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Cheek Reconstruction
Cosmetic Units (Zide)


Defects in zones 1 and 2 can be repaired with cervicofacial rotation-advancement flaps or other local
flaps.
Zone 3 defects are not amenable to correction with cervicofacial flaps, and are best resurfaced with local
or regional flaps (cervicopeectoral)
Zone 1 - Sub Orbital Zone
Small defects
Grafts

poor color and contour match in the cheek

not SSG as contraction may result in ectropion

FTSG, thin skin
Flaps

modified rhomboid flaps, small cheek rotation-advancement flaps, or subcutaneous pedicle flaps.

Use lines of maximal exensibility for moving the flap and closing the defect
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
Borrow from where the skin is loose.

Do not distort functionally or cosmetically sensitive areas

The flap is ideally based inferiorly as this tends to decrease edema of the flap minimizing the trap door
effect.

Flap ischemia is minimized by rounding the end of the transposed flap, thus avoiding a narrow distal tip.
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Medium and Large Defects
Tissue expansion

expansion offers the best match of color and skin texture with the least number of additional wounds
for skin flap harvesting.

Two expanders are usually placed

Expander is inserted superficial to the SMAS/platysma layer over angle and body of mandible

expander or port should not extend over the mastoid because of the increased risk of pressure
exposure in this region.

Guidelines (Wieslander)
1. orient the incision for expander placement perpendicular to the expander (radial incision)
2. choose an expander whose length and width are at least as large as the defect
3. fill expander intraoperatively to safest maximum level to reduce hematoma and seroma formation
4. delay expansion for about 2 weeks postoperatively, then fill expander at least once per week
5. overexpand to a volume 30% to 50% more than necessary to overcome flap contraction at the second
stage of surgery
6. incise the capsule as needed to increase the stretch of the expanded flap, but avoid capsulectomy
Cervicofacial flaps

bring tissue of excellent color, texture, hair, and contour match to the cheek skin

To improve the blood supply and reliability of the cervicofacial flap, dissection can be carried out in
the “deep plane”. Similar in technique to the composite or deep plane rhytidectomy, the flap is
dissected beneath the superficial muscular aponeurotic system (SMAS) in the face. The subplatysma
dissection may extend to the neck, if required. With this modification, larger rotation and
advancement flaps can be constructed, particularly in cigarette smokers where distal flap loss is
common

blood supply of cervicofacial flaps is more random when anteriorly based because the transverse
branches of the superficial temporal artery must be interrupted.

Care is taken to preserve branches of the facial nerve.

To prevent ectropion, anchoring sutures are placed along the anterior aspect of the zygomatic arch
and inferolateral orbital rim. Some authors recommend a lid tightening procedure any time the defect
extends above the infraorbital rim.

The flap may be based posteriorly or inferolaterally, however, carrying a large skin flap dissection
above the preauricular area or anterior border of trapezius may jeopardize distal flap
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survival.(McGregor) This design necessitates an incision across the mandibular border, and the
weight of the flap can lead to ectropion if periosteal anchoring is not achieved.

Most surgeons agree that the extent of safe vertical movement of the laterally based cervicofacial flap
is limited.

Extension to the contralateral neck aids in closure of the neck with minimal tension

In patients on whom there are no time constraints (large nevi, old skin graft, etc.), a large tissue
expander may be placed in the cheek via a facelift or scalp approach. The reservoir should be placed
behind the ear or under the scalp for ease of access and inflation over a 2 to 3 month period .

Longaker/Zide describes the Deep Plane Cervicofacial hike flap (PRS Jan 1997)
o Skin flap inferiorly/anteriorly based
o Especially applicable to defects located over the lateral zygoma, lower lid, and temple.
o Subcutaneous elevation for first 2cm preauricular and retroauricular.
o Go under SMAS, 2cm in front of ear.
o As the dissection progresses medially, only vertically or obliquely oriented spreading
dissection with blunt-tipped scissors is used. By using vertical spreading maneuvers, the
branches of the facial nerve will always stay on the down side, leaving the SMAS above
o lateral border of the orbicularis oculi is identified, and then the soft tissue is cleared off the
zygomaticus major muscle. The firm fibers of the zygomatic restraining ligaments coming
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through the zygomaticus major muscle as well as the SMAS and continuing on into the dermis
are transected
o This maneuver releases and mobilizes the entire cheek flap, allowing for considerable vertical
advancement.
o resulting dog-ear is oriented in a horizontal instead of vertical direction - in line with upper
and/or lower blepharoplasty incisions.
o Flap in anchored to the zygoma – avoid the strip 1cm to 3.5cm in front of the external auditory
meatus.
Line drawing demonstrating the regional area of skin lesions that can be excised and
reconstructed with deep-plane cervicofacial "hike" with dog-ear blepharoplasty(s). The small
arrows indicate that as the lesion's location moves more cephalad, the dog-ear blepharoplasty
excision must be extended more superiorly.
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Line drawing demonstrating the area to be avoided when fixating the flap to the periosteum,
indicated by D, and the area where fixation is considered safe, indicated by C. The area to avoid
when suture fixating the flap to the zygoma begins 1.0 cm anterior to the external auditory canal,
indicated by A, and ends 3.5 cm anterior to the external auditory canal, indicated by B. The area
where fixation is safe is located anterior to this.
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Cervicopectoral flap(Becker)

