Cheek Reconstruction

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Chapter 13 Cheek Reconstruction

As with other areas of the face, the goal of cheek reconstruction is to create the “illusion of normality and the perception that all is as it was.”¹ Normality on the cheeks is defined as symmetrical contour, color, and texture. The face is centered by the nose, eyelids, and mouth and framed by the forehead, chin, and cheeks. Thus, reconstruction on the peripheral cheeks will not be as apparent as on the central nose.

Cheek defects are generally repaired by side-to-side closures or flap closures, if possible. Flap closures are used frequently because of the abundant loose cheek tissue, and generally lead to optimal cosmetic results. Grafts and healing by second intention often produce inferior cosmetic results (granulation, contraction, and epidermization) and, except in unusual circumstances that will be discussed later in this chapter, are not commonly used on the cheek.

Like other areas of the body, cheek reconstruction should take into consideration a number of factors that include the following: location of maximum skin tension lines; surface anatomy; skin texture; subcutaneous anatomy; patient’s age and medical problems; size, depth, and location of the cheek defect; and previous surgery, radiation, and scars. This chapter will discuss the author’s approach to repair of cheek defects.

REGIONAL RECONSTRUCTION PRINCIPLES

Relaxed Skin Tension Lines

As discussed in Chapters 1 and 2, the relaxed skin tension lines (RSTL) generally run inferiorly and posteriorly over the surface of the cheek. If possible scars should be placed along these lines, particularly because these lines eventuate into wrinkle lines. Also scars are best placed in the lines and grooves of the periphery of the cheek in the cosmetic unit junctions, such as the preauricular fold, the melolabial fold, and the nasofacial angle. It should be noted, however, that flap incisions rarely spread when placed perpendicular to the relaxed skin tension lines. The reason for this is that in the cheek, although the inherent pull in the direction of the RSTL is more than the pull in the direction perpendicular to the RSTL, it is not very much more.

Surface Anatomy

The boundaries of the cheek are the preauricular crease, the superior border of the zygomatic arch and malar eminence, the inferior orbital rim, the nasofacial angle, the melolabial crease, and the inferior border of the mandible. The cheek may be roughly divided into seven somewhat overlapping and poorly demarcated subunit areas for the purpose of discussion. These seven areas include the following: medial, anterior (maxillary), infraorbital, zygomatic, buccal, preauricular, and mandibular. In each of these areas some flap types are more preferable than others. Many repairs in the cheek cross over and include more than one of these subunits. In some peripheral borders on the cheek, for instance the cheek and eyelid boundary, the border is best not transgressed by a single flap, but rather two flaps, one from the upper eyelid and one from the cheek so as to reestablish the boundary between the cheek and eyelid zones.¹

Repairs on the face may be regional (eg, the whole cheek) as emphasized by Gonzalez-Ulloa ² or local (small flaps on only a portion of the cheek). The subunit principle applied by Burget and Menick³ to the nose is not as critical on the cheek because the subunits are less distinct. The only defining grooves are at the periphery of the cheek along the cosmetic unit junctions.

The cheek is not a flat surface, but is concave medially as it extends into the nasofacial sulcus; it is convex over the malar eminence. Only in the lateral cheek and preauricular area is the cheek flat. This uneven topography is important for the surgeon to be mindful of as cheek reconstruction is three-dimensional.

Abundant loose skin exists on the cheeks for flap repairs. This abundant tissue is usually found inferior to defects to be reconstructed. With age, cheek skin begins to sag and thus more loose tissue becomes available for repairs. However, in the elderly who have had a facelift procedure or in the young, this normally abundant tissue is generally not as plentiful. Additionally, if prior surgery has been done on the cheek, the underlying anatomy may have been altered and tissue may not move normally.

