The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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666
Fat Necrosis
Fat necrosis is characterized by areas of a flap that are no
longer soft and supple, but rather are palpable masses or
nodules that can be quite concerning to patients who have
been treated for breast cancer. Usually, areas are small and
treatable by simple excision, but occasionally fat necrosis
can be more extensive. The cause of fat necrosis is fairly
straightforward—small areas of underperfusion of a flap.
This can result from arterial underperfusion or venous
congestion. Risk factors from a medical history perspec­
tive have been difficult to consistently identify, but several
studies have shown that radiation therapy increases the
likelihood of fat necrosis. Obesity increases the likelihood
in pedicled TRAM reconstruction but is less convincingly a
problem in free flap reconstruction. Smoking was consis­
tently shown to adversely affect results in pedicled TRAM
reconstruction, but this has been less convincing in free
tissue techniques, likely because of the more robust blood
supply.16
The most important factor in avoiding this complica­
tion is maintaining a diffusely well-perfused flap. Studies
have consistently shown a higher rate of fat necrosis in DIEP
flaps compared with free TRAM flaps.16,17 Regarding perfu­
sion, there are likely several factors worth discussing. Per­
forasomes refer to the innate vascular territory supplied by
any given perforator. Unfortunately, predicting the territory
of a perforasome is challenging. Generally speaking, the fur­
ther tissue is from a perforator, the less reliable the blood
flow. For that reason, we routinely discard the most lateral
abdominal tissue when using an abdominal flap. We serially
resect tissue until normal bleeding (usually not congested)
edges are identified.
The quality and location of the perforators are factors
that should always be assessed when performing a free flap.
Breast free flaps are generally large in volume and fatty tis­
sue, which is sensitive to underperfusion; thus harvesting
a big flap on one small perforator is generally not a good
idea. We sometimes do single vessel perforator flaps from
the abdomen, but the perforator should be easily palpable
and fairly centrally located. Despite being a large perfora­
tor, if it enters the very edge of a flap, the distal perfusion
will likely be inadequate. This is particularly true when us­
ing medial perforators in bilateral free flaps where the ab­
dominal tissue was split in the midline. Therefore centrally
located lateral-row perforators are likely more appropriate
for bilateral free flaps, whereas medial row perforators are
more centrally located in a unilateral flap that incorporates
volume from zones 1, 2, and 3. Whenever possible, we rec­
ommend using several perforators per flap to broaden the
location of perfusion. Having multiple perforators also cre­
ates redundancy in the perfusion in case perforator injury
occurs during dissection or transfer. Fat necrosis rates have
been well studied, and there is ample literature to support
that fat necrosis rates go up as the number of perforators
goes down.18
The first thing to consider in avoiding this complication
is patient selection and taking an appropriate history and
physical. The surgeon should take a moment to specifically
ask questions targeted at identifying hypercoagulability such
as previous deep vein thrombosis (DVT), pulmonary embo­
lism (PE), stroke, or multiple miscarriages in the patient or
first-degree relatives, because 5 to 10% of the population
is estimated to be hypercoagulable.9,10 In our practice, any
unusual history prompts a referral to hematology for a hy­
percoagulable workup to look for genetic conditions such as
factor V Leiden, prothrombin gene mutation, antithrombin
III deficiency, protein C or S deficiency, or acquired condi­
tions such as lupus anticoagulant, antiphospholipid, or an­
ticardiolipin antibodies, to name a few. That being said, a
negative screening does not mean the patient is not hyperco­
agulable; it is estimated that more than 40% of patients who
are clinically hypercoagulable have no identifiable cause.11
Identifying a cause, or at the least a history, allows for proper
patient counseling preoperatively; however, this is not to say
that hypercoagulable patients are not candidates for free flap
reconstruction.
Hypercoagulable patients are at higher risk, with flap
failure as high as 20%.12 This risk can be mollified by the
use of intraoperative and postoperative anticoagulation. A
regimented use of anticoagulation can lead to very success­
ful outcomes. Nelson et al13 have had early success with a
protocol including a 2,000-unit bolus of heparin before anas­
tomosis followed by a therapeutic heparin drip postopera­
tively, then anticoagulation with warfarin for 1 month. Not
surprisingly, this does lead to higher transfusion and hema­
toma rates, which patients should be counseled on.13 Re­
gardless of the use of anticoagulation, flap thrombosis in a
known hypercoagulable patient, in our experience, has had
zero chance of salvage with takeback.
Previous history of radiation should be discussed. Radia­
tion has been shown to lead to a higher rate of intraoperative
vascular complications requiring anastomotic revision and
the use of intraoperative anticoagulation.14 This appears to
be limited to an intraoperative phenomenon and in our ex­
perience does not connote a higher incidence of postopera­
tive thrombosis or flap loss. We do not specifically change
our approach knowing that radiation was received; how­
ever, radiated vessels may be less ideal for teaching purposes,
and the surgeon should have a low threshold for redoing an
anastomosis if it does not look perfect.14
Finally, previous surgery should be considered. The in­
ternal mammary vessels are our preferred site for use as a
recipient. Previous mediastinal surgery may make these ves­
sels more scarred and less healthy, and the surgeon should
not be afraid to look for an alternative recipient site if need
be. Our second choice is almost always the thoracodorsal
vessels, but both have comparable results.15 Abdominal sur­
gery can affect the quality of the pedicle as well. If the qual­
ity of the pedicle does not appear to be normal, the free flap
can be converted into a standard pedicled transverse rectus
abdominis myocutaneous (TRAM) in most circumstances.

667
Chapter 39 Breast Reconstruction with Autologous Tissue
lishing those boundaries first. This may require suturing of
the mastectomy skin flaps down along the inframammary
fold or out laterally. Scattered simple sutures are more than
adequate to prevent further compromise of the blood flow
within the skin flaps. Skin envelope issues are best avoided
by making similar changes bilaterally or paying attention to
differences in asymmetry to begin with. Shape asymmetries
are difficult to avoid. Again, the surgeon should resist the
temptation to do too much shaping with sutures to avoid
fat necrosis. Shape is best addressed once everything has
healed. The one area that should be addressed specifically
if possible is the tail of the breast mound. Fitting the lateral
extent of the flap into the tail helps avoid a divot over the su­
perolateral pectoralis, which is hard to correct in later stages.
Volume asymmetry is best avoided by assessing the patient
in a supine and upright position and trimming as needed.
Finally, sometimes the abdominal donor site is asymmetri­
cal, and the surgeon must account for this during flap har­
vest and inset.
Delayed Wound Healing
Free flap breast reconstruction can be plagued by delayed
wound healing of either the chest or abdomen. Both can be
a result of patient factors or surgical factors. Preoperative
assessment may help avoid some of this, but at the very
least, identifying risk factors helps the surgeon to properly
counsel patients preoperatively and prepare them for a
potentially long road ahead. In multiple studies, diabetes,
smoking, and morbid obesity have been identified as the
biggest risk factors for wound-healing complications.6,8,24,25
This is true for most surgical procedures in general, but it
is particularly true in free flap breast reconstruction, which
creates large wounds to heal. In the setting of cancer, there
may not be time for a patient to quit before surgery; how­
ever, in prophylactic cases, smoking cessation for 30 days
prior and at least 4 to 6 weeks postoperatively will signifi­
cantly improve results.26–28 In addition, checking the he­
moglobin A1C of patients with diabetes is mandatory as a
screening measure to know how effective their long-term
glucose management strategy is. The surgeon should have
a low threshold to consult an endocrinologist to help main­
tain tight glucose control postoperatively. Although it must
be balanced with the need for a second surgery, delayed
reconstruction may be the most appropriate option for pa­
tients of poor health with multiple risk factors for delayed
wound healing.
Aside from generalized wound-healing risk factors, in­
traoperative issues contribute to delayed wound healing as
well. The biggest impact on the healing process of the chest
is the perfusion of the mastectomy skin flaps. Poor wound
healing of the chest is incredibly rare in delayed reconstruc­
tion, because these skin flaps are smaller, are delayed, and
can be made as thick as possible. In immediate reconstruc­
tion, the reconstructive surgeon is reliant on the breast sur­
geon’s contribution, who has a different focus in mind—to
get the cancer out. This can put the reconstructive and ex­
tirpative surgeon at odds, but ultimately it is the reconstruc­
In summary, it is clear that a true DIEP is more likely
to result in fat necrosis than a MSFTRAM. Debate has lin­
gered about the improved abdominal wall function with a
true DIEP or SIEA; however, the results on abdominal wall
function may be less pronounced than previously believed.
In general, women have a hard time recognizing the effects
of free flap reconstruction on abdominal wall function re­
gardless of type of flap.19–21 In the end, women want and
deserve a soft and supple reconstruction without areas of
fat necrosis that remind them of cancer. For this reason, we
recommend erring on the side of sacrificing a little muscle
to maximize perfusion if necessary. This is particularly true
in higher-risk patients who have other risk factors such as
smoking, previous scar, or impending postoperative radia­
tion therapy. When in doubt, the surgeon can temporarily
place micro–bulldog clamps on each perforator and assess
any effects on perfusion before ligation.
The SIEA appears to have a perforasome more confined
to a hemiabdominal location. The arterial perfusion of the
SIEA does not reliably cross the midline.22,23 Therefore we
rarely incorporate a large amount of volume from the con­
tralateral abdomen when a unilateral SIEA is performed. The
superficial venous outflow is sometimes necessary to pre­
vent congestion. Some flaps appear to be inherently drained
by the superficial vessels. We preserve a length of the su­
perficial inferior epigastric vein (SIEV) whenever possible
to allow for a secondary venous anastomosis if congestion
is noted. If a flap appears congested on the abdomen after
anastomosis of the deep system or if the superficial vein
appears incredibly engorged, we often connect this vein to
either a second internal mammary vein (IMV), a perforat­
ing vein, or the retrograde IMV for additional outflow. The
improved outflow is often immediately evident clinically.
Finally, the surgeon should avoid the use of too many
insetting sutures to secure the flap. It is tempting to spend a
considerable amount of effort shaping the flap and smooth­
ing the contour with sutures; however, every bend placed in
the flap or suture tied down decreases perfusion to the area.
These small areas can lead to fat necrosis down the road. It
is easier to smooth the contour and reshape later than it is
to remove large areas of fat necrosis.
Asymmetry
Asymmetry is much more common after unilateral recon­
struction than bilateral reconstruction. Although matching
a contralateral native breast is much easier with a free flap
than with an implant, some asymmetry is unavoidable.
Thus, correcting the problem is likely a bigger topic than
avoiding it.
Nevertheless, there are some factors that are incred­
ibly important to help minimize asymmetry. Asymmetry
can be from positional, skin envelope, shape, or volumetric
causes. From a positional standpoint, the best way to avoid
a problem is to make sure the mastectomy pocket is prop­
erly defined before insetting the flap. Often, the mastec­
tomy extends beyond the natural boundaries of the breast.
It is a fundamental error to inset the flap before reestab­

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668
Postoperatively, these wounds should be followed
closely. The surgeon should avoid the temptation to remove
drains prematurely, because fluid collections can lead to
wound dehiscence. Infection should also be treated aggres­
sively, because the combination of infection and tension
usually has poor outcomes. Perhaps most importantly, pa­
tients must be instructed to eat well. Many patients lack ap­
petite or have a sudden urge to “eat healthy” postoperatively.
This is not the time to eat salad and toast. A high-protein
diet maximizes the body’s ability to heal, and we actively
encourage our patients to increase protein intake.
Hernia/Bulge
Aside from an SIEA, all other abdominal free flaps inher­
ently have the potential to affect the integrity and function
of the abdominal wall long term. Studies have shown mea­
sureable functional differences between an SIEA, DIEP, and
MSFTRAM, most notably in bilateral reconstruction; how­
ever, these differences are imperceptible to patient func­
tioning and have no apparent effect on quality of life.19,20
That being said, to minimize the risk of bulge and weak­
ness, the surgeon should try to preserve as much functional
muscle as possible. The lateral innervation of the rectus
muscle should be left intact if possible, and if a well-per­
fused DIEP can be performed, this should be chosen over
a MSFTRAM.
A hernia is an unfortunate complication that occurs af­
ter 3 to 5% of free flap harvests from the abdomen, with the
exception of the SIEA, which carries no risk. When it occurs,
surgical correction is usually necessary and can be challeng­
ing; therefore attention to detail to prevent a hernia is neces­
sary. Prophylactic mesh has been shown to reduce the risk
of hernia or bulge but mesh is likely more important in bi­
lateral cases where muscle has been sacrificed.30 Because
this is a clean procedure, permanent mesh offers the stron­
tive surgeon’s responsibility to recognize and excise under­
perfused skin if necessary. Although a larger skin paddle is
less aesthetically appealing in the long term, it is better than
having to deal with dressing changes for months and an ugly
tethered scar as a result of leaving underperfused breast skin
at the time of surgery.
Several centers have adopted the use of the SPY System
(NOVADAQ Technologies), which uses indocyanine green
(ICG) and a laser angiography to assess for perfusion of the
mastectomy skin. This technology can be very useful not only
in assessing mastectomy skin flap perfusion, but flap perfu­
sion as well.29 Unfortunately, this technology is expensive
and not universally available. Thus many surgeons resort to
clinical judgment and simple techniques such as bleeding
skin edges and capillary refill to assess for tissue perfusion.
As for the abdomen, tension and perfusion are the big­
gest risk factors for poor outcomes that can sometimes be
modified. If patients have previous scars, such as a cesarean-
section scar, the surgeon should try to place new incisions
in the same position to avoid parallel scars. This may require
shifting the planned flap up or down on the abdomen de­
pending on the location of scars. When dissecting up to free
the upper abdominal tissue for closure, the surgeon should
only dissect the minimum amount necessary to allow for
closure. In large patients, this may require very little dissec­
tion. If full upper dissection is necessary, the surgeon should
at least try to avoid sacrificing perforators in the upper outer
quadrants of the abdomen to maintain perfusion. In addi­
tion, only the amount of tissue necessary to reconstruct the
breasts should be removed. Most women do not require a
very wide flap. The width of the breast mound usually cor­
relates to the height of the tissue taken from the abdomen
in standard reconstruction, in which a contralateral flap is
rotated 90 degrees and connected to the internal mammary
vessels. Taking no more than is necessary will help alleviate
closure under tension.
Skin and subcutaneous fat
Scarpa’s fascia
External oblique muscle
Internal oblique muscle
Transversus abdominis muscle
Transversus abdominis muscle
ABOVE
UMBILICUS
Skin and subcutaneous fat
Scarpa’s fascia
External oblique muscle
Internal oblique muscle
BELOW
ARCUATE LINE
Rectus abdominis
muscle
Rectus abdominis
muscle
Fig. 39.1 Cross-sectional anatomy of the abdominal wall above and below the arcuate line. (Reproduced from Jones GE. Bostwick’s Plastic
and Reconstructive Surgery. 3rd ed. New York: Thieme Publishing; 2010.)

669
Chapter 39 Breast Reconstruction with Autologous Tissue
Managing Unfavorable Results
and Complications in Breast
Reconstruction with Autologous
Tissue
Thrombosis and Flap Loss
An experienced microsurgeon or surgical team can in­
stantly recognize a complete arterial thrombosis character­
ized by loss of a Doppler signal, capillary refill, and warmth
(Fig. 39.2). Likewise, a complete venous thrombosis is eas­
ily diagnosed by an enlarged, congested flap with a blue to
purple appearance (Fig. 39.3). One of the keys to maximiz­
ing clinical outcomes, however, is recognizing an impending
problem. Early recognition is important because the faster
the surgeon is able to correct a problem, the more likely the
chance of flap salvage.32 Impending arterial thrombosis can
be characterized by a changing quality of a Doppler signal.
A bounding signal may change to an intermittent one as
small thrombi form and clear. Capillary refill may become
less brisk. If there is concern, a pinprick or scratch can be
used to assess for bleeding. This should be brisk—any con­
gest closure with the lowest risk of bulge. We therefore rec­
ommend prophylactic mesh within the rectus sheath with
complete fascial coverage for a two-layered closure with
permanent suture when muscle has been taken with the
flap31 (Fig. 39.1). The greatest risk of hernia is below the
arcuate line where all of the strength layers have been vio­
lated; therefore meticulous closure and proper mesh fixa­
tion is required to create the strongest closure. Postopera­
tively, patients should be told to refrain from heavy lifting
for 6 weeks.
The Dissatisfied Patient
Autologous breast reconstruction has a fairly high rate of
postoperative satisfaction; however, dissatisfied patients
are unavoidable. Although good outcomes certainly mini­
mize the likelihood of dissatisfaction, there are dissatisfied
patients with good outcomes and happy patients with bad
outcomes. In the end, the most important step is to choose
patients wisely and manage expectations well. This trans­
lates into spending a considerable amount of time with the
patient preoperatively and educating him or her on the
overall process including the good, the bad, and the ugly. If
the surgeon has told them about the risks adequately in the
beginning, most patients understand when they happen.
Fig. 39.2 (a) Postoperative arterial thrombosis characterized by a typical pale skin paddle. (b) The anastomosis is resected, flushed, and
reperformed to reestablish flow. (c) The skin island subsequently has greatly improved color and capillary refill.
a
b
c
Fig. 39.3 The typical appearance of a venous thrombosis characterized by
increased size and dark discoloration.

