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Approximately ten years after abdominoplasty, transverse rectus abdominis musculocutaneous (TRAM) flaps were utilized for breast reconstruction in two patients. Both had considerable excess lower abdominal tissue that they wanted removed. We assumed that a new perforating system had developed that might support the lower abdominal skin even though all the original perforators would have been sacrificed at the time of the abdominoplasty. The two patients had successful breast reconstructions performed utilizing bipedicle TRAM flaps with full survival of the flaps. However, we do not recommend the general use of TRAM flaps after abdominoplasty.

Supplemental Digital Content is available in the text., Summary: Nipple-areola reconstruction is often one of the final but most challenging aspects of breast reconstruction. However, it is an integral and important component of breast reconstruction because it transforms the mound into a breast. We performed 133 nipple-areola reconstructions during a period of 4 years. Of these reconstructions, 76 of 133 nipple-areola complexes were reconstructed using the keyhole flap technique. The tissue used for the keyhole dermoadipose flap technique include transverse rectus abdominus myocutaneous flaps (60/76), latissimus dorsi flaps (15/76), or mastectomy skin flaps after tissue expanders (1/76). The average patient follow-up was 17 months. The design of the flap is based on a keyhole configuration. The base of the flap determines the width of the future nipple, whereas the length of the flap determines the projection. We try to match the projection of the contralateral nipple if present. The keyhole flap is simple to construct yet reliable. It provides good symmetry and projection and avoids the creation of new scars. The areola is then tattooed approximately 3 months after the nipple reconstruction.

Background Velopharyngeal insufficiency (VPI) remains a common problem in the care of patients with cleft palate and other related conditions. It may be successfully corrected with augmentation of the posterior pharynx. The purpose of this study was to review the experience and results of posterior pharyngeal augmentation over a 40-year period at one cleft center in the United States. Methods All patients from 1968 to 2008 who underwent posterior pharyngeal augmentation for the treatment of VPI were reviewed retrospectively. Diagnosis, age at the time of operation, type of implant used, duration of follow-up, speech performance both pre- and postoperatively, and complications were analyzed. Speech performance preoperatively was assessed by video fluoroscopy and/or nasoendoscopy. Resonance was assessed by both the surgeon and speech pathologist using a 4 point grading scale. Results One hundred eleven patients underwent posterior pharyngeal augmentation. Thirteen patients required removal of the implant because of extrusion (n = 12) or postoperative sleep apnea (n = 1). Five patients with failed implants at the primary operation had successful replacement at a second operation, resulting in a retained implant success rate of 93%. Of the 103 patients who were successfully augmented, 15 were lost to follow-up, leaving 88 patients with full postoperative speech evaluations. Of the 88 patients evaluated, 64 exhibited normal or near normal speech (73%), 22 patients had mildly nasal speech (25%), and 2 patients (2%) were not improved. Highest extrusion rates were seen for smooth surface silicone and rolled gortex implants. Conclusion Augmentation of the posterior pharyngeal wall is a safe and effective treatment for patients with VPI. Implants are well tolerated and speech is substantially improved.

A method of primary cleft lip nasal repair utilizing a medially based composite alar flap with a mucosal tab extension is presented. The procedure modifies, with a 5- to 6-mm mucosal tab extension, a previously described chondromucosal flap technique. Most cases were done concurrent with a modified Tennison lip repair. The flap consists of the lateral crus of the alar cartilage, together with its vestibular lining. The flap is advanced medially so the dome provides the tip support for the affected side of the nose. The goal is to restore symmetry, obviating the need for future major nasal surgery. Experience with this technique in 32 patients over 4 years is reported. Although encouraged by our results, it is anticipated significant percentage of patients will still benefit from secondary nasal surgery when their nasal growth is complete.

An innervated cross-finger flap for treatment of severe fingertip injuries is described. With this method, the dorsal skin over the middle phalanx, together with its sensory nerve, is transferred as a compound skin-nerve flap. A neurorrhaphy is performed between this nerve and the cut end of the digital nerve at the injury site. Seven of eight patients (88 percent) treated with this method (mean follow-up time 14.4 months) achieved measurable two-point discrimination. The average for those who did was 4.8 mm. A group of patients with similar injuries treated with standard cross-finger flaps exhibited slower sensory return that progressed to a lower level. In this group (mean follow-up time 16.3 months), three of six (50 percent) achieved measurable two-point discrimination with a mean value of 9 mm.