Skin Texture

Skin surface characteristics may vary enormously on the cheek from individual to individual and also within the cheek on the same individual. In patients with very oily skin and patulous pores it may be more difficult to get a good cosmetic result than in patients with smooth non-oily skin. Elderly patients with a plethora of skin laxity wrinkles will be easier to reconstruct than the young who have greater elastic skin recoil and no wrinkles. Wrinkles afford camouflage for linear, arciform, and flap incision lines. Because of the unique texture of cheek skin, skin grafts in this location generally provide a poor color and texture match. Skin grafts on the cheek appear as patches and should be avoided if possible. The texture of cheek skin may also vary from one cheek region to another. The beard area on the male needs to be kept in mind. The wrong skin in the wrong place may lead to a less than optimal cosmetic result.

Subcutaneous Anatomy

Beneath cheek skin lies an investing fibrous layer, the submuscular aponeurotic system (SMAS). This layer lies between and is attached to the dermis above and the muscles below. Inferiorly SMAS is continuous with the platysma muscle.⁴ Deep to the SMAS lies the parotid gland and its duct, facial nerve branches, and the superficial muscles of facial expression. All these muscles are supplied by branches of the facial nerve (VII). The buccal branches of the facial nerve over the cheek ramify to such a great extent that any motor loss after reconstruction is usually temporary. The sensory supply to the cheek is mostly from the trigeminal nerve (V). The medial cheek is supplied by the second division (V₂) through the infraorbital nerve. The lateral cheek to the mandible is innervated by third division (V₃) of the trigeminal nerve. A small lower area of the posterior cheek near the lower ear is supplied by the anterior cutaneous nerve of the neck and by the great auricular nerve, which originates from the cervical plexus (C₂, C₃).

The arteries and veins on the cheek generally need not be taken into account to any great extent when performing superficial flaps on the cheek. There is such a good vascular supply on the head and neck that flaps on the cheek flaps are usually randomly placed in relationship to underlying arteries and nerves. The arterial supply to the cheek is from the external carotid artery, which gives rise to the transverse facial artery and the facial artery. Venous drainage is via the anterior facial vein.

There are, however, two motor nerves that are superficial in part of their course on the cheek and that one needs to be wary of. The first is the temporal branch of the facial nerve, which may be superficial as it crosses the zygomatic arch. The second is the marginal mandibular nerve, which crosses over the mandibular artery as it courses along the edge of the mandible.

Special Anatomic Structures

There are two special anatomic structures in the cheek worth noting: the buccal fat pad and the parotid duct. The buccal fat pad is a large well-defined area in the central cheek with a large amount of fat. Its importance is that it is a good landmark for Stenson’s duct, which is the main drainage channel for the parotid gland. The duct courses over the buccal fat pad and descends anterior to it. If Stenson’s duct is transected and a flap repair done over the leaking area, there will be salivary drainage at the flap edge. Sometimes this will be difficult to see and is unavoidable. However, should this drainage occur, it will generally slow down and go away after a few months.⁵ If one sees the salivary leakage, recanalization of the duct may be attempted with a Silastic tube prior to flap repair; however, in the author’s experience this procedure is often unsuccessful.

Which Reconstructive Procedure

Faced with a cheek defect, how does one select the optimal repair? Generally, healing by second intention on most of the cheek will lead to a noticeable scar except in the preauricular area. In this latter area, even very large wounds may be allowed to heal by granulation, often resulting in a healed wound that may be excellent.

As mentioned earlier, skin grafts are generally not used on the cheek. A skin graft matches poorly with the surrounding and contralateral cheek skin in color, texture, type, and degree of hair growth. Furthermore, a skin graft often will not completely fill in a subcutaneous defect and provides less protection to underlying vessels and nerves than a skin flap. There are, however, two exceptions as to when a skin graft may be useful. First, to repair a defect that resulted from an excision of an aggressive tumor, e.g., angiosarcoma or sebaceous gland carcinoma. In this case, a split-thickness graft could be used to immediately repair the defect and to provide a window through which a tumor recurrence could be seen (see Figure 13.1). The second circumstance for doing a split-thickness graft would be to repair a very large defect, which could not be repaired in any other way. Prior to the development of large cheek flaps and cheek–neck rotation flaps, multistaged cheek rotation flaps⁶ or large skin grafts were commonly used to repair cheek defects.⁷

Figure 13.1 (a) Large wound on right cheek after excision of multiple recurrent level II lentigo maligna. (b) Medium-thickness, split-thickness skin graft sutured into wound. Note bolster sutures to tack graft onto recipient wound so as to keep graft from slipping during healing. (c) Healed result 6 months postoperatively.