For extensive cheek defects

risk of necrosis is especially high in smokers, in large wounds under tense closure, and in
patients with a history of irradiation.

blood supply to anteriorly based cervical facial flaps can be improved by elevating the flap in a deep
plane [below the superficial musculoaponeurotic system (SMAS) and platysmal muscle], as in the
modern composite face lift

Anteriorly based flap
o nourished by the anterior thoracic perforators off the internal mammary artery
o flap incision is extended from the hairline down into the neck, several centimeters behind
the anterior border of the trapezius muscle (to avoid late scar webbing), passing lateral to
the acromioclavicular joint and deltopectoral groove following the lateral pectoral border, and,
finally, crossing the chest medially, parallel to the clavicle, 2 to 3 cm above the nippleareola complex in the male patient (third to fourth intercostal space).
o
Flap is elevated subcutaneously but shifts below SMAS 2cm anterior to the tragus,
passing inferiorly under platysmal muscle and with deltoid and pectoral fasciae.
Simultaneous parotidectomy and radical neck dissection can be performed.
o Blood supply is maintained through internal mammary perforators of the pectoralis muscle.
o In the extended flap(pic below, bottom tight), the IMA perforators are ligated with the backcut. Flap is based randomly on neck vessels and requires delay by incising its outline, ligating
the deltopectoral and thoracoacromial perforators over the lateral shoulder, and elevating the
neck in stages during four to five subsequent operations.
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
Posteriorly based flap
o Used for small and moderate-sized anterior cheek defects
o Based on the STA/V superiorly, vertebral and occipital arteries in the neck and via
thoracoacromial perforators/transverse cervical artery in the chest
o move excess skin from the jowl and neck to the cheek.
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o An incision extends from the defect, follows in or parallel to the nasolabial fold past the oral
commissure
o can be extended inferiorly into the middle or lower neck toward the midline and then continue
toward the sternocleidomastoid muscle and upward toward the earlobe or mastoid. For very
large defects, the vertical midline incision can continue inferiorly across the sternum and
sweep laterally across the chest, above the nipple-areola complex, toward the axilla.
o Plastymal muscle may or may not be included
o In all posterior-based flaps, undermining should stop at least several centimeters anterior to
the ear.
o These flaps are not delayed.
o Simultaneous parotidectomy and neck dissection is reported to be safe.
Prefabricated flaps

definition of the prefabricated flap: implantation of a vascular pedicle into a new territory, followed
by a period of maturation and subsequent transfer of that tissue (Shen 1981)

occurs in two stages:
1.
Stage 1: implantation of vascular pedicle. A vascular pedicle (which includes at least the artery and
its venae comitantes surrounded by adventitial tissue, but may also include fascia or a cuff of muscle)
is transferred to a new area of tissue and simply implanted with the distal end ligated and with no
vascular anastomoses. Vascular connections will occur spontaneously between the implanted pedicle
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and surrounding tissue creating a new vascular territory. Vascular pedicles may be placed on top of
the tissue expanders directly underneath the skin to be prefabricated.
2. Stage 2: flap transfer. After maturation, the neovascularized tissue is transferred based on the
implanted pedicle (6-8 weeks). With the aid of microsurgery, it is theoretically possible to transfer
any given tissue to any desired location in the body.

Compared with prelamination - used to describe a process in which tissues or other devices are
implanted into a vascular territory before it is transferred. In flap prelamination, the blood supply is
not manipulated.

Prefabricated flaps are prone to venous congestion and does not withstand manipulation and folding
as well as flaps that contained native axial vessels along their entire length, nor were they as good as
flaps that were axial proximally and random more distally.
Zone 2 – Preauricular Zone

Extends from the superolateral junction of the ear and cheek, crossing medially across the sideburn to
the malar eminence and then inferiorly to the mandible. It includes all tissues over the
parotid/masseteric fascia.
Small Defects

Usually so much loose skin that many defects can be closed directly, grafts are rarely required, at
worst a local flap should suffice
Large defects

Principles
- Borrow from the loose/ available skin.
- Protect the facial nerve
- Broad base to increase flap survival +/- delay

Local Options:
1. Anteriorly-Based Neck flaps
2. Anteriorly Based Cervicopectoral flaps - based on anterior thoracic perforators of the IMA
o The dissection can begin in the subcutaneous plane. The platysma can then be transected 4 cm
below the mandible entering the submuscular plane
o If the lower incision is placed in the neck, it will be quite visible. However, if the
subplatysmal dissection is carried inferiorly 2 cm behind the anterior border of the trapezius
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below the clavicle before it is back-cut, the result is an inconspicuous scar with a well
vascularized flap.
o The plane of dissection deep to the platysma muscle provides access for neck dissection if
necessary. Incisions anterior to the trapezius will often become banded and hypertrophic,
requiring later Z-plasty.

