Cheek Reconstruction Procedures 

Updated: Jul 23, 2018
Author: Mimi S Kokoska, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

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.[2]

The images below depict a mid-cheek defect before and after reconstruction with M-plasties.

Mid-cheek defect. Mid-cheek defect.
Mid-cheek defect reconstructed with M-plasties. On Mid-cheek defect reconstructed with M-plasties. One-month follow-up result.

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 (see the image below). 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.

Diagram of the sensory and motor supply of the fac Diagram of the sensory and motor supply of the face.

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. See Trigeminal Nerve Anatomy for more information.

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. See Facial Nerve Anatomy for moreinformation.

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. See Facelift Anatomy for more information.

 

Treatment

Medical Therapy

The treatment of cheek defects is almost exclusively surgical. The only nonsurgical option is healing by secondary intention. However, situations that allow for favorable results with this option are limited. Healing by secondary intention is most effective for wounds associated with concave surfaces, such as the temple and medial canthus. Defects that are small and superficial and are not closely associated with the eyelid or lip are also well suited for this form of healing. However, exercise caution because wound contracture in the cheek can lead to distortion of the lower eyelid or upper lip. An occlusive dressing and some form of antibiotic ointment, used to keep moisture out of the wound and to minimize bacterial growth, provide the best results for a wound allowed to heal by secondary intention.

Surgical Therapy

Surgical reconstruction of cheek defects can be divided into a number of options, including primary closure, skin grafts, local flaps, soft tissue expansion to accomplish primary closure or to facilitate local flaps, and microsurgical free flaps. The rubric of local flaps can be further subdivided to include advancement, rotation, transposition, and interpolation flaps. Occasionally, a complex case may benefit from a combination of a microvascular free flap or regional flap with a local flap and skin graft. If the underlying bony skeleton or dentition is significantly defective, adequate three-dimensional projection should be provided by the reconstruction or with a prosthesis for optimal results.

A study by Hayashi et al of 26 patients examined factors influencing the choice of reconstruction method (ie, skin graft, local flap, or free flap) after cheek melanoma excision. In the study, skin grafts were used in 12 patients, local flaps in seven others, and free flaps in another seven patients. The investigators found that skin grafts were used in older persons with thick melanomas, because of the general condition of these patients, but that they were also used in patients with a variety of tumor thicknesses. Free flaps were often employed in patients with skin defects over a large area, as well as in those with thicker tumors, with 40 cm being the approximate dividing line between defects treated with free flaps and those reconstructed with local ones.[3]

Primary closure

Wide undermining and subsequent primary closure can close most small defects of the cheek (< 2 cm, central). The degree of surrounding skin laxity predicates this closure. Older patients, who have increased skin mobility and more pronounced rhytides, are ideal candidates for this form of reconstruction. Closure of traumatic defects and postexcisional defects follow the same principles. Pay attention to the position of the final scar, which should rest parallel to or within a relaxed skin tension line (RSTL).

Direct closure of a circular defect leads to a standing cone deformity on both ends of the wound. Therefore, the defect is most commonly converted to an ellipse with 30° apices following a plane parallel to RSTLs. Wide subcutaneous undermining allows for a tension-free closure. The only disadvantage of this technique is that the wound is lengthened. Wound length can be diminished with M-plasties (see the images below). A potential disadvantage of M-plasty is that the limbs of the "M" are not quite parallel to the RSTLs, which may result in a more noticeable scar.

Mid-cheek defect. Mid-cheek defect.
Mid-cheek defect reconstructed with M-plasties to Mid-cheek defect reconstructed with M-plasties to shorten the length of the final closure.
Mid-cheek defect reconstructed with M-plasties. On Mid-cheek defect reconstructed with M-plasties. One-month follow-up result.

Other complex forms of primary closure include running W-plasty, Z-plasty, and geometric broken line closure (GBLC). These techniques are frequently used in scar revision and can also be applied advantageously in primary reconstruction of a defect. In some cases, an oval cheek defect is positioned with the widest diameter oriented perpendicular to the RSTL. Therefore, the orientation of primary closure that results in the least amount of wound tension would cause a lengthy scar perpendicular to the RSTL. In these cases, W-plasty, Z-plasty, or GBLC can be used to reorient the scar primarily and provide better scar camouflage.

Skin grafts

Skin grafting provides a simple and expeditious alternative to other forms of reconstruction. This is one of the least cosmetically satisfying forms of correction because of the unique contour of the cheek and the poor tissue match of the donor site skin with the sun-exposed cheek area. However, skin grafts play a significant role in certain circumstances. For example, a patient with (1) a large (>4 cm) defect, (2) a high-grade skin neoplasm with questionable margins or perineural invasion, (3) poor tolerance of prolonged periods of anesthesia, or (4) a third-degree burn over substantial portions of the face may benefit from immediate wound coverage and possible secondary reconstruction.

