Master Techniques in Otolaryngology - Head and Neck Surgery: Reconstructive Surgery, 1ed.

35. Management of the Cheek Defect: Cervicofacial Advancement Flap

Joseph A. Paydarfar

INTRODUCTION

Reconstructive options for defects of the cheek include healing by second intention, primary closure, skin grafting, advancement flaps, pedicled flaps, and free tissue transfer. The goals of reconstruction are to find the best skin color and texture match, maintain normal hair distribution, minimize noticeable incision lines, reconstruct within a facial subunit, and reduce the effects of scarring on adjacent structures such as the lower eyelid.

The cervicofacial advancement rotation flap is well suited for reconstructing a variety of postablative and traumatic defects of the cheek. The skin has excellent color, thickness and texture match, and when designed and implemented correctly, very acceptable scars are the result. There are a number of methods of elevating the cervicofacial flap depending on the size and location of the defect, patient factors, degree of laxity of surrounding skin, and the skill of the reconstructive surgeon. These approaches include using an anteriorly or posteriorly based flap, extending the elevation onto the chest (the so-called cervicothoracic or cervicopectoral flap), and elevating in a subcutaneous versus deep plane. For composite defects, this flap can also be used in combination with pedicled or free flaps.

A careful history is important in determining the optimal approach for reconstruction of the cheek defect. Specifically, a history of prior radiation and/or surgery to the face and neck, diabetes, malnutrition, autoimmune disease, and smoking should be obtained as these factors may impair healing and lead to flap necrosis. In addition, it is important to know if any other procedures are planned such as parotidectomy or neck dissection.

A clear understanding of the anatomy of the flap is important to ensure that the vascular territory of the flap has not been compromised by prior therapy. The cervicofacial flap is vascularized by the facial artery, in particular the submental branch and the superficial temporal, as well as the transverse cervical, and suprascapular arteries. When elevation of the flap is carried onto the chest, additional arterial supply comes from perforators of the internal mammary artery. If a deep plane dissection is performed, the superficial musculoaponeurotic system (SMAS) layer as well as the platysma is included in the flap elevation. The SMAS lies deep to the subcutaneous adipose tissue superficial to the parotid fascia and is in continuity with the fascia investing the platysma muscle. The facial nerve, as it exits the stylomastoid foramen, travels through the parotid gland and is relatively safe as long as the gland is not entered. The nerve then emerges from the gland and travels deep to the muscles of facial expression. The frontal branch of the facial nerve runs just deep to the temporoparietal fascia about 3.5 cm from the external auditory canal as it traverses the zygoma. The marginal mandibular branch of the facial nerve runs deep to the platysma over the fascia that invests the submandibular gland. In the deep plane dissection, the retaining ligaments of the face, namely the zygomatic ligament that anchors the skin of the cheek to the inferior border of the zygoma and the mandibular ligament that anchors the skin overlying the mandible to the anterior aspect of the mandible will need to be divided in order to improve mobilization of the flap.

The cervicofacial flap is primarily used in the repair of posttraumatic or postablative cheek defects, although there are numerous other applications (Table 35.1). It is an ideal flap for skin resurfacing in the case of facial scarring secondary to trauma or burns, and likewise, it is well suited for repairing large defects created as a result of resection of cancer of the skin. Some of the original indications for this flap were for reconstruction of the orbit after exenteration as described by Beare in 1969 and repair of the lower lid as popularized by Mustarde. Conley described the use of the chest advancement flap based either laterally off of the thoracoacromial or lateral thoracic artery or medially off of the internal mammary perforators. Moore et al describe the use of this flap in conjunction with the pectoralis myofascial flap for coverage of defects of the neck as well as with the radial forearm flap for reconstruction of through-and-through buccal defects. If planned properly, harvest of the flap can be incorporated with the resection; for example, the incisions required for resection of a skin cancer extending into the parotid gland with neck dissection can be incorporated into the cervicofacial flap.

TABLE 35.1 Defects Reconstructed with the Cervicofacial/Cervicothoracic Advancement–Rotation Flap

There are no absolute contraindications to the use of this flap. The surgeon should be cautious in patients with a history of poor wound healing and smoking.

A thorough medical history, in particular, a history of prior radiation to the face and neck, diabetes, malnutrition, autoimmune disease, and smoking should be obtained. Physical examination should make note of any facial nerve deficits, prior facial or neck incisions, cervical or parotid lymph adenopathy, extent of the tumor to be resected or defect to be reconstructed, and actinic changes of the skin. If the defect is being created for the treatment of malignancy, such as cancer of the skin, a delayed reconstruction may be of benefit so as to ensure that final tumor margins are negative. It is also important to know if other procedures such as parotidectomy or neck dissection will be required as this will also influence the timing of the reconstruction as well as the placement of incisions.

The patient is placed in the supine position on the operating room table. Depending on the extent of resection and reconstruction as well as surgeon and patient preference, the procedure may be performed under general anesthesia or monitored anesthesia care.