SECTION V THE BREAST
670
a secondary free flap is not indicated at this time, a tissue
expander can be placed if two-stage reconstruction is an
option. If previous radiation therapy eliminates this option,
then closing the wound and readdressing reconstruction at
a later date is the best course of action.
On a rare occasion, a patient presents with a delayed ve­
nous thrombosis after leaving the hospital. If caught early,
surgical intervention as described previously may be war­
ranted; however, if the vein has been thrombosed for a pro­
longed time, as is often the case, then anticoagulation is the
only option. Leach therapy has been tried and largely aban­
doned because of its complications.34
Fat Necrosis
Small areas of fat necrosis can be treated with excision;
however, larger volumes or areas in the far upper pole can
be difficult to treat with excision without creating obvious
contour deformities or new visible scars. Contour deformi­
ties from excision can be treated with fat grafting, but this
may commit patients to multiple surgeries. An alternative
technique can use liposuction, ultrasonic liposuction, or a
power dissector.35 In this technique, a small cannula is used
to drill holes in multiple directions in the area of fat necro­
sis. This technique is similar to aerating a green on a golf
course. These small holes often soften the feel of the ne­
crotic area and may allow for tissue ingrowth, which leads
to improvement with time.
Asymmetry
Assessing the Problem
Volume
It is useful to categorize deformities based on patient and
surgeon observations. First, volume asymmetry is one of
the biggest drivers of patient dissatisfaction because bra fit­
ting is a challenge. In unilateral reconstruction, the free flap
may be smaller or larger than anticipated; however, even in
bilateral reconstruction, volume asymmetry occurs. Treat­
ment of volume differences greatly depends upon patient
wishes. Small reductions in a flap can be easily performed
with liposuction, whereas large reductions may require a
more formal approach with resection. Conversely, augmen­
tation of the contralateral side can be performed with fat
grafting or implants. Which side to modify greatly depends
on patient goals.
Contour/Shape
Contour irregularities are common after free flap recon­
struction. The cause is multifactorial, but the most common
factor is a baseline mismatch in size or shape between the
breast tissue removed and the free flap inset. This can be
most notable in the upper pole or tail of the reconstructed
breast mound, where a tapered effect is difficult to achieve
cern for decreased bleeding should prompt exploration. An
early venous problem is sometimes only noted by “quick”
capillary refill. Sometimes, the skin paddle may appear
tense or glistening well before purple or blue discoloration
settle in. Regardless, any hint of thrombotic issues should
prompt surgical evaluation. While waiting, a bolus of hepa­
rin is indicated.
Upon exploration, the pocket is reopened through the
same incisions and the insetting sutures are removed to al­
low for complete mobilization out of the pocket and good
exposure. The surgeon can get a better sense of perfusion
by looking at the muscle included in the flap and the pedi­
cle itself. An isolated arterial thrombosis with intact vein is
repaired by placing a proximal bulldog clamp and resect­
ing the entire anastomosis. The surgeon should inspect
the suture line for technical causes to explain the problem.
Both ends should be trimmed back to healthy tissue. Inflow
should be rechecked and, if insufficient, either cut back fur­
ther or converted to an alternative recipient artery. If a sig­
nificant gap exists, either the artery and vein will need to
be both redone to ensure equal length, or an interposition
vein graft will be needed. The success rate of vein grafts is
quite high, so surgeons should have a low threshold for their
use.33 The flap should flush easily with heparinized saline. If
there is no flow distally, thrombolytics or mechanical throm­
bectomy can be used.
A venous thrombosis can be more challenging to correct.
If there is still arterial inflow, the venous anastomosis is re­
sected and the vein is milked of its clot. This is done with­
out clamping the arterial inflow to avoid increasing the risk
of a subsequent arterial clot. If good outflow flows from the
pedicle, then the recipient vein is flushed to confirm distal
outflow as well. After trimming for healthy tissue, the anas­
tomosis is performed again. Again, if an interposition graft
is needed, one should be performed. A more common oc­
currence is an inability to restore outflow in a “no reflow”
phenomenon. In this case, a small butterfly needle can be
placed into the artery and a thrombolytic (2 to 4 mg of tissue
plasminogen activator in 50 mL 5% dextrose) slowly instilled
into the flap over 10 to 20 minutes. If outflow is reestab­
lished, the anastomosis is reperformed. If a secondary vein
such as a superficial inferior epigastric vein is available, this
should be connected if possible as well. If the recipient vein
is clotted or unhealthy after distal resection, then an alter­
native site should be used.
Postoperatively, more aggressive anticoagulation
should be used over the standard subcutaneous heparin
dosing, unless a clear technical problem is found such as
twisting or backwalling. If there is no clear reason, the
surgeon should assume a hypercoagulable state exists
and the patient should be fully anticoagulated postoper­
atively. This may require outpatient conversion to warfa­
rin as well.
If the flap cannot be salvaged, it should be removed in
the acute setting. Before a return to the operating room, the
surgeon should inform the patient of the possibility of an in­
ability to fix the problem and discuss alternatives. Although

671
Chapter 39 Breast Reconstruction with Autologous Tissue
Fat Grafting
The use of fat grafting is possibly the most important tech­
nique available to revise the reconstructed breast (Fig.
39.4). Fat grafting techniques are addressed in detail in
Chapter 19; however, some technical points are worth dis­
cussing here. First, the donor site may play a role in graft
take; some studies have shown the lower abdomen and
inner thighs to be higher in adipose-derived stem cells.36
These cells are believed to aid in survival; however, other
studies have failed to highlight major differences in donor
site value.36–39 The donor site of choice is injected with
1% lidocaine with epinephrine. Fat can be procured using
manual aspiration or a formal liposuction device. Larger
cannula diameters may yield healthier fat cells.40 If a lipo­
suction device is used, it is likely that lower aspiration pres­
sures aid in cell survival, but further research is needed in
this area. The fat must be prepared before use to remove
fluid, debris, and free oil. This can be done using filtration,
sedimentation, or a centrifugation system that spins the fat
down. Centrifugation is more practical for larger volumes;
however, no one method of preparation has been shown
to be most effective.41 Several procurement and process­
ing systems are now marketed to make the process more
efficient and hopefully offer better results, but their effi­
cacy has not been proven. Research on the quality of the
fat based on site of harvest and method of procurement is
constantly evolving and at this time is not convincing that
one method far surpasses another.41
What is likely the most important factor contributing
to long-term survival is the environment in which the fat
is placed. Fortunately, a previously transferred free flap is
usually very well perfused. Fat should be placed in small ali­
quots (no more than 0.5 cc per pass) using a multipass tech­
nique as described by Coleman.42 The fat should be placed
in multiple planes even if the defect feels superficial. Su­
perficial and deep planes allow for placement of each pass
into its own space. Injection can be made directly into the
pectoralis muscle, because it serves as an excellent recipient
site for fat survival. Fat should be injected in multiple direc­
primarily. Small areas of fat necrosis can lead to hollowing
or frank masses, which may require revision. In addition,
lack of central projection relative to a natural breast is a
common complaint. This is generally caused by an inability
to completely cone the central mound in a manner similar
to a native youthful breast. A free flap (particularly a DIEP
without muscle) is often fairly uniform in depth, which can
lead to a flat-appearing breast mound. All of these issues
can be addressed with fat grafting, although on occasion a
small implant centrally can work very well to add central
projection. Many women choose autologous reconstruc­
tion to avoid the issues associated with implants, however,
in which case staged fat grafting may be a better choice.
Position
Patients with grade I ptosis are rarely subject to problems
with flap position in the postoperative period as long as the
mastectomy pocket remains confined to the breast tissue.
Simple changes may be amenable to liposuction, but gen­
erally speaking, major changes require re-creation of the
pocket, movement of the flap, and redefining of the pocket.
Because this is not a minor revision, every attempt should
be made to avoid this problem to begin with.
More likely, positional problems arise in patients with
preexisting ptosis when skin envelope changes are being
made in an immediate reconstruction or in delayed recon­
struction when the envelope is being re-created. A common
issue is a vertical discrepancy, either related to uneven skin
resection from side to side or in a unilateral reconstruction
in which a contralateral balancing procedure is needed. As­
sessing symmetry and patient satisfaction should be ap­
proached similarly to how a surgeon would assess any breast
consultation. Similar techniques also can be used to improve
vertical positioning, such as the vertical mastopexy. Usually,
however, these are skin-only procedures as opposed to for­
mal parenchymal and pillar procedures. In all cases, but de­
layed reconstruction in particular, it is important to ensure
enough time has passed to allow the envelope to relax and
drop before revision.
Fig. 39.4 (a) A patient with left breast cancer planning a bilateral mastectomy. (b) After bilateral deep inferior epigastric perforator flaps,
the patient complained of being too large and of lateral fullness. (c) Result after revision with nipple areolar reconstruction and suction-
assisted lipectomy to reduce volume and lateral fullness. (These photos are provided courtesy of Liza Wu, MD, FACS.)
a
b
c

SECTION V THE BREAST
672
cautious approach initially. The correction simply involves
excising the lateral dog-ear similarly to the lateral exten­
sion of a Wise-pattern reduction.
The other common problem of the skin envelope is of
undercorrection of the vertical component of a vertical pat­
tern skin reduction at the time of mastectomy. In a standard
breast reduction or mastopexy, the vertical component is
generally overcorrected. Tension on the skin is ameliorated
somewhat by pillar sutures; however, this overcorrection
relaxes over the next few months. When a vertical pattern
is chosen during a mastectomy, the surgeon does not have
the luxury of overcorrection. Tension on the mastectomy
skin flaps can further compromise already tenuous mastec­
tomy skin flaps. Thus undercorrection of ptosis is common
and leads to the necessary revision as a result of purposeful
caution. The surgical correction is often fairly straightfor­
ward—further excision of the vertical component without
changing the position of the nipple–areola complex (NAC).
Implants
Although most women choose autologous reconstruction
to avoid a prosthetic device, implants can play a specific
role in adding overall volume, improving large contour de­
formities, or adding central projection (Fig. 39.6). Implant
choice follows the same principles as those used for other
indications. In thin patients, form-stable implants may
have a definitive role to add natural shape. In most circum­
stances, however, the implants used are less than 250 cc,
and at this size the differences between a form-stable and
standard round implant become less noticeable. In these
cases, round implants may be a better choice because of
their softer nature. Saline implants are rarely used. Tex­
tured implants may have some benefit in the irradiated field
in trying to reduce the risk of capsular contracture.47,48 In
terms of style, small implants have a very narrow footprint
regardless of projection. If correction of an overall volume
discrepancy is the goal, a lower-profile implant may be a
good choice to fill out as much width as possible; however,
if central projection is the main goal, then a higher-profile
implant may be warranted. In this case, the pocket should
tions as well. This technique requires multiple access points.
Because this can be done through 1-mm access points, scar­
ring should not be a concern. A three-dimensional cross­
hatch network of lines should be the goal, not simply inject­
ing through convenient locations. When larger volumes are
necessary, the surgeon must avoid the temptation to try to
achieve perfection in one setting. Overfilling leads to lower
retention rates and most patients, if educated properly, will
understand why staged surgical procedures are necessary
and beneficial.43 A radiated bed can still receive fat grafts;
however, retention rates are likely lower.44 Therefore the sur­
geon should inform the patient that fat grafting may require
more stages or even be ultimately less successful after radia­
tion therapy.
Liposuction
Standard suction-assisted lipectomy (SAL) can be very use­
ful not only in reducing volume, but in blending transition
points well.45 The borders of the flap can feel like a step-
off to patients, and gentle liposuction can help smooth the
edges (Fig. 39.5). In addition, the lateral aspect of the flap
can be shaped nicely with liposuction as it transitions to
the lateral chest wall. Injection of 1% lidocaine with epi­
nephrine is usually adequate as opposed to formal tumes­
cence. Regardless of the indication, a free flap will quickly
lose its volume with SAL; therefore it is easy to overliposuc­
tion creating more asymmetry if care is not taken.
Skin Refinement
Refining the skin envelope is not technically challenging;
however, achieving the desired effect without adding new
scars can be difficult. The most common area where the
envelope needs revision is the lateral breast mound as it
transitions to the chest wall. This is particularly true in
women who had large ptotic breasts before mastectomy.
These women would benefit from a Wise-pattern skin re­
duction at the time of mastectomy, but using this approach
would compromise mastectomy skin flap perfusion.46 Thus
the correction is often necessary because of a purposefully
Fig. 39.5 (a) This patient had a history of radiation on the right breast and underwent bilateral mastectomies with bilateral gluteal artery
perforator flap reconstructions. The right side was subsequently smaller and higher than the left. (b) Result after revision with right high-
volume fat grafting and left refinement of the skin envelope.
a
b

673
Chapter 39 Breast Reconstruction with Autologous Tissue
Nipple–Areola Complex Reconstruction
After re-creation of the breast mound with autologous
breast reconstruction, many women opt to re-create the
NAC as a final step in restoring body image. It is very com­
mon for patients to feel asymmetrical and dissatisfied with
their reconstruction until they are healed from NAC recon­
struction. NAC reconstruction not only hides some scar­
ring, it also serves as a visual distraction from the remain­
ing scar that is not hidden. Although some patients forgo
reconstruction, we actively encourage them to at least con­
sider tattooing.
Traditional techniques have included grafting from skin,
buccal mucosa, labia minora or majora, thigh, buttocks,
groin, upper eyelids, or earlobes. Regardless of the technique,
the principles remain the same: to provide color, texture,
size, and projection that are all in line with the patient’s aes­
thetic wishes. The most common method used today con­
sists of local skin flap rearrangement to create texture and
projection followed by tattooing for color (Figs. 39.7–39.9).
NAC reconstruction in most cases is performed more
than 3 to 4 months after mound reconstruction and can be
paired with other revision surgery, as previously discussed.
This delayed timing allows for complete healing of the flap
and ensures stable mound symmetry, which is a key prereq­
uisite before re-creating an NAC. Immediate NAC re-creation
be left small to avoid implant malposition. From a technical
standpoint, we prefer to place implants in a submuscular
plane. This avoids any concern about dissecting the pedicle
off of the muscle and places the implant into an unoperated
tissue plane. When the internal mammary vessels are used
for a recipient site, they are usually far enough away from
the pocket created to avoid injury. Access to the submuscu­
lar plane may be achievable through existing scars, but a
standard inframammary fold incision is generally the best
approach and one that allows for excellent exposure, ease
of dissection, and placement of the implant itself.
Balancing Mastopexy and Reduction
In general, lifting or reduction techniques should follow
standard techniques such as vertical or Wise-pattern skin
resections with standard pedicle design. That being said, the
goal is to match the reconstructed side, not necessarily per­
form the standard technique used elsewhere. For instance,
a standard vertical mastopexy with a superior pedicle is
often performed by tucking the central pillar underneath
the NAC to add central projection and create a more coned,
youthful breast. Often a reconstructed breast with a free
flap lacks this coned effect. If a patient is happy with the re­
constructed side and just wants balance, then avoiding the
central coning with the mastopexy is beneficial.
Fig. 39.6 (a) This patient had right breast cancer with preexisting asymmetry. (b) After a right deep inferior epigastric perforator flap pro­
cedure the right side was larger, but the patient preferred this side to her native left side. (c) After revision with right nipple–areola complex
reconstruction and a left augmentation with a submuscular implant. She would likely benefit from a left circumareolar mastopexy, but she
does not want additional scars. She is overall very happy with the volumetric correction.
a
b
c
Fig. 39.7 (a) Preoperative view of a patient in need of a bilateral mastectomy. (b) Final result after bilateral free flaps from the abdomen,
followed by bilateral nipple–areola complex reconstruction and tattooing.
a
b

SECTION V THE BREAST
674
A
B
Pedicle base
C
A
B
C
A
B
C
A
B
C
Deepithelialized tissue
Deepithelialized tissue
Fig. 39.8 A standard circumvertical flap for nipple
reconstruction.
Island
Island
C
A
B
Island
Island
Pedicle
Discard
Periareolar
incision
Dermal
purse-string
suture
A
C
B
Island
Island
A
C
B
Fig. 39.9 A double-opposing island flap for nipple reconstruction. The opposing islands have been brought together and the outer diameter
has been decreased with a purse-string suture in the deep dermis to obliterate the donor site of the central flap.

