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CME Reconstruction of the Cheek

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CME Reconstruction of the Cheek CME Reconstruction of the Cheek Frederick J. Menick, M.D. Tuscon, Ariz. Learning Objectives: After studying this article, the participant should be able to: 1. Describe the cheek unit and its specific requirements for quality, outline, and contour. 2. Identify factors involving the patient, wound, and donor materials that determine technique. 3. Understand the application of anteriorly based, posteriorly based, and advancement flaps, and the use of serial excisions for specific defects. 4. Identify, prevent, and treat complications of cheek reconstruction. The face can be divided into adjacent topo- visual comparison in almost all views. They are graphic areas of characteristic skin quality (col- fixed units and have the highest priority in or, texture, hair-bearing), outline, and con- reconstruction. Any unexpected alteration of tour, that define its regional units.1 The skin size, shape, character, or symmetry will be ob- quality of the cheek matches the face in color vious and distracting and will indicate that “this and texture and is normally covered by a fine face is broken.” In contrast, the units of the matte hair in women and a beard pattern that facial periphery (cheek and forehead) are like continues into the sideburn in men. The pe- a picture frame, and they are of secondary ripheral outline of the cheek unit is formed by importance. The cheek is flat, expansive, and the hard and soft-tissue contours of the border- uninteresting. Its dimensions and outlines are ing units (forehead, eyelids, nose, lips, neck, variable. Its borders are not fixed but rather and ear). Its outline follows the preauricular change from person to person and with age, contours of the tragus and helix; goes around sex, hairline position, hairstyle, and expres- the sideburn, across the zygomatic arch (abut- sion. The outline of the contralateral cheek ting the slight hollow of the temporal fossa), cannot be fully compared with the other cheek and into the lower lid-cheek junction; and then in any view. Exact symmetry, especially of out- passes inferiorly along the nasal sidewall into line, is not vital. the nasolabial fold and marionette line (abut- The preoperative plan should distinguish be- ting the upper and lower lip units), around the tween central and peripheral features with re- chin and toward the submental crease. It then gard to guidelines for unit reconstruction. For extends laterally along the jawline, passing su- example, when filling a nasal defect (a central periorly up the angle of the jaw and back to the unit), the following rules are recommended2: ear. In contour, the cheek is a relatively flat, 1. Rebuild or resurface entire units; do not expansive surface, except for the soft round- fill defects. ness of the nasolabial folds and cheek promi- 2. Alter the wound in site, size, and outline. nences. Time, sun injury, and ptosis create the 3. Discard adjacent normal tissue within typical alterations in cheek contour associated units and subunits to improve the final with aging. result. The reconstructed demands of any single 4. Use the contralateral normal as a guide. unit vary according to the defect and its unit 5. Use exact templates to design flaps and characteristics and priority. Central facial units grafts to replace missing tissue in precise (nose, lip, eyelid) are complexly and subtly outline and dimension. contoured. They are seen in primary gaze, and their contralateral normal subunit (opposite These rules of central regional unit recon- ala, eyelid, lateral upper lip) are available for struction ensure uniform skin quality, position Received for publication August 7, 2000; revised December 29, 2000. 496 Vol. 108, No. 2 / RECONSTRUCTION OF THE CHEEK 497 scars at the periphery of units so that they are tral face. Such scars are distracting when visible hidden in the joins between them, and harness on direct frontal view. Flap incisions and dog- centripetal wound contraction to reestablish a ear excisions are best hidden in blepharoplasty- convex subunit contour. These principles are type incisions or positioned directly in the na- less appropriate in the reconstruction of a pe- solabial fold, rather than vertically across the ripheral unit, such as the cheek. zygomatic eminence. Cheek defects are filled by sharing tissue Many cheek defects also extend into adja- from adjacent units (neck, submental area, cent units—scalp, eyelid, nose, lips, or chin. chest), not by replacing them exactly with in- Normal residual landmarks, if distorted by terpolating flaps, as a nasal tip defect might be wound tension, gravity, or contraction, must with a forehead flap. It is impractical and un- first be positioned back to normal. Preserva- necessary to excise all adjacent normal tissue tion of lower lid position and oral function are within the large cheek unit. priorities and may require an upper-lid Tripier In peripheral units such as the forehead and skin-orbicularis flap or lip switch flap as a first cheek, the most important element in restor- step. ing