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The treatment of Tessier no. 3 and no. 4 clefts is controversial, and little is published because of their rarity. Frequently, many surgeries are necessary for correction of these defects, and in some cases, the outcomes are less than the ideal. Aware of that problem, we developed a procedure based on the Van der Meulen rotation and advancement flap of the cheek that may correct the cleft with 1 simple procedure and also respects the aesthetic units of the face. We report 3 patients presenting cleft no. 3 and 1 patient presenting cleft no. 4 and describe the rotation and advancement flap of the cheek technique used in their treatment.

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Background The mandible is responsible for vital functions of the stomatognathic system, and its loss results in functional and aesthetic impairment. Mandibular reconstruction with free fibula flap is considered the gold standard for mandibular reconstruction. Case presentation We describe here the 38-year follow-up of the patient who was the first case of mandibular reconstruction with free fibula flap reported in the literature. The original report describes a 27-year-old woman who had undergone extensive mandibulectomy due to an osteosarcoma. A microvascularized fibula flap was used for mandibular reconstruction in 1983. Two years later, a vestibulo-lingual sulcoplasty with skin graft was performed to allow the construction of a total dental prosthesis. Fifteen years after the initial treatment, an autologous iliac crest graft was placed in the fibula flap, aimed at increasing bone thickness and height for rehabilitation with implant supported prosthesis. In 2015, a rib graft was positioned in the mental region, enhancing the support to the soft tissues of the face and improving the oral function. A recent review of the patient shows well-balanced facial morphology and optimal functional results of the procedure. Conclusions The fibula flap method, described in 1975 and first reported for mandibular reconstruction in 1985, continues to be applied as originally described, especially where soft tissue damage is not extensive. Its use in reconstructive surgery was expanded by advancements in surgery and techniques such as virtual surgical planning. However, there is still a lack of evidence related to the long-term evaluation of outcomes. The present work represents the longest-term follow-up of a patient undergoing mandibular reconstruction with free vascularized fibula flap, presenting results showing that, even after 38 years, the procedure continues to provide excellent results.

The aim of this study was to verify the role of the venous drainage system in the pathogenesis of complications in microsurgical head and neck reconstruction. In a nonrandomized cohort study, 52 consecutive cases of complex head and neck microsurgical reconstruction were evaluated. The patients were divided in two groups based on the treatment: the deep (DVDG; n = 30) and superficial (SVDG; n = 22) venous drainage groups. The complications evaluated included vascular obstruction with partial or total loss of the microsurgical flap, inadequate healing (fistulas or suture dehiscence), and infections. The arterial anastomotic site, neoplastic recurrence, use of medications and neoadjuvant radiotherapy, flap selection, tumor histology, smoking/alcoholism, and systemic diseases had no effect on postoperative complications, while the venous component influenced the overall complication rate (chi-square test, P = 0.006). A protective effect was achieved in the DVDG when the overall complication rate was considered--relative risk (RR) 0.65, 95% confidence interval (CI) 0.45-0.94. The recipient vein should be the surgeon's main concern as it influenced the outcomes of patients undergoing complex microsurgical head and neck reconstruction. A protective effect was observed when the internal jugular vein drainage system was used for this purpose.