An effect comparison between Furlow double opposing Z-plasty and two-flap palatoplasty on velopharyngeal closure

The aim of this study was to compare velopharyngeal closure between patients who underwent Furlow palatoplasty and two-flap palatoplasty. A retrospective review of 88 patients with incomplete palate cleft was performed. 48 patients (17 males; 31 females) aged 2-28 years received Furlow palatoplasty. 40 patients (17 males; 23 females) aged 2-21 years received two-flap palatoplasty. Velopharyngeal function was categorized as adequate, marginal or inadequate. Complications associated with the operation were documented. Statistically significant differences were not found amongst sex distribution, age at operation, follow-up time, and preoperative speech intelligibility. After primary repairs using Furlow and two-flap palatoplasty, the surgeon's incidence of postoperative palatal fistula was 0%. The complications were not significantly different between the two groups. The authors achieved the lowest reported incidence of postoperative palatal fistulas in primary Furlow palatoplasty. The outcomes of the velopharyngeal closure were better in patients who received Furlow palatoplasty (P<0.05). Furlow palatoplasty was more effective than two-flap palatoplasty in obtaining perfect velopharyngeal closure. A probable explanation may be that Furlow palatoplasty can reposition and overlap the divergent palatal muscle and lengthen the soft palate.     

Sommerlad–Furlow modified palatoplasty: A retrospective study

The purpose of this study was to introduce the surgical process of Sommerlad–Furlow modified (S–F) palatoplasty and compare its surgical and functional outcomes with conventional Sommerlad (S) palatoplasty.Patients with non-syndromic cleft palate who had undergone either S–F palatoplasty or S palatoplasty were retrospectively reviewed. Data on the outcomes of velopharyngeal function and postsurgical palatal fistula incidence were collected for all patients. Data for preselected factors, including gender, age at palatoplasty, and cleft type, were also collected. Chi-square tests were conducted.1254 patients were included. The postsurgical velopharyngeal competence (VPC) rate after S–F palatoplasty was significantly higher than after S palatoplasty (total, 70.5% vs 57.9%, p < 0.0001; age ≤ 1, 87.0% vs 69.2%, p < 0.0001; 1 < age ≤ 2, 78.3% vs 69.3%, p = 0.0479). With regard to different types of cleft palate, the postsurgical VPC rates after S–F palatoplasty were all significantly higher than for S palatoplasty in all patients younger than 2 years of age (complete cleft palate, 78.7% vs 62.4%, p = 0.0016; hard and soft palate cleft, 84.4% vs 74.8%, p = 0.0172; submucosal cleft and soft palate cleft, 96.6% vs 68.4%, p = 0.0114). The postoperative fistula rate after S–F palatoplasty was 4.3%.This modified palatoplasty technique provided adequate cleft palate closure, with satisfactory speech outcomes and low fistula rates, while older age at palatoplasty may affect the postsurgical outcomes. Within the limitations of the study it seems that the Sommerlad–Furlow modified technique is an option for cleft palate repair.     

华西Sommerlad-Furlow腭裂修复术后腭瘘率的研究

目的 探索华西Sommerlad-Furlow （SF）腭裂修复术后的腭瘘发生率及影响因素。方法 随访四川大学华西口腔医院唇腭裂外科2017年4—12月的385例一期腭裂病例,观察华西SF腭裂修复术后的腭瘘率,并分析可能影响伤口愈合的因素,包括性别、体重、手术年龄、裂隙类型、手术医生资历、术前白细胞计数、术前是否预防性使用抗生素、术后体温。结果 采用华西SF腭裂修复术的总瘘孔率为3.9%（15/385）;在15例腭瘘患者中,1例瘘孔位于牙槽近硬腭,12例位于硬腭,2例位于硬软腭交界。腭瘘的发生与性别、体重、手术年龄、术前是否预防性使用抗生素、术前白细胞计数、术后体温均无关（P>0.05）。在手术医生资历这一影响因素中,正高级职称（3.03%）与副高级职称（2.23%）的瘘孔率之间的差异无统计学意义（P>0.05）,但中级职称的瘘孔率为14.29%,明显高于正高级职称和副高级职称（P<0.05）。双侧完全性腭裂的瘘孔率（20.6%）大于单侧完全性腭裂（3.6%）及硬软腭裂（2.6%）（P<0.05）。结论 华西SF腭裂修复术不做松弛切口,可避免上颌骨的生长抑制,同时并未增加腭裂术后的瘘孔率,其瘘孔发生率与患儿性别、体重、手术年龄、术前是否预防性使用抗生素、术前感染、术后体温等因素关联不大,与术者的年资和腭裂的不同类型有一定相关性。     