The single largest decision when contemplating a cheek reconstruction is whether to repair a wound with a side-to-side linear closure (complex repair) or a skin flap. The same defect that may be repaired side-to-side in an elderly person with excess skin and wrinkles may require a skin flap for closure in a younger person to avoid scar spreading from excess tension.

This author has found empirically that the best way to determine whether a complex repair or a skin flap should be done is to lift the ends of the wound up along the relaxed skin tension lines. If the wound edges close easily across the wound with the skin hooks tenting up the wound at the superior and inferior ends, then a side-to-side linear repair may be done. Sometimes, however, a side-to-side repair may be done but distortion of the melolabial fold may occur. In this instance, a flap may be preferable. When possible, however, one should close a wound with a side-to-side linear repair since it will result in fewer incision lines than those from a skin flap.

Reconstruction Philosophy

In reviewing the literature on cheek reconstruction, this author was struck by two trends. The first is that surgeons like to do one specific flap type for one specific defect at one time. This issue has been raised by other authors.^1,⁸ Part of the reason for this approach has been that surgical training programs emphasize repairing the whole wound at one time; leaving part of the wound open is heresy. The second trend is that even medium-sized wounds on the cheek are repaired by rather large flaps extending into the neck and shoulder when these same wounds could have been closed with an equally good or better result by smaller, less complicated local flaps. The latter trend to do cervical neck or cervical pectoral flaps results in excessive surgery. This is not to say there is not a time and place for such flaps, but many of the case examples presented in the literature show medium-size wounds that could be repaired in other ways.⁹

Flaps to Avoid

On the cheek, two flaps that this author avoids are the subcutaneous island pedicle flap and the bilateral advancement flap. The former usually is very puffy and does not lie flat;¹⁰ the latter produces too many straight lines that are easily seen.

FLAPS BY CHEEK REGION

Medial Cheek

The medial cheek usually has significant skin laxity. If the wound is small to medium in size and its long axis is oriented vertically, a side-to-side repair may easily be done (Figure 13.2). If possible, repairs in this area are closed along the nasofacial angle or melolabial fold. Although some authors⁹ advise deep “periosteal” tacking sutures for side-to-side linear closures in the nasofacial angle, this author does not do this and feels it is usually unnecessary. For vertically oriented wounds on the medial cheek that cannot be closed without excessive tension on the wound edges, the rhombic transposition flap with a double Z-plasty is useful (Figure 13.3). This flap takes advantage of the inferior loose tissue available on the cheek. The double Z-plasty helps to increase the extension of the rhombic flap.¹¹ The angulated incisions of the rhombic flap and Z-plasties generally blend in very well over time.

Figure 13.2 (a) Elliptical wound with long axis oriented vertically on medial cheek. (b) Side-to-side repair. Note running over-and-over sutures. (c) Healed result 1 year postoperatively.

Figure 13.3 (a) Large elliptical wound on medial cheek with long axis oriented vertically. (b) Rhombic flap with double Z-plasty cut and undermined. (c) Flap transposed into wound. (d) Flap sutured into defect. (e, f) Healed result 6 months postoperatively.

For a medial cheek wound with its long axis oriented horizontally, a side-to-side linear closure vertically oriented along the maximum skin tension lines would lengthen the suture line considerably. Therefore it might be best to consider a flap closure. There are three main flap choices for such a wound in this area: the subcutaneous island pedicle flap, the rhombic transposition flap (Figure 13.4), and the advancement flap with a back-cut (Figure 13.5). This author does not like the subcutaneous island pedicle flap in this location as this flap is often puffy, even many months later. When this happens, it is difficult to correct.¹⁰ Nevertheless it may be considered for small wounds just above or within the melolabial fold.