675
Chapter 39 Breast Reconstruction with Autologous Tissue
ity into the preperitoneal space. This may end up being
above or below the rectus muscle; either are acceptable.
The mesh is sewn into place in this plane and the fascia
is closed over the top. If necessary, release of the external
oblique muscles laterally via component separation allows
for midline advancement of the fascia.
The Dissatisfied Patient
As mentioned earlier, not all reasons for dissatisfied pa­
tients are avoidable. Sometimes a patient’s dissatisfaction
is warranted and other times it is not. One major benefit
of autologous reconstruction over implant reconstruction
is that autologous tissue behaves much more naturally
with time. As a result, patients typically become happier
with their reconstruction as the years pass.5 That being
said, some patients return for multiple revisions. Planned
staged fat grafting is one example that can be predictably
necessary and incredibly powerful. When large volumetric
changes are required, three to five fat grafting sessions are
commonly needed. When unplanned multiple revisions
are sought by a patient, the surgeon generally needs to
consider the curve of diminishing returns. Although cancer
patients often have a much more reasonable aesthetic goal
than the typical cosmetic patient, some patients occasion­
ally have persistent complaints about their results. The sur­
geon should approach these patients with caution, always
considering whether the surgeon and patient both agree on
any deformity and whether surgery is likely to be successful
in correcting the problem. Mastectomy and reconstruction
can have a profound effect on self-image, and sometimes
purposefully drawing out the interval between revisions
allows not only for physical evolution of the reconstruction,
but psychological adjustment of the patient to the surgery.
During the wound-healing period and subsequent process,
however, the surgeon should see the dissatisfied patient
frequently to help reassure her that the surgeon is listening.
Like all surgery, if persistent revision does not yield patient
satisfaction, referral for a second opinion can offer either a
fresh approach or, at the very least, peace of mind for the
patient that nothing more should be done.
Conclusion
Autologous breast reconstruction has become more com­
mon in major centers despite the preference for implant
reconstruction nationwide. Free flap reconstruction has
largely replaced pedicled TRAM reconstruction (except in
small community hospitals) because the complication pro­
file has diminished significantly with microsurgery and the
techniques have improved with time. That being said, the
key to developing a successful program and sustaining its
growth is avoiding the major complications as best as pos­
sible and handling the smaller complications well. Compli­
cations are inevitable in surgery, but experience has shown
that major complications after free flap reconstruction are
rare and largely avoidable and small complications can al­
most all be managed with time, proper assessment, and a
variety of well-established methods.
at the time of the flap procedure has been reported but is by
far less common. It should also be noted that although mas­
tectomy has classically included excision of the native NAC,
there has been an increasing interest and study of the safety
and efficacy of nipple-sparing mastectomy.
Delayed Wound Healing
The most common donor site for free flap breast recon­
struction is the lower abdomen. Although most patients
heal well and are happy with their donor site, two com­
mon problems can arise. Delayed wound healing of the
central abdomen is unfortunately a fairly common com­
plication, likely a result of tension or low-grade ischemia
related to perfusion and/or comorbidities. Although small
areas are easily treated with wet-to-dry dressing changes,
sometimes large dehiscence occurs. Débridement with
vacuum-assisted closure is a useful adjunct; however, early
secondary revision and closure has been shown to be safe
and perhaps is a faster way to achieve completely closed
wounds.25 Regardless of duration of healing, the tension on
this wound can lead to fat necrosis and widened scars. Re­
vision of these scars should be undertaken only after the
scar has stabilized and the soft tissue is lax enough to allow
for excision and reclosure without overt tension.
Dog-ear deformities are not uncommon. Although the
surgeon should make every effort to prevent this complica­
tion, sometimes adequate exposure to the far lateral flank at
the time of free flap harvest is limited. Dog-ear excision and
liposuction of the flanks can help improve lateral contour.
Donor site revision can often be performed at the same time
as breast mound revision or NAC reconstruction.
Hernia or Bulge
The hernia that can arise in the abdominal donor site is not
often addressed, but it can be very challenging to correct
and thus is worth discussing. The most common site for
hernia formation is below the arcuate line. Above this line,
the posterior sheath is not violated in the flap harvest and
still has significant strength to possess little risk of hernia
over time. Below the arcuate line, all of the strength layers
of the abdominal fascia are anterior to the rectus muscles
and thus by definition are all violated in a DIEP/MSFTRAM
harvest (see Fig. 39.1). The fascia is universally attenuated
in these hernias; thus primary closure of the hernia de­
fect would lead to unsatisfactory repair and placement of
mesh is a universal tenet. Although biologic mesh plays a
significant role in contaminated wounds, to date little or no
evidence supports their use over permanent mesh in clean
wounds, especially given their high cost.49,50 We therefore
recommend synthetic permanent mesh. If mesh was placed
at the time of original donor site closure, this is usually re­
moved and a new piece used for hernia repair. Because the
hernia defect is commonly under or near the skin incision,
placing any underlay with complete fascial coverage allows
for a two-layered strength closure and complete coverage
of the mesh. The hernia is easily approached via the exist­
ing transverse scar. The hernia sac is dissected in continu­

SECTION V THE BREAST
676
gastric perforator flap breast reconstruction. Arch Plast
Surg 2014;41(1):63–70
19. Selber JC, Nelson J, Fosnot J, et al. A prospective study com­
paring the functional impact of SIEA, DIEP, and muscle-
sparing free TRAM flaps on the abdominal wall: part I. uni­
lateral reconstruction. Plast Reconstr Surg 2010;126(4):
1142–1153
20. Selber JC, Fosnot J, Nelson J, et al. A prospective study com­
paring the functional impact of SIEA, DIEP, and muscle-
sparing free TRAM flaps on the abdominal wall: part II,
bilateral reconstruction. Plast Reconstr Surg 2010;126(5):
1438–1453
21. Selber JC, Samra F, Bristol M, et al. A head-to-head com­
parison between the muscle-sparing free TRAM and the
SIEA flaps: is the rate of flap loss worth the gain in abdom­
inal wall function? Plast Reconstr Surg 2008;122(2):348–
355
22. Holm C, Mayr M, Höfter E, Ninkovic M. The versatility of
the SIEA flap: a clinical assessment of the vascular terri­
tory of the superficial epigastric inferior artery. J Plast Re­
constr Aesthet Surg 2007;60(8):946–951
23. Holm C, Mayr M, Höfter E, Raab N, Ninkovic M. Interindi­
vidual variability of the SIEA Angiosome: effects on op­
erative strategies in breast reconstruction. Plast Reconstr
Surg 2008;122(6):1612–1620
24. Butler PD, Nelson JA, Fischer JP, et al. African-American
women have equivalent outcomes following autologous
free flap breast reconstruction despite greater preopera­
tive risk factors. Am J Surg 2015;209(4):589–596
25. Mirzabeigi MN, Wilson AJ, Fischer JP, et al. Predicting and
managing donor-site wound complications in abdomi­
nally based free flap breast reconstruction: improved out­
comes with early reoperative closure. Plast Reconstr Surg
2015;135(1):14–23
26. Cavichio BV, Pompeo DA, Oller GA, Rossi LA. [Duration of
smoking cessation for the prevention of surgical wound
healing complications]. Rev Esc Enferm USP 2014;48(1):
174–180
27. Pluvy I, Panouillères M, Garrido I, et al. Smoking and plastic
surgery, part II. Clinical implications: a systematic review
with meta-analysis. Ann Chir Plast Esthet 2015;60(1):
e15–e49
28. Pluvy I, Garrido I, Pauchot J, et al. Smoking and plastic
surgery, part I. Pathophysiological aspects: update and
proposed recommendations. Ann Chir Plast Esthet 2015;
60(1):e3–e13
29. Gurtner GC, Jones GE, Neligan PC, et al. Intraoperative
laser angiography using the SPY system: review of the
literature and recommendations for use. Ann Surg Innov
Res 2013;7(1):1
30. Butler PD, Wu LC. Abdominal perforator vs. muscle spar­
ing flaps for breast reconstruction. Gland Surg 2015;4(3):
212–221
31. Jones GE. Bostwick’s Plastic and Reconstructive Surgery.
3rd ed. Thieme Publishing Group; 2010
32. Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM,
Wu LC. Free flap take-back following postoperative mi­
crovascular compromise: predicting salvage versus fail­
ure. Plast Reconstr Surg 2012;130(3):579–589
33. Nelson JA, Fischer JP, Grover R, et al. Vein grafting your
way out of trouble: examining the utility and efficacy of
vein grafts in microsurgery. J Plast Reconstr Aesthet Surg
2015;68(6):830–836
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3. Guyomard V, Leinster S, Wilkinson M. Systematic review
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6. Selber JC, Kurichi JE, Vega SJ, Sonnad SS, Serletti JM. Risk
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7. Greco JA III, Castaldo ET, Nanney LB, et al. Autologous
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19–28
9. Ribeiro DD, Lijfering WM, Barreto SM, Rosendaal FR,
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12. Wang TY, Serletti JM, Cuker A, et al. Free tissue transfer
in the hypercoagulable patient: a review of 58 flaps. Plast
Reconstr Surg 2012;129(2):443–453
13. Nelson JA, Chung CU, Bauder AR, Wu LC. Prevention of
thrombosis in hypercoagulable patients undergoing mi­
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constr Aesthet Surg 2017;70(3):307–312
14. Fosnot J, Fischer JP, Smartt JM Jr, et al. Does previous chest
wall irradiation increase vascular complications in free
autologous breast reconstruction? Plast Reconstr Surg
2011;127(2):496–504
15. Moran SL, Nava G, Behnam AB, Serletti JM. An outcome
analysis comparing the thoracodorsal and internal mam­
mary vessels as recipient sites for microvascular breast
reconstruction: a prospective study of 100 patients. Plast
Reconstr Surg 2003;111(6):1876–1882
16. Khansa I, Momoh AO, Patel PP, Nguyen JT, Miller MJ, Lee
BT. Fat necrosis in autologous abdomen-based breast re­
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17. Man LX, Selber JC, Serletti JM. Abdominal wall following
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44. Garza RM, Paik KJ, Chung MT, et al. Studies in fat grafting:
Part III. Fat grafting irradiated tissue—improved skin qual­
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45. Hallock GG. Liposuction for debulking free flaps. J Recon­
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46. Lin IC, Bergey M, Sonnad SS, Serletti JM, Wu LC. Manage­
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607, discussion 607
34. Pannucci CJ, Nelson JA, Chung CU, et al. Medicinal leeches
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38. Rohrich RJ, Sorokin ES, Brown SA. In search of improved
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39. Small K, Choi M, Petruolo O, Lee C, Karp N. Is there an ide­
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40. Ozsoy Z, Kul Z, Bilir A. The role of cannula diameter in im­
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Discussion by Adrian S.H. Ooi and David H. Song
Autologous tissue remains the gold standard for re­
construction of postmastectomy defects. Although im­
plant-based reconstruction remains the more common
method, it does not give the versatility, feel, texture,
shape, and longevity that autologous tissue does.1 In ad­
dition, the recruitment of fresh, well-vascularized tissue
to an area that has been or will be irradiated helps to
mitigate some of the negative effects of radiation over
time.2 However, as with any operation, the key to a good
outcome begins with the awareness and avoidance of
complications. If they do occur, the surgeon must be
readily equipped to deal with them.
Preoperative Optimization
Any successful procedure begins with adequate pre­
operative assessment (Table 39D.1). By taking an ap­
propriate history and asking targeted questions, po­
tential intraoperative and postoperative problems can
be avoided or planned for. These include a history of
chemotherapy or radiation therapy, smoking, hyperco­
agulable states, and any other conditions that may lead
to poor wound healing. Each of these should be indi­
vidually addressed. For patients who smoke, we will
not perform breast reconstruction unless they have not
used any tobacco for at least 4 weeks. For patients with
diabetes, adequate blood sugar control must be demon­
strated. Patients should be referred to appropriate spe­
cialists such as an endocrinologist or hematologist as
necessary, because adequate nutrition and blood sugar
control help with healing. Any patient with suspected
coagulation problems should receive targeted care to
reduce the risk of postoperative bleeding, deep vein
thrombosis (DVT), or flap thrombosis.3,4 For patients
without contraindications, prophylactic low-molecu­
lar-weight heparin (LMWH) and calf compression de­
vices should be used for DVT prophylaxis.
A thorough physical examination that focuses on
achieving an aesthetically pleasing breast while min­
imizing donor site morbidity should be performed.
For the breast recipient site, key points should include
skin envelope quality, nipple and inframammary fold
(IMF) position, and measurements of breast base width
and height. In immediate reconstructive cases, this is
straightforward. In delayed unilateral cases, the con­
tralateral breast can be used as a template. In delayed
bilateral reconstructive cases, premastectomy pictures
can help, but the patient should be aware that the aim is

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678
Table 39D.1 Targeted points in the history and physical examination for a
patient undergoing autologous breast reconstruction
History
Physical examination
Disease-specific
Oncological history
Radiation
Chemotherapy
Past medical history
Hypercoagulable states
Hypertension
Diabetes mellitus
Long-term steroid use
Past surgical history
Abdominal and pelvic surgery
Cesarean sections
Abdominal liposuction
Personal history
Smoking
Social status
Recipient site
Skin quality
Radiation changes
Inframammary fold
Breast height and base width
Ptosis
Body or breast asymmetry
Contralateral breast
Donor site
Scars
Contour irregularities
Preexisting bulge or hernia
Adequate donor tissue
Ability to close donor site without tension
to achieve symmetry and aesthetically pleasing breasts
that may not be the same as her premastectomy appear­
ance.
Potential donor sites for autologous breast recon­
struction should then be assessed. The abdomen is our
first choice, but if it cannot be used because of inade­
quate tissue or prohibitive scars, other donor sites that
should be examined include the buttock, inner thigh,
and back. Specifically, for the abdomen, midline and
lower abdominal scars should be noted, such as open
appendectomy and cesarean section incisions. Midline
scars eliminate the possibility of using tissue across
the midline without a bipedicled or turbocharged flap,
whereas lower abdominal scars can affect flap vascu­
larity and use of the superficial system. The abdominal
pannus should be assessed with the patient in a stand­
ing position as well as with the hips flexed to simulate
abdominal closure without tension. Any preexisting ab­
dominal hernias or diastasis should be noted, and plans
should be made to address these during the operation.
Timing of Reconstruction
The timing of reconstruction has an important effect on
outcomes. Most of our flaps are planned and executed
in an immediate fashion in concert with the ablative
surgeon. This tends to provide the optimal aesthetic
result when a skin- or nipple-sparing mastectomy is
performed. However, when a patient is to receive adju­
vant radiation therapy, we tend to perform our autolo­
gous breast reconstructions in a delayed setting. This is
determined by a premastectomy sentinel node biopsy
to verify whether a patient has extended disease into
the axillary lymph node basin, thus necessitating ra­
diation. A delayed reconstruction allows for insetting
of a flap in more or less its most aesthetically pleasing
final shape and position, avoiding the negative effects
of radiation on flap and native breast tissue and also
bringing in a fresh blood supply to a radiated, scarred
area, which aids in healing.
Informed Consent
All through the preoperative process, the patient
should be kept informed of the options and risks and be
actively involved in the decision-making process, with
clear documentation. Transparency and attentiveness
go a long way to reducing any misgivings postopera­
tively, and the patient should be given active control of
her care. Allowing the patient to communicate with a
well-trained breast reconstructive nurse, counselor, or
even another patient who had undergone a similar pro­
cedure can help. Before and after photographs of other
patients also help to set expectations to a realistic level.

679
Chapter 39 Breast Reconstruction with Autologous Tissue
Algorithmic Approach
Once the patient’s situation has been optimized for
the operation both medically and psychologically, we
proceed with an algorithmic approach to autologous
breast reconstruction (Fig. 39D.1). We rarely perform
preoperative imaging, because this adds yet another
procedure and cost to the operation and confers very
little benefit. Our first choice for donor site is the ab­
domen, but if this not available we consider other free
flaps such as the superior or inferior gluteal artery per­
forator or vertical or transverse upper gracilis flaps.5
The vertical upper gracilis (VUG) flap is our preferred
secondary choice if the abdominal donor site is inad­
equate (Fig. 39D.2). The vertical orientation allows for
capture of more perforators from the medial circumflex
system and provides a more aesthetically pleasing do­
nor site than the traditional transverse upper gracilis
(TUG) flap6 (Fig. 39D.3). If these options are exhausted
or inadequate or the patient desires otherwise, we con­
sider a pedicled thoracodorsal artery perforator flap
with subpectoral implant. This discussion focuses on
minimizing negative outcomes using abdominal tissue.
Fig. 39D.1 Algorithm for autologous breast reconstruction. DIEP, Deep inferior epigastric artery perforator flap; IGAP, inferior
gluteal artery perforator flap; MS-TRAM, muscle-sparing transverse rectus abdominis myocutaneous flap; PAP, profunda artery
perforator flap; SGAP, superior gluteal artery perforator flap; SIEA, superficial inferior epigastric artery; SIEV, superficial inferior
epigastric vein; TDAP, thoracodorsal artery perforator flap; TUG, transverse upper gracilis flap; VUG, vertical upper gracilis flap.
Yes
No
Adequate
abdominal
tissue?
Yes
No
Bilateral
reconstruction?
Two
unipedicled
free flaps
Yes
No
Tissue across
midline
required?
Bipedicled
free flap
Unipedicled
free flap
Bipedicled
free flap
Unipedicled
free flap
Yes
No
Flap zone IV
required?
Yes
No
Midline
abdominal
scar?
DIEP
MS-TRAM
Bipedicled
free flap
Unipedicled
free flap
Yes
No
Dominant
perforator
palpable?
Yes
No
Tissue across
midline
required?
SGAP, IGAP,
TUG, VUG,
PAP
TDAP with
implant
Yes
No
SIEA palpable
and SIEV
> 1.5 mm?
Yes
No
Desires free
flap?

SECTION V THE BREAST
680
Abdominal Donor Site
The patient is marked in a standing position and the
midline of the anterior trunk is noted (Video 39D.1).
We mark the inferior line of the abdominal incision
lower than most surgeons, approximately 3 to 5 cm
above the mons, incorporating any old scar. This allows
for a postoperative scar hidden lower in the bikini line
and offers the benefit of encountering the superficial
inferior epigastric artery (SIEA) at a larger caliber be­
fore its arborization. Two factors determine the height
of the flap: breast base width must be balanced with
the ability to close the donor site in a flexed position
with relatively little tension to minimize healing prob­
lems. If the height of the flap (correlation with the base
width of the reconstructed breast) is greater than skin
closure will allow, the skin is spared while additional
Fig. 39D.2 (a–c) This 34-year-old patient underwent pedicled transverse rectus abdominis myocutaneous flap reconstruction of
the left breast followed by radiation therapy. (d–f) After free vertical upper gracilis flap reconstruction for contour deformity and
secondary fat injection of 150 cc.
a
b
c
d
e
f
Fig. 39D.3 Vertical upper graci­
lis flap donor site scar.

