Objective evaluation of vertical Z-plasty with double transposition vermillion flaps for secondary whistling deformity correction: A method for uni- and bilateral correction.

OBJECTIVES: This study describes a modified method for secondary correction of whistling deformities in patients with unilateral and bilateral cleft lip/palate (CL/P), using a horizontal double transposition vermilion flap, including parts of the orbicularis oris muscle. The pre- and postoperative results were objectively evaluated. STUDY DESIGN: 34 patients with a whistling deformity who underwent secondary reconstruction between 07/2013 and 11/2018 were included in this study (mean age 20.2 ± 11.6 years). 24 patients were male and 10 female. 30 patients presented with cleft lip and palate (CLP) - 15 bilateral, nine on the left side and six on the right. Four patients had only a left-side cleft lip (CL). The whistling deformity reconstruction was carried out using two triangular transposition vermilion flaps with muscle parts, for a vertical Z-plasty. The surgical procedure is normally performed under local anesthesia in all patients older than 10 years. For statistical evaluation, the size of the whistling defect in the vermilion was determined on photographs before and 6-9 months after surgery. The individual defect score (DS) was evaluated pre- and postoperatively. In all patients, no additional surgical procedures, such as rhinoplasty or scar correction in the upper lip, were carried out simultaneously. RESULTS: Minor (DS < 400), moderate (DS 400-1400), and severe (DS > 1400) whistling defects were surgically corrected. The whistling defect score was significantly reduced in all patient groups (p < 0.001). In six patients the result of surgery was rated as 'acceptable' (DS > 30), in five patients as 'good' (DS 10-30), and in 23 patients as 'very good' (DS 0-10). CONCLUSIONS: This study describes a modified method for whistling deformity reconstruction in uni- and bilateral clefts. The aesthetic results are based on a reconstruction of the subcutaneous muscle layers and the creation of a symmetrical lip contour and prolabium using transposition flaps from the lateral side of the cleft. The great advantage is the uncomplicated performance under local anesthesia, even for all children over 10 years, and the short operation time. Postoperative complications did not occur.

In utero Plastic Surgery in Zurich: Successful Use of Distally Pedicled Random Pattern Transposition Flaps for Definitive Skin Closure during Open Fetal Spina Bifida Repair.

BACKGROUND: One of the intraoperative challenges of fetal spina bifida repair is skin closure when there is an extended skin defect. Thus, we examined whether distally pedicled random pattern transposition flaps (TFs) are a valid option to overcome this problem. SUBJECTS AND METHODS: All patients undergoing in utero repair of spina bifida with application of a TF for back skin closure were analyzed focusing on intraoperative flap characteristics and postoperative flap performance. RESULTS: In 30 (70%) of the 43 fetuses a primary skin closure was achieved, in 5 (12%) a skin substitute was used, and in 8 (18%) a TF was applied. Flap raising and insertion was uneventful and perfusion was sufficient in all 8 fetuses (100%). In 3 fetuses (37%) the donor sites were closed primarily, and in 5 (63%) a skin substitute was used for coverage. At birth, 7 flaps were viable and provided robust skin coverage over the center of the former lesion. Complications included a small skin defect with CSF leakage in 1 patient (13%). CONCLUSION: During open fetal spina bifida repair, TFs can be safely and efficaciously used to obtain solid and durable skin coverage over lesions too large to allow conventional primary skin closure.

Basic flap design.

Basic flap design utilization for reconstruction of head and neck defects requires creativity from the surgeon. Ultimately, the surgeon must closely restore the basic functions and properties of the surgical flap and adjacent tissue. All options within the reconstructive ladder should be considered. When possible, like should be replaced with like (similar tissue) within an esthetic zone. When considering a flap design, the surgeon must remember that the donor site must be closed in an esthetic and functional manner. Finally, knowledge of normal anatomy, the extent of the defect, and the patient is vital for successful outcomes.