Cheek Reconstruction

Question 1

What history should be taken into account during work-up of a cheek defect?

Answer 1

Malignancy timeline, sun exposure, personal/family history of skin cancer, genetic conditions, complicating comorbidities

Question 2

List some genetic conditions relevant to facial reconstruction.

Answer 2

• Xeroderma pigmentosum
• Gorlin’s syndrome (nevoid basal cell syndrome)
• Albinism

Question 3

Describe all things considered in cheek defect analysis and considerations for reconstruction.

Answer 3

Lymph node examination, wound characteristics, confirm absence of involvement of deeper structures (muscle, parotid, facial nerve, mucosa, bone), facial subunit involvement
Also look at skin laxity, and rhytids to evaluate where to place incisions, look at how to avoid color mismatch/ distortion of hair-bearing skin and surrounding structures.

The best option is determined based on the relationship of the defect to the surrounding structures, hair- bearing status, skin laxity, natural wrinkles, previous surgical scars, and relaxed skin tension lines.

Question 4

What should be done if the patient presents without resection of lesion from the cheek?

Answer 4

A biopsy should be performed to establish a diagnosis (full-thickness incisions vs. excisional biopsies only. No shave)

Question 5

What should patients be counseled about post-reconstruction?

Answer 5

Some degree of asymmetry is to be expected

Question 6

What should be confirmed before cheek reconstruction?

Answer 6

Negative margins on final pathology

Question 7

What interim measures can be taken while waiting for reconstruction?

Answer 7

• Local wound care
• Integra
• Temporizing skin graft

Question 8

What considerations must be taken when operating along the eyelid/cheek junction?

Answer 8

Eyelid support must be considered

Question 9

What type of support procedures can be performed for lax eyelids when performing cheek reconstruction?

Answer 9

• Canthoplasty
• Canthopexy

Question 10

When is primary closure indicated in cheek reconstruction?

Answer 10

For smaller defects where adequate skin laxity is present

Question 11

Why might skin grafts be used in cheek reconstruction? Downside of skin graft?

Answer 11

• Poor flap candidate due to comorbidities
• High risk of recurrence or temporary coverage

Disadvantage: Less ideal color match

Question 12

What are transposition flaps used for? Describe examples and design.

Answer 12

Useful for smaller defects of the face.

Banner flap: transfer skin from preauricular or NL area to close defect. May need revision for dog ear

Bilobed flaps: used when defect created by flap to large to close primarily. Hinged on a 45 to 90 degree axis to the primary defect and flaps elevated in subQ plane. Primary flap may be drawn smaller than defect, place scars in tension lines/ natural crease. FlapA sdeisnged at 45 degrees minimize dog ears. Not as useful on cheek.

Rhomboid flaps: decreased propensity for trapdoor scarring or pincushioning compared to bilobed on cheek. USD for lateral, lower cheek, and temporal defects. Use rhombus with 60 and 120 degrees minimize dog angles. Donor flap bisects the 120 degree angle. Flap is drawn to place the donor site incision in normal rhytids.

Question 13

What is the Mustardé cheek rotation flap used for?

Answer 13

Defects of the lower eyelid or infraorbital region

Question 14

What are the characteristic features/ plan of the Mustardé cheek rotation flap?

Answer 14

• Allows tissue to be advanced superiorly to minimize retraction of the lower eyelid; the flap extends along the eyelid margin transversely to the pre-auricular region.
• Burrow’s triangle is removed in the lateral cervical region
• May be elevated in subcutaneous plane or deep to SMAS (to increase blood supply - esp useful in smokers - this is true for any cervicofacial flaps)

Question 15

What is a cervicofacial advancement flap? Describe basics of design. What are the two main types?

Answer 15

An anteriorly or posteriorly-based flap that advances/rotates facial skin to fill a defect. It is similar to the Mustarde flap but does not involve the lower eyelid.
Designed below eyelid transversely to ear, extends inferiorly around earlobe
- Dissected above SMAS, releasing zygomatic retaining ligaments

There are many types of cervicofacial flaps (pic).
- Inferomedially based (outlined in another card)
- Inferolaterally based (outlined in another card)

Question 16

Where on the cheek is use of a cervicopectoral flap appropriate?

Answer 16

Upper border of defects suitable for this flap found by drawling a line connecting tragus to lateral commissure - anything above this is at increased risk of distal fap necrosis.

Question 17

Describe the design and steps in an cervicopectoral flap.

Answer 17

Incisions marked along posterior aspect of the defect, around ear lobe and along the retroauricular hairline. Incision is continued in the neck 2-3 cm behind the anterior border of the trap and across the clavicle at the deltopectoral groove. Back cut may be needed.
Larger defects may require further dissection of the flap by running along the border of the pectoralis and extending across the chest.

Primarily based on internal mammary perforators with some contribution from the thoracoacromial artery and vein.

