the early effect of the VF on maxillary arch form. In our retrospective longitudinal controlled study we investigated two groups of patients using dental stone models obtained at 3 months (at the time of lip repair) and at 6 months (at the time of palate repair). The aim of the current study was to investigate the early effects of a VF procedure on arch form in subjects with UCLP. METHODS In this study a consecutive series of 40 subjects with UCLP was investigated. The study cohort was divided into Presented at the 11th International Congress of Cleft Lip and Palate and Related Craniofacial Anomalies, Fortaleza, Brazil, September 10– 13, 2009, and at the poster session of the 67th Annual Meeting of the American Cleft Plate-Craniofacial Association, Fort Worth, Texas, March 15–20, 2010. Submitted November 2011; Accepted November 2012. Dr. Maggiulli is Surgical Fellow, Plastic Surgeon, Plastic and Maxillofacial Surgery Department, The Bambino Ges`u Children’s Hospital, Rome, Italy. Dr. Hay is Consultant Orthodontist, Dr. Mars is Consultant Orthodontist, Dr. Green is Maxillofacial Prosthetist, and Mr. Sommerlad is Consultant Plastic Surgeon, Great Ormond Street Hospital, London, United Kingdom, and St. Andrew’s Centre, Broomfield Hospital, Chelmsford, Essex, United Kingdom. Dr. Worrell is Consultant Maxillofacial Prosthetist, Great Ormond Street Hospital, London, United Kingdom. DOI: 10.1597/11-297 0 The Cleft Palate-Craniofacial Journal 00(00) pp. 000–000 Month 2013 Ó Copyright 2013 American Cleft Palate-Craniofacial Association