Figure 13.4 (a) Defect medial cheek with long axis horizontal. (b) Rhombic flap cut and undermined. (c) Flap transposed and sutured. (d, e) Healed result 1 year postoperatively.

Figure 13.5 (a) Round defect medial cheek. (b) Advancement flap from inferiorly cut with back-cut. (c) Advancement flap advanced superiorly. The back-cut triangle will be cut off. (d) Flap sutured into place. (e, f) Healed result 2 years postoperatively.

The rhombic transposition flap works well for medium-sized wounds in the medial cheek (Figure 13.4). As emphasized by Borges,^12,¹³ it is important to design the rhombic flap so the base of the flap (that is, the base of the flap triangle) is perpendicular to the maximum skin tension lines on the cheek. Also, as Becker¹⁴ points out, the main flap tension is at the donor area, and these flaps on the cheek are generally laterally and inferiorly based. Cabrera and Zide¹⁵ further recommend that one base the rhombic flap inferiorly as this orientation tends to minimize the trapdoor effect, which may or may not be true.

Horizontally oriented defects in the medial cheek are often best repaired with a rotation/advancement flap from the inferior direction (Figure 13.5). An incision line is made inferiorly along the melolabial crease line, often with a back-cut. The tissue is rotated and advanced superiorly and the back-cut triangle is removed. The incision down the melolabial crease with excision of a Burow’s triangle rather than a back-cut was described by Imre.¹⁶ This author prefers the back-cut triangle because there is less likelihood of nerve injury. One problem with the advancement/rotation flap with a back-cut is that medial canthal tenting may occur (Figure 13.6), particularly when this flap is used to repair horizontally oriented defects high in the medial cheek. To help prevent this problem, Jelks and Jelks¹⁷ advise deepithelializing the flap tip and fixing it to the medial canthal tendon. The tenting, if bothersome, may be released by a V-to-Y or Z-plasty. One should also employ a periosteal suture to hold the weight of the flap and decrease wound tension.

Figure 13.6 (a) Wound on medial cheek and nose with long axis horizontally. (b) Advancement flap from inferiorly cut and advanced superiorly. Back-cut triangle will be cut off. (c) Flap sutured into place. Note tenting in medial canthus. (d, e) Healed result 1 year postoperatively. Note tenting about same in both medial canthi.

As the wound size increases, so does the complexity and difficulty of the flap. For large defects (especially those oriented vertically) in the medial or anterior cheek area, a whole cheek advancement/rotation flap may be created from the lateral cheek. Using the entire cheek lateral to a large defect as a single flap is considered by some physicians to be ideal because it is less noticeable compared to smaller flaps, which may cross the lines and natural creases of the face.^9,¹⁸ Furthermore, this flap is a very vascular and therefore safe flap, which rarely has tip necrosis.

The cheek advancement flap has a medial inferior base and a forward and medial destination. The initial incision for a cheek rotation/advancement flap is made horizontally and laterally from the cheek defect extending on top of the orbital rim; as it progresses laterally at the point of the lateral canthus it is gently curved superiorly above the zygomatic arch to at least the level of the lateral canthus to decrease the chance of ectropion. This latter incision places the vector of any scar contraction in an upward posterior direction so that it will counteract any inferior pull on the lid. If this flap stops above the zygomatic arch in the temple, it is similar to the Mustarde flap used to close defects on the lower eyelid ¹⁹ (Figure 13.7).

Figure 13.7 (a) Large irregular wound with widest diameter oriented horizontally. (b) Flap incision extending laterally over cheek. Note that laterally, it arches superiorly at the lateral canthus. (c) Flap advanced medially. (d) Flap sutured into defect. (e, f) Healed result 1 year postoperatively.

