Does the Sequence of Tattooing and Nipple Reconstruction Affect Nipple Projection?

BACKGROUND: In nipple reconstruction, the maintenance of adequate projection is one of the most important and challenging aspects. However, no reports have evaluated whether tattooing after nipple reconstruction affects nipple projection. This study aimed to test our hypothesis that tattooing after reconstruction adversely affects nipple projection. METHOD: Between September 2001 and July 2009, 384 nipples were reconstructed using the modified top hat technique after breast reconstruction with a transverse rectus abdominis musculocutaneous flap. Of these, 320 were reconstructed before tattooing, and 64 were reconstructed after tattooing. Projection at 6 months and 1 year was compared with that measured immediately after the operation, and projection was compared between the nipples reconstructed after tattooing and those reconstructed before tattooing. RESULTS: After 6 months, the mean loss of projection was 52.5% in the tattoo-after group and 55.1% in the tattoo-before group. After 1 year, it was 59.2% in the tattoo-after group and 58.6% in the tattoo-before group. There were no significant differences between the groups regarding the sequence of the procedures. The additional tattoo and retattoo rate was 20% in the tattoo-before group and 1% in the tattoo-after group. CONCLUSIONS: These findings showed that the sequence of nipple reconstruction and tattooing had no significant effect on the projection of the reconstructed nipple. It is easier to tattoo homogeneously before nipple reconstruction because of the flat surface but more difficult to make a smooth areolar peripheral margin and circular areolar shape when reconstructing the nipple. The sequence of tattooing and nipple reconstruction can be determined according to esthetic and clinical considerations.

Augmentation of the Nipples Reconstructed with Modified Top-Hat Flap Using Dermal Grafts in Implant-Based Breast Reconstruction: A Comparative Study.

BACKGROUND: Nipple reconstruction in implant-based breast reconstruction remains challenging, as the remaining thin skin envelope results in a less projected neo-nipple with a reduced volume. This study presents a modified top-hat flap technique with rolled dermal grafts from the dog-ears of lateral wings for augmenting reconstructed nipples during implant-based breast reconstruction. METHODS: Between April 2011 and December 2014, among 34 patients who underwent immediate post-mastectomy reconstruction with a direct silicone implant, nipple reconstruction was performed using the modified top-hat flap technique in only 21 patients (group A), whereas 13 patients underwent the modified top-hat flap technique with rolled dermal grafts from the dog-ears of lateral wings (group B). The projection and width of the neo-nipple were measured at the time of surgery and at 1 year post-surgery, respectively. RESULTS: All modified top-hat flaps were successful without any complications. The mean nipple projections at the time of surgery were 0.75 ± 0.107 cm (range 0.5-0.9 cm) and 1.29 ± 0.064 cm (range 1.2-1.4 cm) in groups A and B, respectively (p < 0.001). The mean nipple widths at the time of surgery were 0.90 ± 0.184 cm (range 0.6-1.2 cm) and 1.43 ± 0.076 cm (range 1.3-1.5 cm) in groups A and B, respectively (p < 0.001). The maintenance of nipple projection and width was significantly increased in group B compared with group A. CONCLUSION: The modified top-hat flap technique with rolled dermal grafts from the dog-ears of lateral wings is a useful and easy method to expand and augment the volume of reconstructed nipples in implant-based breast reconstruction. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Inverted Nipple With Nipple-Sparing Mastectomy.

