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The focus of secondary rhinoplasty for patients with a cleft lip after facial growth has been on correcting nasal tip asymmetry and distorted cleft-side lower lateral cartilage. However, some patients present with mid-vault asymmetry even after secondary rhinoplasty. The authors propose camouflage procedures for patients with a unilateral cleft lip and without symptoms of nasal airway obstruction. In camouflage procedures, autologous cartilage or acellular dermal matrix was used for onlay grafting and placed on the upper lateral cartilage. In this report, case examples are described to illustrate the surgical techniques and results. This method enables the correction of mid-vault asymmetry without the use of an additional septal spreader graft.

Background Due to the concern of circulation compromise, many surgeons hesitate to dangle or challenge the flap in the early postoperative phase. In our experience, early compression may have advantages such as collapse of dead space, evacuation of hematoma, reduction of edema, and stabilization of flap when ambulating. In this study, the effect of early compression of flaps with regard to flap physiology and outcome is evaluated. Methods From postoperative day 3 to 5, a custom-made compression garment was fitted aiming to compress with a pressure of 30 to 35 mmHg. A total of 52 patients (52 flaps) were enrolled for the study and 48 flaps underwent early compression. The compression was applied not only over the flap but also over the extremity or trunk. The flap outcome as well as flow velocity and flow volume of the pedicle before and after compression was measured and evaluated. Results There was no flap complication during the early compression and early ambulation. And, there was no statistical difference either in the flow velocity or in the volume before and after the compression therapy (29.21 vs. 29.42 cm/s and 7.13 vs. 6.56 cm3/s, respectively). Conclusion Early compression with a 30-mmHg pressure customized pressure garment after the flap surgery does not affect the hemodynamics of the perforator and can be safely used after extremity reconstruction before ambulation.

Background Slim patients or those with large breasts may be ineligible for breast reconstruction with an abdominal flap, as the volume of the flap may be insufficient. This study aimed to establish that abdominal tissue–based breast reconstruction can be well suited for Korean patients, despite their thin body habitus. Methods A total of 252 patients who underwent postmastectomy breast reconstruction with an abdominal flap from October 2006 to May 2013 were retrospectively reviewed. The patients’ age and body mass index were analyzed, and a correlation analysis was performed between the weight of the mastectomy specimen and that of the initial abdominal flap. Results The average weights of the mastectomy specimen and initial abdominal flap were 451.03 g and 644.95 g, respectively. The ratio of the weight of the mastectomy specimen to that of the initial flap was 0.71±0.23. There was a strong positive linear relationship between the weight of the mastectomy specimen and that of the initial flap (Pearson correlation coefficient, 0.728). Thirty nulliparous patients had a final-to-initial flap weight ratio of 0.66±0.11. The 25 patients who underwent a contralateral procedure had a ratio of 0.96±0.30. The adjusted ratio of the final flap weight to the initial flap weight was 0.66±0.12. Conclusions Breast weight had a strong positive relationship with abdominal flap weight in Koreans. Abdominal flaps provided sufficient soft tissue for breast reconstruction in most Korean patients, including nulliparous patients. However, when the mastectomy weight is estimated to be >700 g, a contralateral reduction procedure may be considered.

Reconstruction of a temporal bone defect after tumor ablation should provide watertight filling and adequate resurfacing. A muscle-sparing rectus abdominis musculocutaneous (ms-RAMC) flap with de-epithelized skin paddle has been used and early experience was reported. Case series enrolled 7 patients who underwent free ms-RAMC flap after tumor ablation for external auditory canal cancer. Vertically oriented flap was harvested with central strip of muscle. Distal skin paddle was de-epithelized to fill the bony defect. Immediate facial nerve reconstruction was performed whenever indicated. The average operation time for reconstruction was 280 minutes. No early complication was reported. An ms-RAMC flap with de-epithelized skin paddle can be used for temporal bone defect reconstruction with its anatomic consistency and technical simplicity. It can provide sufficient bulk for water tight packing that lasts after irradiation. The 11th intercostal nerve can be harvested during pedicle dissection. Muscle sparing technique could minimize donor-site morbidity.

Background This article investigates the effect of 180° rotating propeller flaps and evaluates whether each flap has a “preferable” rotating direction. Methods Part 1 evaluates the flap pedicle velocity and flow volume in neutral, 180°counterclockwise, and clockwise rotated position for 29 consecutive flaps. The data (velocity and volume) were divided into three groups: neutral, high value, and low value group then evaluated. Part 2 compares the outcome from the prospective study where a preferable rotation with high value was selected against 29 patients from 2012 to 2016 who had the same operation without selecting a preferable rotation direction. Results In part 1, the three groups (neutral, high value, and low value groups) showed mean velocity of 28.06 ± 7.94, 31.92 ± 10.22, 24.41 ± 8.12 cm/s, respectively, and mean volume of 6.11 ± 4.95, 6.83 ± 6.69, 4.62 ± 3.55 mL/min, respectively. The mean velocity and volume of the perforator in the high value group were significantly higher than that in the low value group (p = 0.0001). In part 2, although no statistical significance in the outcome was observed, there were two cases of total, two cases of partial flap loss, and three cases of wound dehiscence in the patients where preferable rotations was not selected compared with only two wound dehiscence for flaps with preferable rotation. Conclusion The velocity and flow of the flap are significantly different based on the rotation direction of the flap. Using the preferred rotation direction with statistically higher value of velocity and flow may increase the overall outcome of the propeller flap, especially where larger flaps are used.