For very large defects of the medial or anterior cheek, the incision should be carried over the zygomatic arch and down the preauricular crease to a point 2 to 3 cm below the earlobe. Here a Burow’s triangle may be excised and hidden behind the earlobe ²⁰ (Figure 13.8). The flap is then rotated medially as it is advanced superiorly. It is critical to place tacking sutures along the lateral and inferior lateral orbital rim and the malar eminence to support the heavy flap and prevent ectropion. It is also important to thin the subcutaneous tissue along the superior flap border to match the skin thickness of the lower eyelid.

Figure 13.8 (a) Large wound with wide axes both horizontally and vertically. (b) Incision made laterally and superiorly over anterior cheek, then inferiorly in front of ear and then inferior to earlobe and then superiorly behind the earlobe. (c) Cheek flap rotated medially. Burow’s triangle removed under earlobe. (d, e) Healed result 4 years postoperatively.

For large defects in the medial or anterior cheek, some authors ^9,²¹ prefer the cheek–neck (cervical facial) rotation flap. The flap incision on the cheek is similar to that of the cheek rotation flap just described. The incision follows the orbital rim laterally and at the lateral canthus is arched superiorly. The incision is continued posteriorly along the temporal hairline and preauricular crease. At the inferior lobule of the ear, the incision is then continued either inferiorly and anteriorly into a neck crease along the sternocleidomastoid muscle or posteriorly around the lobule and along the lateral inferior hairline.^22,²³ The extended incisions allow recruitment of tissue from the neck and retroauricular areas. Undermining is done in the mid-subcutaneous level (the face lift plane) with sufficient fat maintained to ensure adequate blood supply and adequate tissue thickness. As the flap is rotated, tacking sutures are placed into the deep tissues of the medial and lateral orbital rim to prevent inferior lid displacement. Tacking sutures are also advisable along the line between the lateral eyebrow and the superior attachment of the ear.²⁴ Even though this flap may extend over the entire cheek, drains or suction catheters are rarely needed.²⁵

For even larger defects on the medial and anterior cheek, the incision may be carried further down the neck to recruit even more tissue. Instead of bringing the incision anteriorly into a neck crease, as in the cervical facial rotation flap, the incision continues along the posterior border of the trapezius muscle and then medially at the end of the clavicle either along the clavicle or more inferiorly into the pectoral chest (cervicopectoral flap).²⁶ If one makes the incision on the posterior border of the trapezius muscle there will be little likelihood of scar contracture or hypertrophy. Although the cervicopectoral flap has been considered a safe flap, some authors would disagree, particularly if the flap is under considerable tension.

As an alternative to basing the cheek advancement/rotation flap medially, some authors ^15,²⁷^–²⁹ have suggested a laterally based cheek advancement/rotation flap in which an incision is made down the melolabial fold and onto the neck. This flap would mostly advance tissue superiorly with little rotation (thus the name the “hike flap”). Most of the blood supply to this latter flap would come from branches of the facial artery as it crosses over the inferior border of the mandible, where it can be palpated. In addition if one includes the platysma muscle in the flap, the blood supply will be further enhanced.³⁰ However, because of the forces of gravity on this flap, great care needs to be taken to carefully tack the flap superiorly along the orbital rim to prevent ectropion.

Problems that can occur with large advancement rotation flaps on the cheeks include anterior transfer of hair-bearing tissue, which may be obvious in men, and ectropion. Therefore, it is important to fastidiously tack these flaps to underlying deep tissue in the zygomatic region. Also, if the wound edges are not carefully everted, the scar line may be easily seen (Figure 13.8d).

Anterior Cheek

A defect on the anterior cheek can be closed with a side-to-side closure if small (Figure 13.9). For medium-sized defects the rhombic flap (Figure 13.10) and the rhombic flap with two Z-plasties is useful (Figure 13.11). For large defects, a single lobe transposition flap may be considered (Figure 13.12). The flap may be superiorly based as shown in Figure 13.12 or inferiorly based.^10,¹⁵ Also, as on the medial cheek, a cheek rotation advancement flap may be considered, especially if the defect is large.

