# Clinical Cases: Plastic and Reconstructive Surgery

## Case 1: Cleft Lip and Palate Repair

### Patient Presentation
**Demographics:** 3-month-old male infant

**Chief Complaint:** "Born with a gap in his upper lip and roof of the mouth"

**History of Present Illness:**
This 3-month-old male infant was born at 38 weeks gestational age via spontaneous vaginal delivery to a 28-year-old G2P2 mother. Prenatal ultrasound at 20 weeks had identified a left-sided facial cleft. At birth, examination confirmed a left unilateral complete cleft lip and palate extending through the alveolar ridge, hard palate, and soft palate. Birth weight was 3.2 kg.

The infant initially had significant difficulty with breastfeeding due to inability to generate adequate negative pressure for suction. He was transitioned to a specialized cleft palate bottle (Haberman feeder) and has been gaining weight appropriately, currently at the 35th percentile for age. He has been followed by the multidisciplinary cleft team since birth, including plastic surgery, speech-language pathology, audiology, orthodontics, and genetics.

A nasoalveolar molding (NAM) device was placed at 2 weeks of age to approximate the cleft lip segments and reshape the nasal cartilage prior to surgical repair. Genetic workup including chromosomal microarray was normal, and no syndromic features were identified. The family is now presenting for planned surgical repair of the cleft lip.

**Past Medical History:**
- Left unilateral complete cleft lip and palate
- Two episodes of acute otitis media
- No other congenital anomalies identified on echocardiogram and renal ultrasound

**Medications:**
- Multivitamin drops with iron 1 mL daily
- Amoxicillin recently completed for otitis media

**Social History:**
- Lives with both parents and a 3-year-old sibling
- No family history of cleft lip or palate
- Non-smoking household
- Mother took prenatal vitamins with folic acid throughout pregnancy

**Family History:**
- No family history of craniofacial anomalies
- Father has history of mild childhood speech delay

### Physical Examination
- **Vital Signs:** HR 140 bpm, RR 32/min, Temp 36.8°C, Weight 5.4 kg (35th percentile), Length 59 cm (40th percentile)
- **General:** Alert, active, well-nourished infant in no distress
- **Head:** Normocephalic, anterior fontanelle open and flat
- **Face:** Left unilateral complete cleft lip extending from the left nostril through the vermilion border. Left nasal ala is flattened and displaced laterally. NAM device in place with improved alignment of lip segments
- **Oral Cavity:** Complete cleft of the primary and secondary palate on the left side. Cleft extends through the alveolar ridge, hard palate, and soft palate to the uvula. Vomer visible in the cleft
- **Ears:** Bilateral middle ear effusions noted on otoscopic examination
- **Cardiac:** Regular rate and rhythm, no murmurs
- **Lungs:** Clear to auscultation bilaterally
- **Abdomen:** Soft, non-tender, no organomegaly

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Hemoglobin | 10.8 g/dL | 9.5-13.5 g/dL |
| Hematocrit | 32% | 28-42% |
| WBC | 9,200/μL | 6,000-17,500/μL |
| Platelets | 310,000/μL | 150,000-400,000/μL |
| PT | 12.1 seconds | 11-14 seconds |
| PTT | 28 seconds | 25-35 seconds |
| Basic Metabolic Panel | Within normal limits | -- |

**Imaging/Additional Studies:**
- Echocardiogram: Structurally normal heart
- Renal ultrasound: Normal bilateral kidneys
- Chromosomal microarray: No pathogenic copy number variants
- Audiology: Bilateral conductive hearing loss consistent with middle ear effusions (ABR thresholds 35-40 dB bilaterally)

### Clinical Image

![Cleft lip and palate anatomy and surgical repair diagram](case_01_image.jpg)

*Anatomical diagram of unilateral complete cleft lip and palate showing affected structures and the rotation-advancement repair technique. Source: Educational illustration.*

### Diagnosis
**Left Unilateral Complete Cleft Lip and Palate (ICD-10: Q37.1)**

**Key Diagnostic Criteria:**
- Complete cleft of the lip extending through the nostril floor
- Cleft of the primary palate (alveolar ridge)
- Cleft of the secondary palate (hard and soft palate)
- Non-syndromic presentation confirmed by genetic testing