681
Chapter 39 Breast Reconstruction with Autologous Tissue
flap subcutaneous tissue is captured. Skin above the
umbilicus is rarely if ever harvested with the flap, fur­
ther minimizing superior migration of the donor site
scar.
When raising the flap, the aim is to minimize dis­
ruption of abdominal wall fascia while maximizing per­
fusion of the flap. The lower abdominal incision is made
first to search for an adequate SIEA. If its pulse is palpa­
ble and an accompanying superficial inferior epigastric
vein (SIEV) larger than 1.5 mm is found, we immediately
proceed with the SIEA flap.7 For pure single-pedicle SIEA
flaps, we do not use tissue across the abdominal midline.
If this is required, we perform a bipedicled free flap. Re­
gardless of whether an SIEA flap is performed, we dis­
sect the medially positioned SIEV long to be used as a
second outflow tract or as a vein graft if required. If a
simultaneous vascularized lymph node transfer is to be
performed, the fat and lymphatic tissue surrounding the
superficial inferior epigastric vessels can be harvested
and placed in the axilla.8
If the SIEA is inadequate, we proceed to identify ap­
propriate deep inferior epigastric perforators (DIEP).
Again, palpability of the perforator is our criteria for use.
If possible we include two or more perforators with the
flap, especially if they are in the same row, and perform
a muscle-sparing transverse rectus abdominis myocu­
taneous (MS-TRAM) flap to recruit multiple perforators
if adequate perforators are not found in the same row.
This philosophy has been proven to minimize fat necro­
sis and partial flap loss.9,10 If tissue across the midline
is to be used, we prefer medial row perforators, and if
tissue from zone IV (distal zones) needs to be used or a
midline scar is present, we do not hesitate to perform
a bipedicled flap. Following this algorithm, we have not
found any need to convert to a pedicled transverse rec­
tus abdominis myocutaneous (TRAM) flap.
Careful and considered abdominal donor site clo­
sure minimizes morbidity. The literature is replete with
data showing minimal difference in donor site complica­
tions between the SIEA, DIEP, and MS-TRAM flaps.11,12
The SIEA flap donor site is ideal, because fascia is not
breached. Still, plication of the rectus muscle with in­
terrupted nylon can be done in patients with preexist­
ing rectus diastases. For DIEP flaps and MS-TRAM flaps,
we find primary two-layer closure with interrupted
followed by continuous nylon leads to very little donor
site bulge and negates the need for mesh repair. In our
practice, an inlay nylon mesh repair is rarely done and
only if a large fascial defect is present after flap harvest
in the presence of excessive tension or displacement of
the umbilicus. We place a percutaneous topical anes­
thetic pain pump within the rectus fascia to help with
postoperative pain control.
For the skin closure, the patient’s hips are flexed
until the upper and lower skin flaps can be brought to­
gether without tension over a single suction drain. The
edges are first approximated using staples, gathering
the upper skin flap medially compared with the lower
skin flap to minimize unsightly dog-ears at the lateral
abdominal scar. Once this is done, the Scarpa’s fascia is
sutured with interrupted absorbable polyfilament, and
the dermis is closed with continuous subcuticular ab­
sorbable barbed suture. The umbilicus is brought out
through an incision of choice at its natural level, ensur­
ing its position in the previously marked abdominal
midline. Care must be taken to ensure no twisting of
the umbilical stalk and a wide enough skin incision to
prevent umbilical necrosis.
Recipient Site Preparation,
Microanastomosis, and Inset
Recipient site preparation is key to allowing for ease
of microanastomosis and flap inset while minimizing
secondary deformities or asymmetry after reconstruc­
tion. In a primary reconstruction, the pocket is often
determined by the resecting surgeon. Communication
points between the resecting and reconstructive teams
should include scar placement and preservation of the
IMF, axillary vessels, and internal mammary vessels. If
oncologic clearance creates a wider than ideal pocket,
positioning sutures can be used but should be kept to a
minimum to avoid inadvertently compressing parts of
the flap and causing fat necrosis.
In a secondary reconstruction, the reconstructive
surgeon is in control of the breast pocket. Preopera­
tively, the IMF and breast pocket should be marked and
matched to the nondiseased breast. If this is not evident,
as in a delayed bilateral reconstruction, the midpoint of
the humerus is used as a guide for the position of the
IMF. This should also be the point of maximal projection
of the eventual reconstructed breast. It is important to
note that if a previous implant or expander was in situ,
or in the presence of preoperative radiation, there may
be a slight concavity of the chest wall as a result of car­
tilage warping, which may lead to more tissue being re­
quired to fill the pocket. Moreover, if a subpectoral im­
plant or expander needs to be removed, the pectoralis
major muscle is dissected free from the skin and sutured
back to the chest wall to restore normal anatomy.
The previous mastectomy scar is excised and sent
for histopathological examination to confirm clearance
from tumor recurrence. The inferior chest flap is dis­
sected thin, just beneath the dermis, leaving the sub­
cutaneous fat on the chest wall. The reverse is done for
the superior chest flap, raising the subcutaneous fat off
the pectoralis muscle together with the skin. This move
allows for shaping of the lower pole of the breast accord­
ing to how the abdominal flap sits to give it a smooth
contour; keeping fat on the superior skin helps with

SECTION V THE BREAST
682
masking upper pole deflation, a common problem af­
ter reconstruction. Any scar in the axilla should be re­
leased, because this can aid in reducing postoperative
lymphedema and allows for placement of lymph nodes
if planned.13
A decision should then be made regarding the re­
cipient vessels. Our preferred recipient vessels are, in
order of preference:
1. Internal mammary (IM) perforator
2. Rib-sparing IM vessels (if more than 2 cm of inter­
costal space is available)
3. IM vessels with removal of costal cartilage
4. Axillary vessels
For the IM system, the third interspace is preferable,
because the vessels are more horizontally oriented and
easier microanastomosis is possible. We use a number
of techniques to prevent injury to the vessels. In rib re­
moval, we cut through the perichondrium and remove
the cartilage before using sharp dissection to carefully
peel the perichondrium off the IM vessels. Around the
IM vessels, we minimize cautery and use micro-hemo­
clips for any branches. The recipient artery should be
cut and robust flow should be noted before the anas­
tomosis.
The flap pedicle is only ligated from its origin once
the recipient vessels have been fully prepared. It is
placed on the chest wall in its rough final position, de­
pending on whether an ipsilateral or contralateral flap
is used, with no twisting of the pedicle, and secured to
the skin with staples. We prefer a pedicle positioned
with a gentle curve on the chest wall, with care taken
to ensure there is no kinking by the remnant rib. Micro­
anastomosis is then performed with a venous coupler
and interrupted sutured artery. If a bipedicled free flap
is used, the second vascular pedicle is anastomosed to
the retrograde IM vessels. The flap is then tucked onto
the pocket and unnecessary skin is deepithelialized un­
der visualization by retraction of breast skin. With expe­
rience, partial deepithelialization can be done with the
flap in situ at the abdomen. These moves all minimize
the risk of pulling apart the anastomosis. Closure of the
breast pocket to the flap is then done with minimal po­
sitioning dermal sutures to allow for flap edema without
compression and continuous subcuticular absorbable
skin sutures.
Postoperative Protocol
By following the appropriate preoperative steps and
operative algorithm, we have had very high success
rates with autologous tissue reconstruction without
the need for secondary procedures. However, vigilant
postoperative monitoring and close follow-up after dis­
charge is still important.
In the immediate postoperative period, our favored
methods of monitoring an exposed flap skin paddle is
by clinical examination and by the use of near-infrared
spectroscopy (NIRS—the ViOptix system). This system
essentially measures the balance of oxygenated and de­
oxygenated hemoglobin in the blood flowing through
the surface of the flap. Although the initial readings vary
from patient to patient, guidelines have been set regard­
ing the trend of arterial or venous occlusion, and it has
been shown to be extremely sensitive and specific for
flap perfusion problems, enabling early take back if re­
quired.14,15 An added bonus is that it can be monitored
remotely from a mobile device for convenience. Once
there is any clinical or NIRS evidence of flap perfusion
problems, the attending surgeon and on-call resident or
fellow sees the flap within the hour and makes a deci­
sion for immediate operative exploration as necessary.
It is imperative that any compromised flap be
brought back to the operating room within 2 hours of
detection of compromise. Isolated arterial or venous
thrombosis is usually salvageable, but a combined arte­
rial and venous thrombosis has a very poor prognosis.
A bolus of 5,000 units of heparin is given as a one-off
dose. We do not routinely use thrombolytics. If a flap is
compromised, it is more likely a vein problem than the
artery. Our preferred management of venous thrombosis
is to use a cephalic vein turndown and bring in a virgin
venous recipient system. This is easily done by finding
the cephalic vein in the deltopectoral groove and dis­
secting distally into the arm. Our secondary choice for
venous outflow is an external jugular vein turndown.
For this a small counter incision in the ipsilateral neck
is required, and the vein is readily identified and turned
down. Secondary arterial revisions involve a more ceph­
alad dissection of the IM artery by removing the second
costosternal cartilaginous junction.
Postoperatively the patient should be kept hydrated
with a good urine output and pain kept to a minimum.
If the patient is stable after the first 12 hours, she may
eat and drink, sit out of bed, and ambulate as tolerated,
gradually standing straight from a flexed position. We
typically recover the patient on a routine surgical ward
and discharge our patients on the third to fourth post­
operative day with a gentle compression bra and 1 week
of oral antibiotics.
Secondary Procedures
Long-term follow-up is imperative to ensure holistic
patient outcomes. We have given a comprehensive
guide to addressing most of the postdischarge prob­
lems. We consult with the patient at 1 week, 1 month,

683
Chapter 39 Breast Reconstruction with Autologous Tissue
Conclusion
Autologous microsurgical breast reconstruction is the
gold standard and our primary choice for postmastec­
tomy breast reconstruction. When performed appro­
priately, success rates should border on 100%, it results
in a breast that looks and feels natural, and it avoids the
pitfalls of implants and lasts a patient’s lifetime. The
key tenets of avoiding pitfalls and complications can be
summarized into four areas (Table 39D.2):
1. Targeted preoperative assessment
2. A clear algorithmic operative approach
3. Vigilant postoperative monitoring and intervention
as necessary
4. Follow-up and ambulatory surgery touch-ups if
required
Following these tenets leads to high patient and sur­
geon satisfaction with minimal morbidity.
and 3 months postoperatively. Any issues with wound
healing, seroma, and hematoma can be addressed at
the initial visits, and additional visits can be arranged
as required. Small areas of wound dehiscence at the
breast or abdominal donor site can be managed by lo­
cal wound care, whereas larger wounds may require
operative intervention, which should be performed
early if possible. At the third month, when postopera­
tive healing is close to stabilizing, the patient can be as­
sessed for the need for revision procedures. Although
prevention is better than cure, there is an occasional
need to perform these. The most common complaints
include upper pole concavity, asymmetry, and fat ne­
crosis. Most cases of the former two can be addressed
by a combination of fat grafting, skin excision, or con­
tralateral balancing procedures. An implant is rarely, if
ever, required. Small areas (smaller than 2 cm) of fat
necrosis can be left to liquefy and resorb, but larger
areas (larger than 2 cm) of hardening should be fol­
lowed up closely and excised if nonresolving to pre­
vent infection.
Table 39D.2 Pearls and pitfalls for autologous breast reconstruction
Pearls
Pitfalls
Preoperative assessment
Perform markings with patient
standing up.
Missing an existing coagulation
problem
Operative approach
An algorithmic approach minimizes
surprises.
Wide exposure of the recipient vessels
enables easier microanastomosis.
Chest wall deformities caused by
implants or radiation
Twisting and kinking of the pedicle
during inset
Postoperative monitoring
Use near-infrared spectroscopy
(NIRS).
Waiting too long before operative
intervention for vascular
compromise
Long-term follow-up
Allow 3 months for postsurgical
healing to set in before
performing secondary procedures.
Ignoring large areas of nonresolving
fat necrosis
References
1. Basta MN, Gerety PA, Serletti JM, Kovach SJ, Fischer JP.
A systematic review and head-to-head meta-analysis
of outcomes following direct-to-implant versus con­
ventional two-stage implant reconstruction. Plast
Reconstr Surg 2015;136(6):1135–1144
2. Chang DW, Barnea Y, Robb GL. Effects of an autolo­
gous flap combined with an implant for breast re­
construction: an evaluation of 1000 consecutive re­
constructions of previously irradiated breasts. Plast
Reconstr Surg 2008;122(2):356–362
3. Chang EI, et al. Comprehensive evaluation of risk fac­
tors and management of impending flap loss in 2138
breast free flaps. Ann Plast Surg 2016;77(1):67– 71
4. Wang XL, Liu LB, Song FM, Wang QY. Meta-analysis of
the safety and factors contributing to complications
of MS-TRAM, DIEP, and SIEA flaps for breast recon­
struction. Aesthetic Plast Surg 2014;38(4):681–691
5. Yu SC, Kleiber GM, Song DH. An algorithmic approach
to total breast reconstruction with free tissue trans­
fer. Arch Plast Surg 2013;40(3):173–180
6. Park JE, Alkureishi LWT, Song DH. TUGs into VUGs
and friendly BUGs: transforming the gracilis territory

SECTION V THE BREAST
684
into the best secondary breast reconstructive option.
Plast Reconstr Surg 2015;136(3):447–454
7. Dorafshar AH, Januszyk M, Song DH. Anatomical and
technical tips for use of the superficial inferior epi­
gastric artery (SIEA) flap in breast reconstructive sur­
gery. J Reconstr Microsurg 2010;26(6):381–389
8. Nguyen AT, Chang EI, Chang DW. Simultaneous vas­
cularized lymph node transfer with microvascular
breast reconstruction. Plast Reconstr Surg 2013;132
(4S-1):22
9. Baumann DP, Lin HY, Chevray PM. Perforator num­
ber predicts fat necrosis in a prospective analysis of
breast reconstruction with free TRAM, DIEP, and SIEA
flaps. Plast Reconstr Surg 2010;125(5):1335–1341
10. Grover R, Nelson JA, Fischer JP, Kovach SJ, Serletti JM,
Wu LC. The impact of perforator number on deep in­
ferior epigastric perforator flap breast reconstruction.
Arch Plast Surg 2014;41(1):63–70
11. Selber JC, Nelson J, Fosnot J, et al. A prospective study
comparing the functional impact of SIEA, DIEP, and
muscle-sparing free TRAM flaps on the abdominal
wall: part I, unilateral reconstruction. Plast Reconstr
Surg 2010;126(4):1142–1153
12. Selber JC, Fosnot J, Nelson J, et al. A prospective study
comparing the functional impact of SIEA, DIEP, and
muscle-sparing free TRAM flaps on the abdominal
wall: part II, bilateral reconstruction. Plast Reconstr
Surg 2010;126(5):1438–1453
13. Nguyen AT, Chang EI, Suami H, Chang DW. An al­
gorithmic approach to simultaneous vascularized
lymph node transfer with microvascular breast re­
construction. Ann Surg Oncol 2015;22(9):2919–2924
14. Keller A. A new diagnostic algorithm for early predic­
tion of vascular compromise in 208 microsurgical
flaps using tissue oxygen saturation measurements.
Ann Plast Surg 2009;62(5):538–543
15. Pelletier A, Tseng C, Agarwal S, Park J, Song D.
Cost analysis of near-infrared spectroscopy tis­
sue oximetry for monitoring autologous free tis­
sue breast reconstruction. J Reconstr Microsurg
2011;27(8):487–494

S E C T I O N V I
Pediatric and
Craniofacial Surgery

Head of a figurine, Corinth, Greece, 4th century BC.
(Stillwell, R. Corinth II. The Theatre, ASCSA, 1952. American School of Classical Studies
at Athens [ASCSA]. Photo: Petros Dellatolas. ASCSA Corinth Excavations.)

687

Cleft Lip and Cleft Palate
Mimis N. Cohen
CHAPTER
40
Patients born with cleft lip and/or palate require the care of
several specialists and a number of surgical procedures and
other interventions, from infancy to adulthood, to achieve
total habilitation and have the opportunity to live normal
and productive lives. The goals for habilitation include nor­
malization of facial appearance and functions including
improvements in soft tissues as well as skeletal, dental, and
occlusal relations. Speech, hearing, and psychosocial issues
are also addressed and managed.
The need for multidisciplinary management using com­
prehensive protocols designed to address each patient’s mul­
tiple and complex needs has been well recognized, and the
role of the team approach has become the gold standard of
cleft care. Members are responsible for the longitudinal eval­
uation and coordinated care and provide for regular interac­
tive encounters between all necessary professionals repre­
senting a variety of disciplines. They meet to communicate,
collaborate, and consolidate knowledge.
Extensive initial evaluation plans are made for immedi­
ate and future care based on each patient’s individual needs
and the team’s treatment protocols. A prime responsibility
of each team also includes careful record keeping. Collected
data are studied and analyzed periodically to fully appreciate
the outcome of protocols and surgical procedures, identify
possible drawbacks, and modify or improve them as needed.1
Evaluation of results after cleft lip and palate repair is
not easy, and several flaws are recognized in the reported
outcomes of retrospective or prospective studies. Nearly
2 decades from infancy to adulthood are necessary for the
completion of care and subsequent evaluation of functional
and aesthetic results. Thus the final evaluation of outcomes
can be problematic for several primary reasons:
•• Turnover of team members
•• Change of protocols
•• Introduction of new surgical procedures
•• Patients’ relocation
•• Incomplete records for services provided outside the
institutions
•• Changes in insurance coverage
•• Denial of insurance coverage for some necessary
services and refusal of patients to undergo final
aesthetic or reconstructive procedures
Many studies include a small number of patients with
multifaceted problems related to the deformity, as well
as significant variations in treatment protocols, timing for
each procedure, surgical technique(s), and experience and
skills of the individual surgeon, and many have an incom­
plete follow-up period.2 Furthermore, the vast majority of
current studies rely primarily on subjective, not objective,
evaluation. For example, evaluation of facial features using
only photographs provides information about facial sym­
metry, but this may not be the most appropriate way to
judge a surgical outcome given that only static results are
displayed and asymmetries or irregularities during anima­
tion could have been missed.
The need for well-planned, well-designed, ethical, mul­
ticenter, prospective long-term studies has been well rec­
ognized. Such studies could provide quantifiable, nonbiased
data and assist in improving patient care by addressing re­
maining controversial issues, such as appropriate timing for
specific surgical procedures as well as selection of the best
possible surgical technique(s). Until such studies are avail­
able surgeons must rely on data from existing studies and
honest evaluation and analysis of their own results to pro­
vide the best possible care for their patients.
With improved knowledge and collective experience,
extensive long-term follow-up studies, appropriate coordi­
nated care, cooperation among specialists, close monitor­
ing, and analysis of short- and long-term results, as well as
adequate funding to cover all necessary services, manage­
ment of patients with facial clefts could further improve so
consistently superior results can be achieved.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
688
cleft palate, and bilateral cleft lip and palate. These unique
studies are based on the experience of one surgeon and a
center with a relatively stable patient population.
Despite the lack of detailed longitudinal data, however,
there is general agreement that regardless of protocol of
care, subsequent procedures will be necessary from infancy
to adulthood to achieve the best possible functional and aes­
thetic results and complete habilitation.
Avoiding Unfavorable Results
and Complications of Cleft Lip
and Palate Repair
Cleft Lip
The objectives of primary cleft lip repair are to establish
anatomy and symmetry of the upper lip and nostrils and
improve form and function. Criteria for satisfactory cleft lip
repair, regardless of surgical technique, are summarized in
Box 40.1.
The value of preoperative orthopedics and lip taping in
the final outcome is still debated. Repositioning of the max­
illary alveolar segments in an anatomically correct position
could facilitate a tension-free closure and allow for a simul­
taneous periosteoplasty in selected cases. Such an approach
might result in a better appearance of the lip, alveolus, and
nose and potentially reduce the total number of secondary
procedures. At my center we use a modified nasoalveolar
molding device to improve the position of the maxillary seg­
ments and facilitate nasal repair.11 Intermediate results ap­
pear promising, but definitive final long-term results of such
interventions and potential adverse effects on maxillofacial
Residual Deformities
Residual deformities have several primary causes:
•• Failure to recognize and treat the full spectrum of
problems associated with facial clefting
•• Tissue deficiencies inherent to the cleft
•• Inappropriate timing
•• Poorly designed and performed procedures
•• Complications of the initial surgery
Additional operations and revisions are required to cor­
rect deformities that were not addressed during the pri­
mary procedure, inherent tissue deficiencies, maxillofacial
changes, and/or scar contractures. Additional procedures
might also necessary to address otologic, dental, and speech
problems and to improve persisting residual functional
and aesthetic deformities. These procedures have been de­
scribed at length in many textbooks and scientific articles.
The average number of procedures necessary to achieve
the best possible functional and aesthetic habilitation has
not been clearly defined, and it is difficult to accurately es­
timate from existing data. In some studies secondary proce­
dures, such as alveolar bone grafts and orthognathic surgery,
are barely mentioned or included, and most studies do not
include dental or otologic procedures in the average total
numbers. Thus the total number of procedures or interven­
tions is definitely underreported.3 Few surgeons have re­
ported on the actual average number of procedures required
to achieve the best possible long-term results.4–7 More re­
cently David and others8–10 presented a series of papers enti­
tled “From Birth to Maturity: A Group of Patients Who Have
Completed Their Protocol Management” that included evalu­
ation of patients with unilateral cleft lip and palate, isolated
Summary Box
Cleft Lip
•• Dehiscence
•• Bleeding
•• Infection
•• Unfavorable scarring
•• Discrepancies of the upper lip
○
○Vertical axis, long lip
○
○Horizontal axis, short lip
○
○Tight upper lip
○
○Whistling deformity
○
○Combinations
•• Intraoral (mucosal) scar contracture
•• Orbicularis oris deformities
•• Mucocutaneous deformities
•• Vermilion deformities
•• Sulcus obliteration
•• Combinations
Cleft Palate
•• Dehiscence
•• Palatal failures/fistulas
•• Scar contracture
•• Velopharyngeal deficiencies
•• Skeletal deformities
•• Combinations
Common Complications Related to Cleft Lip and Palate Repair