Other regional flaps:
o
deltopectoral flap, cervicohumeral flap, trapezius flap, pectoralis major flap. The
cervicohumeral flap may be applied to zone 1 and 2 defects.
o Trapezius myocutaneous flap can serve as a composite flap including bone. However, its arc
of rotation may be limited by variable venous drainage. The effective axis of the flap is the
point where the transverse cervical vein joins the subclavian vein.

The pectoralis major muscle and its overlying skin can be paddled to provide cheek lining as well
as coverage.

The latissimus dorsi myocutaneous flap has a thoracodorsal pedicle 8–12 cm in length, giving it
sufficient rotation to be used in facial reconstruction. The flap may be transferred via a tunnel
through or over the pectoralis major, depending on the best fit. This flap provides bulk from an
area outside the irradiated field with an inconspicuous donor site and without significant
functional loss.

Microvascular transfer frequently provides a better result for large defects than these pedicled
regional alternatives.
Zone 3- Buccomandibular Zone
Lower anterior cheek area, inferior to suborbital zone 1 and anterior to preauricular zone 2.
Reconstruction may require not only cheek skin but potentially lining and lip as well
Goals
1. waterproof closure on the lining
2. Functioning oral sphincter
Flaps available- are the same as all those recently discussed
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Lining
A) Local lining flaps
- Hemitongue flap - based on one of the paired axial lingual arteries.
- Turnover flaps or hinge flaps - when the defect involves the angle of the mouth.
Both the raw muscular surface of the tongue flap and the turnover flaps must be covered with a secondary
flap. In contrast, buccal fat pad flaps, masseter crossover flaps, and galeal flaps with periosteum do not
require skin intraorally because they are quickly epithelialized.
B) Fasciocutaneous/Musculocutaneous Flaps
- Can be folded, split, or paddled immediately or after appropriate delay.
-
Include the deltopectoral flap, pectoralis major myocutaneous flap and trapezius
muocutaneous flap.
-
Can also use a combinations of flaps, such as the pectoralis major flap for lining and the
cervicopectoral flap for cutaneous cover
-
split ascending neck flap – Muscle perforators are preserved over the midportion of
the sternocleidomastoid muscle. The dissection extends 6 to 8 cm below the clavicle into
the chest, releasing all attachments to the clavicle and sternum. This thin, elastic flap can
be advanced up to 6 cm superiorly to cover the lower cheek and chin. It can be split to
resurface the lower lip. No delay is required.
C) Free Flaps
- Advantages: - Single stage reconstruction
- Versatility of tissue usage and placement
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- Can avoid an irradiated field
- Transfer of composite tissues
- Can provide its own lining
- Can provide acceptable aesthetic facial contour
- If the defect includes the lip, this same flap can be used for lip
reconstruction complete with commisuroplasty
- Include radial forearm, TFL (both are thin and have a fascial sling (ITB or PL)
- For large facial defects, free flaps provide large amounts of composite tissue for bulk and
cover. Parascapular, scapular and latissimus flaps can fulfill skin, subcutaneous tissue, and
bone requirements as needed
THROUGH AND THROUGH DEFECTS
Requirements
1. Cutaneous coverage
a. reliable and well vascularized
b. Sufficient bulk to achieve symmetry and natural contour
c. Color match and hair growth patterns
d. Ideally, aesthetic units of the face should be respected and reconstructed accordingly
2. Bony reconstruction
a. Mandible
i. support for the tongue and larynx
ii. mobility of the mandible
iii. dental restoration with osseointegrated implants
iv. capacity to withstand the stresses of mastication.
v. symmetry and well-contoured mandibular arch
b. well vascularized, thin, pliable, hairless, and, ideally, sensate
3. Mucosal coverage
4. Maximise function. Consider:
a. Preserving the vermilion and muscle of the lip
b. Choosing a pliable and sensate skin paddle of appropriate size for the oral lining, which will
avoid tongue tethering, allow for sensory recovery, and prevent pooling of secretions
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c. Preserving motor function to the so-called “suprahyoid diaphragm” to avoid gravitational pull
of the larynx
d. Considering the possibility of osseointegrated implants or other forms of dental restoration
Options:

