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The authors present their experience with 15 years of organizing cleft lip and palate surgical volunteer missions in Latin America. The history, basic principles, and objectives of Operation San Jose, a volunteer goodwill program from Christus St. Joseph Hospital in Houston, Texas, are covered. This report addresses the different problems encountered and solutions found. Following the principles set by Operation San Jose, CIRPLAST is a Peruvian foundation for plastic surgery that travels to remote areas in Peru, operating on patients with cleft lip and palate deformities. This report highlights the importance of working with local plastic surgeons and their residents, and emphasizes that the program should be organized by and the operations performed by accredited plastic surgeons and with the auspices and support of the national plastic surgery society and the local medical board. Operation San Jose promotes the creation of long-term benefits by offering a program to teach local surgeons cleft lip and palate repair techniques and to set up guidelines to organize local surgeons so that they can continue this effort by treating their own patients in their own countries.

Many patients are now consulting plastic surgeons for evaluation of their silicone gel breast implants. This study assesses the accuracy of a clinician's ability to determine if a silicone gel breast implant has failed. In addition, it sheds light on the long-term integrity of the silicone gel breast implant. This study examined the condition of 350 silicone gel breast implants in a group of 159 of the authors' patients who previously had undergone augmentation mammaplasty or breast reconstruction. These women underwent secondary open procedures including capsulotomy or capsulectomy for fibrous capsule contractures, exchange of implants, or other revisional surgery. The condition of the implant was noted at the time of this secondary operation. The preoperative evaluation, which included the patient's history and physical examination and often mammography, was then matched against the operative findings to determine the pertinent factors that predict the integrity of a silicone gel breast implant. A history of trauma and/or a reported change in shape of a patient's breast correlated with implant failure. An analysis of implant failure as a function of implant age revealed that 63 percent of silicone gel breast implants in place 12 years or greater in this study population were not intact. A change in the patient's physical examination, including a softened breast consistency and/or the presence of a nodule or mass adjacent to an implant, also was suggestive of implant failure. Several different mammographic presentations of implants that were not intact were identified. This modality predicted implant failure in 89 percent of implants studied. It is hoped that this information will help clinicians to make a more accurate assessment of the condition of a patient's silicone gel breast implant. It should be noted that all women in our study underwent secondary procedures, as stated above. The results obtained apply to this patient group but may not specifically pertain to the general implant-bearing population.

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.

Donor site seroma continues to be the most common complication of latissimus dorsi flap reconstruction. Numerous preventive methods and treatments have been described. The use of fibrin sealant in the donor site before closure may be an effective means of seroma prevention. The authors evaluated the efficacy of fibrin sealant in conjunction with closed suction drainage in a series of 17 latissimus flap donor sites. They also determined their approximate institutional seroma rate with a retrospective chart review of 20 donor sites. The fibrin sealant patients had a seroma rate of 11.8% compared with a rate of 35% among the untreated patients (P = 0.047). This compares favorably with seroma rates as high as 79% described in the literature. In conclusion, the use of fibrin sealant in the latissimus flap donor site appears to be effective in preventing seroma.

Although algorithms for the repair of soft and hard palatal clefts continue to be debated, the appropriate length of postoperative stay has not yet been defined. Recent reports of cleft palate repair advocate a 2- to 5-day hospitalization. The plastic surgery service at St. Joseph Hospital frequently uses same-day admission with 23-hour observation postoperatively, with no increase in complications from the reported 2- to 5-day stay. The authors inspected the records for all the cleft palate patients undergoing cleft repair at St. Joseph Hospital Cleft Clinic from August of 1988 through June of 1998. After excluding syndromic patients and secondary or revision surgical cases, 79 patients remained in the study. These 79 patients underwent 104 procedures; all procedures were performed by a single surgeon (E.D.C.) with resident assistance. Short-term morbidity, length of stay, and operation performed were studied. All patients were admitted the day of surgery. Mean age at the time of operation was 13.2 months, with a range of 6 months to 20 years. The length of operation averaged 1 hour and 37 minutes; 94 percent of patients stayed 24 hours or less postoperatively, and 97 percent stayed 36 hours or less. The longest stay was 72 hours, which was related to delay in resuming adequate oral intake. The overall complication rate was 3.8 percent for this cohort, which included two partial palatal dehiscences and two small fistulas. No blood transfusions were needed, and no infections were noted postoperatively. No patients required readmission postoperatively for bleeding, respiratory compromise, or inadequate oral intake. The authors do not advocate a 1-night stay for all cleft palate cases. However, they do think it is safe for a healthy group of patients undergoing routine cleft palate surgery. The decision to discharge a patient early must always be left to the treating physician.

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.

For breast reconstruction the latissimus flap provides a safe and relatively simple road whose landmarks are familiar to plastic surgeons. These are reviewed. The aesthetic quality of the new breast may depend on a few key planning considerations, one of which is the flap inset site on the anterior chest wall. Theoretic and actual results of using vertical, horizontal, oblique, or curvilinear insets are examined. In many cases ignoring the old scar in favor of a fresh inferolateral curvilinear inset will provide a superior result and is to be strongly considered.

A one-stage procedure to reconstruct the nipple-areola complex is presented, with special attention given to nipple volume and projection using local dermis-fat flaps. The preliminary results have been very encouraging.

The authors review the technical refinements that have come about through their increased use of the latissimus dorsi flap for reconstruction of the female breast following mastectomy, referring to over 90 of their cases. These refinements involve careful selection of patients in whom the flap is used; planning the flap, including determination of the limits of the muscle; and the location and shape of the skin island. Placement of the patient on the table and the position of her arms and hips are discussed. The dissection and transfer of the flap, as well as closure of the donor defect, can present particular problems, which are outlined. Implant placement, wound closure, and postoperative care of the patient are also discussed.