689
Chapter 40 Cleft Lip and Cleft Palate
repositioning of the premaxilla and improve alignment with
the maxillary segments.15 In extreme cases, and when con­
servative management is unsuccessful, premaxillary setback
can also be used to bring the premaxilla within the occlu­
sal plane and facilitate a tension-free lip and palate repair.16
Immediate surgical complications after cleft lip repair
are extremely rare but include bleeding, infection, and de­
hiscence. Early wound dehiscence is rare and primarily is a
result of technical errors or closure under tension or occurs
after accidental trauma. In such cases, immediate manage­
ment with minimal débridement, additional undermining
as needed, and layered closure without undue tension is rec­
ommended (Fig. 40.1).
growth are only partially available.12–14 Disadvantages of this
protocol include the additional expenses and the need for
multiple visits for adjustment, but these could be offset by
the reduction of subsequent surgical procedures.
Preoperative orthopedics for bilateral clefts with repo­
sitioning of the prominent premaxilla is more widely ac­
cepted. Several techniques have been described to achieve
premaxilla repositioning. We use a noninvasive appliance,
fabricated by our prosthodontist, which is helpful in opti­
mizing the position of the premaxilla and, if needed, com­
bined with nasoalveolar molding extensions. Negative
effects on facial growth and development have not been ob­
served. Several weeks are necessary to achieve a favorable
Box 40.1
•• Detailed markings of all landmarks, taking into consideration the anatomy of the upper lip, alveolus, and
nostrils
•• Accurate measurements and markings of all proposed incisions
•• Gentle tissue handling
•• Development of flaps on either side of the cleft with adequate tissue mobilization
•• Release of superficial and deep fibers of the orbicularis oris from their abnormal attachments
•• Dissection and reposition of the cleft-side lower alar cartilage in a more symmetrical three-dimensional
position
•• Reconstruction of the nasal floor
•• Accurate skin, muscle, and mucous membrane union
•• Closure under minimal or no tension to achieve the optimal scar
•• Symmetrical vermilion border with alignment of the vermilion (dry lip) and the mucosa (moist lip)
•• Slight eversion of the lip, accurate reconstruction of the Cupid’s bow and the tubercle, and correct alignment
of the white roll
•• Symmetrical nostril floors and elongation of the columella, as needed
Criteria for Satisfactory Cleft Lip Repair
Fig. 40.1 (a) A 7-month-old patient 7 days after bilateral cleft lip repair with complete dehiscence on the left side after a fall at home.
(b) After cleansing and minimal débridement. (c) The lip was repaired again in layers. (d) Two months later the lip has healed well.
a
b
c
d

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
690
They result from closure under tension and the use of
tight sutures left in place for too long. Such problems can
be avoided in most cases by using fine techniques with
meticulous tissue handling and a tension-free closure,
fine sutures, or even tissue adhesives. Other aggravating
factors include postoperative bleeding, infection around
the suture line, and dehiscence. The surgeon should be
able to differentiate these unsightly scars from the hyper­
trophic scars that form without apparent cause and usu­
ally fade away slowly without need for additional surgical
intervention.
Timing for scar revision is important to the final out­
come. Waiting several months before a revision to allow the
scar to mature is recommended. After careful evaluation,
the appropriate surgical procedure should be planned. El­
liptical excision of the scar, with precise approximation and
closure after limited undermining, is the simplest solution.
This technique, however, can only be applied for relatively
narrow scars. Excision of wider scars might result in de­
fects that, if directly repaired, might cause distortion of
the lip in the vertical or horizontal axis and/or narrowing
of the nostril sill. To prevent these problems, the excision
should be planed accordingly, preferably with a wavy style
of excision, undermining on either side of the defect and
performing tissue rearrangement as needed. Geometric tis­
sue rearrangement with z-plasties and other techniques
should be avoided, because the subsequent scar will per­
manently carry the marks of such designs. Dermabrasion
is helpful in some cases and is primarily recommended
for improvement of residual surface irregularities. Finally,
single hair micrografts have been recommended for male
patients to further camouflage the lip scar and allow for a
moustache.18
Long Lip
An excessively long lip on the cleft side is truly technique
related. It has been encountered with LeMesurier and the
initial Tennison repairs but can result with other techniques
as well. Correction is difficult, because in most instances all
lip layers are involved. If the discrepancy is minor, it can be
corrected with appropriate excision just below the nostril
sill. If a significant discrepancy is present, however, the lip
should be completely divided after appropriate markings
are made and carefully repaired in layers.
Lip Revision
Residual lip deformities might vary from minor ones cor­
rected with minimal interventions, to major asymmetries
and deformities that may even require complete revision
of the lip repair. It is beyond the scope of this chapter to
describe all residual deformities and present all reported
techniques and modifications. The most common deformi­
ties are presented with the recommended treatment and
with reliable techniques based on my experience and time-
honored procedures.
A revision lip surgery should only be chosen after ex­
tensive consultation with the family and the child and with
a clear understanding of the expectations. Objectives of the
procedures, the surgical plan, and possible outcomes should
be outlined and false expectations dispelled. Timing can af­
fect the outcome and should be taken into consideration,
but decisions should be individualized and not made in a
rigid and dogmatic fashion. Procedures should be postponed
if an adolescent is not willing to have surgery, even when
parents desire and request it. Conversely, some procedures
might be scheduled earlier than initially planned if there is
evidence of a negative psychologic effect on the child. If pos­
sible, several procedures should be bundled to reduce time
away from school or work, additional psychological trauma
from multiple interventions, and cost.
Before planning a revision, the entire lip, including the
oral mucosa; sulcus; alveolus; and nostrils should be exam­
ined at rest and during animation. The deformity should be
analyzed and all contributing factors taken into consider­
ation. All necessary soft tissue landmarks should be appro­
priately marked and measured. All contributing elements to
the deformity should be corrected in one setting whenever
possible (Fig. 40.2). Careful planning, appropriate timing,
and detailed execution are extremely important, because
failure of the revision procedure to correct the deformity
may result in additional scarring and tissue loss that could
further reduce the chances for adequate habilitation.3,17
Lip Deformities
Scars
Wide, poorly healed persistent scars of the upper lip with
unsightly stitch marks are encountered less commonly.
a
b
Fig. 40.2 The entire lip, including the oral
mucosa; sulcus; alveolus; and nostrils should
be evaluated and all necessary soft tissue
landmarks marked and measured.

691
Chapter 40 Cleft Lip and Cleft Palate
z-plasty can be designed and incorporated with the revi­
sion, preferably below the nostril sill. The drawback to such
approaches is the small gain achieved and the addition of
a Z-shaped scar on the lip. If a significant discrepancy ex­
ists, the only solution is to redo the lip repair, extending the
rotation advancement design to increase lip height (Figs.
40.3 and 40.4).
Short Lip
A short lip results primarily from straight-line closures, in­
adequate rotation, and advancement techniques and scar
contractures. Small discrepancies can be corrected with el­
liptical, diamond-shaped, or wavy excisions of the entire
scar and closure after adequate undermining. If needed, a
Fig. 40.3 (a,b) This 5-year-old had a significant residual deformity of the lip and nose including a short lip, dehisced orbicularis oris, and
lateral flaring of the cleft-side nostril. Excess skin of approximately 1-cm width in the horizontal axis was identified during markings.
(c) Excess skin with corresponding vermilion was excised, the orbicularis oris was approximated after undermining, and the nostril floor was
repositioned after reduction of the skin of the sill. (d) Immediate postoperative result.
a
b
c
d
Fig. 40.4 (a–c) This patient had a significant residual deformity after bilateral cleft lip repair. He had a short lip, no orbicularis contact in the
midline, exposed moist mucosa in the vermilion, and bilateral scar contractures in the oral mucosa. (d) Appropriate tailoring of the philtrum,
approximation of orbicularis oris muscle fibers in the midline, excision of redundant vermilion, release of intraoral scars, and coverage of
the mucosal defect with sliding flaps. (e) Final result 4 months after revision with improved symmetry and balance.
a
b
c
d
e

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
692
functional and aesthetic result and a balanced profile, accu­
rate design of the dimensions of the flap to match the cre­
ated defect, placement of the flap in the center of the lip to
simulate the philtrum, and placement of the final scars to
simulate the philtrum columns are necessary. The width of
the flap should be adequately planned and narrower from
the normal philtrum to encounter for subsequent widen­
ing from natural tension. The layers of the flap should be
sutured carefully to the corresponding layers of the lateral
lip segments and the upper buccal sulcus20 (Fig. 40.5).
Tight Upper Lip
The tight upper lip deformity primarily occurs in patients
with bilateral clefts. Local tissue rearrangement and even
revision of the repair is not beneficial in most cases because
of the limited tissue availability and scarring. Because of
the paucity of tissue, a flap from the lower lip, an Abbé flap,
should be added after all scarred tissue is removed.19 This
procedure is not recommended for young children because
of the temporary junction of the lips. To achieve a superior
Fig. 40.5 (a) This woman had a very short and tight upper lip after bilateral cleft lip repair
and a subsequent revision. The upper sulcus was completely obliterated. (b) Design of
the Abbé flap. (c) Design of the flap and proposed areas of inset on the upper lip. (d) At
3 weeks postoperatively, before division and inset of the flap. (e,f) Final result 15 years
after division and inset of the flap demonstrating improved symmetry and balance of the
upper lip. (b Reproduced from Bentz ML, Bauer BS, Zuker RM. Principles and Practice of
Pediatric Plastic Surgery. 2nd ed. New York: Thieme Publishing; 2016.)
c
d
e
f
Vermilion-mucosal
junction
Labial artery
b
a

693
Chapter 40 Cleft Lip and Cleft Palate
tion, giving the lip an unnatural look. For small deformities,
the lip scar can be excised and the muscle fibers identified
and freed from their abnormal attachments and sutured
together. When a significant deformity or dehiscence ex­
ists, a total lip repair should be planned with all anatomic
elements of the lip dissected and repaired correctly (Figs.
40.6 and 40.7).
Orbicularis Oris Deformities
Reconstruction of the orbicularis oris muscle is incorpo­
rated during lip repairs. Failure to release and fully recon­
struct the muscular sling or partial or complete dehiscence
of the muscle repair will result in unsightly bulging of the
muscle on either side of the lip scar or depressions and
asymmetries that are further accentuated during anima­
Fig. 40.6 (a,b) Complete dehiscence of orbicularis oris excess skin, including partially obliterated upper buccal sulcus and excess tissue in
the horizontal axis. (c) Excision of excess scar, excess skin, and vermilion according to markings. (d) Layered closure.
a
b
c
d
a
b
c
Fig. 40.7 (a) Residual lip and nose deformity after unilateral cleft lip repair. The patient had a short lip, dehiscence of the lower third of the
orbicularis oris repair, lateral fullness of the vermilion depression, scarring of the nostril sill, and lateral deflection of the lower alar cartilage
with nostril asymmetry. (b) The orbicularis oris fibers were identified after undermining and reapproximated. (c) The nasal deformity was
simultaneously corrected through an open rhinoplasty approach.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
694
scar at the vermilion border should be excised; the fibers
of the orbicularis are identified after limited undermining
and approximated carefully with eversion of the margins.
In the past, small local filler grafts or autologous fascial
grafts were recommended. Currently, autologous fat graft­
ing is considered to be the procedure of choice and has
been added to my armamentarium.21
Minimal whistling deformities of the lip resulting pri­
marily from scar contractures in the area of the vermilion
and the mucosa of the lip can be corrected with z-plasties
by placing the central limb on the existing scar. A central
whistling deformity with good height of the lip occurs pri­
marily after repair of bilateral clefts of the lip. For this re­
sidual deformity, lipofilling is also considered as long as an
adequate sulcus is present and there is no mucosal contrac­
ture. Vermilion fullness on the cleft side of the lip can also
be encountered. As long as the rest of the lip is not involved,
this deformity can be corrected with a horizontal elliptical
excision. The surgeon should be very careful to avoid over­
resection or mismatch between the dry and moist portions
of the lip.
Mucocutaneous Deformities
Mucocutaneous deformities result from poor alignment of
the white roll during the initial lip repair. Accurate place­
ment of the skin suture on the white roll assists in prevent­
ing this problem. This deformity is primarily corrected with
an elliptical or rhomboid excision of the scar and accurate
reapproximation of the mucocutaneous junction. Only a
few millimeters in vertical height can be gained with this
technique. As an alternative, a small z-plasty can be used
to allow for interposition of the vermilion and a skin flap
and ultimately results in realignment of the mucocutane­
ous line.
Vermilion and Free Border Deformities
Lack of bulk or poor alignment of the vermilion can cause
several deformities. Lack of bulk is primarily a result of
inherent tissue deficiency, dehiscence, or failure to ap­
proximate the lower portion of the orbicularis oris muscle
during the initial lip repair. To correct such deformities, the
a
b
c
d
e
Fig. 40.8 (a,b) After two revisions, this patient had re­
sidual deficiency of the vermilion border and bulge of
the orbicularis oris muscle lateral to the lip scar. (c) Intra­
oral scarring and contracture accentuating the deformi­
ty. (d) Preoperative marking on the skin and vermilion.
(e) Release of the intraoral scar with direct approxima­
tion of the mucosal flaps (arrows) after undermining.
(f,g) Final result 2 years after reconstruction; the upper
lip is well healed and soft.
f
g

695
Chapter 40 Cleft Lip and Cleft Palate
Cleft Palate
The primary objective of cleft palate repair is to establish
the anatomy of the hard and soft palate as close to normal
as possible, provide an adequate mechanism for velopha­
ryngeal function and speech, and improve middle ear func­
tion. Regardless of surgical technique, the final goal should
be a palate of adequate length, with reconstruction of the
muscular velopharyngeal sling, and approximation with­
out tension.
Timing for cleft palate repair has been controversial
because of the potential negative effects on facial growth.
Since the landmark publication by Dorf and Curtin,23 most
surgeons agree that early palatoplasty, before the child’s
first birthday, has beneficial effects on speech without det­
rimental effects on facial growth. We follow this protocol
with the understanding that timing of palatal repair should
not be determined by age only but should be individual­
ized, taking into consideration anatomic findings and the
patient’s health. With careful palatal dissection, complete
muscle dissection and approximation, flap approximation
without tension, and avoidance of large residual lateral raw
areas, speech results have been superior and skeletal defor­
mities reduced.
Further longitudinal studies are necessary to fully clar­
ify conflicting issues, but based on the existing information,
Labial Mucosal Contracture
The upper lip might also appear short because of muco­
sal scar contracture or even obliteration of the sulcus (Fig.
40.8). This contracture should be released independently
or managed along with other deformities of the lip. In most
cases of unilateral cleft lip, release can be achieved with
excision of the scar, and reconstruction of the mucosal de­
fect and mucosal rearrangement can achieve full coverage;
raw surfaces will result in further scarring, contracture,
and deformity. Despite advanced techniques for bilateral
cases, some patients still present with partial or complete
obliteration of the upper labial sulcus.22 In such cases, the
lip will appear short and retracted, with incisor and even
gingival show. Complete release of the soft tissues from
the premaxilla and coverage of the subsequent defect are
necessary. Skin or mucosal grafts were used in the past to
resurface the sulcus and complete the vestibuloplasty. The
surgeon should avoid denuding the premaxilla from its
periosteum, completely release the lip, suture the graft in
place with absorbable sutures, and stabilize it with a small
stent. I currently almost exclusively use mucosal flaps ad­
vanced from the lateral lip segments with superior results
and reserve the use of grafts only for the rare occasion that
the defect cannot be covered with flaps because of signifi­
cant preexisting scarring of the labial mucosa (Fig. 40.9).
Fig. 40.9 (a) Near-total obliteration of the upper buccal sulcus in a patient after bilateral cleft lip repair. (b) After excision of the scar and
exposure of the maxilla a significant mucosal defect remained. (c) Immediate postoperative result after coverage of the defect with sliding
mucosal flaps. (d) Final result several months after the reconstruction; the patient has a well-maintained upper sulcus.
a
b
c
d

