Trials of management are inevitably long

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7017.1431a (Published 25 November 1995) Cite this as: BMJ 1995;311:1431
  1. R W Pigott
  1. Consultant plastic surgeon Department of Plastic Surgery, Frenchay Hospital, Bristol BS16 1LE

    EDITOR,--In their editorial Tony Markus and Peter Ward Booth1 seek to discredit the work of most British surgeons working in cleft lip and palate on the basis of results in patients treated in the 1970s published by Shaw et al.2 They imply that no lessons have been learnt and state that the “functional repair” of Delaire produces vastly superior results. However, Delaire failed to publish his results, and Markus and Ward Booth merely reiterate his hypothesis. The almost identical technique of Malek produced as good but not better results than those achieved in Toronto by the Langenbeck technique when assessed by an independent authority.3

    But let us suppose Delaire is right. It will be appreciated that one cannot take up every good idea that comes along when one is in the middle of a trial. In a career that started in 1969, with a caseload equivalent to that of Markus, it has taken me nearly 25 years to get articles published on a sufficient number of cases treated 10 years ago by the Veau technique for the findings to be significant. With three times the caseload treated in the 1980s by the Langenbeck technique, a comparable series will be reported in a mere 15 years. A final cohort, which I began to gather in 1989,4 is being compared with 5 year olds treated by the Langenbeck technique. Treatment in this final cohort embodies Malek's and Delaire's principle of restricting mucoperiosteal undermining to the palatal shelf mucosa. If an overwhelming increase in the ideal relation among the incisor teeth (Angle class I) is found in this group it will encourage surgeons to concentrate on this aspect of planning treatment. But these will be prepubertal results (as were those of Joos) obtained sequentially, not synchronously. In the end only a randomised prospective trial will elucidate this problem.

    As is to be expected in papers written by dentists, facial growth is considered to be the preeminent outcome. It is unfortunate that speech, appearance, and social integration, which are the pre-eminent concerns of patients, are more difficult to evaluate, though results with regard to speech that are achieved in Britain compare extremely favourably with any in the English speaking world.


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