A number of factors will determine the best reconstructive approach including the size, location and depth of the defect, the involved layers in the defect, the relationship between the defect and aesthetic units and subunits, as well as patient factors such as a history of smoking, autoimmune disease, or radiation therapy. The general principles of flap design and elevation are such that the flap to be inset should be under minimal tension and should require the least amount of resection of normal skin (i.e., for management of dog ears). The incisions should be made in a stepwise fashion, reassessing the extent of tissue rotation and suture line tension prior to each subsequent incision. Depending upon the size and location of the defect, an anteriorly based or posteriorly based flap may be elevated.

Anteriorly Based Flap

This flap is also referred to as the forward cervicofacial advancement flap or the inferiorly based cervicofacial advancement flap. A horizontal incision is made at the posterior–superior aspect of the defect along the inferior orbital rim, carried superiorly to the lateral canthus and then inferiorly into the preauricular crease. The incision is then carried inferiorly behind the earlobe and into the neck along the hairline. A back cutting incision may be required, and this may be placed in a crease in the neck. For larger defects, a cervicothoracic or cervicopectoral flap may be used. In this case, the incision along the hairline is carried inferiorly into the lower neck, staying 1 to 2 cm posterior to the anterior border of the trapezius, then creating a curvilinear incision that runs lateral to the acromioclavicular joint, stays along the lateral edge of the pectoralis muscle and then extends medially on the chest, parallel to the clavicle. The medial incision is usually placed at the level of the third intercostal space (or just above the areola in males) although it may be carried down to the costal margin if needed.

The flap is elevated superficial to the SMAS layer and parotideomasseteric fascia in the subcutaneous plane thereby avoiding the branches of the facial nerve. If the flap elevation is carried inferiorly, it can be elevated superficial or deep to the platysma. With elevation deep to the platysma, dissection should be kept in the subplatysmal plane to minimize the risk of injury to the marginal mandibular branch of the facial nerve. If dissection is carried onto the chest, elevation is in the plane deep to the deltoid and pectoralis fascia. Care should be taken to avoid injury to the internal mammary perforators, which arise about 2 cm lateral to the lateral border of the sternum.

As the flap is advanced into the defect in question, the edges are trimmed accordingly. A standing cone deformity will normally occur at the medial–inferior incision line usually in the melolabial groove; the greater the rotation of the flap, the larger the deformity. This can be addressed primarily once the flap is inset. Closure of the donor site is usually achieved primarily and occasionally by V-Y advancement or with skin grafting. Placement of a suction drain will minimize hematoma or seroma formation especially when more extensive dissection is carried out.

Posteriorly Based Flap

This flap is also referred to as the reverse cervicofacial advancement flap or laterally based cervicofacial advancement flap. This rotation advancement moves redundant skin from the jowl and neck superiorly into the cheek defect. The incision starts along the anterior–inferior aspect of the defect and is carried inferiorly either through or parallel to the nasolabial crease and then lateral to the oral commissure. The incision can then be carried inferiorly over the mandible into the neck. The incision may then be made in one of three ways: (1) An anteriorly directed back cutting incision may be made in a submental neck crease; (2) the incision may be carried inferiorly as a vertical midline incision and then posteriorly along a neck crease parallel to the mandible toward the sternocleidomastoid muscle and superiorly to the earlobe/mastoid; and (3) the vertical midline incision may be extended inferiorly on the chest and then extended laterally above the areola and into the axilla.

Elevation and inset of the posteriorly based flap is similar to the anteriorly based flap. When elevating posteriorly, it is critical to discontinue undermining when within 2 to 3 cm of the ear thereby avoiding possible injury to the superficial temporal artery. Closure of the donor site can be achieved primarily as with the anteriorly based flap, although occasionally a V-Y advancement or skin graft is necessary.

Deep Plane Elevation

The cervicofacial advancement-rotation flap as described above is a random pattern flap. As such, there is concern that necrosis of the edges may occur especially with larger flaps. The likelihood of necrosis of the flap is higher among smokers. A deep plane approach has been advocated by some authors in order to improve the vascularity of the flap. Born out of the deep plane rhytidectomy technique, this flap is elevated deep to the SMAS layer but superficial to the facial muscles. The preauricular/pretragal incision is elevated in the subcutaneous plane for about 2 cm and then into the plane deep to the SMAS layer. The dissection also includes the adipose tissue of the cheek. As the dissection is carried anterior to the parotid gland, the surgeon should be careful not to injure the branches of the facial nerve as they exit the parotid gland. Inferior elevation is carried out deep to the platysma muscle that is included with the flap. Staying just deep to the platysma will minimize the risk of injury to the marginal mandibular branch of the facial nerve. Injury to the frontal branch of the facial nerve in the temporal region can be avoided by carrying the dissection more superficially onto the temporoparietal fascia along the inferior border of the zygoma. Because the flap includes the SMAS layer, adipose tissue of the cheek, and platysma, it benefits from improved vascularity and greater ability to handle tension. Releasing the facial suspensory ligaments will improve mobility and transfer of the flap. Closure of the defect can be performed directly or with V-Y transfer.