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
696
layers, or infections. Anterior fistulas just behind the pre­
maxilla may occur in patients with wide bilateral clefts in
whom, because of a paucity of soft tissues in the area, com­
plete closure was not possible or closure under tension re­
sulted in dehiscence.10
Fistulas may become evident immediately after the pala­
toplasty or may develop several years later during orthodon­
tic treatment and transpalatal expansion. Early dehiscence,
particularly in the posterior third of the soft palate, is caused
primarily by errors in technique or accidental trauma. If de­
hiscence is identified early, it should be repaired immedi­
ately to allow for early habilitation, prevention of contrac­
ture, and subsequent shortening of the soft palate. Larger
fistulas may become symptomatic, resulting in nasal re­
gurgitation of saliva, fluids, and food particles and affect­
ing speech, causing hypernasality and articulation distur­
bances. Some surgeons propose conservative management
for asymp­tomatic fistulas, whereas others recommend clo­
sure of even small fistulas given that regurgitation of food
and liquids into the nasal cavity might result in constant
irritation of the nasal mucosa. This may cause swelling, oc­
casional bleeding, and have potential effects on breathing,
speech, or oronasal hygiene. I recommend waiting for sev­
eral months after the palatoplasty before closing a palatal
fistula, because in the early postoperative period the tissues
around the fistula are inflamed, edematous, and friable. Thus
attempts for repair are more likely to fail. Reported success
rates vary widely.26 Better understanding of the timing and
mechanics of fistula repair increases the rate of success and
significantly reduces the possibility of recurrence. Large fis­
tulas should be closed as soon as possible, but the tempo­
rary option of an obturator should also be kept in mind (Fig.
40.10). Premaxillary setback can be used when the premax­
it seems reasonable to recommend early palate repair for
most patients to improve speech outcome. The poten­
tial negative effect on maxillofacial growth should not be
overlooked; it must be taken into consideration and closely
monitored.24,25
Palatoplasty Failures
Despite advances in techniques and better understanding
of their effects on speech and facial growth, several compli­
cations or failures requiring additional surgery are still en­
countered. The most significant ones include the following:
•• Palatal repair failures and fistulas
•• Velopharyngeal deficiencies
•• Skeletal deformities (see Chapter 43)
Palatal Fistulas
There is a wide range of reported incidence of palatal fistu­
las after palatoplasty, and various classifications are used.
For the purposes of this discussion only fistulas presenting
in areas of previous palatal repair are included. Incidence
seems to be independent of the surgical technique but is
significantly higher in bilateral cases.
Palatal fistulas represent failures of the surgical tech­
nique and might be due to several factors from poor designs
to technical errors. Such errors might include incomplete
dissection or mobilization of the flaps, failure to completely
detach the muscles of the soft palate from their abnormal
attachment to the hard palate, incomplete approximation
and suturing of all soft tissue layers, closure under undue
tension, postoperative bleeding between the oral and nasal
Fig. 40.10 (a) This 5-year-old had a large
anterior palatal fistula with food and air
escape to the nasal cavity after palato­
plasty and three failed revisions. (b) An
obturator was fabricated by a prosth­
odontist to provide temporary functional
and aesthetic resolution of the problem
and immediate improvement in speech.
(c,d) The obturator in place.
a
b
c
d

697
Chapter 40 Cleft Lip and Cleft Palate
respect to fistula closure. The surgeon should first decide
whether the surrounding tissues are adequate for the closure
or whether additional tissues, brought primarily from other
areas of the oral cavity, will be necessary. For small dehis­
cences or fistulas in the area of the uvula or soft palate with
adequate palatal length and movement and with no evidence
of velopharyngeal deficiency, the dehiscence or fistula should
be repaired with a relatively straightforward procedure with­
out extensive dissection. The margins of the dehiscence or
fistula should be excised and the palatal scar extended an­
teriorly and posteriorly of the fistula, as needed, to allow for
better visualization and mobilization of the nasal lining and
muscles and a tension-free, layered closure (Fig. 40.12).
illa cannot be retropositioned to the occlusal plane (Video
40.1). This should be done after appropriate palatal expan­
sion and even combined with anterior fistula closure and
alveolar bone grafts (Fig. 40.11).
Before planning a fistula repair, the surgeon must fully
appreciate the anatomy: the length of the palate, size and
location of the defect, and tissue availability. The surgeon
should also evaluate the movement of the soft palate and the
possible inadequate dissection and release of the muscles of
the soft palate during the initial surgery.3 Complete speech
evaluation and even endoscopy might be necessary to obtain
all preoperative information and plan management accord­
ingly. Each area of the palate has different requirements with
a
b
c
d
e
f
Fig. 40.11 (a–c) This 8-year-old had significant protrusion of the premaxilla, collapse of the lateral maxillary segments, and a bilateral oro­
nasal and anterior palatal fistula after bilateral cleft lip and palate repair. (d) Near completion of palatal expansion. (e) After completion of
orthodontic expansion setback of the premaxilla allowed for simultaneous closure of palatal and oronasal fistulas and bone grafting of the
maxilla. (f) Final appearance with improved facial symmetry and harmony.
Fig. 40.12 (a) Dehisced uvula and posterior third of the soft palate with a dehisced muscular sling. (b) Extension of the incision to the hard
palate with undermining over and under the muscles and release of the muscles from their abnormal attachment. (c) Final result after
layered closure.
a
b
c

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
698
of palatal mucoperiosteum for oral coverage. These flaps oc­
casionally can be successful. For larger defects, I prefer to
redo the palatoplasty with complete mobilization of bilat­
eral palatal flaps; repair of the nasal lining directly or with
vomer flaps, if needed; and reapproximation of the pala­
tal flaps without tension (Fig. 40.15). When vomer flaps
are not available, a patch of acellular dermal matrix can be
used to completely repair the nasal defect before suturing
the palatal flaps.27 I place a couple of through-and-through
sutures from the palatal flaps to the acellular dermal matrix
to obliterate the dead space between the two layers and pro­
vide direct contact of the matrix with the well-vascularized
palatal flaps.
For large palatal defects resulting from multiple inter­
ventions and failures, the options for successful reconstruc­
tion are virtually absent. In such cases, paucity of local tis­
sues can be addressed with the addition of tissue recruited
from the oral region in the form of pedicle flaps. Free vascu­
larized flaps have also been suggested to manage extremely
large defects. The surgeon should be careful when dealing
with such complex conditions, individualizing the plan and
designing each reconstructive procedure with extreme care,
because additional failure could result in further tissue loss
and magnify the defect. The surgeon must also know when
to stop and remember that some patients could be better
served with an obturator, which of course is not the first
choice for management of fistulas but is a viable option
when managing multiple failures.
For larger fistulas extending to the junction between the
hard and soft palate, attempting to directly repair the fistula
might result in undue tension with subsequent failure. Lat­
eral relaxing incisions with undermining and mobilization
of the mucoperiosteum of the hard palate will facilitate a
tension-free layered closure in most cases. The muscles of
the soft palate should be released from their abnormal at­
tachment on the posterior wall of the hard palate. Failure to
do so will prevent adequate muscle approximation and pro­
vide no improvement of the palate movement during speech
(Fig. 40.13). A critical issue with repair of such fistulas is
the adequacy of nasal lining, because failure to repair the
nasal surface of the palate might predispose to contracture
or recurrence. For relatively small defects a z-plasty of na­
sal lining flaps is adequate, whereas for larger defects the
introduction of fresh tissue, such as buccal flaps, might be
necessary.3
A superiorly based pharyngeal flap can be used when
the palate is relatively short and velopharyngeal insuffi­
ciency (VPI) is also present. The surgeon should first con­
sider redoing the palatal repair and retropositioning the pal­
ate at the time of fistula repair or using a pharyngeal flap to
provide additional support, in conjunction with correction
of the VPI (Fig. 40.14).
Fistulas of the hard palate represent a different chal­
lenge. Some surgeons have suggested the use of local turn­
over flaps from the periphery of the fistula for nasal lining
closure and the use of local rotation or transposition flaps
a
b
c
d
Fig. 40.13 (a) Residual palatal fistula in the junction between the soft and hard pal­
ate many years after palatoplasty. (b,c) Margins of the fistula were stripped from the
mucosa; all layers of the soft palate including oral mucosa, muscles, and nasal lining
were identified; palatal flaps were mobilized after extensive undermining to achieve a
tension-free closure; and the defect was repaired in layers. (d) Final result 14 months
after repair.

699
Chapter 40 Cleft Lip and Cleft Palate
Fig. 40.14 (a,b) Small palatal fistula with complete dehiscence of the palatal muscles and uvula and significant hypernasality. (c,d) The
margins of the fistula were excised, the scar of soft palate was incised to the junction with the hard palate, palatal muscles were detached
from their abnormal attachment in the hard palate, and a superiorly based pharyngeal flap was raised (arrow) and sutured to the palate.
(e) The palate was then closed in layers.
a
b
c
d
e
Fig. 40.15 (a) A large anterior palatal fistula in an 8-year-old after cleft lip and palate repair. (b,c) The margins of the fistula were incised
and flaps were turned over to achieve complete closure of the nasal lining. Bilateral flaps were elevated and approximated without tension.
(d) Palatal flaps were elevated to fully visualize and delineate the nasal margins of the fistula before repair. (e) Final result several months
after the reconstruction, demonstrating an intact palate without fistula recurrence.
d
e
a
b
c

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
700
the size of the defect and 5 to 6 cm long to prevent tether­
ing of the tongue during speech or eating. The flap should
be about 0.5 cm thick and consist of mucosa and muscle fi­
bers. The donor site is closed primarily, almost to the base
of the flap. The flap is then inset around the margins of
the fistula using absorbable mattress sutures. After 2 to 3
weeks, the pedicle is divided and inset in the posterior area
of the fistula after freshening of the palatal margins. The
remaining pedicle is discarded, and additional sutures are
placed to completely repair the tongue defect. There have
been no problems with tongue mobility or swallowing after
this procedure, although there are isolated reports of nega­
tive effects on speech and articulation.28 They occur with
bulky flaps, which interfere with the position of the tongue
during speech and could have been prevented with careful
planning, designing, and insetting of the flap.
Large anterior palatal fistulas not treated previously
and those caused by failures of previous attempts and pre­
senting with stiffness or lack of elasticity of the palatal tis­
sues might require additional well-vascularized tissue for
a successful closure. Tongue flaps can be very helpful in the
management of such difficult cases (Fig. 40.16). Two stages
are required with this technique. Eating or speaking is not
restricted during the interim period. Planning and atten­
tion to all technical details are important. The extent of
the fistula should be delineated completely. Turnover flaps
from the margins of the fistula should be used, if feasible,
to achieve full closure of the floor of the nose. The palatal
tissues around the fistula should be undermined circum­
ferentially for a few millimeters to allow for adequate in­
setting and suturing of the tongue flap around the defect.
I prefer anteriorly based flaps designed a little wider than
a
b
c
d
e
f
Fig. 40.16 (a) A large anterior palatal fistula after multiple interventions in an 8-year-old. (b,c) Turnover flaps from the margins of the fistula
were first used to completely repair the nasal lining. (d,e) An anteriorly based tongue flap measuring 5 by 2 cm was used. (f) Tongue flap
inset around the margins of the fistula. (g,h) Final result with complete healing of the fistula and excellent tongue movement.
g
h

701
Chapter 40 Cleft Lip and Cleft Palate
responses, and the results of other diagnostic tests, deter­
mine whether the nasal airway needs to be managed to in­
crease patency before an additional resistive load, such as a
pharyngeal flap, is introduced into the airway.35
Techniques and measurements used to assess velopha­
ryngeal function generally can be classified into three cat­
egories and are summarized in Table 40.1.
Managing Unfavorable Results
and Complications
Procedures to Correct Velopharyngeal
Insufficiency
If after completion of a course of speech therapy and ex­
tensive evaluation a determination of a need for additional
treatment is made, the following options can be considered:
•• Revision palatoplasty
•• Furlow double Z-opposing plasty
•• Superiorly based pharyngeal flap
•• Sphincter pharyngoplasty
•• Retropharyngeal implants or fat grafting
•• Prosthetic management (for nonsurgical candidates)
Revision palatoplasty is recommended when the muscles
of the soft palate were not properly released and the mus­
cular sling was not properly constructed during the initial
procedure.36 A double Z-opposing plasty can also be used
and can provide superior speech results, because of the pal­
atal lengthening.37,38 For relatively small gaps, fat injections
in the posterior aspect of the soft palate and the pharyngeal
wall are gaining some popularity.39 For most other cases, a
superiorly based pharyngeal flap or a pharyngoplasty are
considered to be procedures of choice.40–42 Some surgeons
still recommend augmentation of the posterior pharyn­
geal wall with various autogenous or alloplastic materials;
prosthetic rehabilitation is reserved for surgical failures or
for patients with significant medical problems who are not
considered good candidates for a surgical procedure.43,44
Another popular technique is the use of bucket-handle
flaps from the upper labial sulcus to manage large anterior
defects. These flaps are random but dependable. Attention
to the design and technical details is again very important.
Preexisting scars from the lip repair should be taken into
consideration; obliteration of the buccal sulcus should be
avoided (Fig. 40.17).
A paucity of tissue in the area of the junction between
the hard and soft palate, in both the oral and nasal surfaces,
can be managed with buccal mucosa flaps. These flaps are
designed on the buccal mucosa, approximately 2 cm wide
and of appropriate length to reach the defect. The base of
the flap should be placed anterior to the maxillary crest and
tunneled under the palatal tissues, turned so the mucosa
faces the nasal cavity and sutured to the defect of the nasal
lining. Alternatively, the flap can be used to replace missing
oral tissue. In such cases, the palatal tissue must be incised
to allow for inset of the flap.29 The buccinator and facial ar­
tery myomucosal flaps could be viable alternatives for larger
defects.30,31 These flaps are dependable and have a long ped­
icle based on the facial and buccinator pedicles but are bulk­
ier and sometimes difficult to deliver to palatal defects.
Velopharyngeal Disturbances
Despite better understanding of the physiology of speech,
the effects of early palate repair on speech outcome, and
the improvement of surgical techniques, an average of 20%
of patients will have residual velopharyngeal disturbances
after cleft palate repair. This rate does not seem to be influ­
enced significantly by the surgical technique used for the
palatoplasty.32–34 Close cooperation between the surgeon
and the speech pathologist is necessary to obtain appropri­
ate data, fully appreciate the condition, and prescribe the
most appropriate individualized plan. Accurate diagnosis is
cardinal for a successful outcome. Before testing, a detailed
history should be obtained to gain information on previ­
ous orofacial and nasal procedures, feeding or swallowing
problems, nasal regurgitation, speech problems, and fre­
quent ear infections. When surgical management of the ve­
lopharyngeal valve is anticipated, we include questions to
determine whether nasal airway obstruction exists. These
Fig. 40.17 (a) Oronasal and large anterior palatal fistulas simultaneously covered with a large labial mucosa flap at the time of bone graft­
ing of the residual alveolar cleft. (b,c) The bone graft and palatal fistula were simultaneously covered with the labial flap. The donor site
was closed primarily.
a
b
c

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702
With advances in pediatric anesthesia, better under­
standing of the anatomy, improvement of techniques, and,
above all, increased awareness of the potential serious prob­
lems associated with pharyngeal flap procedures, the intra­
operative complications have decreased significantly, but
some complications are still encountered. Death resulting
from obstruction is extremely rare, but occasional intraoper­
ative and postoperative bleeding and acute airway obstruc­
tion can be anticipated. The prime source of bleeding has
been the donor site in the posterior pharyngeal wall. Infiltra­
tion with vasoconstrictive agents facilitates dissection and
reduces bleeding during surgery, but the surgeon should be
very careful of mucosal and muscular bleeders that retract
away from the wound margins. Meticulous hemostasis be­
fore insetting of the flap is extremely important.
According to several series, the incidence of acute air­
way obstruction caused by bleeding, tissue swelling, or in­
appropriate position of the flap has decreased significantly.
It is currently recognized that, in the vast majority of pa­
tients, some degree of transient obstruction will be present
immediately after surgery. Such obstruction can be identi­
fied clinically and with polysomnographic sleep studies and
monitoring of the arterial saturation. Most of the obstruc­
tive signs and symptoms resolve a few days or months af­
ter surgery.45,46 However, because transient obstruction has
been well documented, it is extremely important to carefully
monitor patients in the immediate postoperative period. De­
spite changes in the health care system to a reduction of
postoperative hospitalization days, all patients undergoing
pharyngeal flap operations should be admitted and moni­
tored closely for early signs of obstruction. Nasopharyngeal
Pharyngeal Flap
The superiorly based pharyngeal flap is a widely accepted
procedure for management of VPI. This flap is favored be­
cause its design allows for more natural movement of the
soft palate toward the tubercle of the axis. Unfortunately,
there is no standardized procedure, and several technical
variations that could affect the final outcome are included
under this term. Some surgeons prefer division of the soft
palate to insert the flap, whereas others favor the sandwich
technique with an incision in the posterior free palatal bor­
der, undermining of the palatal layers, and introduction of
the flap through this opening. Lining of the raw undersur­
face of the flap with posteriorly based mucosal flaps from
the nasal surface of the palate is recommended to prevent
contracture and narrowing or “tubing” of the flap with sub­
sequent increase in port size. Other surgeons do not believe
in the importance of lining and demonstrate successful re­
sults without lining of the raw surface. The size of the ports
is another area of controversy. Some recommend the lateral
port control technique using appropriately sized catheters
to precisely tailor the size of the ports, whereas others do
not support this technique. Finally, several surgeons rec­
ommend the immediate approximation of the donor site
defect of the posterior pharyngeal wall, claiming that such
practice reduces the danger of postoperative bleeding and
speeds up the healing period. Others recommend leav­
ing the donor site open, allowing it to heal in a secondary
intention for fear of interference with the anatomy of the
pharynx that could accentuate potential episodes of airway
obstruction in the immediate postoperative period.
Table 40.1 Techniques and measurements of velopharyngeal function
Perceptual
Anatomic
Physiological
Speech evaluation by a speech
and language pathologist
Standardized speech sound
(articulation) testing
Assessment of oronasal resonance
balance to include judgments
regarding the presence of
consistent or inconsistent
mild, moderate, or severe
hypernasality or hyponasality
Intraoral examination
Presence, location, and size of palatal
fistulas (if any); size of tonsils; status of
dentition/occlusion
Length, movement, and symmetry of velum
Direction, degree, and symmetry of
visualized pharyngeal wall movement
If pharyngeal flap/ pharyngoplasty are
present, evaluation of width and position
of the base of the flap, size of ports, and
degree of visualized flap motion
Rhinoscopic evaluation to determine
septal deviations, inferior turbinate
hypertrophy, airway congestion, and
other pathology
Radiologic evaluation and nasal endoscopy
Acoustic rhinomanometry
Aerodynamic assessment/
pressure flow technique
Determination of velopharyngeal
opening during speech
production—possible partial or
complete obstruction
Airway patency and resistance
during respiration