BACKGROUND: The inverted nipple is a relatively common aesthetic problem seen by plastic surgeons. The etiologies of an inverted nipple include insufficiency of supporting tissues, hypoplasia of the lactiferous ducts, and retraction caused by fibrous bands at the base of the nipple. Many different surgical techniques have been described, either individually or in combination, but none represents a landmark strategy. In our present study, we report our experience of spontaneous improvement immediately after nipple-sparing mastectomy with simple buried interrupted sutures to maintain nipple base in inverted nipple patients. METHODS: We describe our 10 years' experience in using a simple approach to correct inverted nipples after nipple-sparing mastectomy with pedicled transverse rectus abdominis myocutaneous flap reconstruction. Between January 2001 and August 2010, we observed 23 inverted nipples after nipple-sparing mastectomy by using only a buried baseline suture to tighten the base of the nipple. The follow-up period ranged from 3 to 13 years. RESULTS: After nipple-sparing mastectomy with tightening of the base of the nipple, improvements were seen in 18 of the 23 patients. No complications associated with surgery occurred, such as infection, depigmentation, sensory disturbance, or nipple necrosis. CONCLUSIONS: The simple method of baseline suturing that only tightens the nipple base with nipple-sparing mastectomy has been used in our center over a 10-year period in patients with breast cancer and an inverted nipple. The retractile duct or fibrous cord was completely cut with nipple-sparing mastectomy, and over 70% of inverted nipples in the patients were improved and maintained with only the tightening of the base of the nipple. Our results show that inverted nipple is caused by tight fibrous band or short duct rather than a lack of subareolar tissue.

Patients' Aesthetic Concerns After Horizontally Placed Abdominal Free Flap Breast Reconstruction.

PURPOSE: The present study aimed to analyze patients' aesthetic concerns after breast reconstruction with abdominal free flap by reporting secondary cosmetic procedures performed based on the patients' request, and analyzed the effect of adjuvant therapies and other variables on such outcomes. METHODS: All patients who underwent unilateral immediate reconstruction were enrolled prospectively. Free abdominal flaps were placed horizontally with little manipulation. Secondary procedures were actively recommended during the follow-up period to meet the patients' aesthetic concerns. The numbers and types of the secondary procedures and the effects of various factors were analyzed. RESULTS: 150 patients met the eligibility criteria. The average number of overall secondary surgeries per patient was 1.25. Patients with skin-sparing mastectomy required significantly higher number of secondary surgeries compared with those who underwent nipple-areolar skin-sparing mastectomy. When confined to the cosmetic procedures, 58 (38.7 %) patients underwent 75 operations. The most common procedures were flank dog ear revision, fat injection of the reconstructed breast, and breast liposuction. None of the radiated patients underwent liposuction of the flap. Most commonly liposuctioned regions were the central-lateral and lower-lateral, while fat was most commonly injected to the upper-medial and upper-central part of the breast. CONCLUSION: The present study delineated the numbers and types of the secondary operations after horizontally placed abdominal free flap transfer with analysis of the influence of various factors. Addressing such issues during the primary reconstruction would help to reduce the need and extent of the secondary operations and to maximize aesthetic outcome. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Local recurrence of breast cancer in reconstructed breasts using TRAM flap after skin-sparing mastectomy: clinical and imaging features.

OBJECTIVES: To evaluate clinical and imaging features of cancer recurrence in reconstructed breasts following skin-sparing mastectomy (SSM) or nipple areolar skin-sparing mastectomy (NASSM). METHODS: This study was approved by our Institutional Review Board. In this retrospective study, we included patients with pathologically confirmed recurrent cancer who had transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after SSM or NASSM and whose follow-up radiological studies were available. Each patient's demographic data, imaging studies and clinical outcomes were reviewed. Two breast radiologists analysed the imaging findings of follow-up mammography, ultrasound and magnetic resonance imaging. RESULTS: Of the 964 patients, 16 (1.7%) had local cancer recurrence. The average follow-up period until the detection was 31.1 months (range, 7-84 months). Fourteen (87.5%) patients had recurrence on the skin or in subcutaneous fat. Of the 16 patients, recurrence was detected by breast self-examination in 13 (81.3%) patients. Eight (50%) lesions mimicked benign lesions. The other eight (50%) lesions manifested various degree of suspicion for the malignancy. CONCLUSIONS: Recurrent cancer after TRAM flap reconstruction following SSM and NASSM is often recognised by breast self-examination and mimics imaging findings of benign lesions. Therefore, meticulous physical examination and history-taking are important. Pathological confirmation is worthwhile even in the benign-appearing lesions. KEY POINTS: Overview of clinical and imaging features of cancer recurrence in reconstructed breasts. 50% of recurred malignant lesions mimicking imaging findings of benign lesions. Patients may benefit from thorough self-breast examination.

