This document discusses cheek reconstruction techniques following defects caused by trauma, burns, or surgery. The cheek is anatomically complex with three subunits supplied by the facial artery and drained by veins that communicate with the cavernous sinus. Reconstruction options include primary closure for small defects, skin grafts for large wounds, and various local flaps like advancement, transposition, and rotation flaps. Free tissue transfer using flaps like the radial forearm flap may also be used. Complications include hematoma, ectropion, asymmetry, and scarring.

1. Cheek reconstruction
Dr. Diyar A. Salih
Plastic Surgery Resident
February, 2009
KURDISTAN, SLEMANI

2. Problematic
 Its prominence and central position.
 Its unique characteristics as an anatomic
subunit.

3. 3 subunits
 Suborbital
 Preauricular, and
 Buccomandibular.

4. Cheek wounds
 Classified by depth into:
1. Superficial
2. Full-thickness, and
3. Subcutaneous contour deficits.

5. Reconstruction challenging
1. Cheek contour is paramount to facial
aesthetics. No existing reconstructive
option can universally recreate the
volume loss created by a subcutaneous
tissue defect.
2. The dynamic function of the cheek is not
easily reproduced.
3. Reconstruction can alter or obliterate the
lines that divide facial subunits.

6. Etiology
1. Neoplasia
2. Burns, and
3. Trauma.
Etiology  affect presurgical planning:
For example:
Skin graft: considered:
Full-thickness burn.
History of radiation
Acne as teenagers
Multiple skin cancers.
Traumatic defect  primary closure or local flap.

7. Indications of reconstruction
 Congenital
 Traumatic, and
 Mohs surgery defects.
Subsequent soft tissue deficit can be
corrected with various techniques.

8. Anatomy

9. Extension
 Extends from the
inferior orbital rim
superiorly to the
mandibular rim
inferiorly and from the
lateral nasal sidewall
and nasolabial crease
medially to the
preauricular area
posteriorly.

10. Arterial supply
 External
carotid
artery
(ECA)
 The
greatest
contribution
is from the
facial
artery.

11. Venous drainage
 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.

12. Lymphatic drainage
 Is primarily
directed to:
1. Intraparotid LN
2. Submandibular
LN, and
3. Submental LN.

13. Nerve supply
 Divided into sensory and motor systems.
 Sensation: second (maxillary) and third
(mandibular) divisions of the trigeminal
nerve.
 Motor: the facial nerve (cranial nerve VII)
provides innervation to the muscles of
facial expression.

14. Facial nerve anatomy
 Stylomastoid
foramen.
 Travels through the
parotid gland.
 Branches into upper
(zygomaticofacial)
and lower
(cervicofacial)
divisions.
 Upper division:
temporal and
zygomatic branches.
 Lower division:
buccal, marginal
mandibular, and
cervical branches.

15. Muscles of facial expression
1.Zygomaticus
major & minor
2.O occuli M
3.OOM
4.Levator labii sup.
5.Platysma.
6.Risorius m.

16. SMAS
 Is a continuous fascial covering known as
the superficial musculoaponeurotic
system (SMAS) covers each of facial
expression 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.

17. Reconstruction

18. Healing by secondary
intention
1. Concave surfaces, such as the temple and medial
canthus.
2. Defects that are small and superficial and are not
closely associated with the eyelid or lip.
 Exercise needed 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.

19. Surgical Therapy
1. Primary closure:
 Wide undermining.
 Small defects (<2 cm,
central).
 The degree of
surrounding skin laxity
predicates this closure.
 Older patients (ideal
candidate).
 Final scar, should rest
parallel to or within a
relaxed skin tension line
(RSTL).

21. 2. Skin grafts
 least cosmetically satisfying forms of correction
because of the poor tissue match of the donor
site skin with the sun-exposed cheek area.
 Indications:
(1) large (>4 cm) defect
(2) a high-grade skin neoplasm with
questionable margins or perineural invasion.
(3) poor tolerance of prolonged periods of
anesthesia.
(4) a third-degree burn over substantial
portions of the face.

22. 3. Local flaps:
Advancement flaps
 are typically random.
 relying on the subdermal plexus for blood
supply.

23. V-Y advancement flap

24. Cervicofacial flap (upper cheek)

25. 3. Local flaps:
Transposition flaps

26. Transposition flaps (Banner F)

27. Transposition flaps (Bilobed F)

28. Transposition flaps (Rhomboid F)

29. Cont.

30. 3. Local flaps:
Rotation flaps.

31. Cervicofacial flaps (Inf. Based)

32. Cervicofacial flaps (Lat. Based)

33. Cervicopectoral flap

34. Cervicopectoral flap, cont.

35. 3. Local flaps:
Local composite flaps:
 Pectoralis major flap.
 Trapezius flap.

36. 3. Local flaps:
Tissue expansion:
 Benign lesions.
 Secondary scar revision.
 High rate of complications.

37. Free tissue transfer
 Radial forearm flap.

38.  Parascapular flap:

39.  Anterolateral thigh flap

40.  Rectus abdominis flap.
 Fibula osteocutaneous flap.

41. Complications
 Hematoma, most serious & within the first
12 hours: leading to flap necrosis.
 Ecrtopion or lower eyelid edema.
 Distal flap necrosis.
 Hair bearing shift.
 Asymmetry
 Scarring

43. Thank you