703
Chapter 40 Cleft Lip and Cleft Palate
•• Augmentation of the flap with additional tissue from the
posterior pharyngeal wall (patch flap) or the palate
•• Alteration of the size of the ports and tightening with
rearrangement of tissues using z-plasties and other
tissue rearrangement techniques
•• Division of the old flap and performance of a new
pharyngeal flap or pharyngoplasty
For relatively small defects, I prefer tissue rearrangement
using local flaps based on existing surrounding tissues.
More recently I have used fat grafting to reduce the size of
the ports in relatively minor cases. Preliminary results are
promising, but additional experience with long-term fol­
low up is necessary.
For larger defects, additional flaps from the posterior
pharyngeal wall can be used to reduce the size of the ports.
For very large defects, I prefer to divide the old flap and
use a new one based on the scarred posterior pharyngeal
wall.50–52
Prerequisites for success include extensive preoperative
evaluation, appropriate planning and execution, and close
cooperation with a speech pathologist. Residual raw surfaces
should be avoided to reduce the incidence of contracture.
Postoperative speech therapy is required to assist in the cor­
rection of articulation problems, including compensatory
strategies after surgery, taking into consideration adequate
hearing and appropriate learning level.
Persistent Hyponasality
Partial or complete obstruction is a serious complication
of flap surgery, with potential detrimental effects on the
patient’s health. Symptoms may vary but include snoring,
sleep-wake disturbances, loss of olfactory acuity, and in­
tranasal or sinus infections. Obstruction might have sig­
nificant effects on dentofacial growth and even systemic
effects on the cardiopulmonary and other systems. The
exact incidence of this complication is not known, because
several investigators do not consider hyponasality to be a
failure of pharyngeal flap surgery.
airway tubes are used, if necessary, to improve breathing;
in extreme cases, reintubation may be necessary to control
the airway.
Results after Pharyngeal Flap Surgery
Several long-term studies evaluating the long-term effects
of pharyngeal flap surgery on breathing and speech have
been reported. The reported success rates range from 40
to 90%. This vast discrepancy in outcome can be explained
in several ways. Different groups of patients with various
forms of clefts, or even patients without clefts, are lumped
together in some studies. Age at the time of procedure
varies from very young to adulthood; yet it is well under­
stood that speech outcome after a pharyngeal flap per­
formed later in life is significantly inferior to the outcomes
achieved in children. Finally, most studies are retrospective,
missing important data from the preoperative or postop­
erative evaluation.47,48
The modalities used to evaluate postoperative improve­
ment in speech vary as well. Some studies rely on a percep­
tual (subjective) judgment of speech. Others include direct
evaluation of the modified anatomy of the nasopharynx
during speech with nasopharyngoscopy, video fluoroscopy,
and/or objective assessment of velopharyngeal function us­
ing aerodynamic or acoustic assessments. Interpretation of
the findings of these tests is also controversial. Some au­
thors consider the elimination of hypernasality as the sole
criterion for success and do not consider hyponasality as a
failure.49 Thus the reported percentages for success of this
procedure are affected greatly by the methodology of eval­
uation and interpretation of findings. We use both speech
and breathing outcomes to judge the success of pharyngeal
flap surgery.
Despite its drawbacks, pharyngeal flap surgery remains
an important procedure for the management of patients
with VPI, as long as the indications for the procedure are
well understood and the patients have undergone extensive
preoperative evaluation. Attention should be given to all sur­
gical details and postoperative follow-up.
Pharyngeal Flap Failures
Persistent Hypernasality
Persistent hypernasality is primarily caused by partial or
complete detachment of the flap, contracture, and narrow­
ing of the flap with residual widening of the ports or poor
design and inappropriate, low placement of the flap. Each
of these conditions can result in deficient ports on one or
both sides of the flap (Fig. 40.18). Established hypernasal­
ity requires extensive evaluation before treatment. Once
the cause of hypernasality is determined, revision of the
size of the ports is recommended. Several procedures have
been recommended for correction of residual hypernasal­
ity, including the following:
Fig. 40.18 Significant scarring of the pharyngeal flap resulting in
contracture, a deficient port, and subsequent hypernasality.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
704
Life-threatening bleeding has not been a problem with
pharyngoplasties. Perioperative nasal airway obstruction
and obstructive sleep apnea can occur, however, and the sur­
geon should be prepared to manage these situations. These
findings are well documented, and careful evaluation in the
immediate postoperative period is recommended.54 Success
rates of sphincter pharyngoplasties are high, ranging from
80 to 90% according to various reports.55,56 Low insertion of
the flaps has been identified as the most significant reason
for failure.57 Flap dehiscence caused by technical errors can
contribute to failure. Failure has also been encountered in
patients with previous tonsillectomies, leading to atrophy
and scarring of the palatopharyngeus muscles, which might
undermine the integrity and adequate function of the pha­
ryngoplasty.
Persistent Hypernasality
Persistent hypernasality after pharyngoplasty requires
special attention. Extensive evaluation and determination
of the causative factors are necessary before embarking on
revision surgery. When significant scarring is present be­
cause of dehiscence of the flaps, contractures in the area of
the donor site, or other reasons, the chances for success of
any additional procedure may be diminished. If the central
port is too large and a deficient sphincter is present, I prefer
tightening it after partial or complete mobilization of the
flaps from their attachments to the posterior pharyngeal
wall (Fig. 40.20). This procedure might be tedious, because
it can be difficult to reelevate and reuse the flaps after de­
hiscence and scarring. In such cases, I prefer discarding the
remnants of the flaps and use a lined superiorly based pha­
ryngeal to assist in velopharyngeal closure.58,59
Nasopharynx Obstruction
Partial or complete obstruction of the nasopharynx is a
significant problem. Obstruction might result in several
symptoms, as noted earlier. The severity of these symptoms
should be evaluated carefully. Before any intervention, the
Milder hyponasality without other clinical symptoms
might be considered an acceptable result, but when this con­
dition interferes with speech or the patient’s general health,
revision of the ports is recommended. Because there is no
appropriate formula for the recommended size of the ports,
the surgeon should be very careful to avoid overcorrection,
creating ports that are too large and result in recurrence of
hypernasality.3
Direct excision of a portion of the flap around the ports
can be performed. Local z-plasties and other designs of tis­
sue rearrangement have also been recommended, but out­
comes are not always predictable. When significant scarring
is present, I use temporary stenting of the ports with red
rubber tubes to reduce scar contracture around newly cre­
ated ports (Fig. 40.19). Complete transection of the obstruct­
ing flap can be used as a last resort. In such cases, no rough
surfaces should be left that could result in further scarring
and obstruction.53
Sphincter Pharyngoplasty
Sphincter pharyngoplasty has gained popularity as a more
anatomically correct procedure. Flaps based on the poste­
rior tonsillar pillars, including the underlying palatopha­
ryngeus muscles, are elevated and attached to the posterior
wall of the nasopharynx to construct a sphincter. Some sur­
geons recommend this procedure for all patients with ve­
lopharyngeal incompetence, whereas others suggest that a
pharyngoplasty should be reserved for patients with good
palatal movement without a large velopharyngeal gap.
Attention to the technical details significantly influ­
ences the outcome. The flaps should be elevated sharply
and should include as much muscle as possible; the inci­
sion of the posterior pharyngeal wall should be placed at the
highest possible level. Overlapping of the flaps rather than
joining them in the midline is important in the creation of
a competent sphincter. The surgeon should avoid unneces­
sary tension during flap approximation, which could result
in partial or complete dehiscence of the flaps or obstruction
with hyponasality.
Fig. 40.19 (a) Pharyngeal flap failure with flap contracture, widening of both ports, and hypernasality. (b) Patch flaps from the posterior
pharyngeal wall were used to reduce the size of the ports. (c) Temporary stenting with red rubber tubes (arrows) was used for 2 weeks to
prevent scarring and contracture.
a
b
c

705
Chapter 40 Cleft Lip and Cleft Palate
tical maxillary growth and no adverse effect on maxillary
growth after early bone grafting.61–63 These findings are
supported by our long-term clinical observations as well.
Unfortunately, there are several conflicting reports of the
effects of bone grafting on the growth of the maxillofacial
skeleton because of the variety of protocols and surgical
techniques and modifications currently used. As a result,
additional parameters are constantly introduced, mak­
ing analysis and comparison of results almost impossible.
Despite the controversy, however, based on vast available
clinical information, it is reasonable to state that secondary
surgeon must extensively discuss the procedure with the
patient and the family and explain the pros and cons of the
revision. The surgeon should always bear in mind the risk
of transforming an overcorrected sphincter into a deficient
one, with significant effects on speech. If possible, revision
of the port should be performed in the “nondynamic” area
of the sphincter, on the posterior pharyngeal wall. Partial
mobilization and retroposition of the flaps, if feasible, may
provide improved results. For extreme cases, takedown of
the flaps may be recommended, followed by a pharyngeal
flap, if persistent VPI is identified.
Secondary Bone Grafting of Residual
Alveolar Clefts
Reconstruction of the residual bony cleft of the alveolar
process and the hypoplastic maxilla with simultaneous
closure of coexisting oronasal fistulas at the stage of tran­
sitional dentition is a time-honored procedure. The value
of the procedure has been demonstrated in several long-
term studies.60 The goals of the procedure are summarized
in Box 40.2.
Planning and Timing of the Procedure
Well-defined principles must be taken into consideration
to consistently achieve good results and reduce the inci­
dence of complications. They include, among others, close
cooperation between the surgeon and the orthodontist,
appropriate timing, type of bone graft, flap selection, and
attention to technical details. The decision for and timing
of surgical treatment should be based on a combination
of developmental, orthodontic, and surgical factors. Den­
tal age, rather than chronologic age, is the primary factor
guiding the decision regarding the timing of a bone grafting
procedure. Ideally, this procedure should be performed in
the early transitional dentition stage, after eruption of the
permanent central incisors. Several investigators reported
no evidence of disturbance of the anteroposterior or ver­
Box 40.2
•• Closure of oronasal fistulas
•• Improvement of oral and nasal hygiene
•• Formation of a stable alveolus with sufficient
three-dimensional volume
•• Stabilization of maxillary segments
•• Support and preservation of adjacent teeth
•• Tooth eruption through bone graft
•• Facilitation of orthodontic care
•• Reduction of need for prosthetic rehabilitation
•• Facilitation of implant placement and
rehabilitation with implant-retained prosthesis,
when needed
•• Improvement of nasal and facial symmetry and
appearance
•• Increased alar support and projection
•• Improved aesthetics of the alveolus and nasal
vestibule
•• Improvement in speech (after large fistula
closure)
•• Facilitation of subsequent orthognathic surgery
Goals of Secondary Bone
Grafting of Residual Alveolar
and Maxillary Clefts
Fig. 40.20 (a) Failed pharyngoplasty with persistent hypernasality. The flap position was notably low. (b) The flaps were completely mobi­
lized from the posterior pharyngeal wall, tightened, and reinserted in a superior position in the posterior pharyngeal wall. (c) Completed
reconstruction after inset of flaps and palatal repair.
a
b
c

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
706
more, teeth are programmed to erupt through keratinized
gingiva but will not erupt spontaneously through oral mu­
cosa (Fig. 40.22).
Unfavorable Results
Complications arise primarily from inadequate soft tissue
coverage of the graft, resulting in bone exposure to the oral
or nasal cavities. This might result in partial or complete
resorption of the bone graft (Fig. 40.23). Furthermore, if
teeth are not available to erupt through the graft, there will
be bony resorption to the crest of the maxilla a few months
after grafting. In a retrospective study of 138 patients, we
did not encounter any major flap dehiscence or significant
bone graft loss in unilateral cases. Major dehiscences in the
palate or floor of the nose were encountered in 10% of the
bilateral cases and resulted in partial or complete loss of
the bone graft. Two patients with complete loss of the bone
graft were successfully repeat bone grafted. Eight more
patients with unilateral clefts developed minor intraoral
dehiscences that were treated conservatively and without
significant bone graft loss. In 9% of the cases, we encoun­
tered partial resorption of the lowest portion of the graft,
without bone exposure, resulting in an unattractive notch
in the alveolus. When present, 95% of teeth erupted sponta­
neously through the bone graft without the need for surgi­
cal exposure. Postoperative orthodontic treatment was re­
quired in all patients to achieve full alignment of the newly
erupted teeth with the adjacent ones, close existing spaces,
and complete the symmetry of the maxilla.66
Because the main reason for failure is soft tissue defi­
ciency and exposure of the bone graft, the surgeon should
not attempt further bone grafting until fresh tissue is
bone grafting at the stage of transitional dentition has no
deleterious effects on the growth of the midface and should
be supported.
Technical Considerations
Consistently successful bone grafting of residual maxillary
and alveolar clefts requires several well-defined steps (Box
40.3).
Superior results can be obtained when cancellous bone
particles are used. These particles incorporate faster than
the cortical bone, remodel nicely with the rest of the max­
illa, and permit dental eruption through their substance.
Currently, most surgeons favor the use of autogenous bone
particles harvested from the iliac crest. A few favor the use of
grafts from the calvarium, tibia, rib, or mandible, and some
recommend allografts with equally good results.64 Findings
from previous long-term studies and our own comparative
study comparing patients who received iliac or cranial bone
grafts support the notion that the source of bone graft does
not significantly influence the success or failure of this pro­
cedure. The use of cancellous bone particles only and close
adherence to well-accepted steps of the procedure are by
far the most important factors influencing a successful out­
come.65
Several local mucosal flaps have been proposed to cover
the bone graft (Fig. 40.21). Gingival mucoperiosteal flaps
seem to be superior to other mucosal flaps for alveolar
clefts.66 They are well vascularized, have a broad base, and
can be advanced medially to provide tension-free coverage
over the graft. Tissue of similar color, thickness, and texture
to the surrounding alveolus is used; thus the final aesthetic
appearance of the reconstructed area is superior. Further­
Box 40.3
•• Gingival mucoperiosteal flaps designed on either side of the cleft and raised to completely expose the bony
cleft and piriform aperture of the maxilla
•• Stripping of all soft tissue from the margins of the bony defect and the areas to be bone grafted
•• Closure of coexisting palatal fistula by raising bilateral palatal flaps and approximating them without tension
•• Repair of the soft tissue defect of the floor of the nose to complete the creation of a watertight pocket for
placement of the bone graft
•• Cancellous bone chips packed tightly within the defect to fill the bony cleft and restore thickness and height of
the nasal floor, the maxilla, and the alveolus as close to normal as possible
•• Coverage of any permanent tooth erupting through the cleft with a bone graft
•• Careful reconstruction of the maxilla and the alveolar ridge by placing additional onlay bone graft along the
cleft from the nasal floor, the maxilla to the level of the alveolar ridge to provide better support to the teeth
adjacent to the cleft, and to the teeth that eventually will erupt through the graft
•• Placement of bone particles on the hypoplastic piriform aperture of the maxilla to provide support for the
nasal bone, raise the depressed nostril ala and sill, improve symmetry, and facilitate future correction of the
residual cleft nasal deformity
•• Gingival mucoperiosteal flaps sutured together and to the palate, without tension, to provide complete
coverage of the bone graft
Technical Steps of Secondary Bone Grafting

707
Chapter 40 Cleft Lip and Cleft Palate
brought in. This condition is primarily encountered in bi­
lateral cases presenting with anterior palatal fistulas in ad­
dition to the oronasal ones. When the use of palatal flaps
cannot successfully address the problem, large labial flaps
or even tongue flaps should be considered. Staging the re­
construction by first closing the palatal fistula and then ad­
dressing the oronasal fistulas some months later is also an
option. After this modification in our protocol the amount
of exposure in bilateral cases was reduced by more than 75%
from our initial study with practically no complete failures.
Prosthetic Rehabilitation
Prosthetic rehabilitation should be considered when ad­
equate soft tissue and bone are not available, after multiple
failures, and in cases with missing teeth. Careful evaluation,
planning, and close cooperation with an orthodontist and
prosthodontist are necessary to achieve the best possible
Fig. 40.21 Flaps of labial mucosa should be avoided as much as possible, because they have different texture, color, and thickness from the
surrounding tissues, and teeth cannot erupt through.
a
b
c
Fig. 40.22 (a) Bilateral oronasal fistulas. (b–d) Results 2 years after bone graft­
ing and orthodontic treatment. All permanent teeth erupted spontaneously
through the bone grafts.
d
Fig. 40.23 Bone graft exposure (arrow) and subsequent loss because
of incomplete closure of the palatal fistula at the time of bone graft­
ing.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
708
plant is placed upon completion of orthodontic treatment
to ensure proper edentulous space width and occlusal re­
lationship after the patient has completed facial growth.
The key requirement for success of this procedure is ad­
equate bone volume in both height and width.43 Before im­
plant placement the bone height and width and position
of adjacent teeth roots are evaluated radiographically. It is
important that a three-dimensional radiograph be used,
when possible, because it provides a more accurate picture
of the bone volume than a two-dimensional one. If addi­
results. Permanent teeth around the area of the cleft might
be missing, malformed, or impacted in a patient with a
cleft lip and/or palate. There are several options to restore
the edentulous space. If a well-formed permanent tooth is
present in the maxilla, it may be moved into normal posi­
tion with a combination of orthodontics and surgery. When
an edentulous space is maintained, some type of prosthetic
reconstruction is necessary. This can be achieved with a
fixed or removable partial denture (Fig. 40.24), or with a
fixed implant-retained prosthesis67 (Fig. 40.25). The im­
Fig. 40.24 (a) Edentulous space after two failed bone grafts. (b–d) After treatment with a conventional three-unit fixed partial denture.
a
b
c
d
c
e
d
a
b
Fig. 40.25 (a) A missing lateral incisor after
bone grafting. (b) Radiographic documen­
tation of the bone graft. (c) Implant and
abutment in place. (d) The postoperative
radiograph. (e) Final result after prosthetic
rehabilitation.