normal facial surface appearance is unifor- Surgeons tend to place a single flap into a mity of skin color and texture, not contour or single wound during a single operation. How- outline. In the cheek, as Feldman3 has pointed ever, reconstruction in stages may be best. out in facial burn resurfacing, uniformity of When a nasal defect accompanies a significant skin color and texture is vital to the restoration lip and cheek defect, only the lip and cheek of the normal facial appearance. When treat- should be reconstructed primarily.2 The nose ing subtotal facial scarring, skin grafts are should be repaired secondarily after a stable avoided, because they produce a patched ap- cheek platform is ensured. If the lip, cheek, pearance owing to their unpredictable color and ala are reconstructed simultaneously, sub- and shiny texture match where they abut nor- sequent wound settling distorts the position of mal facial skin. Local and regional flaps are the the ala. Wound contraction and gravity shift first choice. For total facial resurfacing, either a the lip and the cheek platform, dragging the complete skin graft or a complete flap are op- reconstructed nose inferiorly and laterally. tions. Combinations of grafts and flaps are not A defect of both cheek and hair-bearing aesthetic. scalp or sideburn should be reconstructed with Skin quality also guides the use of distant the appropriate materials. To restore both the microvascular tissues in cheek reconstruction.4 cheek and scalp units, scalp rotation flaps or Large, deep, and compromised wounds are superiorly based transposition hair-bearing often filled with distant tissue, usually by mi- flaps should be positioned to reestablish the crovascular transfer. Although available, highly position of the hairline, based on the template vascular, and able to repair complex wounds, of the contralateral normal hairline outline. distant skin is a poor-quality match for facial skin. When an aesthetic appearance is impor- PLANNING tant, local, and regional tissues are required for Thoughtful consideration of the patient, resurfacing the cheek. Distant tissues should be wound, and available donor material is helpful used only for what they do best—supply “hid- to identify the most appropriate technique. den” lining and bulk, and revascularize diffi- cult wounds (contaminated, ischemic, radiat- THE PATIENT ed)—not permanently resurface the face. Most patients want to be restored to their Local and regional flaps should be advanced normal appearance before injury or surgery. secondarily to provide permanent external Most are grateful to the surgeon who provides skin after other, deeper soft-tissue needs are information and options and is committed to supplied by distant tissues. achieving a result that fits their goal. Although scars are best placed in the joins In general, the difference between male and between units or hidden along the hairline or female patients is overemphasized. However, contour lines, the presence and position of when planning cheek flaps in the child or male facial scarring are less important in a periph- adult patient, the position of facial hair must eral unit. However, Zide5 has pointed out that be considered. Beard or sideburn areas should vertical incisions anterior to a line drawn from lie only where normally expected. The absence the lateral canthus are best avoided in the cen- of a beard pattern is equally distracting. The 498 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2001 male beard pattern must be realigned to the ture dog-ear excisions should be considered sideburn. during planning, and hidden in contour lines, Skin laxity associated with aging can be used if possible. to advantage. Interestingly, preadolescent chil- dren seem to have exceptionably elastic skin, Depth which can be undermined widely, permitting The deeper the wound, the greater the risk significantly greater flap stretch than expected. to the facial nerve, and the greater the require- In any patient, preexisting scars, deformity due ment for soft-tissue bulk or oral lining. Cheek to previous surgery or trauma, or the risk of contour is best restored by resupplying the subsequent primary cancers will alter the re- appropriate amount of skin and underlying construction. Other medical illnesses may pre- soft tissue. Although a skin and superficial sub- clude a complicated reconstruction. cutaneous random skin flap is ideal to cover a superficial wound, deeper excisions are best DEFECT resurfaced with thicker and better-vascularized Site deep-plane cheek techniques. However, a thicker composite flap will require substantial The site of the cheek defect influences the thinning if it is advanced to cover the adjacent direction of skin-flap motion, pedicle base lo- lower lid or nasal sidewall unit. Isolated bulk cation, and risks to the adjacent and underly- losses in the medial cheek are often associated ing structures. Small-to-moderate defects in the with adjacent nasal and lip defects. Medial soft anterior cheek are repaired with posteriorly tissues can be replaced with the Millard fat based rotation advancement flaps.
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