### Treatment Plan
1. **Cleft lip repair (cheiloplasty)** at 3 months of age using the Millard rotation-advancement technique with primary nasal correction
2. **Myringotomy with bilateral pressure equalization tube placement** at the time of lip repair to address conductive hearing loss
3. **Palate repair (palatoplasty)** planned at 10-12 months of age using the Furlow double-opposing Z-plasty technique
4. **Continued nasoalveolar molding** until lip repair
5. **Speech-language pathology** monitoring beginning at 12 months with formal assessment at 18-24 months post-palatoplasty
6. **Orthodontic management** for alveolar bone grafting planned at age 7-9 years during mixed dentition
7. **Long-term follow-up** through skeletal maturity for possible secondary rhinoplasty, orthognathic surgery, or lip revision

### Key Learning Points
- The "Rule of 10s" guides timing of cleft lip repair: 10 weeks of age, 10 pounds body weight, and hemoglobin of 10 g/dL
- Cleft palate repair is typically performed at 10-12 months to optimize speech development before the onset of meaningful language
- Nasoalveolar molding (NAM) prior to surgery reduces cleft width and improves nasal symmetry, potentially reducing the number of future surgical revisions
- Eustachian tube dysfunction is nearly universal in cleft palate patients, making otologic monitoring and early PE tube placement essential
- A multidisciplinary cleft team approach is the standard of care, involving plastic surgery, ENT, audiology, speech pathology, orthodontics, pediatric dentistry, genetics, and psychology

---

## Case 2: Free Flap Reconstruction After Mandibulectomy

### Patient Presentation
**Demographics:** 58-year-old male construction worker

**Chief Complaint:** "I noticed a painful sore in my mouth that won't heal for the past 3 months"

**History of Present Illness:**
This 58-year-old male construction worker presents with a 3-month history of a non-healing ulcer on the right side of his lower gum. He initially attributed it to trauma from a rough tooth edge but became concerned when it continued to grow despite dental extraction of the adjacent molar 6 weeks ago. The ulcer is now approximately 3 cm in diameter and causes constant dull pain rated 5/10, worsened by eating. He reports a 15-pound unintentional weight loss over the past 2 months and difficulty opening his mouth fully.

He has a 40-pack-year smoking history and drinks 4-6 beers daily. He reports no prior history of head and neck cancers. He was referred by his dentist after an incisional biopsy revealed moderately differentiated squamous cell carcinoma of the mandibular gingiva. CT and MRI imaging demonstrated tumor invasion into the mandibular body with no radiographic evidence of distant metastases but a suspicious 2.5 cm right level IB lymph node.

PET-CT confirmed FDG-avid primary tumor and the right level IB lymph node. After multidisciplinary tumor board discussion, the recommended treatment plan is segmental mandibulectomy with right selective neck dissection followed by fibula free flap reconstruction and adjuvant radiation therapy.

**Past Medical History:**
- Hypertension
- Type 2 diabetes mellitus (HbA1c 7.2%)
- Chronic obstructive pulmonary disease (moderate, FEV1 62% predicted)
- Peripheral vascular disease (ankle-brachial index 0.9 bilaterally)
- Dental caries with multiple extractions

**Medications:**
- Lisinopril 20 mg daily
- Metformin 1000 mg twice daily
- Tiotropium inhaler daily
- Albuterol inhaler as needed
- Ibuprofen 600 mg as needed for pain

**Social History:**
- 40-pack-year smoking history, currently smoking 1 pack/day
- Alcohol: 4-6 beers daily for 30 years
- Construction worker
- Married with two adult children
- No illicit drug use

**Family History:**
- Father died of lung cancer at age 67
- Mother alive with hypertension
- Brother with oral cancer diagnosed at age 62

