Plastic surgery





The cheeks represent the largest surface area of the face and frame the central facial units. This anatomic arrangement exposes the skin of the cheek to trauma and to the effects of sun exposure, and, in turn, there is a frequent requirement for reconstructive surgery. Reconstruction must be planned carefully and executed meticulously to (1) restore the natural contours; (2) maintain hair patterns; and (3) camouflage scars.

The face can be divided into units based on a number of characteristics, including skin color, skin texture, hair, contour, relaxed skin tension lines, and boundaries between anatomic structures. The cheek, however, is less amenable to “aesthetic unit” analysis. Zide and Longaker1 divided the cheek into three overlapping zones: suborbital, preauricular, and buccomandibular based on reconstructive needs. Similarly, Jackson divided the cheek into five areas based on reconstructive techniques and anatomic characteristics (lateral, lower, malar, superomedial, and alar base–nasolabial).2 The classification systems are helpful for planning, but principles used for subunit reconstruction in other areas (e.g., resurfacing entire units, discarding remaining tissues of a subunit, and using the contralateral side to make exact templates) are less applicable to cheek reconstruction.


The cheek is bounded by the preauricular crease laterally, the zygomatic arch and lower eyelids superiorly, the nasal sidewall and nasolabial fold medially, and the mandibular border inferiorly.

The sensory innervation of the cheek is provided by the maxillary and mandibular divisions of the trigeminal nerve, as well as a small contribution from the anterior cutaneous nerve of the neck and the great auricular nerve, both of which arise from the cervical plexus.

Motor innervation of the superficial facial muscles is provided by the facial nerve. The masseter and temporalis muscles (muscles of mastication) are innervated by the trigeminal nerve. In the preauricular area, the facial nerve is protected by the superficial lobe of the parotid gland and runs deep to the parotid masseteric fascia over the masseter muscle.

The arterial supply of the cheek is provided by branches of the external carotid artery, including the facial artery, the superficial temporal artery, and the transverse facial artery. Venous drainage follows the arteries and is abundant. The lymphatic drainage of the cheek is provided by lymphatic channels within the parotid nodes and along the facial vessels to the submandibular nodes.


Analysis of the defect or anticipated defect is a critical part of any reconstructive procedure. Defects may be superficial (simple) and include only the skin and subcutaneous tissues, or may be more complex and include the muscle, parotid gland, facial nerve, mucosa, and bone. Ideally, surgical incisions are placed at the cheek margins or within established skin creases to camouflage the resulting scars. Care is taken to avoid, if possible, placement of hair-bearing skin into non–hair-bearing areas. Similarly, rotation of non–hair-bearing skin into areas of the male beard and distortion of the sideburn are avoided. Contour deformities and color mismatches are avoided when possible. Distortion of surrounding structures such as the lower eyelid and upper lip is disfiguring and is an important consideration in any reconstructive plan. According to Zide and colleagues, vertical incisions placed medial to a line drawn from the lateral canthus remain obvious on frontal view and ideally should be replaced by incisions along the nasolabial fold or by blepharoplasty incisions.3 Defects involving the full thickness of the cheek occur from invasion of skin cancers, from extensive trauma, or as a result of advanced intraoral cancers. Appropriate reconstruction of all layers, while maintaining reasonable contour, is planned if possible. A successful reconstruction will recreate the missing tissues using the most similar tissues. As with nasal reconstruction, plans for lining, support, and coverage are developed individually. Secondary revisions for contour may be necessary, particularly for complex reconstructions, and should be described to the patient prior to initiation of therapy.

Facial nerve reconstruction is ideally performed as a planned procedure, with the ends of the nerve stimulated and tagged at the time of resection since later identification of nerve ends is difficult and tedious. In addition, nerve transection is performed sharply to avoid cautery damage at the site of neurorrhaphy. Nerve grafts may be harvested from the neck (ansa cervicalis and great auricular nerve) or from distant sites (e.g., sural nerve).

For a given defect, more than one reconstructive option is usually available. The best option is determined based on the relationship of the defect to the surrounding structures, hair-bearing status, skin laxity, natural wrinkles, previous surgical scars, relaxed skin tension lines, and avoidance of lower eyelid and lip distortion. Contaminated wounds undergo serial debridement and dressing changes until bacterial content is reduced to an acceptable level before definitive reconstruction is accomplished. Previous radiation therapy may prohibit local flap reconstruction.


Healing by Secondary Intention

The simplest method of closure is healing by secondary intention. Unfortunately, the indications for this technique are limited as large wounds may result in contour irregularities, distortion of surrounding structures, and unstable coverage. This technique may be useful for small (<1 cm), superficial defects located in cosmetically inconspicuous areas (e.g., below the sideburns) in patients with solar-damaged, irregularly pigmented skin.