Local tissues generally not sufficient for large defects

Free flap techniques
o skin portion of the flap can be designed and raised as two paddles on separate perforators of the
same vessel (anterolateral thigh flap, lateral arm flap)
o raised on 2 branches (scapula-parascapular flap, latissimus dorsi-serratus anterior)
o de-epithelialization of a strip of the flap along the folded edge, allowing part of the flap to act as
oral lining and part to serve as external coverage
o sequential free flaps
o combined free and pedicled flap
Radial Forearm flap

regarded by most microsurgeons as the best lining for intraoral defects

possible to create a sensate skin paddle and raise a portion of the radius to reconstruct the mandible

long vascular pedicle of the radial artery, venae comitantes, and cephalic vein, which may obviate the use
of vein grafts

may also be raised with the palmaris longus as a vascularized tendon graft to resuspend the lower lip to
the oral commissure.

limitation of this flap for through and through defects rests primarily in the quality of the bone. It is raised
as unicortical bone at best, which limits its strength when compared with the fibula or iliac crest.

Not as good for chin and mentum reconstruction
o Compared with the skin and subcutaneous tissue of the face, which are slightly more rigid, the
loose pliable radial forearm skin is atrophic
o Poor color match

Histology of radial skin when used for oral lining (D Soutar)
o Grossly, some flaps are seen to become buccal-mucosa like (30%), whilst others remain skin-like
o Apart from loss of hair follicles, changes are not related to use of radiotherapy
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o Changed flaps showed a significantly thicker epithelium, larger numbers of dermal leukocytes,
and more intraepidermal inflammatory cells per unit length than flaps that retained the gross
appearance of thin skin.
o However epithelium not changed – in a 15 year followup study:

In the transplanted skin, there was persistence of all epidermal layers with production of
orthokeratin and melanin, and persistence of papillary and reticular dermis with viable hair
follicles and sweat glands.

junction of epidermis and mucosa was distinguished by a strongly positive PAS staining
of the mucosal epithelium. There were no differences in the observations on splitthickness grafts and pedicle flaps. After 15 years of exposure to an intraoral environment,
"mucosalization" of the skin was not evident.
Scapular/Parascapular Flap

may be lengthened by extending it proximally to include the subscapular vessels

may be raised with a large folded or bipaddled skin component, with or without bone

One of the particular advantages of this osseocutaneous flap lies in its flexible inset capabilities. The bone
component may be taken from the medial portion of the scapula, as described by Thoma, with a separate
vascular branch to the bone, providing some independence from the cutaneous paddle; this is unlike the
flap raised with bone from the lateral scapula that was originally described. Ability of this somewhat
thinner bone to incorporate biointegrable implants is unproven.

offers the advantage of providing thicker subcutaneous tissue and a more suitable color match to the face
than the radial forearm or fibula skin in most patients.

possibility of raising two separate skin paddles, one transversely based over the spine and one vertically
based (parascapular).

This technique allows for a more precise inset and reconstruction of the oral lining and overlying skin.
The scapular skin is considered to have an acceptable tissue thickness and color match for the face.
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Fibula Flap

circulation pattern is based on nutrient endosteal, periosteal, septal, and muscular pedicles

may be neurotized by harvesting a branch of the superficial peroneal nerve.

superior quality results from the tricortical bone, which tolerates multiple osteotomies, allowing for a
precise reconstruction of the mandibular arch.

allows for osseointegrated implants for dental restoration.

Disavantage: low reliability and potential absence of adequate septocutaneous perforators of the
overlying skin paddle
DCIA

can include a branch of the 12th thoracic nerve to provide sensation.

particularly important in large resections, where it can provide sufficient soft tissue bulk to eliminate
dead space
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
curved shape of the crest is particularly appropriate for reconstructing the central segment or the arch of
the hemimandible

limitations of the pedicle length (6–8 cm) as compared with such options as the radial forearm flap

donor-site complications with this flap are significant and include abdominal wall hernias, chronic pain,
deformity, and meralgia parasthetica from injury to the lateral femoral cutaneous nerve.

One of the major limitations of this flap when used for intraoral lining and external cover is the thickness
of the subcutaneous tissue
Other options:

lateral arm flap, which may be harvested with a portion of the humerus.
o donor-site complications are few, provided care is taken to protect the radial nerve, and the
neurotized skin and subcutaneous paddle are well suited for intraoral lining and external coverage.
o major limitation is the short and small vascular pedicle of the radial collateral artery and venae
comitantes

second metatarsal and dorsalis pedis osseocutaneous flap, based on the first dorsal metatarsal artery and
venae comitantes and dorsalis pedis artery and saphenous veins
o short bone segment and thin, pale skin paddle with its inherent donor-site complications (skin
graft take, chronic foot pain) make it less desirable for anything but small bone segments.