eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Cheek Reconstruction

Author: Mimi S Kokoska, MD, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences; Chief, Department of Otolaryngology-Head and Neck Surgery, Central Arkansas Veterans Healthcare System
Coauthor(s): Stephen Prendiville, MD, Otolaryngology, Facial Plastic Surgery, Ft. Myers Centre for Facial Plastic and Laser Surgery
Contributor Information and Disclosures

Updated: Feb 15, 2008

Introduction

History of the Procedure

Formalized knowledge of facial reconstruction has been present since the last millennium. The Byzantine physician Oribasius first described procedures for facial reconstruction in the fourth century. The Synagogae Medicae, a 70-volume medical encyclopedia written by Oribasius, describes the principles of basic advancement flaps for brow, nasal, and auricular defects. Interestingly, this ancient writing addresses the importance of flap thickness in relation to its viability and closure without tension in wound healing.

Problem

The prominence and central position of the cheek define its unique characteristics as an anatomic subunit. Zide further divides the cheek into 3 subunits: suborbital, preauricular, and buccomandibular.1 Cheek wounds can be further classified by depth into superficial, full-thickness, and subcutaneous contour deficits. Reconstruction of the cheek is a challenging problem for a number of reasons. First, cheek contour is paramount to facial aesthetics. No existing reconstructive option can universally recreate the volume loss created by a subcutaneous tissue defect. Second, the dynamic function of the cheek is not easily reproduced. Third, reconstruction can alter or obliterate the lines that divide facial subunits.

Etiology

Cheek defects occur as a result of 3 main etiologies: neoplasia, burns, and trauma. The cause of the defect contributes significantly in presurgical planning. For example, a skin graft may be considered an acceptable initial alternative to cover the defect from a full-thickness burn. Likewise, a skin graft is a reasonable alternative for patients with a history of radiation for acne as teenagers who are likely to develop multiple skin cancers. However, a traumatic defect is better suited for primary closure or use of a local flap.

Indications

Congenital, traumatic, and Mohs surgery defects all provide indications for cheek reconstruction. A subsequent soft tissue deficit can be corrected with various techniques.

Relevant Anatomy

The cheek is a protuberant structure that extends from the inferior orbital rim superiorly to the mandibular rim inferiorly and from the lateral nasal sidewall and melolabial crease medially to the preauricular area posteriorly.

The external carotid artery (ECA), with contributions from the internal carotid artery (ICA) system, is the predominant arterial blood supply to the skin and muscle of the cheek. The greatest contribution is from the facial artery, which crosses the mandibular border at 2-3 cm anterior to the angle, traverses the face obliquely, and terminates in the angular artery. The transverse facial artery arises from the superficial temporal artery (STA) and follows a path implied by its name across the face. The dorsal nasal artery runs along the path implied by its name and is a terminal branch of the ophthalmic artery, which is a terminal branch of the ICA. Many smaller branches and communications also exist.

The venous drainage system of the cheek predominantly functions via the anterior facial vein, which subsequently communicates with the internal jugular (IJ) vein. However, substantial drainage via the ophthalmic, infraorbital, and deep facial veins communicates with the cavernous sinus. This venous system is valveless, which can lead to bacterial spread from a localized skin infection and subsequent cavernous sinus thrombosis. However, the incidence of such events is low.

Lymphatic drainage in the area is primarily directed to intraparotid, submandibular, and submental lymph nodes.

The nerve supply of the cheek can be divided into sensory and motor systems. Sensation to the cheek is carried primarily by the second (maxillary) and third (mandibular) divisions of the trigeminal nerve (cranial nerve V). The facial nerve (cranial nerve VII) provides motor innervation to the muscles of facial expression.

The maxillary division of the trigeminal nerve provides sensation to the cheek via the infraorbital, zygomaticofacial, and zygomaticotemporal branches. The area covered by these nerve branches includes the cornea, lower eyelid, infraorbital region, upper lip, and malar eminence. The mandibular division of the trigeminal nerve provides sensation to the cheek via the mental, buccal, and auriculotemporal branches. The areas innervated by these branches include the lower lip, mandibular border, and temporal regions.

The facial nerve exits the temporal bone at the stylomastoid foramen and travels through the parenchyma of the parotid gland, where it branches at the pes anserinus into upper (zygomaticofacial) and lower (cervicofacial) divisions. The upper division forms the temporal and zygomatic branches, which primarily supply the frontalis and orbicularis oculi, zygomaticus major and minor, and levator labii superioris muscles. The lower division forms the buccal, marginal mandibular, and cervical branches, which primarily supply the buccinator, orbicularis oris, and platysma muscles. A great deal of arborization is present between the zygomatic and buccal branches. Indeed, variations in individual anatomy, exact patterns of branching, and patterns of innervation are common. The zygomaticus major, orbicularis oculi, and risorius muscles are of particular clinical relevance because they are innervated via the deep surface of their muscle bellies.