Palate morphology after unilateral and bilateral cleft lip and palate closure

The aim of the present study was to compare the morphology of the hard palate of patients with uni- and bilateral cleft lip and palate after palatoplasty using vomer and palatal pedicled flaps with the palatal morphology of non-cleft individuals. Eighty patients were enrolled into this retrospective study: 40 patients with cleft lip and palate (30 unilateral, 10 bilateral) and 40 non-cleft patients with class I occlusion, who served as controls. Analysis of the development of the maxillary arch and evaluation of palatal morphology were accomplished from reformatted CT scans from plaster casts of the maxilla at the age of 4, 10 and 15 years (cleft patients) and 10 years (controls). Width and symmetry of the maxillary arch and morphology of the hard palate were assessed in the canine and molar region and compared both among the cleft groups and the controls. Maxillary arch width as assessed from plaster casts did not differ significantly between uni- and bilateral cleft patients and was not significantly different from controls at the age of 10. Deviation from symmetry was present in both types of cleft and significant in unilateral clefts when compared to bilateral clefts and non-cleft patients. Palatal morphology did not differ significantly between uni- and bilateral clefts until the age of 15, but was significantly different from control patients in the molar area at the age of 10 presumably due to the medial shift of soft tissue flaps used for palatoplasty. It is concluded that palatoplasty significantly alters hard palate morphology particularly in the posterior area. The relevance of this alteration for speech and articulation remains to be explored.     

Evaluation of fistula rates in three cleft palate techniques without relaxing incisions

The aim of the present study was to investigate the incidence of postoperative fistula formation from a hybrid cleft palate repair compared to that from two well-established techniques.We performed a modified technique, Sommerlad-Furlow (SF), which combined the repositioning of the levator veli palatini muscles as described by Sommerlad with the double opposing Z-plasty of Furlow to lengthen the soft palate. A retrospective cohort study was conducted to evaluate patients who underwent cleft palate repair utilizing SF, Sommerlad, or Furlow techniques with the incidence of palatal fistula as the target endpoint.A total of 1,164 patients were included in the present study and underwent the following techniques: 603 cases with SF, 244 cases with Furlow, and 317 cases with Sommerlad. In addition to not requiring relaxing incisions, SF advantages included a consistently lower fistula rate compared to that of the Sommerlad technique, as well as the lowest fistula rate in patients with both hard and soft palate clefts without a cleft lip (OR:2.62 95% CI: 1.35, 5.09). However, the differences among the three techniques did not reach statistical significance in terms of a bilateral or unilateral cleft lip/palate, or in patients with a soft palate only or a submucosal cleft palate(OR: 2.22,95% CI:0.77, 6.37).Based on the results of our study, the Somerlad-Furlow technique should be preferred whenever possible.     

Comparison of speech outcomes using type 2b intravelar veloplasty or furlow double-opposing Z plasty for soft palate repair of patients with unilateral cleft lip and palate

BackgroundThe aim of this study is to compare speech outcomes, fistula rates, and rates of secondary speech surgeries after palatoplasty using Furlow palatoplasty or type 2b intravelar veloplasty for soft palate repair.Patients and methodsPatients with unilateral cleft lip and palate who had either Furlow palatoplasty or intravelar veloplasty for soft palate repair were retrospectively evaluated for demographic and perioperative variables and speech outcomes. Fistula rate, secondary surgical intervention for improved speech results, and findings of speech assessment were further reviewed for the patients who met the inclusion criteria.ResultsA total of 76 patients, 36 in the Furlow palatoplasty group and 40 in the intravelar veloplasty group, were included in the study. In the speech assessment, nasalance values were statistically similar between the two groups. Also, there was no statistically significant difference between the groups in velopharyngeal motility (p = 0.103). The total rates of secondary surgeries and fistula were statistically similar between the groups (p = 0.347 and 0.105, respectively).ConclusionThe similar outcomes of speech and surgical evaluation between the two groups make the surgeon's preference determinant in the selection of the surgical technique for soft palate repair.     