709
Chapter 40 Cleft Lip and Cleft Palate
tinctly. The nose is flat, lacking projection, the alar domes
are laterally displaced, the columella is short, and the nos­
trils flare laterally, with horizontal rather than oblique incli­
nation. The deformity could be further accentuated by the
poor alignment of the maxilla and the presence of maxillary
or alveolar clefts.
The severity of the residual nasal deformity varies, de­
pending on the original deformity and the degree, if any, of
nasal and maxillary correction performed during the initial
lip repair or during subsequent revisions. Previous proce­
dures and scarring produce additional “iatrogenic” deformi­
ties that may include malposition of the alar base, depres­
sion of the nostril sill, an excessively large or small nostril,
or external scars. Many patients with residual cleft nasal
deformities may demonstrate a degree of airway obstruc­
tion, as well. This obstruction might be a result of one of
several factors or a combination of factors, including septal
deviation, skeletal deformities, hypertrophy of the inferior
turbinates, and intranasal swelling or scarring. Other con­
tributing factors to the obstruction might include palatal or
oronasal communications or an obstructive pharyngeal flap
or a pharyngoplasty. These factors should be evaluated, re­
corded, and taken into consideration for the treatment plan
(Box 40.4).
Numerous procedures and modifications have been
described over the years to manage residual cleft nasal de­
formities. Most surgeons focus primarily on the aesthetic
aspects of the deformity and little or no attention is given
the functional outcome. Hence very little functional out­
come information has been reported.73,74 However, airway
obstruction can cause many symptoms, including snoring,
postnasal secretions, nasal bleeding, sinus infections, loss of
olfactory acuity, and even sleep apnea. Therefore treatment
plans should be individualized based on extensive evalua­
tion and analysis. All contributing factors to the deformity
should be addressed, and every effort should be made to
correct both the aesthetic and the functional aspects of the
deformity in one setting.
tional bone grafting is required, this should be performed
before the placement of implants. In the event of inade­
quate bone volume after additional grafting, a fixed bridge
must be considered as an alternative treatment. A second
scan is taken 4 to 5 months later to confirm adequate bone
volume. A surgical guide may be digitally designed and
fabricated from the scan. This will ensure proper implant
placement in surgery. Once the implant is placed, tooth res­
toration may be completed after several months. Benefits
of implants include the fact that they do not have to be con­
nected to any teeth, ease in cleaning, normal function and
appearance, and that they are intended to last indefinitely.
Correction of Residual Cleft Nasal
Deformity
Correction of unilateral or bilateral cleft lip nasal defor­
mities is currently incorporated with the initial lip repair.
Thus facial symmetry and harmony are restored early on,
and patients are given the opportunity to grow up with­
out the psychosocial burden of a nasal deformity. Early in­
tervention produces overall long-lasting improvement in
nasal symmetry and appearance without detrimental ef­
fects on nasal or facial growth.68–71 Despite the use of these
advanced techniques, however, a number of patients still
require a definitive secondary procedure to restore symme­
try and improve function.72
The classic secondary nasal deformity associated with
unilateral cleft lip is caused by factors intrinsic to the nasal
structures such as deformed, depressed, and laterally de­
flected lower alar cartilages; a deviated septum; an asym­
metrical nasal tip, columella, and nostrils; and asymmetrical
and deviated nasal bones and nasal pyramid. Extrinsic skel­
etal factors such as hypoplasia of the maxilla and alveolar
process or a coexisting cleft of the maxilla with lack of bony
support for the nasal base also contribute to the deformity.
In patients with bilateral clefts, the deformity differs dis­
Box 40.4
There are several distinct advantages to this approach:
•• In patients with unilateral clefts, the maxillary platform assumes a symmetrical position after realignment of
its segments and bone grafting of the maxillary cleft and the hypoplastic area of the piriform aperture. The
depressed unsupported nostril is raised to a level similar to that of the contralateral side.
•• In patients with bilateral clefts, after the premaxilla is realigned with the lateral segments and the maxillary
clefts are bone grated, both nostrils are supported and raised, and the nasolabial angle is improved.
•• After closure of residual oronasal fistulas and reestablishment of the natural barrier between the oral and
nasal cavities, regurgitation of food and saliva is controlled and irritation of the nasal mucosa is eliminated.
More accurate evaluation of the intranasal abnormalities is feasible, leading to more appropriate and
successful management of the various components of any coexisting airway obstruction.
Protocol for Correction of Cleft Nasal Deformity

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
710
visualization of the deformity and more accurate correction.
Repositioning of the alar cartilages and domes, placement of
cartilage grafts when needed, and overall establishment of
symmetry is facilitated greatly under direct vision. A coex­
isting septal deviation can be managed accurately through
this approach (see later discussion).
When small discrepancies are present between the alar
cartilages, tip symmetry can be achieved by mobilization
and suturing of the depressed dome to the contralateral one.
If the discrepancy is more significant, this maneuver alone
might not be sufficient, because the lateral crus on the cleft
side are tethered during medial mobilization of the dome
and a lining deficiency might be present. In such cases, I
dissect the lateral crus with its mucosal lining as a medially
based flap. This is achieved by extending the lateral infra­
cartilaginous incision around the lateral border of the alar
cartilage and back along its cephalic border. With this ma­
neuver, the alar cartilage can be mobilized freely in a more
medial and superior position and sutured to the contralat­
eral dome. The residual lateral mucosal defect left after this
mobilization can be closed with local mucosal flaps, but
when there is considerable shortage of lining, a composite
graft from the ear is used to resurface this intranasal de­
The final correction of the nasal deformity should be
deferred until after orthodontic alignment of the maxilla;
bone grafting of the hypoplastic maxilla, maxillary cleft, and
alveolus; and closure of the coexisting oronasal fistulas.3 The
advantages to this approach are summarized in Box 40.4.
The information gained from preoperative clinical,
physiological, and endoscopic evaluation assists the sur­
geon to formulate an individualized plan of action. I also
depend on rhinomanometry, an objective test, to gain ad­
ditional information on airway patency and level of possi­
ble obstruction.72 After the detailed evaluation and analysis,
the surgeon should use the most appropriate techniques to
correct the deformities with simultaneous management of
the airway obstruction, when present. The principles and
techniques of rhinoplasty apply to correction of cleft nasal
deformities, as well, but successful outcome is not always as
predictable as with cosmetic rhinoplasties because of the
existing nasal asymmetry, inherent soft tissue deficiencies
and cartilage iatrogenic deformities, and scarring from pre­
vious procedures as well as the coexisting airway obstruc­
tions.
An open rhinoplasty approach is preferred, with a V-
shaped columellar incision. This approach allows for direct
a
b
c
d
e
f
Fig. 40.26 (a) Significant contracture of the right nostril and total airway obstruction after multiple previous procedures. (b) Contracture
of the nasal lining and deficiency of the lateral crus of the lower lateral cartilage. (c) The almost–2 cm lateral intranasal defect after en bloc
release of the nasal lining and cartilage. (d) This maneuver allowed for mobilization and approximation of the domes in a favorable posi­
tion. (e) A composite graft from the ear including skin and cartilage was used to reconstruct the defect. (f) The postoperative result with
improved contour and significant improvement in the right side airway.

711
Chapter 40 Cleft Lip and Cleft Palate
lateral alar cartilage and increased nasal tip projection with
grafts. In these patients, the shape and size of the nostrils
can be modified additionally with appropriate alar resec­
tions designed according to the deformity. They can be sym­
metrical or asymmetrical.
Correction of Airway Obstruction
With open rhinoplasty, the septum is exposed after lateral
reflection of the medial crura. The mucoperichondrium on
either side of the septum is dissected from the cartilage
to completely expose it to the perpendicular plate of the
ethmoid bone, the crest of the maxilla, and the vomer (Fig.
40.27). Thus the septal anatomy and configuration are visu­
alized and directly managed. In most patients with unilat­
eral clefts there is some degree of deviation of the septum.
In some patients, only the deviated caudal portion of the
septum needs to be managed, whereas in others the entire
septum requires manipulation to alleviate airway obstruc­
tion. To reposition it in the midline, it should be completely
freed from the maxilla. If the septal deformity is severe
and cannot be corrected with these maneuvers, a resection
should be performed, leaving an L-shaped portion of the
septum for nasal support. Additional obstructive factors
might be present, such as a deviated perpendicular plate
and bony spears in the crest of the maxilla and should be
taken into consideration and treated accordingly. Spreader
grafts and other techniques are used as with corrective rhi­
noplasty techniques (see Chapter 25).
Hypertrophy of the inferior turbinates must be also ad­
dressed, if needed. Obstruction caused primarily by mucosal
swelling can be relieved by excision of the redundant mu­
cosa (Fig. 40.28). However, when inferior turbinate hyper­
trophy is caused by bony hypertrophy, a reduction of the
inferior portion of the turbinate should be performed. Over­
resection leading to atrophic rhinitis and other problems
should be avoided. Finally, if a pharyngeal flap or pharyn­
goplasty are contributing to the obstruction, they should be
managed accordingly in the same setting.
fect (Fig. 40.26). The underlying cartilage of this composite
graft acts as a splint and prevents contracture and collapse.
A cartilaginous strut harvested primarily from the septum
is used to provide support to the tip and increase projec­
tion, as needed. The graft is designed to be long enough to
extend from the nasal spine to just above the nasal tip. It is
secured to the medial crura with two or three sutures. Addi­
tional tip projection and improved tip contour and symme­
try can be achieved with tip grafts. Conchal cartilage grafts
are ideal. Residual depressions of the alar cartilages are cor­
rected with small local cartilaginous grafts, and asymme­
tries of the upper lateral cartilage are managed by limited
resections or placement of additional grafts. Deviation of the
bony pyramid requires bilateral osteotomies for correction.
The nasal skin is then draped over the reconstructed bony
and cartilaginous skeleton. The columellar incision is closed
in a V-Y manner, which can provide a gain of 0.5 to 0.8 cm
in length for the columellar skin, when needed. As soon as
the incisions are closed, the symmetry of the nasal base is
evaluated. Small discrepancies are corrected by local exci­
sions in the floor of the nostril. These excisions should be
closed with care to prevent notching of the nostril sill. For
greater discrepancies, complete detachment of the cleft-side
nostril and resetting it in a more appropriate position and
level are needed. A nostril with a circumference greater than
that of the ­noncleft-side nostril is treated with an appropri­
ate resection. A more difficult condition to correct is a nos­
tril smaller than the normal one. In such cases, the nostril
is completely detached, and a composite graft from the ear
of appropriate size and shape used to achieve symmetry.75
Residual Nasal Deformity from a Bilateral
Cleft Lip
With improved surgical techniques for management of bi­
lateral clefts and incorporation of columella-lengthening
procedures with the original operation, fewer patients re­
quire major secondary procedures. These deformities are
approached through an open rhinoplasty, as well. The fibro­
fatty tissues between the domes and the medial crura are
excised and the domes mobilized medially and stabilized
with sutures. Additional projection is achieved, as described
for unilateral deformities, by placement of columellar strut
grafts and/or onlay tip grafts. In many patients a dorsal aug­
mentation with onlay cartilage or bone grafts is necessary
to increase projection and improve facial harmony. Most pa­
tients are treated by onlay cartilage grafts, but when a con­
siderable augmentation is necessary, costochondral grafts
can be used. Bilateral osteotomies are indicated when the
nasal pyramid is found to be wide or if skeletal asymmetry
is present.
The columellar incision is closed as in the unilateral
cases in a V-Y manner to increase length. Excess flaring of
the nostrils may persist despite medial mobilization of the
Fig. 40.27 Significant septal deviation visualized after reflection of
the medial crura of the lower lateral cartilages. This deviation sig­
nificantly contributed to the airway obstruction.

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
712
In contrast, residual airway obstruction should be evalu­
ated and treated, when appropriate. Unfortunately, the vast
majority of publications deal primarily with the aesthetic
improvements of cleft nasal deformity and very little in­
formation is given for the functional outcome after these
procedures.76,77 In a recent unpublished study of 36 con­
secutive patients, we found significant improvement of
airway patency in 80.5% of the patients. This improvement
was not only based on subjective information but was ob­
jectively substantiated, based on comparison of preoperative
and postoperative rhinomanometric data.78 Four patients
(11.1%) with a pharyngeal flap in place had only modest im­
provement. The residual postoperative airway obstruction
in these patients was attributed to the flap; however, no at­
tempt was made to revise the ports, because the patients’
preoperative speech was judged to be very good and any
intervention in the ports could have resulted in deteriora­
tion in speech. Finally, three patients had no functional im­
provement; they had several previous procedures with sig­
nificant intranasal scarring and mucosal contracture (Figs.
40.29–40.32).
Results
Despite extensive evaluation, analysis, planning, and care­
ful execution, a number of patients will have suboptimal
aesthetic and functional results. Patients who have under­
gone multiple previous procedures with tissue resections
and scarring will have worse results because of tissue defi­
ciencies of skin, lining, and/or cartilage and the presence of
residual scars or contractures. By far the most difficult area
to correct is the asymmetry of the nostrils. Critical evalu­
ation of postoperative results in many publications will
reveal a degree of residual asymmetry in the basal views
despite near-normal appearance in all other views. Other
commonly encountered residual deformities include asym­
metrical tip projection, lack of adequate tip projection, per­
sistent lateral flaring of the nostril, asymmetry and short­
ness of the columella, and persistent skeletal deviations,
among others. Some of these deformities, particularly the
significant ones, should be corrected to improve form and
function. Judgment and caution are necessary, and a deci­
sion for surgery should be made only when there is reason­
able expectation for improvement.
Fig. 40.28 Significant inferior turbinate hypertrophy
completely obstructing the airway on the right side.
a
b
c
d
Fig. 40.29 (a–d) A 17-year-old with a repaired left side cleft lip presenting with residual nasal deformity and airway obstruction.
Continued

713
Chapter 40 Cleft Lip and Cleft Palate
Fig. 40.29, cont’d (e–g) Postoperative result 18 months after the reconstruction. Preoperative (h) and postoperative (i) rhinomanometric
evaluation demonstrate significant improvement in airflow and reduction in resistance.
e
f
g
Nasal cavity left
Nasal cavity TOTF = 282
Nasal cavity left
Nasal cavity TOTF = 276
Nasal airway resistance
Nasal cavity left
400
300
200
100
0
-100
-200
-300
-400
400
300
200
100
0
-100
-200
-300
-400
400
300
200
100
0
-100
-200
-300
-400
Pressure (cm H2O)
Flow (cc /second)
-4 -3 -2 -1 0
1
2
3
4
-4 -3 -2 -1 0
1
2
3
4
-4 -3 -2 -1 0
1
2
3
4
Pressure (cm H2O)
Pressure (cm H2O)
Nasal airway resistance
Nasal cavity left
400
300
200
100
0
-100
-200
-300
-400
400
300
200
100
0
-100
-200
-300
-400
400
300
200
100
0
-100
-200
-300
-400
Pressure (cm H2O)
Flow (cc /second)
-4 -3 -2 -1 0
1
2
3
4
-4 -3 -2 -1 0
1
2
3
4
-4 -3 -2 -1 0
1
2
3
4
Pressure (cm H2O)
Pressure (cm H2O)
Flow (cc /second)
Flow (cc /second)
Flow (cc /second)
Flow (cc /second)
i
h

SECTION VI PEDIATRIC AND CRANIOFACIAL SURGERY
714
e
f
g
d
a
b
c
h
i
Nasal airway resistance
Nasal cavity total flow = 282.05 cc/sec
P
F
R
A
Nasal cavity right
0.00
224.36
3.92
26.28
Nasal cavity left
0.00
57.69
115.25
6.76
Nasal cavity total
0.00
282.05
3.12
33.04
Velopharynx
xxxxx
xxxxx
0.00
xxxxx
Total nasal airway
0.00
282.05
3.12
33.04
NCR =3.12 (100% contribution) P: Presssure in cm H20
F: Flow in cc/sec
R: Resistance in cm H20/L/sec
A: Area in mm2
VPR = 0.00 (    0% contribution)
NAR= 3.12
Nasal airway resistance
Nasal cavity total flow = 275.64 cc/sec
P
F
R
A
Nasal cavity right
0.12
83.33
1.44
26.43
Nasal cavity left
0.12
192.31
0.62
61.01
Nasal cavity total
0.12
275.64
0.43
87.44
Velopharynx
xxxxx
xxxxx
xxxxx
xxxxx
Total nasal airway
0.12
275.64
0.43
87.44
NCR =0.43
P: Presssure in cm H20
F: Flow in cc/sec
R: Resistance in cm H20/L/sec
A: Area in mm2
VPR = xxx
NAR= 0.43
Fig. 40.30 (a–c) Residual cleft nasal deformity and airway obstruction after two revisions. (d) Preoperative scan demonstrating significant
septal deviation and inferior turbinate hypertrophy. (e–g) Result 6 months postoperatively, demonstrating modest aesthetic improvement
and residual nostril asymmetry. Preoperative (h) and postoperative (i) rhinomanometric data reveal significant improvement in airflow and
reduction of airway resistance.