Adjuvant chemotherapy reduces the incidence of abdominal hypertrophic scarring following immediate TRAM breast reconstruction.

Among the many factors that affect the degree of completion and satisfaction of breast reconstruction, the scarring is one issue that a surgeon cannot completely control. We hypothesized that the administration of cytotoxic drugs following the immediate breast reconstruction using transverse rectus abdominis musculocutaneous (TRAM) flap might affect the process of scarring, thus resulting in reduced incidence of hypertrophic scarring at the donor site. Data have been collected from 1,000 consecutive patients between July 2001 and December 2009. The relationship between the adjuvant chemotherapy and the incidence of hypertrophic scarring was studied, and the influence of other presumed risk factors was analyzed. The incidence of hypertrophic scarring was 18.6 % (75 of 404) in the non-CTX group and 3.8 % (20 of 530) in the CTX group. Univariate analysis using logistic regression modeling confirmed the statistical significance of the reducing effect of chemotherapy on the incidence of hypertrophic scarring (p < 0.001; OR: 0.172). The incidence of donor-site hypertrophic scarring following immediate TRAM breast reconstruction was found in nearly 20 % of the patients without chemotherapy, showing a significant difference from the patients with chemotherapy. We believe that Asian patients who undergo immediate TRAM breast reconstruction without chemotherapy are a high-risk group that is prone to hypertrophic scarring, requiring active preventive measures.

Loss to follow-up after direct-to-implant breast reconstruction.

Loss to follow-up is inevitable in retrospective cohort studies, and patients are lost to follow-up after direct-to-implant reconstruction despite annual follow-up recommendation. We analyzed more than 500 patients to analyze the rate of loss to follow-up to plastic surgery and to investigate the factors affecting it. A retrospective review of patients who underwent direct-to-implant reconstruction between July 2008 and August 2016 was performed. Loss to follow-up to plastic surgery was defined as a difference of ≥24 months between the total and plastic surgery follow-up. The rate of loss to follow-up and associated factors including patients' demographics, surgery-related variables, oncological data, and early and late complications were analyzed. Of 631 patients who underwent direct-to-implant reconstruction, 551 patients continued visiting the hospital for breast cancer-related treatment. Of the 527 patients who were eligible for the study, 157 patients (29.8%) were lost to plastic surgery follow-up. Surgery-related variables, early complications, cancer stage, and adjuvant therapies were not significantly different. Younger age was significantly associated with loss to follow-up in univariate analysis. However, logistic regression revealed that a long total follow-up period, distant metastasis, and absence of late elective complications were significant factors contributing to follow-up loss. Late elective complications such as malposition, capsular contracture, and mastectomy flap thinning were more common in the follow-up group (48%) than in the loss to follow-up group (22%). Follow-up loss after direct-to-implant reconstruction was not associated with specific demographic or surgery-related variables, and postoperative courses significantly affected the loss to follow-up.

Outcomes of smooth round implant-based immediate breast reconstruction: Long-term follow-up results.