腭帆提肌重建联合岛状颊黏膜肌瓣在先天性腭裂中的应用

目的:探讨一种对上颌骨发育影响较小且具有良好腭咽闭合功能的腭裂修补术的临床应用。方法:采用腭帆提肌重建联合岛状颊黏膜肌瓣术,共修补37例腭裂患者。结果:所有患者均一期愈合,随诊1～3年,语音清晰度满意,无腭瘘发生。结论:腭帆提肌重建联合岛状颊黏膜肌瓣术较好地恢复了腭帆提肌正常的解剖结构和位置,获得了良好的腭咽闭合,有效降低了腭瘘的发生率,是一种值得推荐的功能性腭裂修复术。     

Increased fistula risk following palatoplasty in Treacher Collins syndrome.

OBJECTIVE: Patients with Treacher Collins syndrome have abnormal vascular supply to the palate, yet it is unknown whether there are increased postoperative healing problems following palatoplasty. This study investigated the correlation between Treacher Collins syndrome and postoperative palatal fistula formation. DESIGN: Retrospective chart review was performed. PATIENTS: Children undergoing palatoplasty at Children's Hospital Los Angeles from 1987 to 2000 were evaluated. Ten children with Treacher Collins syndrome, 92 children with other syndromes and cleft palate, and 458 nonsyndromic patients with isolated cleft palate were studied. INTERVENTIONS: All children were treated with a one-stage, double-reversing Z-plasty cleft palate repair. MAIN OUTCOME MEASURES: Outcome measures included intraoperative observations of surgical anatomy and postoperative clinic follow-up of fistula formation. Palatal fistula rates between patients with Treacher Collins syndrome, other syndromes, and no syndrome were compared with chi-square analysis. RESULTS: Children with Treacher Collins syndrome had significantly greater palatal fistula rates (50%) than children with other syndromes (8.7%) or no syndrome (4.1%). Treacher Collins patients demonstrated large palatal fistulas and poor flap vascularity. CONCLUSIONS: Children with Treacher Collins syndrome and cleft palate have significantly higher palatal fistula risk than other children with cleft palate when double-reversing Z-plasty palate repair is performed. Our findings suggest that children with Treacher Collins syndrome and cleft palate may have poor vascularity to palatal flaps created during palatoplasty. Furthermore, we recommend that surgeons performing palatoplasty minimize the dissection of mucoperiosteal flaps around the greater palatine arterial pedicle and utilize closure techniques creating the least vascular disruption of palatal tissue.     

Two-stage palatoplasty,is it still a valuable treatment protocol for patients with a cleft of lip,alveolus, and palate?

IntroductionSpeech development is of utmost importance and requires early closure of a palatal cleft. On the other hand, it is well known that all types and timings of surgical repair of facial clefts are detrimental to maxillary growth. Nevertheless, these days one is more and more confronted with a world-wide tendency in favour of the one-in-all operation to close clefts of the lip, alveolus, and palate. Therefore, a three-centre study was performed for testing – once more – the value of two-stage palatoplasty as a means to reduce the detrimental effects of surgery on palatal growth and at the same time to also enable early speech development.Material and methodsPlaster casts from 85 patients have been re-evaluated. All of them had a complete unilateral cleft of lip, alveolus, and palate. They had been treated according to the old therapy protocols followed in either one of the three different cleft centres many years ago, namely in Hamburg, (Western) Germany, Iowa City, IO, USA, and Rostock, (in those days still Eastern) Germany. The impressions had been taken already in 1987 from patients being either 8 years (36 pts.) or 16 years of age (49 pts.). Three different treatment protocols had been followed for these patients in those centres in those days: The main difference was that in centres A and B the palates were closed in two stages whilst in centre C palatoplasty was performed in just one operation.ResultsThe most interesting results regarding the palatal growth were that: 1. In centre C (one-stage palatoplasty) the patients had more constricted palates. 2. In centre A (two-stage palatoplasty) the patients had least often an anterior cross-bite.Discussion and ConclusionIt appears that it was possible to show once more that closing the palate in one stage at age 1 year or less is interfering most with maxillary growth. This study leads us to conclude that two-stage palatoplasty is still a valuable treatment protocol for patients with a complete unilateral cleft of lip, alveolus, and palate, especially as apparently good guidance of speech development can lead to satisfactory speech for cleft patients in whom the hard palate was closed at a later age.     