BACKGROUND The conventional approach during orthognathic surgery for cleft-related deformities has focused largely on restoration of maxilla retrusion, using the maxillary advancement as a standard treatment objective. However, the authors thought that maxillary vertical shortening and deficient incisor show could be additional key elements of cleft-related deformities. Although slight vertical lengthening can be obtained with only maxillary advancement, it would not be enough to obtain satisfactory aesthetic results in terms of the anterior facial height. The authors hypothesized that vertical deficiency and anteroposterior maxillary retrusion exists in cleft-related deformities. Therefore, orthognathic surgery including intentional vertical lengthening and advancement would be better than the conventional simple advancement. METHODS A new approach was used to treat consecutive patients with dentofacial deformities between December of 2007 and December of 2016. Patients with cleft-related dentofacial deformities were included in the study. RESULTS Forty-one patients with cleft-related dentofacial deformities were included. The distance from the nasion to the incisor tip was 76.70 mm; the angle of the lines connecting the sella, nasion, and point A was 74.03 degrees; and the incisor show was 1.02 mm. Corresponding measurements in 40 patients without clefts were 81.57 mm, 80.08 degrees, and 3.38 mm, respectively. Postoperatively, the average vertical lengthening achieved was 0.88 mm in the simple maxillary advancement group and 7.65 mm in the intentional vertical lengthening accompanied by maxillary advancement group. CONCLUSION The authors' results suggest that simultaneous maxillary vertical lengthening with horizontal advancement is a viable approach to orthognathic surgery for cleft-related deformities, given the long-term stability of outcomes demonstrated in this study. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Background A decreased flap volume can be an obstacle to proper phonation and swallowing. In this study we verified the proportion of volume decrease using 3D reconstructed images and identified the contributors to flap volume loss. Methods We retrospectively analyzed all patients who underwent radical excision of tongue cancer and reconstructive surgery in our institution from January 2003 to October 2016. Segmentation of the DICOM images, 3D rendering of the neotongue flap, and analysis of the reconstructed images were performed using SPlanner V1® software. Results The first postoperative imaging work-up was performed within an average of 22 days (T1). The last follow-up images were taken at an average of 6.25 months (T2). The mean flap volume at T2 was reduced to 82.99 per cent compared with T1, and flap height was reduced to 91.85 per cent, giving mean volume and height decreases of 17.01 per cent and 8.15 per cent, respectively. Neither the volume/height difference between T1 and T2 nor the flap volume/height discrepancy compared with the preoperative tongue affected speech or feeding function. The difference between the flap and preoperative tongue volumes was significantly related to the presence of complications (p = 0.0153). Initial flap volume was significantly related to the flap volume reduction (p = 0.0159). Conclusions The mean flap volume reduction is the only factor significantly related to initial flap volume. Our realistic 3D reconstructed image and novel software enables us to more precisely predict the flap volume of the postoperative state and preoperatively evaluate the required flap size for covering defects.

The two major perforators supplying the superficial circumflex iliac artery perforator flap are the medial (superficial) and lateral (deep) perforators; however, they lack detailed description. The purpose of this study was to clarify the anatomy.In a prospective analysis of 142 patients, computed tomographic angiograms of 284 superficial circumflex iliac artery perforator regions were evaluated, and 142 superficial circumflex iliac artery perforator flaps were surgically correlated. The origin of the superficial circumflex iliac artery, the origin of the medial perforator, the location where it penetrates the deep fascia, and its pattern of pathway after penetration of the superficial fascia were evaluated.There was 100 percent correlation between computed tomographic angiogram and surgical findings. The superficial circumflex iliac artery originates mostly from the femoral artery in 84.8 percent. The medial perforator originated from the superficial circumflex iliac artery in 94 percent. The medial perforator typically penetrated the deep fascia within an oval of 4.2 × 2 cm located 4.5 cm lateral and 1.5 cm superior from the pelvic tubercle. After passing the superficial fascia, the medial perforator either anchored directly into skin (56 percent) or traveled in an axial pattern (44 percent) beyond the anterior superior iliac spine.Despite the origin of the medial perforator, it was constantly observed penetrating the deep fascia. However, the pathway of the medial perforator can be either anchoring directly into the dermis or extending as an axial pattern artery, implicating a different effect on the survival of the flap. These new findings will allow better understanding for elevating the superficial circumflex iliac artery perforator flap based on the medial perforator.