Summary: A defect of the central upper lip vermillion generally requires “like for like” reconstruction because this part of the upper lip can attract attention and has a unique structure and color. In this article, we report use of a labial artery-based horizontal long cross-lip flap for central upper lip vermillion reconstruction. In the first stage of surgery, a horizontal long vermillion flap from the lower lip starting at the left commissure with a vascular pedicle containing an inferior labial artery was raised and transposed to the upper vermillion defect. In the second stage, 12 days later, the pedicle was divided to complete the reconstruction. There were no postoperative complications in articulation or eating, and the patient was satisfied with the esthetic outcome. This surgical technique reduces microstomia and inconvenience in eating and speaking compared with a common horizontal cross-lip flap and provides better color- and texture-matched tissue compared to reconstruction using a tongue flap or mucosal flap. The technique is simple, requires a relatively short surgical time, has minimum donor-site morbidity and permits good esthetic and functional reconstruction of the central upper lip vermillion for a relatively small defect.

Summary:Postoperative seroma is still the main complication after a latissimus dorsi (LD) flap procedure. The etiology of seroma is currently thought to comprise tissue fluids resulting from inflammatory reactions in affected tissue caused by the use of monopolar electrocautery (EC). It is possible that seroma formation can be reduced by using alternative devices such as the PEAK PlasmaBlade (PPB), which provides atraumatic scalpel-like cutting precision while the blade temperature remains close to body temperature. The subjects were 44 patients who underwent breast reconstruction with LD flaps from August 2015 to April 2017. They were retrospectively split into groups treated with a PPB (n = 21) and with conventional EC (n = 23). Outcomes such as rate of seroma formation, total drain discharge volume, indwelling period of drainage at the donor site, length of hospital stay, and operation time were compared between the 2 groups. The incidence of seroma was significantly lower in the PPB group (19.0%) than in the EC group (47.8%). The total drain discharge volume was significantly lower and the indwelling period of drainage and length of hospital stay were significantly shorter in the PPB group. In summary, use of PPB in an LD flap procedure can reduce seroma formation and the lengths of the drainage period and the hospital stay.

Mandibular reconstruction using computer-aided design and computer-assisted manufacturing (CAD/CAM) techniques has received recent attention. This technique has theoretical advantages, although this approach can be commercially used in the limited area of the world. The aim is to describe our experience using in-house CAD/CAM guides and the situations in which CAD/CAM may present benefit in the region where commercial guides are unavailable. The authors developed our In-house CAD/CAM approach for mandibular reconstructions with a free fibular flap. Patients were divided into 2 group; CAD/CAM and conventional groups. In the CAD/CAM group, reconstructions were planned virtually using CAD/CAM; these CAD/CAM guides were used in the surgery. In the conventional group, free-hand cutting and fitting of the fibular segments were performed as reconstructions. Later, the bone computed tomographic image was compared with the plan. The averaged deviations and the percentages of the points within 1 mm, 2 mm, and 3 mm deviations were recorded. Total and ischemic time were also recorded. Reconstruction points within 1 mm deviation were 59% of CAD/CAM group (n = 9) and 42% of conventional group (n = 10, P = 0.04), within 2 mm 82% and 69% (P = 0.03). Total time were 1012 and 911 minutes, while flap ischemic time were 147 and 175 minutes (P = 0.03), respectively. In-house CAD/CAM mandibular reconstruction also supported accuracy and shorter flap ischemic time. For a detailed accurate reconstruction, CAD/CAM showed superiority than conventional method. Use of the In-house CAD/CAM guides might be an option where commercial guides are not available.

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Computer-aided design/computer-assisted manufacturing (CAD/CAM) is now being evaluated as a preparative technique for maxillofacial surgery. Because this technique is expensive and available in only limited areas of the world, we developed a novel CAD/CAM surgical guide using an in-house approach. By using the CAD software, the maxillary resection area and cutting planes and the fibular cutting planes and angles are determined. Once the resection area is decided, the necessary faces are extracted using a Boolean modifier. These superficial faces are united to fit the surface of the bones and thickened to stabilize the solids. Not only the cutting guides for the fibula and maxilla but also the location arrangement of the transferred bone segments is defined by thickening the superficial faces. The CAD design is recorded as .stl files and three-dimensionally (3-D) printed as actual surgical guides. To check the accuracy of the guides, model surgery using 3-D-printed facial and fibular models is performed. These methods may be used to assist surgeons where commercial guides are not available.

Computer-aided design/computer-aided manufacturing (CAD/CAM) guides are now widely used in maxillofacial reconstruction. However, there are few reports of CAD/CAM guides being used for scapular flaps. The authors performed the secondary maxillary and orbital floor reconstruction using a free latissimus dorsi muscle, cutaneous tissue, and scapular flap designed using CAD/CAM techniques in a 72-year-old man who had undergone partial maxillectomy four years previously. The patient had diplopia, the vertical dystopia of eye position, and a large oral-nasal-cutaneous fistula. After the operation, the authors confirmed that the deviation between the postoperative and preoperative planning three-dimensional images was less than 2 mm. Because scapular guides require 3 cutting surfaces, the shape of the scapular guide is more complex than that of a conventional fibular guide. In orbital floor reconstruction, the use of a CAM technique such as that used to manufacture the authors' fixation guide is as necessary for accurate, safe, and easy reconstruction as is preoperative CAD planning. The production of a fixation guide as well as a cutting guide is particularly useful because it is difficult to determine the angle for reconstructing the orbital floor by freehand techniques. In this case, the orbital floor was reconstructed based on a mirror image of the healthy side to avoid overcompression of the orbital tissue. Although the patient's vertical dystopia of eye position was improved, diplopia was not improved because, for greater safety, the authors did not plan overcorrection of the orbital volume.