The issue of breast implant-associated anaplastic large cell lymphoma in 2019 has resulted in the discontinuation of textured breast implants and resumption in the use of smooth round implants. However, in the field of breast reconstruction, long-term follow-up data for direct-to-implant reconstruction using smooth round implants is insufficient. This retrospective study aimed to evaluate the long-term outcomes of breast reconstruction using smooth round implants. This study included 185 patients (208 breasts) who underwent smooth round implant-based immediate breast reconstruction between 2007 and 2018. Their demographic information and surgical and oncological data were collected. Early (within 90 days) and late (after 90 days) complications, reoperations, implant maintenance, and the survival rate were analyzed to evaluate the long-term outcomes and identify the related factors. The mean follow-up period was 112.08 months. The most common early complications were skin necrosis (9.13%) and infection (3.85%). The factors influencing the development of early complications were the mastectomy specimen weight (237.14 ± 114.84 cc and 298.04 ± 141.53 cc for no complication and any complication, respectively; p = 0.0123) and implant volume (222.79 ± 77.76 cc and 264.48 ± 89.03 cc for no complication and any complication, respectively; p = 0.0082). The most common late complication was capsular contracture (13.46%). Approximately 91.35% of the implants were maintained during the follow-up period. The factors affecting the development of early complications and implant maintenance were the mastectomy specimen weight and implant volume. This study provides information on long-term follow-up results useful in cases where only smooth round implants are available, which can then serve as a basis for future related studies.

Midfacial degloving approach for resectioning and reconstruction of extensive maxillary fibrous dysplasia.

OBJECTIVE: The traditional unilateral or bilateral buccogingival or bicoronal approach often seems to impose limitations on achieving complete resection and reconstruction of the extensive midfacial fibrous dysplasia. Therefore, we hypothesized that the midfacial degloving approach could be used for the correction of maxillary fibrous dysplasia, which has been primarily used for paranasal sinus lesions or nasopharyngeal tumor. METHODS: The study involved 5 maxillofacial fibrous dysplasia patients who underwent a midfacial degloving surgical procedure. There were 4 male patients and 1 female patient with a mean age of 16.8 years. The average, mean follow-up duration was 17.8 months. A wide, subperiosteal dissection was made along the anterior wall of the maxilla and pyriform aperture over the level of the infraorbital foramen. A bilateral, circumferential, nasal vestibular incision and dissection allowed for bilateral degloving of the middle third of the face over the infraorbital rim. Then total or subtotal resection, followed by reconstruction using an iliac bone graft, was performed. RESULTS: The midface, degloving approach provided visualization of the medial maxillary wall, the pterygoid junction, nasofrontal suture, infraorbital rim, and laterally to the temporal process of the zygoma. Subtotal or total resection of the lesions and reconstruction with bone grafts was possible in all 5 patients, and there were no complications. There was also no visible facial scarring and all patients expressed satisfaction with the cosmetic outcome. CONCLUSIONS: The midfacial, degloving approach was found to be safe and effective for maxillofacial fibrous dysplasia, and nearly total resection was possible. This approach allows for a wider dissection and resection compared with the traditional buccogingival approaches, and there was no visible facial scarring.

Use of lyophilized allogeneic costal cartilage: is it effective to maintain the projection of the reconstructed nipple?

The maintenance of adequate projection is one of the most important aspects in nipple reconstruction. A total of 17 nipples were reconstructed using the modified top hat flap technique with lyophilized allogeneic costal cartilage, and patients were followed up for 1 year. Projection at 6 months and 1 year was compared with the immediate postoperative result, as well as with the results of nipples reconstructed without cartilage. After 6 months and 1 year, there were significant reductions in projection, with the average losses of 51.7% and 57.7%, respectively. There were no significant differences between groups with or without cartilage. These findings show that nipples reconstructed with lyophilized allogeneic cartilage beneath the modified top hat flap showed no benefit compared with nipples reconstructed without cartilage.

Selection of the recipient veins for additional anastomosis of the superficial inferior epigastric vein in breast reconstruction with free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator flaps.

