The management of alveolar clefts has changed through the years as medical knowledge has improved. An alveolar cleft is the result of abnormal primary palate formation during weeks 4 to 12 of gestation. The rationale for its closure includes 1) stabilizing the maxillary arch, 2) permitting support for tooth eruption, 3) eliminating oronasal fistulae, and 4) providing improved esthetic results. Methods for closure of the alveolar cleft have been solidified during the last century with the use of bone grafting. Secondary bone grafting is now the preferred method of treatment, because early grafting has proven detrimental to midfacial growth. Various materials for bone grafting have been proposed, including iliac crest, cranium, tibia, rib, and mandibular symphysis. Regardless of the timing and materials used, the main principles in approaching alveolar clefts have been well described. They include 1) appropriate flap design, 2) wide exposure, 3) nasal floor reconstruction, 4) closure of oronasal fistula, 5) packing bony defect with cancellous bone, and 6) coverage of bone graft with gingival mucoperiosteal flaps. Certain alveolar clefts are difficult to manage by grafting alone, and orthodontic preparation may be required. Complications of alveolar bone grafts include donor site morbidity as well as graft exposure and loss.
In the authors' experience, there is no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM flap and the free DIEP flap. Thus, the authors advocate using the most expeditious and reliable flap based on the vascular anatomy of the DIEP system.
Localized breast cancer can be treated with lumpectomy and postoperative radiation therapy, also called breast conservation therapy, with an efficacy equivalent to that of mastectomy. Reports evaluating the effects of radiotherapy suggested that breast conservation therapy had "acceptable" cosmetic outcomes; thus, posttreatment evaluation for aesthetic impact has not been instituted as a standard of care. More recent reports have suggested that the effect of breast conservation therapy on aesthetic outcome is not minimal and that patients may benefit from reconstructive consultation. The purpose of this study was to measure objectively the aesthetic change in women who undergo breast conservation therapy and whether the extent of change is significant enough (objectively and subjectively) to warrant plastic surgery consultation. The authors evaluated 21 patients who had undergone breast conservation therapy. Eleven non-breast cancer patients seeking plastic surgery consultation were used as controls. Standardized five-view photographs (frontal, left and right lateral, and left and right lateral oblique views) were obtained. Patient photograph sets were compiled and evaluated independently by eight reviewers (four surgeons, two nurses, and two medical students). Reviewers evaluated the photographs using the breast asymmetry score (score range, 0 to 9) assessing breast size, ptosis, nipple-areola position, shape, scar appearance, contour deformity, and skin changes. The authors considered 2 SD above the control mean as significant. Breast conservation therapy patients also completed a 15-item questionnaire targeting objective and subjective data about treatment-related breast change. Breast conservation therapy patients had an average treatment-related asymmetry score of 1.93, with 35 percent demonstrating significant change as compared with controls. Although most patients (86 percent) were satisfied with the cancer treatment outcome, all patients noted asymmetry. The authors' data indicate that breast conservation therapy can cause significant asymmetry; thus, an option for plastic surgery consultation as part of the treatment protocol is warranted.
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