Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.     

Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?

The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap and the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap (MS-2) are well recognized. Both techniques optimize abdominal function by maintaining the vascularity, innervation, and continuity of the rectus abdominis muscle. The purpose of this study was to compare these two methods of breast reconstruction and determine whether there is a difference in outcome. The study considered 177 women who have had breast reconstruction using muscle-sparing flaps over a 4-year period. This includes 89 women who had an MS-2 free TRAM flap procedure, of which 65 were unilateral and 24 were bilateral, and 88 women who had a DIEP flap procedure, of which 66 were unilateral and 22 were bilateral. The total number of flaps was 223. Mean follow-up was 23 months (range, 3 to 49 months). For all MS-2 free TRAM flaps (n = 113), outcome included fat necrosis in eight (7.1 percent), venous congestion in three (2.7 percent), and total necrosis in two (1.8 percent). For the women who had an MS-2 free TRAM flap, an abdominal bulge occurred in three women (4.6 percent) after unilateral reconstruction and in five women (21 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in 63 women (97 percent) after unilateral reconstruction and 20 women (83 percent) after bilateral reconstruction. For all DIEP flaps (n = 110), outcome included fat necrosis in seven (6.4 percent), venous congestion in five (4.5 percent), and total necrosis in three (2.7 percent) patients. For the women who had DIEP flap reconstruction, an abdominal bulge occurred in one woman (1.5 percent) after unilateral reconstruction and in one woman (4.5 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in all women after unilateral reconstruction and in 21 women (95 percent) after bilateral reconstruction. These results demonstrate that there are no significant differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap reconstruction. The percentage of women who are able to perform sit-ups and the percentage of women who did not develop a postoperative abdominal bulge is increased after DIEP flap reconstruction; however, this difference is not statistically significant.     

The osteocutaneous free fibula flap: is the skin paddle reliable?

This clinical and anatomic study was undertaken to see if the skin paddle of the osteocutaneous fibula flap could be made more reliable. Eighty cadaver limbs were dissected to evaluate the type, number, and location of the cutaneous perforators supplying the lateral leg. Three types of perforators were identified: septocutaneous, musculocutaneous, and a type we termed septomuscular, which does not actually run within the muscle substance but is adherent to the muscle. Although not a true musculocutaneous perforator, it should be treated as such clinically. Musculocutaneous perforators were found to be more numerous and more proximal than the septocutaneous perforators. Eighteen clinical cases demonstrate a 33 percent skin paddle survival when dissected as a septocutaneous flap and a 93 percent skin paddle survival when dissected as a septomusculocutaneous flap. In using the osteocutaneous fibula flap, it is recommended that a cuff of soleus and flexor hallucis longus be incorporated into the flap to help ensure flap viability.     

The extended Segmüller flap

A modification of the homodigital lateral V-Y advancement flaps described by Segmüller in 1976 for the treatment of fingertip injuries is described. The extended flap used in this series makes this flap more versatile in the treatment of injuries with considerable soft-tissue loss from the volar aspect of the fingertip. The Segmüller flap technique, its applications, and the results of 100 flaps are reported and discussed.