Figure 13.9 (a) Elliptical wound on anterior cheek with long axis oriented vertically. (b) Side-to-side repair; note running over-and-over sutures. (c, d) Healed result 1 year postoperatively.

Figure 13.10 (a) Round wound on anterior cheek. (b) Rhombic flap cut and undermined. (c) Rhombic flap transposed into defect. (d) Rhombic flap sutured into place. (e, f) Healed result 1 year postoperatively. Note slight noticeable scar at leading edge of rhombic flap.

Figure 13.11 (a) Round wound on anterior cheek. (b) Rhombic flap with double Z-plasty. (c) Rhombic flap transposed into defect. (d) Rhombic flap sutured into place. (e, f) Healed result 1 year postoperatively. Note the telangiectasias on flap.

Figure 13.12 (a) Wound on anterior cheek. (b) Single-lobe flap cut and undermined. (c) Flap transposed into defect. (d) Flap sutured into place. Note standing cone (dog-ear) laterally, which is left in place to ensure flap survival. (e) Healed result 6 months later at which time dog-ear to be excised. (f) Proposed dog ear excision. (g) Dog ear excised wound sutured (h, i) Healed result 1 month later.

Infraorbital Cheek

This area of the cheek can be a difficult area to repair. It is important to stress that although the transition from the lower eyelid onto the infraorbital cheek seems to be gradual; in many individuals there is a well-defined zone of sebaceous skin on the cheek and smooth skin on the upper eyelid. Here, it is best to keep the sebaceous skin in one area and the smooth eyelid skin in its area. If a wound includes a significant part of the lower eyelid in addition to the cheek, it is often preferable to use a full-thickness skin graft (or a Tripier flap) to repair the eyelid part of a wound and a cheek flap to repair the cheek part of the wound.

Malar Cheek

The malar cheek can also be closed linearly or with either a rotation/advancement flap or a transposition flap. The dynamics of closure in this area are similar to those on the medial cheek. Care needs to be taken to avoid damaging the temporal branch of the facial nerve, which is superficial in this area. When close to the lateral canthus, one should place tacking sutures to prevent distorting the lower lid and creating an ectropion.

If the wound is small in this area, a Burow’s wedge advancement flap may be done. An incision is made laterally and the Burow’s triangle taken out lateral to the lateral canthus.³¹

Buccal Cheek

The buccal cheek can be repaired linearly or with a rotation flap, a rhombic flap, or a single-lobe transposition flap.

Preauricular Cheek

Fortunately in this area, even large wounds can often be closed side-to-side. The rotation advancement (or the Burow’s wedge advancement) flap may be useful for small or medium-sized wounds in this area. For the latter flap, an incision is made inferiorly along the preauricular crease and a Burow’s triangle removed inferior and posterior to the earlobe. The flap is advanced superiorly. The Burow’s wedge advancement flap helps to preserve the cosmetically significant preauricular hairless area in men. Occasionally large preauricular wounds may be closed with a transposition flap. Generally the rhombic flap is inferiorly based.

Very large wounds in the preauricular cheek may be re-paired with a cervical neck flap from below or a postauricular banner transposition flap ³² (Figure 13.13). The posterior auricular banner transposition flap uses non-hair-bearing skin. An incision is made posterior to the earlobe superiorly along the postauricular sulcus; it is then arched superiorly and descends along the lateral posterior hairline. It utilizes the thin skin overlying the superficial cervical fascia covering the sternocleidomastoid muscles and the posterior auricular muscles. The base of the flap is posterior to the angle of the mandible and over the sternocleidomastoid muscle. The platysma muscle is present at the inferior and anterior portion of the flap base. The flap is richly vascularized in its subdermal plexus by vessels originating in the thyroid branch of the external carotid artery. Also, there are muscle perforators supplying the flap after coming through the sternocleidomastoid muscle. The dissection is done inferiorly above the platysma so that the cervical and marginal mandibular branches of the facial nerve are not injured. The posterior auricular flap is transposed over the ear to the preauricular cheek.