### Physical Examination
- **Vital Signs:** BP 148/88 mmHg, HR 78 bpm, RR 16/min, Temp 37.0°C, SpO2 95% on room air, BMI 24.1
- **General:** Thin-appearing male, appears older than stated age
- **Head/Neck:** 3 cm ulcerative, indurated mass of the right mandibular gingiva extending from the first premolar region to the retromolar trigone. Lesion is fixed to underlying bone. Trismus present with maximum interincisal opening of 28 mm. Palpable 2.5 cm firm, fixed lymph node in the right submandibular triangle (level IB). No contralateral lymphadenopathy
- **Oral Cavity:** Poor dentition, leukoplakia of the right buccal mucosa. Tongue mobility preserved
- **Cranial Nerves:** Intact including mental nerve sensation bilaterally
- **Lower Extremities:** Bilateral pedal pulses 2+, no significant varicosities. Fibula palpable with adequate length bilaterally
- **Cardiac:** Regular rate and rhythm, no murmurs
- **Lungs:** Diminished breath sounds bilaterally with scattered expiratory wheezes

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Hemoglobin | 12.1 g/dL | 13.5-17.5 g/dL |
| WBC | 8,400/μL | 4,500-11,000/μL |
| Platelets | 245,000/μL | 150,000-400,000/μL |
| Albumin | 3.2 g/dL | 3.5-5.0 g/dL |
| Prealbumin | 15 mg/dL | 20-40 mg/dL |
| HbA1c | 7.2% | <7.0% |
| Creatinine | 1.0 mg/dL | 0.7-1.3 mg/dL |
| AST | 38 U/L | 10-40 U/L |
| ALT | 42 U/L | 7-56 U/L |
| INR | 1.0 | 0.8-1.2 |
| Calcium | 9.4 mg/dL | 8.5-10.5 mg/dL |

**Imaging/Additional Studies:**
- CT Neck with contrast: 3.2 cm enhancing mass of right mandibular gingiva with cortical erosion and invasion of the mandibular body. 2.5 cm right level IB lymph node with central necrosis
- MRI Face/Neck: Tumor invasion through buccal and lingual cortices of the mandible with marrow involvement over a 4 cm segment. No perineural invasion along the inferior alveolar nerve
- PET-CT: FDG-avid primary tumor (SUV max 12.4) and right level IB node (SUV max 8.7). No distant metastases
- CT Angiography of lower extremities: Patent peroneal arteries bilaterally, adequate three-vessel runoff to both feet
- Biopsy: Moderately differentiated squamous cell carcinoma, p16-negative
- Staging: T4aN1M0, Stage IVA

### Clinical Image

![Fibula free flap mandibular reconstruction diagram](case_02_image.jpg)

*Diagram illustrating fibula free flap harvest and transfer for mandibular reconstruction, showing vascular anastomosis and reconstruction plate fixation. Source: Educational illustration.*

### Diagnosis
**Squamous Cell Carcinoma of the Mandibular Gingiva, Stage IVA (T4aN1M0), Requiring Segmental Mandibulectomy with Fibula Free Flap Reconstruction**

**Key Diagnostic Criteria:**
- Biopsy-proven moderately differentiated squamous cell carcinoma
- Cortical erosion and invasion of the mandibular body (T4a)
- Ipsilateral lymph node metastasis <3 cm (N1)
- No distant metastases (M0)

### Treatment Plan
1. **Preoperative optimization:** Smoking cessation (minimum 2-4 weeks preoperatively), nutritional supplementation with high-protein oral supplements, glycemic optimization targeting glucose <180 mg/dL perioperatively, pulmonary function optimization with bronchodilators
2. **Surgical procedure:** Right segmental mandibulectomy with 1.5 cm bony margins, right selective neck dissection (levels I-IV), fibula free flap reconstruction with titanium reconstruction plate, microvascular anastomosis of peroneal artery and vein to facial artery and vein
3. **Perioperative care:** Free flap monitoring with hourly Doppler checks for 72 hours, nasogastric tube feeding initiated postoperative day 1, tracheostomy for airway protection
4. **Adjuvant therapy:** Concurrent chemoradiation (cisplatin 100 mg/m² every 3 weeks with 66 Gy in 33 fractions) given positive lymph node and close/positive margins
5. **Rehabilitation:** Speech-language pathology for swallowing rehabilitation, prosthetic dental rehabilitation after radiation, physical therapy for lower extremity donor site
6. **Surveillance:** Clinical examination and imaging per NCCN guidelines every 1-3 months for the first year

