Comparison of the rotation-advancement and philtral ridge techniques for unilateral cleft lip repair.

BACKGROUND: The Millard rotation-advancement flap has become the most widely used technique for unilateral cleft lip repair. The philtral ridge repair is a modified straight-line technique that was developed to further optimize the scar associated with the rotation-advancement flap. The purpose of this article is to introduce the philtral ridge repair and objectively compare the outcomes of these two techniques. METHODS: Two senior board-certified surgeons, who are active members of their respective craniofacial teams, use different surgical techniques for the unilateral cleft lip: the philtral ridge and rotation-advancement repairs. The authors retrospectively analyzed preoperative and postoperative photographs of consecutive patients who underwent repair performed by each surgeon between 2003 and 2009. Using Adobe Photoshop imaging software, facial points on the cleft and noncleft sides were measured, including height and symmetry of Cupid's bow, width and height of the nasal vestibule, height of the vermilion, and alar base position. Ratios of cleft side to noncleft side measurements were calculated to standardize comparisons between patients. In addition, the symmetry of each lip repair was graded subjectively by health care professionals and the general public. RESULTS: There were no differences in preoperative ratios between the two techniques with the exception of a wider cleft nasal vestibule in the rotation-advancement group (p = 0.04). There were no statistically significant differences in postoperative measures or subjective analysis of symmetry between the groups. CONCLUSION: Both the rotation-advancement and philtral ridge techniques produced outcomes with a high degree of facial symmetry and are excellent options for unilateral cleft lip repair.

Postoperative management following sphincter pharyngoplasty.

OBJECTIVE: To evaluate postoperative airway-associated outcomes following sphincter pharyngoplasty. STUDY DESIGN: Case series with chart review. SETTING: Academic tertiary care medical center. SUBJECTS AND METHODS: Postoperative management of sphincter pharyngoplasty (SP) conventionally includes overnight observation to monitor for upper airway obstruction. To evaluate for postoperative airway-related outcomes, 36 patients who underwent SP between April 2003 and January 2009 were evaluated retrospectively. RESULTS: Mean patient age was 8.1 (SD 4.3) years. Mean follow-up was 6.5 (SD 10.7) months. Cleft palate (36.1%), velo-cardio-facial syndrome (22.2%), and post-adenoidectomy (16.7%) were the most common causes of velopharyngeal insufficiency. All patients underwent overnight observation postoperatively. Mean hospital stay was 1.2 (SD 0.5) days. Five patients remained inpatient two or three days owing to fever (2 patients), bleeding ear after concurrent otoplasty (1 patient), minimal oropharyngeal bleeding with spontaneous resolution (1 patient), and medication allergy (1 patient). No patient had a documented apneic event or desaturation below 95 percent. Although no desaturations were documented, four patients received supplemental oxygen: three for less than two hours, and one for 12 hours. All patients had adequate oral intake and pain control on oral medications prior to discharge; nine patients required one to three doses of intravenous narcotic medication for pain on postoperative day zero. CONCLUSION: Upper airway obstruction requiring overnight observation following SP is uncommon. In otherwise healthy patients, performing SP in an outpatient setting, given appropriate recovery room evaluation for airway concerns, oral intake, and pain control, should be considered.

Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions.

Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant-based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

Muscle-sparing abdominal free flaps in head and neck reconstruction.

BACKGROUND: Our aim in this retrospective case series was to review the indications, results, and complications of abdominal muscle-sparing free flaps in head and neck cancer reconstruction. METHODS: A retrospective review of all head and neck cancer defects reconstructed with abdominal muscle-sparing free tissue transfers from 1999 to 2004 was performed. Data collected included patient demographics, etiology and site of the defect, reconstructive technique, flap size, recipient vessels, complications, reconstructive technique, and clinical follow-up. RESULTS: Sixteen patients underwent reconstruction with the deep inferior epigastric perforator (DIEP) flap (n = 11), the superficial inferior epigastric artery (SIEA) flap (n = 4), or the superficial circumflex iliac artery (SCIA) flap (n = 1). Average age was 61 years (range, 41-77 years). The average hospital stay was 7.6 days (range, 6-14 days). The average defect size was 74.5 cm(2) (range, 30-240 cm(2)). No subsequent abdominal wall hernias or other donor site complications occurred after a mean follow-up of 21 months. CONCLUSIONS: Muscle-sparing abdominal free flaps are attractive options for head and neck cancer reconstruction. The SIEA and SCIA free flaps have the distinct advantage of eliminating abdominal hernias and other morbidity related to the excision of rectus abdominus fascia or muscle. In addition, the incisions are very low on the abdomen and are more cosmetically pleasing to the patient.

Aesthetic reconstruction of the nose following skin cancer.

Nasal reconstruction after skin cancer can be very demanding, especially if the patient's expectations are high. Careful assessment of the defect and thorough preoperative planning are as important to the final result as is the technical execution of the procedure. Often, staged procedures will be required to achieve the optimal result. A successful reconstruction can provide a lifetime of satisfaction for the patient, however, and can be almost equally rewarding for the meticulous surgeon.