Cheek reconstruction: current concepts in managing facial soft tissue loss

Abstract

Significant defects of the cheek present a reconstructive challenge due to their extremely visible site, as well as limited local tissue supply. In addition, the cheek abuts several structures of expressive function, such as the eye, mouth, and local facial musculature. To achieve satisfactory functional and aesthetic results, reconstruction of such defects requires careful three-dimensional restoration of all missing components, adequate texture matching, as well as functional restoration. Aesthetic reconstruction of facial defects should adhere to the priority goals of first preserving function and second achieving cosmesis. According to the size of the defect, location on the cheek, relationship to adjacent structures, available donor tissue, and existing skin tension lines, a host of techniques is available for closure. As a well-established principle in facial reconstructive surgery, one should use local tissue whenever possible to provide the best tissue for color and contour restoration. However, thoughtful reliance upon the "reconstructive ladder," including direct closure, skin grafting, local flap creation, regional flap placement, and free-flap repair, will invariably guide the surgeon in an optimal approach to cheek reconstruction.

Keywords: Considerations for cheek reconstruction; flap placement; free-flap repair; free-tissue transfer; skin grafting.

Figure 1

The demarcation of the three overlapping, aesthetic zones of the cheek: (1) suborbital, (2) preauricular, and (3) buccomandibular.

Figure 2

(A) Transposition flaps take advantage of laxity of skin adjacent to the defect and provide skin flaps very similar to the skin that had been excised. (B) A particular condition of the transposition flap is the rhomboid flap which is designed to cover a defect that occasionally is converted to a rhomboid shape. When two angles of the defect are 60 degrees and two angles are 120 degrees the design of the flap is easier and the name of the flap is Limberg.

Figure 3

Bilobed flaps rotate adjacent tissue over the cheek defects for coverage.

Figure 4

The cervicofacial flap transposes cutaneous tissue from the submandibular and lateral facial planes with excellent color and texture matching results.

Figure 5

The deltopectoral flap is beneficial for significant reconstruction of the cheek, offering up to 250 cm² of transferable cutaneous tissue.

Figure 6

Substantial full-thickness cheek defects may be repaired by a pectoralis major flap, which can provide both external skin coverage and cheek lining.

Figure 7

The radial forearm free flap can either offer coverage of superficial cheek defects or provide density for re-creation of the mandible, external, and oral lining.

Figure 1

Full-thickness color matched skin graft reconstruction of a large cheek defect in an elderly patient.

Figure 2

Linear closure of a large central cheek defect.

Figure 3

Spontaneous resolution of significant perioperative lip retraction.