There have been many methods to use the superficial inferior epigastric vein (SIEV) for improvement of flap circulation during breast reconstruction with free abdominal flap. If the SIEV is used for the purpose of adding another draining route, selection of ideal recipient vein is a crucial step. We reviewed our experiences of using the SIEV as additional vein in free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator breast reconstruction to find out the ideal recipient vein for SIEV. Between April 2006 and July 2010, 153 cases of breast reconstruction were performed using free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator flaps. Additional SIEV anastomosis was performed in 45 cases with risk factors. First choice of the recipient vein was the lateral thoracic vein if the SIEV was placed laterally after the inset of the flap. If the lateral thoracic vein was ablated with lymph node dissection, the branch of the thoracoacromial vein was selected. If the SIEV was placed medially, the perforator of the internal mammary vein was used. No vascular compromise was observed in cases with additional SIEV anastomosis with those recipient veins, whereas 9 cases of flap-related complications were observed in the remaining 108 cases without additional SIEV anastomosis. The incidences of the venous congestion were significantly different between the 2 groups. Combination of the lateral thoracic vein, branch of the thoracoacromial vein, and the perforator of the internal mammary vein provided an excellent choice of the recipient vein for the SIEV with reliability and availability.

Changing trends in cleft lip and palate management taught in training programs in Korea.

To assess changes in trends of cleft management and achieve an overview of the current status, a replication of 2000 national survey was conducted. Questionnaires containing 46 categories were distributed to 72 senior residents of all Korean institutes with plastic surgery training programs. Forty-two of the questionnaires were returned in completed form. The results were (1) new surgeries numbering less than 10 per year were reported by 50% for the cleft lip and by 45% for the cleft palate; (2) 61% were using presurgical orthopedics before the repair of the cleft, and most common method was presurgical nasal-alveolar molding (43%); (3) the rotation advancement technique (94%) was the most popular method for the unilateral cleft lip repair and the Millard method (54%) for the bilateral cleft lip repair; (5) the double-opposing Z-plasty was the most common method for the repair of the complete (56%) and the incomplete cleft palate (80%); (6) 85% of the respondents reported performed the alveolar cleft repair during the period of mixed dentition, and the gingival mucoperiosteal flap and bone graft method was the most favored methods (92%); (7) the multidisciplinary team approach was practiced by 36%. Although the current result cannot be regarded as a significant advance in cleft management, the overall cleft services in Korea were getting standardized and shown to be turning to more efficient structure.

Nipple areola skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous flap reconstruction is an oncologically safe procedure: a single center study.

OBJECTIVE: The present study evaluated the oncological safety and technical outcomes following nipple areola skin-sparing mastectomy (NASSM), skin-sparing mastectomy (SSM), and mastectomy. SUMMARY BACKGROUND DATA: Cosmetic issues associated with breast cancer surgery are important. The original SSM technique included removal of the gland and the nipple areola complex (NAC). However, the risk of tumor involvement of the NAC has been overestimated. PATIENTS AND METHODS: This retrospective study included 520 patients who underwent SSM (368 patients) or NASSM (152 patients) with immediate breast reconstruction using a pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, and 1990 patients who underwent a mastectomy between July 2001 and December 2006. The indications for NASSM were any stage, any tumor size, and any tumor areola distance. Briefly, the NAC was preserved when the shape, color, and palpation of the nipple were normal. RESULTS: The median follow-up durations for NASSM and SSM were 60 and 67 months, respectively. Complete nipple areola necrosis developed in 11 (9.6%) NASSM patients. The 5-year disease-free survival rates were 89% and 87.2% for NASSM and SSM, respectively (P = 0.695). The 5-year overall survival rates were similar for NASSM and SSM (97.1% and 95.8%, respectively; P = 0.669). Local failure occurred in 3 (2%) NASSM and 3 (0.8%) SSM patients (P = 0.27). There were 2 (1.3%) nipple areola recurrences in NASSM patients. The LRRs were similar for NASSM and mastectomy patients. CONCLUSION: NASSM with immediate transverse rectus abdominis musculocutaneous reconstruction is a viable surgical treatment in breast cancer patients in any stage. Recurrence and complication rates for NASSM were similar to those for standard surgical breast cancer treatments.