The muscles of facial expression, which are anatomically associated with the cheek, include the zygomaticus major and minor, orbicularis oculi, orbicularis oculi, levator labii superioris, platysma, and risorius muscles. A continuous fascial covering known as the superficial musculoaponeurotic system (SMAS) covers each of these muscles. The branches of the facial nerve lie deep to the SMAS as they course more superficially in the anterior face. The more medial and anterior areas of the face have the most superficial facial nerve branches.

More on Cheek Reconstruction

Overview: Cheek Reconstruction
Treatment: Cheek Reconstruction
Follow-up: Cheek Reconstruction
Multimedia: Cheek Reconstruction
References
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References

  1. Zide BM. Deformities of the lips and cheeks. In: McCarthy JG, ed. Plastic Surgery. WB Saunders Co;1990.

  2. Baker SR. Local cutaneous flaps. Otolaryngol Clin North Am. Feb 1994;27(1):139-59. [Medline].

  3. Banducci DR, Manders EK. Reconstruction of the cheek. In: Baker SR, Swanson SA, eds. Local Flaps in Facial Reconstruction. Vol 1. Mosby;1995:397-420.

  4. Becker FF, Langford FP. Deep-plane cervicofacial flap for reconstruction of large cheek defects. Arch Otolaryngol Head Neck Surg. Sep 1996;122(9):997-9. [Medline].

  5. Boutros S, Zide B. Cheek and eyelid reconstruction: the resurrection of the angle rotation flap. Plast Reconstr Surg. Oct 2005;116(5):1425-30; discussion 1431-3. [Medline].

  6. Cook TA, Israel JM, Wang TD, et al. Cervical rotation flaps for midface resurfacing. Arch Otolaryngol Head Neck Surg. Jan 1991;117(1):77-82. [Medline].

  7. Futran ND, Mendez E. Developments in reconstruction of midface and maxilla. Lancet Oncol. March 2006;7(3):249-58. [Medline]. [Full Text].

  8. Gibson T. The physical properties of skin. In: Converse JM, ed. Reconstructive Plastic Surgery. WB Saunders Co;1977:1.

  9. Hollinshead WH. The face. Anatomy for Surgeons. 3rd ed. JB Lipincott;1982:291-324.

  10. Khazanchi RK, Rakshit K, Thakur KK, Manikumari B. A new design for reconstruction of composite defects of cheek and lips. Plast Reconstr Surg. Aug 1996;98(2):370-2. [Medline].

  11. Lascaratos J, Cohen M, Voros D. Plastic surgery of the face in Byzantium in the fourth century. Plast Reconstr Surg. Sep 1998;102(4):1274-80. [Medline].

  12. Moore BA, Wine T, Netterville JL. Cervicofacial and cervicothoracic rotation flaps in head and neck reconstruction. Head Neck. Dec 2005;27(12):1092-101. [Medline].

  13. Rohrich RJ, Sheffield RW. Lip and cheek reconstruction. Selected Readings in Plastic Surgery. Vol 17. 1987:11.

  14. Swenson RW. Tissue expansion. In: Papel ID, Nachlae NE, eds. Facial Plastic and Reconstructive Surgery. Vol 1. Mosby;1992:56-67.

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Further Reading

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Keywords

cheek reconstruction, local flap reconstruction, cervicofacial advancement flap, transposition flap, primary closure, skin graft, full-thickness graft, FTSG, split-thickness graft, STSG, local flap, soft tissue expansion, microsurgical free flap, full thickness skin graft, split thickness skin graft, facial plastic surgery, cheek defects, cervicofacial rotation flap, bipedicled flaps, V-Y subcutaneous island advancement flap, local advancement flaps, dog-ear deformity, facial reconstruction, cheek neoplasia, cheek tumor, cheek burns, cheek trauma, rhombic flap, Dufourmentel flap, Z-plasty, bilobed flap, note flap, W-plasty, melolabial flap, interpolation flap, paramedian forehead flap, mechanical creep, fasciocutaneous scapular flap, radial forearm flap, myocutaneous rectus flap

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Contributor Information and Disclosures

Author

Mimi S Kokoska, MD, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences; Chief, Department of Otolaryngology-Head and Neck Surgery, Central Arkansas Veterans Healthcare System
Mimi S Kokoska, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American College of Surgeons, American Head and Neck Society, and Arkansas Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Stephen Prendiville, MD, Otolaryngology, Facial Plastic Surgery, Ft. Myers Centre for Facial Plastic and Laser Surgery
Stephen Prendiville, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Medical Editor

Terance (Terry) Ted Tsue, MD, Vice-Chairman for Administrative Affairs, Professor, Residency Program Director, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine
Terance (Terry) Ted Tsue, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, Association for Research in Otolaryngology, Johns Hopkins Medical and Surgical Association, Missouri State Medical Association, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals of Cleveland Case Medical Center
David W Stepnick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Advanced Headache Intervention Consulting fee Consulting; Covidien Corp Consulting fee Consulting

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