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Sir: I thank Nardini and Flores for their commentary on the recently published article, “A Systematic Review Comparing Furlow Double-Opposing Z-Plasty and Straight-Line Intravelar Veloplasty Methods of Cleft Palate Repair.” The commentary raised important questions on the evolution of intravelar veloplasty and on the exclusion criteria of the published article.1 As Nardini and Flores pointed out, there was an evolution over time by some cleft surgeons on how the levator veli palatini muscles are dissected and repositioned in intravelar veloplasty. In the present systematic review, the evolution of intravelar veloplasty was accounted for, as most studies (all studies except one) were published at least two and half decades after the initial description by Kriens.2 Furthermore, despite its evolution, intravelar veloplasty remains operator dependent, and there is great variability among surgeons. The large variations in the outcomes of intravelar veloplasty could be secondary to improper identification, mishandling, or incomplete posterior repositioning of the levator veli palatini muscles.3 The exclusion criteria in the review 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. These exclusion criteria in the systematic review sought to control for confounding variables and to capture a population of patients whose age at repair and protocol of palate repair were more consistent with the nationally accepted standards of care. Data were stratified by cleft type (isolated cleft palate or unilateral cleft lip and palate), as previous studies has demonstrated that persistent velopharyngeal insufficiency was associated with Veau classification and the patient’s age at palatoplasty.4,5 The age of 4 years was chosen, as children with velopharyngeal sufficiency at this age are highly unlikely to develop subsequent velopharyngeal insufficiency.6 Publications with excellent and poor speech outcomes in both groups (intravelar veloplasty, Furlow Z-plasty) were excluded from the systematic review, as they did not meet the inclusion criteria. By adhering to a strict protocol, my colleagues and I sought to control confounding variables and to minimize selection bias. Thus, despite the excellent publications and outcome on intravelar veloplasty reported by Drs. Cutting, Sommerlad, and Andrades, those publications were not included for not respecting the inclusion criteria. DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. Gaby Doumit, M.D., M.Sc. Division of Plastic Surgery CHU Sainte Justine University of Montreal Montreal, Canada Dermatology and Plastic Surgery Institute Cleveland Clinic Cleveland, Ohio

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