Primary Closure

Primary closure is the reconstructive method of choice if excessive tension and distortion of surrounding tissues can be avoided. The scars are ideally placed along minimal skin tension lines or within natural skin contours, such as the nasolabial or preauricular folds (Figure 35.1). This technique results in the simplest scar, avoids donor-site deformity, and avoids interpolation of distant tissues into the defect. The size of the defect suitable for primary closure is variable and depends on the amount of skin laxity present. Wide undermining in an elderly patient with significant skin laxity may allow closure of relatively large defects. Dog-ears created by wound closure should be excised while avoiding excessive lengthening of the scar. The disadvantage of primary closure for larger defects is the long, straight scar in an area where there are normally no straight lines. The nonlinear scar from a local flap is preferable in many circumstances.

FIGURE 35.1. Primary closure. Preoperative (A) and postoperative (B) photographs of a patient treated with primary closure of Mohs excision for basal cell cancer. Note the closure along nasolabial fold with well-concealed scar and minimal distortion. Also note the new basal cell cancer excision on nasal sidewall (arrow).

Skin Grafts

On rare occasions, skin grafts are useful for cheek reconstruction. Although skin grafts may be associated with shiny, patchlike, depressed scars, they may be reasonable in patients with significant comorbid conditions. Skin grafts have also been advocated by some authors in patients at high risk for local recurrence. In addition, skin grafts may be used to resurface less critical areas of the cheek (e.g., just below the sideburns), particularly when the defects are donor sites of flaps used to resurface more critical, medial areas. Full-thickness skin grafts exhibit less secondary contraction and should be used in situations where contracture would result in distortion of adjacent structures (e.g., lower eyelid). Full-thickness skin grafts have the additional advantage of better color match if harvested from the neck, preauricular/postauricular skin, or upper back. Full-thickness skin grafts are also thicker than split-thickness skin grafts and may be more useful for deeper defects. In general, excisions greater than 5 mm in thickness treated with skin grafts will likely exhibit a permanent contour deformity.

Local Flaps

Advancement Flaps. Advancement flaps are useful for reconstruction of superomedial defects, particularly in elderly patients with significant skin laxity. These flaps may be performed as advancement flaps with excision of Burrow triangles or as V-Y advancements. Ideally, the lesion is excised as a rectangle or square to avoid trapdoor scarring. Advancement flaps are random pattern flaps raised in the subcutaneous plane and should be of appropriate width to avoid tip necrosis. A base-to-length ratio of 1:1 is usually safe. In addition, advancement flaps should be anchored to the periosteum of zygoma or maxilla at points higher than the lower eyelid to prevent ectropion.

V-Y advancement flaps are an excellent choice for closure of defects that lie along the medial cheek and alar base, particularly if primary closure of the defect results in distortion of the lower eyelid or nasal base (Figure 35.2).4 The excision is performed as a square or rectangle in the medial cheek or as a wide crescent at the alar base. Skin incisions are preformed to the subcutaneous tissues and the flap is advanced based on a subcutaneous blood supply. The length of the flap should be sufficient to avoid tension on the closure.

FIGURE 35.2. V-Y advancement flap to medial cheek defect. A. Flap design. B. After advancement. Note the advancement of nasolabial flap with rectangular excision of the defect.

Zide and colleagues described the deep-plane cervicofacial “hike” repair as an advancement flap that removes dog-ears in a cosmetically acceptable blepharoplasty incision.3 The flap is dissected together with the SMAS (superficial musculoaponeurotic system), and the authors believe that it has a better blood supply than a subcutaneous flap. The dissection of the facial nerve is performed with blunt scissors, using vertical spreading, thus enabling advancement of the remaining cheek unit. Dog-ears are excised as an upper or lower blepharoplasty incision. Alternatively, the redundant upper eyelid skin may be used to reconstruct lower-lid defects, while the advancement flap is used to reconstruct the cheek defect (Figure 35.3).

Transposition Flaps. Transposition flaps such as banner flaps, bilobed flaps, and rhomboid flaps are useful for most medium to large defects of the cheek and are designed to transfer lax skin while the donor sites are closed primarily. Although these flaps have some drawbacks (e.g., complex scars, pincushioning, trapdoor scarring, patchlike scarring, and alterations in hair pattern), good results can be obtained in appropriately selected patients and with carefully designed flaps. Donor scars are planned carefully to fall, as much as possible, within relaxed skin tension lines or existing folds. Dog-ears are excised without narrowing the base of the flaps.

FIGURE 35.3. Cervicofacial flap to upper cheek defect. Redundant upper eyelid skin was used to repair lower eyelid defect while the cheek advancement flap was used to repair the cheek defect. A. Defect before operation. BD. Postoperative appearance. Note the well-camouflaged scar and lack of lower eyelid distortion.

Banner flaps are the simplest form of transposition flap and transfer the skin from the preauricular or nasolabial area to close the defect (Figure 35.4). Secondary revisions may be necessary to remove remaining dog-ears or to defat pincushioned flaps. Although these repairs usually have excellent contour and reasonable color match, the scars may be conspicuous, particularly with facial animation.