Skin grafts may be harvested as full-thickness skin grafts (FTSGs) from areas such as the supraclavicular region and the preauricular and postauricular creases. Split-thickness skin grafts (STSGs) can be harvested from a wide variety of sites, including the lateral thigh, upper arm, and abdomen.[4] FTSGs from the areas mentioned provide a reasonable color match for cheek defects; however, the success rate of STSGs is higher than the success rate of FTSGs. STSGs are more likely to contract and are less likely to match the color of the defect site than FTSGs. Both STSGs and FTSGs can leave a considerable contour deficit if the wound is deep. Small slit incisions in the graft and absorbable tacking sutures that essentially spot weld the graft to the recipient base can be used to improve graft attachment to the site. An FTSG can be expected to contract 10-15%. An STSG is likely to contract up to 25-30% over time.

Dress the site of the recipient wound with a bolster. Numerous bolster materials are available, including Vaseline gauze or Xeroform bolster secured with sutures attached to the peripheral edges of the wound. These dressings decrease the chances of hematoma or seroma formation and graft failure. This point is important because skin grafts rely on plasma imbibition for the first 48-72 hours, followed by ingrowth of vascular buds. Collections beneath the graft may inhibit angiogenesis. STSGs leave a donor site that requires an occlusive dressing until the wound has reepithelialized. The donor site of FTSGs requires undermining and primary closure.

A retrospective study by Ebrahimi et al found advantages to local flaps over skin grafts in cheek reconstruction. The study, in which 20 patients underwent treatment with local flaps and the rest were treated with skin grafts, all following skin tumor excision, reported that after 2 weeks the local flap patients demonstrated greater patient satisfaction, tissue coordination, and skin color improvement than did the graft patients. Better improvement in skin color was still seen in the flap group at 12-month follow-up.[5]

Local flaps

Advancement flaps

Advancement flaps require linear advancement of tissue in a single vector to assist in closure of the primary wound. Usually, secondary movement of local tissue in the direction opposite the movement of the primary flap is also required. Wide local undermining enables the movement of this tissue. Patients with a greater degree of skin laxity are better suited for this form of closure. Advancement flaps are typically random, relying on the subdermal plexus for blood supply.

Although advancement flaps may be single-pedicled or bipedicled, single-pedicled flaps are generally preferable in cheek reconstruction. Bipedicled flaps are better suited to the forehead. The exception to this rule is the V-Y subcutaneous island advancement flap, which is based on subcutaneous vessels and muscular perforators.[6, 7]

Medial cheek defects are suitable for local advancement flaps. The medial cheek is amenable to reconstruction with local or cervicofacial advancement flaps. In designing these flaps, situate the flap adjacent to the wound, using the borders of the wound as the borders of the flap. Ideally, place the flap borders parallel to RSTLs or within lines that separate anatomic subunits, such as the melolabial or preauricular creases. The Burrow triangles are usually resected at the lateral base of the flap to allow for increased reach and to remove a dog-ear deformity. Z-plasties can be used to achieve a similar effect.

A study by Al Shetawi et al found that in reconstruction of cheek defects, cervicofacial flaps had a 93% success rate, with the flaps offering an excellent match with regard to skin color, thickness, and texture. Reconstruction was performed in single or multiple cheek zones. Wound complications developed in just two of the study’s 28 patients (7%).[8]

Transposition flaps

Transposition flaps rotate skin from an area of relative laxity on a pivotal point located at the base of the flap pedicle to an area of skin deficit. As the arc of rotation increases, so does the dog-ear deformity at the flap's base. Certain similarities exist between transposition and rotation flaps. The major difference is that the axis of the transposition flap is straight, whereas the axis of the rotation flap is curvilinear. Transposition flaps can be used for a wide variety of defects in the cheek. The downside of this subgroup of flaps is the potential for formation of a trapdoor deformity, in which the borders of the transposed skin are raised above or below the surrounding native skin. Forms of transposition flaps include the rhombic flap, the Dufourmentel flap, Z-plasties, the bilobed flap, and the note flap.

The rhombic flap is the classic form of transposition flap. Four reconstructive options exist for each of the flaps designed. This versatile flap is elevated in a subcutaneous plane and is typically random.

Bilobed flaps use a flap that is slightly smaller than the existing defect and are used to transpose skin from an area of relative skin excess to an area of skin deficit. These flaps are typically based on a random blood supply. The first lobe of the flap is used to fill in the existing defect, and the second lobe is used to fill the defect created by the first lobe. The practicality of this flap is based on skin laxity in the donor site sufficient enough to allow for primary closure. This flap is better suited for moderate-to-large central cheek defects, using preauricular skin as the donor site. One of its primary disadvantages is that the line of the flap may not correspond to the natural anatomic lines of the face.

Melolabial flaps can be used as transposition flaps, particularly for the medial cheek. Melolabial flaps are based on a branch of the facial artery or are designed with a random blood supply. These flaps can be transposed directly or pedicled subcutaneously.

Rotation flaps

Rotation flaps, like other local facial flaps, are elevated subcutaneously and are usually based randomly, relying on the subdermal plexus (see the images below). However, deep-plane musculocutaneous rotation flaps have been described for closure of large cheek defects. The proposed advantage of this deeper-plane dissection is similar to the rationale for deep-plane facelifts.