Raised subcutaneously over the cheek and lower mandible and enter the deep plane below the platysma 3-4 cm below the mandibular border. Platysma can be safely transected here to improve reach. Flap is advanced and rotated into the defect and the donor area oof the flap lateral to the pectoralis muscle is closed V-Y. Skin graft to donor site can be necessary for tension free closure. Immobilize head a bit post-op.

Question 18

What type of flaps are particularly useful for large defects?

Answer 18

Regional flaps

Examples include deltopectoral, cervicohumeral, pectoralis major, trapezius, and latissimus flaps.

Question 19

What is a disadvantage of using regional flaps?

Answer 19

Less ideal skin and color match than local flaps

Local flaps use skin from the same area, providing a better match.

Question 20

What is tissue expansion in the context of cheek reconstruction?

Answer 20

A technique used when few reconstructive options exist and reconstruction may be delayed

Care must be taken to avoid compression over the carotid artery.

Question 21

When is microvascular reconstruction performed?

Answer 21

When loco-regional options are absent or inadequate

It is helpful for reconstruction of large oral mucosal defects or when composite tissue reconstruction is necessary.

Question 22

What is a disadvantage of microvascular reconstruction?

Answer 22

Poor color and texture match

This can lead to aesthetic concerns post-reconstruction.

Question 23

What are common complications seen in cheek reconstruction and how to you address them?

Answer 23

• Ectropion - lid support
• Partial flap loss - wound care
• Contour abnormalities and unsightly incisions/ color match
• Alteration of hair bearing region with advancement of hair into previously hairless areas, vice versa
• Hematoma - place drains under large flaps at initial procedure

Question 24

What is a recommended precaution for large flaps during reconstruction?

Answer 24

Drains should be placed at the initial procedure

This helps to prevent hematoma formation.

Question 25

What is the Mustardé cheek rotation flap used for?

Answer 25

Reconstruction of defects involving the lower eyelid ## Footnote It is a specific technique designed to address lower eyelid defects.

Question 26

What is a critical error in facial reconstruction related to pathology?

Answer 26

Failure to obtain negative margins on pathology prior to reconstruction ## Footnote Negative margins are essential to ensure that cancerous cells have been fully removed.

Question 27

What is a common mistake in flap design for facial reconstruction?

Answer 27

Poor flap design which is inadequate to reconstruct a sizeable facial defect ## Footnote It is recommended to err on the side of larger flaps to ensure adequate coverage.

Question 28

What is a potential consequence of failing to consider the lower eyelid in facial reconstruction?

Answer 28

Ectropion ## Footnote Ectropion is a condition where the eyelid turns outward, leading to exposure and irritation.

Question 29

What can result from inadequate support of the lower eyelid?

Answer 29

Ectropion ## Footnote Canthoplasty or canthopexy are surgical procedures that can provide necessary support.

Question 30

What design flaw can increase the risk of ectropion in facial reconstruction?

Answer 30

Poor design of flap with downward vector along lower eyelid ## Footnote This design flaw can lead to inadequate tension and support for the eyelid.

Question 31

Describe design and steps in an inferomedially based cervicofacial flap. Complications?

Answer 31

- Design: incision starts at the superior aspect of the defect and extends to the outer canthus and along the zygomatic arch. The incision is brought along the preauricular fold, extended below the ear, and along the retroauricular hairline to the mid- posterior line of the neck. - Wide subcutaneous undermining of the skin flap is then performed, enabling advancement and rotation of the flap into the defect with primary closure of the donor site. - The flap should be anchored to the periosteum of the zygoma and lateral orbital wall with permanent sutures to avoid postoperative ectropion. Simultaneous lower-lid tightening may be considered. - Skin excess formed at the nasolabial fold is excised carefully so as to avoid narrowing the base of the flap. - Occasionally, FTSG is necessary to close donor site to avoid undue tension. This skin graft is best camouflaged below the sideburn. - The primary draw- back of this procedure is skin necrosis of the distal flap (esp. in smokers). It also shifts the normal hair-bearing pattern of the cheek and may result in ectropion or prolonged lower-lid edema. Hematoma may also occur and should be closely monitored as it can lead to large areas of skin necrosis.

Question 32

Describe the design and steps in an inferolaterally based cervicofacial flap. Advantages & disadvantages?

Answer 32

- Designed to transfer the lax skin of jowls and along NL fold to reconstruct upper medial defects - Skin incision may be extended across mandible. Back-cuts enable tension free closure. Extension of incision to contralateral neck along established neck crease increase reach. - Less likely to undergo necrosis at the distal end than inferomedially based flaps BUT leave scar in central face. - For smaller defects, excision of Burrow triangle may be necessary to allow rotation-advancement. - Must secure to periosteum to avoid ectropion. - Can Z-plasty the incision across the mandible to better hide the scar.