Oncological safety of skin sparing mastectomy followed by immediate reconstruction for locally advanced breast cancer.

BACKGROUND AND OBJECTIVES: Skin sparing mastectomy (SSM) has been demonstrated as an oncologically safe procedure for early breast cancer in several studies. But few studies concerned the safety of SSM for patients with locally advanced breast cancer; therefore, its safety for these patients is less clear. The purpose of this study is to examine the oncological safety of SSM followed by immediate reconstruction for locally advanced breast cancer. METHODS: We retrospectively analyzed 897 breast cancer patients who underwent mastectomy for stage IIB (T3N0)-III between 1996 and 2005. Of 897, 87 underwent SSM (n = 73) or nipple sparing mastectomy (NSM, n = 14). We compared the local recurrence (LR) rate, disease-free survival (DFS) and overall survival (OS) for SSM group with conventional mastectomy group. RESULTS: The 5-year DFS and OS of SSM group were not worse than those of CM group for all stages. LR rate was 3.0% (2/67) for IIB, 2.8% (1/36) for IIIA, 4.5% (1/22) for IIIC, and 5.0% (1/20) for T3 in SSM group. There was no difference in LR rates between SSM group and CM group for all stages. CONCLUSIONS: Our study demonstrates that SSM followed by immediate reconstruction is oncologically safe for locally advanced breast cancer.

Clinical features of the microform cleft lip and the ultrastructural characteristics of the orbicularis oris muscle.

OBJECTIVE: To clarify the clinical features of the microform cleft lip and to establish the ultrastructural characteristics of the orbicularis muscle. DESIGN: Clinical observations of the characteristic deformities and associated anomalies were made. Muscle biopsies were harvested for histologic and ultrastructural analyses. PATIENTS: Seventy-one consecutive patients with microform cleft lip were included in the study. Muscle biopsies were investigated in 11 patients among them. RESULTS: Nasal deformity, a ridge or a groove from the vermilion to the nostril sill, and interruption of the "white roll" were present in all patients. Lack of a philtral column and a free border notch was observed in over 97% of patients. The orbicularis muscle demonstrated hypoplastic myofibers with nonneurogenic atrophy and focal accumulation of subsarcolemmal mitochondria. CONCLUSION: The typical gross morphology of the microform cleft lip is a surface manifestation of muscular defect, and the disruption of the muscle further extends down to the ultrastructural level. The clinical features, taken together with the ultrastructural defects of the musculature, might help with a more precise delineation of the microform cleft lip, and provide better understanding of cleft lip in general.

Geometric Measurements of Nipple Position in Breasts Reconstructed with Transverse Rectus Abdominis Musculocutaneous Flap: A 5-Year Prospective Study.

BACKGROUND: After breast reconstruction, nipple position and other long-term changes in the reconstructed breast relative to the contralateral breast remain poorly understood. In this prospective cohort study, the authors performed serial nipple position measurements over 5 years in patients who had undergone breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. The effects of adjuvant radiotherapy on nipple position over time were also investigated. METHODS: The authors studied 150 patients who had undergone nipple-sparing mastectomy, using radial incision followed by immediate unilateral pedicled TRAM flap breast reconstruction. Measurements of sternal notch-to-nipple, midline-to-nipple, and inframammary fold-to-nipple distances were performed 1 day before reconstruction and 6, 12, 36, and 60 months after surgery, on patients' reconstructed and nonoperated breasts. RESULTS: The average sternal notch-to-nipple distance increased in both reconstructed and nonoperated breasts at every follow-up visit, with an average difference of 0.393 cm at the 60-month visit (p < 0.0001). Comparing the pattern of distance change, reconstructed breasts tend to change more slowly than nonoperated breasts until 36 months postoperatively. In irradiated breasts, the sternal notch-to-nipple distance was significantly smaller than in nonirradiated breasts, and nipple position changed minimally between 1 and 3 years after surgery. CONCLUSIONS: Nipple position in TRAM flap-reconstructed breasts changed over time compared with that in nonoperated breasts, especially along the vertical axis. The pattern of nipple position change in reconstructed breasts became similar to nonoperated breasts 3 years after surgery. In patients who had undergone adjuvant radiation therapy, nipple position remained consistent for 1 to 3 years. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evolution of the pedicled TRAM flap: a prospective study of 500 consecutive cases by a single surgeon in Asian patients.