Large medial cheek defect. Large medial cheek defect.
Large medial cheek defect. Reconstruction with a c Large medial cheek defect. Reconstruction with a cervicofacial rotation flap.
Eight-month follow-up result. Reconstruction with Eight-month follow-up result. Reconstruction with a cervicofacial rotation flap to correct a large medial cheek defect.

Rotation flaps are designed adjacent to the defect and are rotated about a pivot point opposite the flap incision (see the images below). The flap incision is semicircular and carried into a line that separates anatomic subunits. The medial cheek is an appropriate area for this flap because the incision line can be started in the subciliary crease and carried down into the preauricular crease. The dog-ear deformity created in the region of the pivot point must be excised. Frequently, a suture must be used in the region of the lateral orbital rim to suspend the superolateral portion of the flap.

Large lateral cheek and tragal defect. Large lateral cheek and tragal defect.
Cheek reconstruction with cervicofacial rotation f Cheek reconstruction with cervicofacial rotation flap, 3-month follow-up result.

A study by Liu et al suggested that for defects of the medial cheek and adjacent regions, reconstruction with a lateral cheek rotation flap combined with Z-plasty has advantages over the use of a conventional cervicofacial flap. According to the investigators, whose study included nine reconstruction cases, the rotation flap/Z-plasty procedure is simpler, requires a shorter flap incision and minimal undermining, and avoids such complications as distal flap necrosis and lower lid ectropion.[9]

Interpolation flaps

The most recognizable type of interpolation flap is the paramedian forehead flap, based on the supratrochlear vessels. The paramedian forehead flap is a true axial flap, which is best suited for reconstruction of large nasal defects. However, it can be used in certain circumstances for large medial cheek defects.

Soft tissue expansion

Soft tissue expansion can be used in the reconstruction of cheek defects in areas that lack adequate skin laxity or in situations in which a large defect is expected. The purpose of the implant is to provide a larger surface area of tissue from which a defect can be resurfaced. Slow expansion of skin over a slowly enlarging subcutaneous mass, known as mechanical creep, is achieved through gradual inflation of the subcutaneous implant with saline starting approximately 2 weeks after insertion. The use of rapid intraoperative expansion devices can produce biological creep, which is a phenomenon that displaces the mucopolysaccharide ground substance and causes parallel realignment of collagen fibers.

Tissue expanders cause slight thickening of the dermis and slight thinning of the epidermis. The disadvantages of implants include the possibility of infection, exposure or extrusion, flap necrosis, and alopecia in the male cheek.

Microsurgical free flaps

Large deep defects of the cheek that cannot be repaired with local flap closure, especially those in which the skin is completely penetrated, can be reconstructed with microsurgical free flaps. Depending on exact tissue requirements, the fasciocutaneous scapular flap, radial forearm flap, or the myocutaneous rectus flap can be used. Typically, the superficial temporal or facial vessels are used for vessel anastomoses. The fasciocutaneous scapular flap and the radial forearm flap can be folded to provide both external and internal skin lining. The radial forearm flap is often the flap of choice in the thinner portion of the cheek near the mouth, whereas the scapular flap is usually more suitable for larger defects or in the thicker, more lateral aspect of the cheek. The rectus flap can provide bulk, when necessary, and can be skin grafted to provide an internal mucosal surface. Achieving good contour with free tissue transfer can be challenging, but obtaining good tissue color and texturematchisevenmoredifficult.

Complications

The usual complications of facial plastic surgery must be considered during cheek reconstruction. The most serious of these complications is hematoma, which generally occurs postoperatively within the first 12 hours. Hematoma may threaten the viability of a flap and lead to flap necrosis. As with many surgical mishaps, the best treatment is prevention via meticulous intraoperative hemostasis. A large cervicofacial flap may require a drain to prevent a collection. A hematoma should be drained expeditiously in a sterile environment.[10]

Careful preoperative evaluation should determine if a patient may be hypocoagulable. Patients should discontinue aspirin use 2 weeks prior to surgery. Make arrangements for alternative forms of perioperative anticoagulation for patients who take warfarin. Patients are also advised to avoid large doses of vitamin E preoperatively. Smoking is strongly discouraged because of its detrimental effects on the dermal microvasculature.

Partial or complete flap necrosis is a potential complication that generally occurs secondary to hematoma. Partial necrosis usually manifests as epidermolysis. Local wound therapy and healing by secondary intention are generally the best methods to use when approaching partial necrosis. Complete flap necrosis can be managed as above or closed with a skin graft. However, full-thickness skin graft (FTSG) or split-thickness skin graft (STSG) closure may leave a less aesthetically pleasing outcome than healing by secondary intention.

Future and Controversies

Reconstruction of the cheek requires a thoughtful approach to the etiology of the defect, the functional status of the patient, and the best solution with the least morbidity. The prominence, dynamic function, and contour of the cheek make it a challenging structure to repair. A wide variety of options are available, ranging from a simple skin graft to microvasculature free tissue transfer. However, the reconstructive flap must suit the defect and the patient. Likewise, the surgeon must be able to use a wide variety of reconstructive options should an alternative be required.