### Key Learning Points
- The fibula free flap is the workhorse flap for mandibular reconstruction due to its adequate bone stock (up to 25 cm), reliable pedicle (peroneal artery and venae comitantes), and ability to be osteotomized for contouring
- Preoperative CT angiography of the lower extremities is mandatory to confirm three-vessel runoff to the foot before fibula harvest
- Nutritional optimization (albumin >3.0, prealbumin >15) is critical for wound healing and flap survival; consider preoperative nutritional supplementation
- Free flap success rates exceed 95% in experienced centers, but risk factors for failure include atherosclerosis, diabetes, prior radiation, and tobacco use
- Dental rehabilitation with osseointegrated implants in the fibula can be performed 6-12 months after completion of radiation therapy to restore masticatory function

---

## Case 3: Breast Reconstruction with DIEP Flap

### Patient Presentation
**Demographics:** 45-year-old female elementary school teacher

**Chief Complaint:** "I want breast reconstruction after my mastectomy for cancer"

**History of Present Illness:**
This 45-year-old female elementary school teacher was diagnosed with left breast invasive ductal carcinoma 4 months ago after presenting with a palpable mass on self-examination. Core needle biopsy revealed a 2.8 cm ER+/PR+/HER2-negative invasive ductal carcinoma, grade 2. Genetic testing revealed she is a BRCA1 mutation carrier. After extensive counseling, she elected to undergo bilateral skin-sparing mastectomy with immediate reconstruction.

She completed neoadjuvant chemotherapy with dose-dense adriamycin and cyclophosphamide followed by weekly paclitaxel, achieving a near-complete clinical response. She strongly desires autologous tissue reconstruction rather than implant-based reconstruction, citing concerns about implant longevity and desire for a more natural result. She has adequate lower abdominal tissue for bilateral DIEP (Deep Inferior Epigastric Perforator) flap reconstruction. She has no prior abdominal surgeries.

The patient met with the reconstructive microsurgeon and after discussion of options including DIEP flap, TRAM flap, latissimus dorsi flap, and implant-based reconstruction, she chose bilateral DIEP flap reconstruction for the most natural result with minimal donor site morbidity.

**Past Medical History:**
- Newly diagnosed left breast invasive ductal carcinoma (ER+/PR+/HER2-, BRCA1+)
- Completed neoadjuvant chemotherapy 4 weeks ago
- Mild seasonal allergies
- No prior surgeries

**Medications:**
- Loratadine 10 mg daily as needed
- Ondansetron 4 mg as needed (post-chemotherapy)
- Prenatal vitamin (as general supplement)

**Social History:**
- Non-smoker, never smoked
- Occasional wine (1-2 glasses/week), none during chemotherapy
- Elementary school teacher
- Married with two children (ages 8 and 12)
- Regular exercise: jogging 3x/week, yoga 2x/week
- BMI 26 with adequate lower abdominal panniculus

**Family History:**
- Mother diagnosed with breast cancer at age 48 (BRCA1+)
- Maternal aunt with ovarian cancer at age 55
- Maternal grandmother with breast cancer at age 52

### Physical Examination
- **Vital Signs:** BP 118/72 mmHg, HR 68 bpm, RR 14/min, Temp 36.7°C, SpO2 99% on room air, BMI 26.2, Weight 68 kg, Height 161 cm
- **General:** Well-appearing female in no acute distress, alopecia from chemotherapy with early regrowth
- **Breasts:** Left breast with 2 cm residual palpable mass at 10 o'clock position (decreased from 2.8 cm pre-chemotherapy). No skin changes, no nipple discharge. Right breast without masses. No axillary lymphadenopathy bilaterally
- **Abdomen:** Soft, non-tender. Adequate lower abdominal panniculus for bilateral flap harvest. No surgical scars. Pinch test >3 cm of subcutaneous tissue at the lower abdomen. No hernias detected
- **Vascular Assessment:** Palpable bilateral deep inferior epigastric artery perforators on handheld Doppler at paraumbilical locations
- **Cardiac:** Regular rate and rhythm, no murmurs
- **Lungs:** Clear to auscultation bilaterally
- **Extremities:** No edema, normal range of motion

