A second superior gluteal artery perforator flap with previous liposuction to the same breast after resection of initial SGAP breast reconstruction due to cancer recurrence.

Free superior gluteal artery perforator (SGAP) flaps are a reliable option for breast reconstruction in patients with insufficient abdominal tissue or abdominal scarring. Liposuction in a donor site is a relative contraindication for harvesting a free flap, despite current case reports challenging this tenet. We describe a case of a 36-year-old woman who underwent unilateral breast reconstruction with free SGAP flap. She underwent liposuction of the contralateral buttock for symmetry. Approximately, one year post-operatively, she developed local recurrence of the breast cancer. Previously liposculpted buttock was used as donor site for a second free SGAP flap anastomosed to internal mammary artery.

Use of dermal fat graft for augmentation of the labia majora.

Dermal fat grafts have been utilized in plastic surgery for both reconstructive and aesthetic purposes of the face, breast, and body. There are multiple reports in the literature on the male phallus augmentation with the use of dermal fat grafts. Few reports describe female genitalia aesthetic surgery, in particular rejuvenation of the labia majora. In this report we describe an indication and use of autologous dermal fat graft for labia majora augmentation in a patient with loss of tone and volume in the labia majora. We found that this procedure is an option for labia majora augmentation and provides a stable result in volume-restoration.

Pediatric nasal fractures: evaluation and management.

Nasal fractures have been reported as 1 of the 3 most commonly encountered pediatric facial bone fractures. The most common causes of nasal fractures in this age group are auto accidents (40%), sports injuries (25%), intended injuries (15%), and home injuries (10%). Nasal fractures are usually treated with closed reduction (Higuera S, Lee EI, Stal S. Nasal trauma and the deviated nose. Plast Reconstr Surg 2007;120:64S-75S). This results in a significant incidence of posttraumatic deformities, often requiring secondary surgical treatment. For this reason, it is paramount to pay careful attention to the underlying structural nasal anatomy during the initial diagnosis and management.

Correction of secondary cleft lip deformity: the whistle flap procedure.

BACKGROUND: The Kapetansky flap was described to repair a whistle deformity or central vermilion defect following a primary bilateral cleft lip repair. The authors studied a modification of this technique, called the Whistle (wide-hinged island swing transposition labial enhancement) flap, to correct a wide array of secondary cleft lip deformities. METHODS: Patients with secondary cleft lip deformity who underwent the Whistle flap correction were studied (n = 21). Vertical lip height, lateral lip projections, and three-dimensional volumetric measurements were recorded along with physician and parent-patient satisfaction surveys. RESULTS: From 1994 to 2006, 23 Whistle flap procedures were performed on 21 cleft lip patients (bilateral, n = 13; unilateral, n = 8). The average age at surgery was 15.4 years (range, 13 to 21 years). The average follow-up was 27.6 months. The vertical height of the cleft side Cupid's bow to vermilion bottom had a mean increase of 164 percent. Lateral projection of the upper lip showed a mean increase of 117 percent. Preoperatively, patients exhibited mean volumetric asymmetry of 29.4 percent, and this was reduced following treatment to approximately 3.1 percent. Physician satisfaction using a modified Whitaker classification (categories I through IV) demonstrated that 56 percent of patients were category I (no refinements necessary) and 44 percent were category II (minor revisions are advisable). Parent-patient satisfaction in the follow-up period was a mean of 3.5 as measured using a five-point scale ranging from 0 to 4. There were minimal perioperative complications. CONCLUSION: The Whistle flap procedure provided a versatile and reliable option for the correction of vermilion defects from secondary cleft lip deformities.

Microform cleft lip repair with intraoral muscle interdigitation.