Early maxillary growth in complete cleft lip, alveolus and palate patients following Widmaier-Perko's, or a modified Furlow's technique of soft palate repair.

INTRODUCTION: The aim was to study the differences in early maxillary growth following the use of two techniques for soft palate repair in complete cleft lip, alveolus and palate patients. MATERIAL AND METHODS: Out of sixty-four primary soft palate repairs, two model samples (one of each) having been matched (gender, age, cleft type, maxillary anterior and posterior width at time of soft palate repair) were selected from the groups treated according either to Furlow or to Widmaier-Perko. The Wilcoxon Test for small samples was used to test for differences. RESULTS: At the age of 4 years, posterior transverse cleft size was significantly smaller by 2.26 mm on average (SD 2.23) in the Furlow sample. The posterior maxillary segment had grown sagitally 1.5 mm (SD 0.76) more in the Furlow sample. At the age of 4 years, all other parameters, including inter-canine point and inter-tuberosity distances did not significantly differ between the two samples. CONCLUSION: Transverse posterior growth was not statistically different between the samples and seemed to be within normal limits in both. There was more sagittal growth in the posterior maxillary segment in the Furlow sample, possibly related to less fibrotic contracture in the posterior hard palate and the soft palate. The transverse posterior cleft size was more reduced in the Furlow sample. This could not be correlated with the techniques chosen to close the hard palate cleft at the age of 4 years.     

The buccal flap--a useful technique in cleft palate repair?

OBJECTIVE: To evaluate speech quality and oronasal fistula after primary palate repair using a buccal mucosal flap. DESIGN: Retrospective study cohort of patients with cleft palate. SETTING: Primary care center for treatment of craniofacial congenital anomalies. PATIENTS AND METHODS: One hundred fifty-six nonsyndromic patients underwent palatoplasty with the buccal myomucosal flap by the senior surgeon between 1989 and 2002. The preoperative workup, surgical technique, and other factors that might affect the outcome were identical in every case. Oronasal fistula and variables affecting speech quality were analyzed. RESULTS: The most common type of cleft was unilateral cleft lip and palate (43.5%). The median follow-up was 5.8 years (0.4 to 21 years), and the median age at repair was 6.2 months. The overall fistula formation was 3.6%, decreasing progressively: 1989 to 1994: 2.9%, 1995 to 2002: 0.7% (p <.05). Velopharyngeal incompetence (VPI) occurred in 8.8% of the patients, decreasing from 5.3% to 3.5% in the last years. VPI and oronasal fistulae were observed mainly in unilateral and bilateral clefts of the lip and palate. Velopharyngeal adequacy occurred in 91.1% of the children, and resonance was normal in 91.1 %. None of the patients had severe hypernasality or hyponasality. Articulation was normal in 97.9% of the children. Speech quality was good in 89% of the patients. CONCLUSIONS: The technique presented has been effective, with the advantages of palatal closure without tension, good muscular reconstruction, lengthening of the nasal layer, and palatal closure without raw areas. The technique, early repair, and surgeon's skills were the most important variables for good outcomes regarding speech and fistula formation.     

Comparative study of maxillary growth and occlusal outcome after autogenous rib grafting in complete cleft palate defect

Cleft palate is a congenital deformity with soft tissue and hard tissue defects. Normal cleft palate repairing surgery only repairs soft tissue defects, whereas bone defects in the hard palate still exist. Therefore, we conducted this study in beagles to observe the influence of bone grafting at primary surgery on craniofacial growth and occlusal relationships in individuals with complete cleft palate and to provide experimental evidence for optimal surgical procedures for cleft palate.Using 60 beagle puppies as subjects, we tested the effects of bone grafting in surgically induced palatal defect. The animals were randomly and equally divided into four groups: (1) unoperated controls; (2) surgically induced unilateral cleft palate, not repaired; (3) two-flap palatoplasty used to close the soft defect of the surgically induced cleft palate; (4) autogenous bone (a piece of rib bone) implanted into the palatal defect before two-flap palatoplasty was performed.Cephalometric roentgenography and plaster casts of the maxillary were taken preoperatively and every 4 weeks after surgery. Sixty metric cranial variables were measured directly from the cleaned skulls after the animals were killed the 34th week postoperatively.The measurement results indicated that bone grafting may reduce the disturbance of maxillary growth caused by the cleft palate and the denuded bone, but it may cause other maxillary deformities. This finding suggests that surgeons should be careful in choosing the method of primary bone grafting in repairing complete cleft palate.     