### Workup and Results

**Laboratory Studies:**
| Test | Result | Reference Range |
|------|--------|-----------------|
| Hemoglobin | 11.2 g/dL | 12.0-16.0 g/dL |
| WBC | 5,100/μL | 4,500-11,000/μL |
| Platelets | 198,000/μL | 150,000-400,000/μL |
| Albumin | 3.8 g/dL | 3.5-5.0 g/dL |
| Prealbumin | 22 mg/dL | 20-40 mg/dL |
| INR | 1.0 | 0.8-1.2 |
| BMP | Within normal limits | -- |
| Type and Screen | A positive, antibody screen negative | -- |

**Imaging/Additional Studies:**
- CT Angiography of the abdomen: Bilateral dominant deep inferior epigastric artery perforators identified. Right side: two large periumbilical perforators (1.2 mm and 1.0 mm diameter). Left side: one dominant periumbilical perforator (1.4 mm diameter). No anatomic variants
- Breast MRI (post-chemotherapy): 1.2 cm residual enhancement at the known tumor site in the left breast, consistent with partial response. Right breast unremarkable
- Staging PET-CT: No evidence of metastatic disease
- Genetic testing: BRCA1 pathogenic variant (c.68_69delAG)
- Oncotype DX: Recurrence score 18 (intermediate risk)

### Clinical Image

![DIEP flap breast reconstruction diagram](case_03_image.jpg)

*Diagram illustrating the DIEP flap harvest from the lower abdomen, showing perforator vessels passing through the rectus abdominis muscle (which is preserved) and microsurgical anastomosis to the internal mammary vessels for breast mound reconstruction. Source: Educational illustration.*

### Diagnosis
**Left Breast Invasive Ductal Carcinoma (ER+/PR+/HER2-, BRCA1+) Status Post Neoadjuvant Chemotherapy, Planned Bilateral Skin-Sparing Mastectomy with Immediate Bilateral DIEP Flap Reconstruction**

**Key Diagnostic Criteria:**
- Biopsy-proven invasive ductal carcinoma with favorable receptor status
- BRCA1 mutation carrier warranting bilateral mastectomy
- CT angiography confirming suitable perforator anatomy for DIEP flap
- Adequate abdominal donor tissue with BMI 26.2 and no prior abdominal surgery

### Treatment Plan
1. **Surgical procedure:** Bilateral skin-sparing mastectomy (performed by breast surgical oncologist) with sentinel lymph node biopsy on the left, followed by immediate bilateral DIEP flap reconstruction with microsurgical anastomosis to internal mammary vessels
2. **Intraoperative monitoring:** Implantable Cook-Swartz Doppler placed on venous anastomosis for postoperative flap monitoring; ICG angiography to confirm flap perfusion
3. **Postoperative care:** ICU admission for first 24 hours with hourly flap checks (color, temperature, capillary refill, Doppler signal). Strict bed rest for 48 hours. Sequential compression devices and low-molecular-weight heparin for DVT prophylaxis. Abdominal binder for 6 weeks
4. **Adjuvant therapy:** Adjuvant endocrine therapy (aromatase inhibitor or tamoxifen) based on final surgical pathology. Radiation therapy if indicated by final pathology. Risk-reducing bilateral salpingo-oophorectomy recommended by age 35-40 (or after childbearing) given BRCA1 status
5. **Secondary procedures:** Nipple-areolar complex reconstruction with local flaps and tattooing planned 3-4 months after initial reconstruction. Possible fat grafting for contour refinement at 6-12 months
6. **Follow-up:** Microsurgery clinic at 1 week, 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. Breast oncology surveillance per NCCN guidelines

### Key Learning Points
- The DIEP flap preserves the rectus abdominis muscle and anterior rectus sheath, significantly reducing donor site morbidity (hernia, bulge, core weakness) compared to the traditional TRAM flap
- Preoperative CT angiography is essential for DIEP flap planning to identify the dominant perforators, map their intramuscular course, and plan the flap design
- The internal mammary vessels (typically the third rib interspace) are the preferred recipient vessels for DIEP flap breast reconstruction due to their reliable caliber and location
- Immediate autologous reconstruction does not delay adjuvant chemotherapy or radiation in most cases, and radiation can be delivered to the reconstructed breast, though it may affect the aesthetic outcome
- BRCA mutation carriers benefit from bilateral mastectomy with reconstruction, and autologous reconstruction provides a durable, lifelong result without the need for implant exchanges