Choice of Approach

When deciding on the anterior versus posterior approach, the size and location of the defect as well as the degree of rotation and resultant excision of the skin must be taken into account. As a rule of thumb, the anteriorly based flap is better suited for posterior and large anterior defects, while the posteriorly based approach is applied to small to moderately sized anterior defects. Boyette and Vural found that for defects medial to the lateral canthus, the ratio of height to width best determines the approach to minimize rotation and excision of normal skin. With this approach, defects with a larger horizontal dimension are managed with a posteriorly based flap, whereas for defects with a larger vertical component, the anteriorly based flap should be used.

The decision for using a subcutaneous or deep plane dissection will depend upon the size of the defect as well as the patients smoking history and other factors that may affect wound healing such as a history of radiation therapy, diabetes, or autoimmune disease. The subcutaneous flap is easier and quicker to elevate; the risk of injury to the facial nerve is minimal. However, there may be greater risk of necrosis of the edges, especially in larger flaps. The deep plane flap may be better suited for larger defects, especially in smokers; however, it is a more difficult dissection and introduces greater risk of injury to the facial nerve.

Routine incisional wound and drain care is appropriate. It is important that patients not be exposed to cigarette smoke as this may cause necrosis of a poorly perfused skin flap.

The most common complications associated with this flap are listed in Table 35.2. Distal necrosis of the flap edges is a concern, particularly with larger defects and in smokers and as such consideration should be given to the deep plane approach. However, with proper flap design and efforts to minimize tension, distal necrosis in smokers can still be avoided with subcutaneous elevation.

TABLE 35.2 Complications

The other significant complication associated with the cervicofacial flap is ectropion. This occurs when the lower lid is displaced as a result of tension on the flap or gravitational pull. Older patients and those with resected or denervated orbicularis oculi muscle are at greater risk. To avoid this potential complication, when the flap is designed, the horizontal limb is curved superiorly above the level of the lateral canthus. When the flap is inset, it is imperative to secure the flap to the deeper tissues, if possible the periosteum of the lateral or inferior orbit, in order to direct suture line tension away from the lower eyelid and to the anchor point above the lateral canthus. Placement of sutures along the lower lid suture line last will also reduce the risk of ectropion. A canthopexy at the time of flap inset can also be performed.

Injury to the facial nerve is a greater risk with the deep plane dissection. During dissection over the parotid gland, the nerve is relatively safe as it travels through the gland; however, the nerve branches run in a superficial plane as they emerge from the gland anteriorly. Injury to the frontal branch of the facial nerve can be avoided by staying superficial to the temporoparietal fascia when the dissection reaches within 1 cm of the inferior border of the zygoma. By staying in a tight subplatysmal plane, injury to the marginal mandibular branch of the facial nerve can be avoided.

Results with this technique are often considered the best. I find that this technique provides reliable and reproducible results with excellent color and texture match to the adjacent native skin. Figure 35.1demonstrates a defect that is amenable to this reconstructive approach. Figure 35.2 demonstrates the immediate postoperative results.

FIGURE 35.1 Cheek defect involving the full thickness of the skin.

FIGURE 35.2 Anteriorly based cervicofacial rotation advancement flap used for reconstruction of large cheek defect following resection of an advanced cancer of the skin invading the parotid gland. Note how the incision follows the hairline inferiorly onto the clavicle.

• Posterior defects should be reconstructed with an anteriorly based flap; small to medium anterior defects should be reconstructed with a posteriorly based flap.

• For large anterior defects, if the horizontal dimension is the larger dimension, an anteriorly based flap should be used; if the vertical dimension is the larger dimension, a posteriorly based flap should be used.

• Deep plane dissections may be advantageous for larger defects and in smokers or those with a history that predisposes to poor wound healing.

• Skin incisions made during flap elevation should be performed in a stepwise fashion, reassessing rotation and tension prior to each subsequent incision.

• Planning of the flap harvest incisions should take into account the extent of the resection portion of the operation.

• Inset of the flap should be done to minimize tension along the lower eyelid. This can be partly achieved using deep anchoring sutures superior to the lateral canthus.

• Because the vascular supply to the flap can be compromised by vasoconstrictors, the patient should be restricted from tobacco use or contact with active smokers during the healing process to prevent necrosis.

• Standard facial plastic surgical set

SUGGESTED READING

Juri J, Juri C. Advancement and rotation of a large cervicofacial flap for cheek repairs. Plast Reconstr Surg 1979;64(5):692–696.

Kroll SS, Reece GP, Robb G, et al. Deep-plane cervicofacial rotation-advancement flap for reconstruction of large cheek defects. Plast Reconstr Surg 1994;94(1):88–93.

Menick FJ. Reconstruction of the cheek. Plast Reconstr Surg 2001;108(2):496–505.

Moore BA, Wine T, Netterville JL. Cervicofacial and cervicothoracic rotation flaps in head and neck reconstruction. Head Neck 2005;27(12):1092–1101.

Austen WG, Parrett BM, Taghinia A, et al. The subcutaneous cervicofacial flap revisited. Ann Plast Surg 2009;62(2):149–153.

Boyette JR, Vural E. Cervicofacial advancement-rotation flap in midface reconstruction: forward or reverse? Otolaryngol Head Neck Surg 2011;144(2):196–200.