Preoperative pharyngeal depth is associated with postoperative velopharyngeal function following primary cleft palate repair at the age of five and above

To determine prognostic factors for postoperative velopharyngeal function following the primary cleft palate repair at the age of five and above.This study reviewed patients with cleft palate who had undergone Furlow palatoplasty at age 5 or older from 2009 to 2014. We obtained intraoperative measurements, including velar length, pharyngeal depth, cleft width, maxillary width, cleft palate index (cleft width/maxillary width) and palatopharyngeal ratio (velar length/pharyngeal depth), as well as speech evaluation results at least 1 year after surgery. Logistic regression and retrospective analyses were performed to determine factors associated with speech performance after the primary cleft palate repair.Among the six intraoperative measurements of velopharyngeal morphology, only pharyngeal depth was incorporated into the regression model, and was found to have an inverse association with postoperative velopharyngeal function, Exp (B) 0.883 (95% CI 0.798-0.976). Moreover, a pharyngeal depth greater than 16 mm was significantly associated with a higher risk of postoperative velopharyngeal insufficiency (P < 0.01).Pharyngeal depth is potentially a prognostic indicator for the primary management of cleft palate in older patients. Pharyngoplasty may need to be considered when the pharyngeal depth is large and the patient’s access to surgery is limited.     

Influence of the Furlow palatoplasty for patients with submucous cleft palate on facial growth

The purpose of this study was to investigate the facial growth in patients with submucous cleft palate operated on using the Furlow palatoplasty. A total of 30 patients with submucous cleft palate underwent Furlow palatoplasty from 1993 to 1998. The mean follow-up period was 4 years and 3 months. Twenty-five of 30 patients were followed up. Mid-facial growth was measured using lateral cephalograms in 18 patients whose age was greater than 8 years. The parameters obtained in the lateral cephalogram were compared with those of a healthy population in Korea. Eleven (61.1%) of 18 patients observed were within the clinical normal range for the age group for the parameter of the span between the anterior nasal spine and posterior nasal spine, 6 patients (33.3%) were over the range, and 1 patient (5.6%) was below the range. For the sella-nasion-subspinale angle, 55.6% of patients were within the clinical normal range, 27.8% were over the range, and 16.6% were below the range. For the sella-nasion-supramentale angle, 55.6% of patients were within the clinical normal range, 22.2% were over the range, and 22.2% were below the range. For the sella-nasion-subspinale-sella-nasion-supramentale angle, 72.2% of patients were within the clinical normal range, 27.8% were over the range, and none were below the range. For the span between the basion and posterior nasal spine, 50.0% of patients were within the clinical normal range, 27.8% were over the range, and 22.2% were below the range. In conclusion, our results suggest that the Furlow palatoplasty is a useful procedure as an initial treatment of submucous cleft palate and that this technique has a less harmful effect on facial growth because there is no excessive surgical intervention on the hard palate and alveolar process.     

Dentoalveolar growth of patients with complete unilateral cleft lip and palate by early two-stage furlow and push-back method: preliminary results.

OBJECTIVE: This study examined dentoalveolar growth changes prior to the time of palatoplasty up to 3 years of age by the early two-stage Furlow and push-back methods. SUBJECTS: Thirty-four Japanese patients with complete unilateral cleft lip and palate (UCLP) treated with either a two-stage Furlow procedure (Furlow group: seven boys, eight girls) from 1998 to 2002 or a push-back procedure (push-back group; 12 boys, 7 girls) from 1993 to 1997. METHOD: Consecutive plaster models were measured by three-dimensional laser scanner, before primary palatoplasty, before hard palate closure (Furlow group only), and at 3 years of age. Bite measures were taken at 3 years of age. RESULTS: In the Furlow group, arch length, canine width, first and second deciduous molar width and cross-sectional area, and depth and volume at midpoint showed greater growth than in the push-back group. In the Furlow group, the crossbite score was also better than in the push-back group at 3 years of age. In comparison with the push-back group, inhibition of growth impediment in the anterior region was observed in the horizontal direction in the Furlow group. In the midregion, it was observed in the horizontal and vertical directions, and in the posterior region it was observed in the horizontal direction. CONCLUSION: The results demonstrate that the early two-stage Furlow method showed progressive alveolar growth. Therefore, the early two-stage Furlow method is a more beneficial procedure than the push-back method.     