Although free flap has largely replaced pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, the latter has also evolved by increased understanding of anatomy and physiology. We report the outcomes in 500 consecutive pedicled TRAM in Asian patients performed by a single surgeon, providing incidences of complications and ideas of prevention. Fascia was minimally harvested with full width of muscle. The eighth intercostals nerve was severed and back-cut was made at the lateral belly. Anterior rectus sheath was directly repaired. Breast complication occurred in 24.6% with the most common being skin envelope necrosis. Major flap loss occurred in 1 (0.2%), and the incidence of fat necrosis was 14.2%. Abdominal complication rate was 16.4%, and bulging occurred in 3%. Exercise performance was almost completely restored after 1 year. Pedicled TRAM is still a competitive procedure with overall flap survival rate of 99.8%, yielding consistent results with acceptable complication rates for most patients under experienced hands.

Effect of unrestricted bottle-feeding on early postoperative course after cleft palate repair.

Although bottle-feeding after cheiloplasty is widely accepted, postoperative feeding regimen after palatoplasty is still controversial. The aim of this prospective randomized study was to evaluate the effect of bottle-feeding on early postoperative course after palatoplasty in a relatively homogeneous group of patients. Eighty-two consecutive patients with nonsyndromic cleft palate undergoing 2-flap palatoplasty by a single surgeon were randomized to feeding from a bottle with the usual nipple (G1, N = 42) or to feeding with a spoon, cup, or syringe (G2, N = 40). Complication rates, postoperative sedative use, oral intake for the first 6 days, and relative weight gain at 1 and 2 months were compared. There were no significant complications such as bleeding or respiratory problem. The overall complication rate including wound dehiscence and oronasal fistula was similar in G1 and G2 (11.9% versus 12.5%, P = 1.000) as was postoperative sedative use and mean daily oral intake for the first 5 days. Mean intake on the sixth day was significantly higher in G1. There were no significant between-group differences in relative weight gain after 1 and 2 months. In conclusion, bottle-feeding had no adverse effect on the early postoperative course after palatoplasty including complication rate, oral intake, and weight gain. These findings suggest that an unrestricted feeding regimen is appropriate immediately after palatoplasty.

Inferiorly based postauricular periosteofascial flap for reconstruction of intractable small postauricular defects.

BACKGROUND: Small postauricular defects are a common problem after treatment of chronic otitis media and after excision surgery for small skin cancers. Blood supply to the postauricular area is poor, and bone exposure is common. Grafts involving alloplastic materials, cartilage, and bone often yield unsatisfactory results. A standard surgical procedure for successfully treating such defects has yet to be established. The present study examined the use of postauricular fascial free flaps for the reconstruction of small intractable postauricular defects. METHODS: From August 2006 to August 2007, 3 patients (2 with chronic otitis media and 1 patient with squamous cell carcinoma) with postauricular defects underwent mastoid flap surgery. The inferiorly based postauricular fascial flap included the periosteum and the sternocleidomastoid muscle. The flaps measured 2 to 4 x 2.0 to 3.5 cm, and the mean follow-up period was 11.5 months. RESULTS: There were no serious complications, such as fistula recurrence, infection, or flap necrosis during the follow-up period. CONCLUSIONS: Current methods for repairing small postauricular defects often fail. Although free flap surgery is generally considered inappropriate for such defects, the postauricular flap method applied here appeared to be successful.