BACKGROUND: With a microform (forme fruste) cleft lip, obtaining an optimal functional and esthetic result is a challenge to a reconstructive surgeon. We describe modifications to existing techniques by Mulliken, Furlow, and Cutting that provides an optimal functional result with correction of the cleft furrow, vermillion notch, and cleft nose deformity. METHODS: Sequential unilateral microform cleft lip patients underwent our microform cleft lip repair modified from the following 3 techniques: the Mulliken microform cleft lip repair with no cutaneous scar, the Furlow complete cleft lip repair with interdigitating muscle, and the Cutting cleft nose repair (n = 12). From follow-up (1 year) examinations, photographs (and 3-dimensional images), and video, 3 reviewers scored esthetic and functional outcomes using a 0 to 4-point scale. In addition, parental surveys were obtained. RESULTS: For our microform cleft lip repair, there were no infections, bleeding, or other complications. Esthetic outcome score, evaluating the cutaneous scar, symmetry of philtral columns, alignment of lip line and vermillion border, and nasal tip symmetry was a mean of 3.7 (+/-0.3). Thus, the reviewers' scored the cleft lip and nose repair as "Very Good" (minor cleft lip/nose deformity but no need for revision) to "Excellent" (Imperceptible cleft lip or nose deformity). The functional outcome score, based on the ability to smile, pucker their lips, and whistle, was a mean of 3.8 (+/-0.2). The parental survey, including postoperative course, functional, and cosmetic outcome, demonstrated a high level of satisfaction with a score of 3.9 (+/-0.2). CONCLUSIONS: The modified microform cleft lip and nose technique provided very good to excellent esthetic and functional results in a series of patients with this rare deformity.

"Stuffy nose" rhinoplasty: diced cartilage grafts for correction of cleft nasal tip deformities.

BACKGROUND: Numerous techniques exist to address poor nasal tip projection in the cleft nose deformity. The authors describe a secondary closed rhinoplasty technique using diced cartilage nasal tip grafting. METHODS: Cleft patients who previously underwent lower lateral cartilage repositioning with residual poor nasal tip projection underwent the "stuffy nose" rhinoplasty technique in which diced septal cartilage grafts were placed in a pocket made from a unilateral marginal incision over the lower lateral cartilages. Preoperative and follow-up (1 year) comparative measurements included (1) columellar length, (2) alar base-nasal tip-columellar base angle, and (3) lateral tip projection. RESULTS: Twenty cleft patients had improvement in nasal form and tip projection from the stuffy nose rhinoplasty. Mean change from preoperatively to follow-up was as follows: columellar length, 11.3 mm to 13.3 mm (17.7 percent); alar base-nasal tip-columellar base angle, 42.0 to 33.5 degrees (8.5 degrees, or 20.2 percent decrease); and lateral tip projection, 7.7 mm preoperatively to 9.0 mm postoperatively (16.9 percent increase). Two patients developed complications (one graft exposure and one infection) but healed with conservative treatment. Two different patients underwent revisionary nasal surgery but for other concerns (alar base asymmetry and internal nasal valve collapse). CONCLUSIONS: The stuffy nose rhinoplasty was shown to objectively improve nasal tip projection in cleft patients with secondary nasal deformities, with minimal complications and decreased need for revisions.

Management of sternal wounds with pectoralis major musculocutaneous advancement flaps in patients with a history of chest wall irradiation.

Although debridement and pectoralis major musculocutaneous advancement flap closure has proved to be an effective treatment of sternal wounds in the general population, the purpose of this study was to examine the use of these flaps in patients with previously irradiated chest walls. The authors examined 5 patients with a history of breast cancer and chest wall radiation therapy who developed poststernotomy wound complications that were treated with debridement and pectoralis major musculocutaneous advancement flaps. The average patient age was 76 years. Three patients had previously undergone a radical mastectomy and had only 1 pectoralis major muscle remaining. There were no intraoperative deaths. One patient died during the 30-day postoperative period. There were no hematomas, seromas, or dehiscences. One woman developed a postoperative wound infection. Functional and aesthetic results were excellent. This study demonstrates that early, aggressive sternal debridement and closure with pectoralis major musculocutaneous advancement flaps is effective in patients with a history of chest wall irradiation, including those who have had 1 pectoralis major muscle previously resected.