Influence of patient age and experience of the surgeon on early complications after surgical closure of the cleft palate – A retrospective cohort study

Comparative studies on timing of palatoplasty are rare. The aim of this retrospective cohort study was to compare the influence of early (<14 months) and later (>14 months) one-step closure of the soft and hard palate on early complications.All non-syndromic patients from 1999 to 2009 were included; 6–14 months n = 41 and 15–24 months n = 53. Each palatoplasty was performed as a single-step procedure using bipedicled flaps by a team of two Maxillofacial Surgeons either supervising or operating. The surgeon was rated as “non-experienced” when having performed less than 10 palatoplasties under supervision. Main outcome variable is the occurrence of residual fistula. Fistula occurred in four (4.5%) of the patients. In the multivariate model with respect to the occurrence of fistula neither age, leucocyte count, duration of surgery, nor experience of the surgeon showed a significant influence on the occurrence of a fistula. Only reduced weight contributed to a significantly higher risk of post-operative fistula.In conclusion patient age, experience of surgeon, and duration of surgery had no influence on the early outcome. High leucocyte count had a tendency for and reduced weight had a significant influence on fistula occurrence. Long-term outcome on speech development and maxillary growth have to be collected.     

Furlow腭成形术对腭咽闭合功能的影响

目的：研究腭裂患儿经Furlow腭成形术后软腭长度,软腭厚度以及腭咽腔深度的变化,探讨Furlow腭成形术在促进腭咽闭合功能中的作用。方法：2002年11月至2006年11月运用Furlow腭成形术完成不完全性腭裂或隐性腭裂患者45例,术前术后测量软腭长度,软腭厚度和腭咽腔深度。采用SPSS10.0软件包进行成对样本检验。P〈0.05定义为有显著统计学差异。结果：术前术后软腭长度;软腭厚度和腭咽腔深度分别做成对样本＂T＂检验,结果P〈0.01,均有显著统计学差异。结论：Furlow腭成形术延长了软腭长度,增加了软腭厚度,并使腭咽腔的深度变窄。对手术后腭咽闭合功能的恢复具有促进作用。     

Vomer flap for hard palate repair is related to favorable maxillary growth in unilateral cleft lip and palate

Objective

Vomer flap repair is assumed to improve maxillary growth because of reduced scarring in growth-sensitive areas of the palate. Our aim was to evaluate whether facial growth in patients with unilateral cleft lip and palate was significantly affected by the technique of hard palate repair (vomer flap versus two-flap).

Materials and methods

For this retrospective longitudinal study, we analyzed 334 cephalometric radiographs from 95 patients with nonsyndromic complete unilateral cleft lip and palate who underwent hard palate repair by two different techniques (vomer flap versus two-flap). Clinical notes were reviewed to record treatment histories. Cephalometry was used to determine facial morphology and growth rate. The associations among facial morphology at age 20, facial growth rate, and technique of hard palate repair were assessed using generalized estimating equation analysis.

Results

The hard palate repair technique significantly influenced protrusion of the maxilla (SNA: β?=??3.5°, 95 % CI?=??5.2-1.7; p?=?0.001) and the anteroposterior jaw relation (ANB: β?=??4.2°, 95 % CI?=??6.4-1.9; p?=?0.001; Wits: β?=??5.7 mm, 95 % CI?=??9.6-1.2; p?=?0.01) at age 20, and their growth rates (SNA p?=?0.001, ANB p?<?0.01, and Wits p?=?0.02).

Conclusions

The results suggest that in patients with unilateral cleft lip and palate, vomer flap repair has a smaller adverse effect than two-flap on growth of the maxilla. This effect on maxillary growth is on the anteroposterior development of the alveolar maxilla and is progressive with age. We now perform hard palate closure with vomer flap followed by soft palate closure using Furlow palatoplasty.

Clinical relevance

These findings may improve treatment outcome by modifying the treatment protocol for patients with unilateral cleft lip and palate.