Bilobed flaps are an extension of the banner flap and use a secondary flap to close the defect created by the primary flap (Figure 35.5). Bilobed flaps are used when the defect created by the primary flap (i.e., the banner flap) is too large to close primarily. The flaps are designed on a 45° to 90° axis to the primary defect and are elevated in the subcutaneous plane. Generally, the primary flap may be drawn somewhat smaller than the defect and is designed, as much as possible, to place the scars along minimal tension lines and within natural skin creases. Flaps designed at 45° angles minimize dog-ear formation. The resultant scars are complex and may be quite conspicuous. Pincushioning is a problem with bilobed flaps, particularly relatively small flaps, and may require secondary revisions.Because of the laxity in the cheek, bilobed flaps are infrequently used on the cheek.

Rhomboid flaps are a geometric modification of banner flaps and are useful in the treatment of medium to large defects (Figure 35.6). These flaps are more difficult to design but have a decreased propensity for trapdoor scarring or pincushioning. Rhomboid flaps are useful primarily for lateral, lower cheek, and temporal defects. The excision is performed using a rhombus with 60° and 120° angles. The donor flap bisects the 120° angle. The flap is drawn to place the donor site scar within a normal facial crease or wrinkle. This can be determined by identifying the area of adjacent skin with the greatest laxity. Thus, redundant surrounding skin is transferred to the defect while the donor area is closed primarily. Modifications of the flap may be performed to avoid unnecessary excision of normal skin; however, more circular excisions resembling banner flaps may be complicated by pincushioning.

Rotation Flaps

Cervicofacial Flaps. Cheek rotation flaps are useful for moderate to large defects of the upper medial region. These flaps use the loose preauricular and neck skin and are most useful for full-thickness skin and subcutaneous excisions. Repair of deeper defects may result in contour abnormalities.

FIGURE 35.4. Banner flap to central cheek defect. A. Flap design. B. After transfer. Note the location of final incision corresponds to lines of minimal tension/natural skin creases.

FIGURE 35.5. Bilobed flap closure of central cheek defect. A. Flap design. B. After transfer. See text for details.

There are a variety of cheek rotation flaps (Figure 35.7). In their 1979 description, Juri and Juri popularized the inferomedially based rotation flap. This flap is designed such that the incision starts at the superior aspect of the defect and extends to the outer canthus and along the zygomatic arch (Figure 35.8). The incision is then brought along the preauricular fold, extended below the ear, and along the retroauricular hairline to the midposterior line of the neck. Wide subcutaneous undermining of the skin flap is then performed, enabling advancement and rotation of the flap into the defect with primary closure of the donor site. The flap is anchored to the periosteum of the zygoma and lateral orbital wall in such a way that there is absolutely no tension on the lower eyelid. Simultaneous lower-lid tightening may be considered, particularly in patients with excessive lower-lid laxity. Skin excess formed at the nasolabial fold is excised carefully so as to avoid narrowing the base of the flap.Occasionally, a full-thickness skin graft is necessary for closure of the donor site to avoid undue tension and is best hidden below the sideburn. The primary drawback of this procedure is skin necrosis of the distal flap. This complication is more likely in smokers. Disadvantages include rotation-advancement shifts of the normal hair-bearing of the cheek and creation of ectropion or prolonged lower-lid edema. Hematoma is also common and should be closely monitored as it can lead to large areas of skin necrosis.

FIGURE 35.6. Rhomboid flap closure of cheek defects. A and C. Flap design. B and D. After transfer. Note that the flap is drawn along minimal tension lines and within natural skin creases.

FIGURE 35.7. Various designs for cervicofacial rotation flap closure of cheek defects: A. Esser; B. Blascowicz; C. Ferris Smith; D. Mustarde; E. Converse; F. Stark; G. Juri and Juri; H. Zide and Schruder; I. Kroll. (Adapted from Al-Shunnar B, Manson P. Cheek reconstruction with laterally based flaps. Clin Plast Surg. 2001;28:283-296, with permission.)

Inferolaterally based rotation flaps are designed to transfer the lax skin along the nasolabial fold and jowls to reconstruct upper medial defects (Figure 35.9).5 The skin incision may be extended across the mandible and back-cut to enable tension-free closure. In addition, extension of the incision to the contralateral neck along an established neck crease may increase the reach of the flap. These flaps are less likely to undergo necrosis at the distal end than the previously described inferomedially based flaps. The disadvantage is the scar in the central face. For smaller defects, excision of a Burow triangle may be necessary to allow rotation-advancement of the flap. Although these flaps are susceptible to the effects of gravity with resulting ectropion, this is usually prevented by anchoring securely to the underlying bone/periosteum in the medial canthal region. Resections performed close to the lower eyelid may be complicated by lower-lid edema, medial ectropion, pin cushioning, and nasolabial fold asymmetry. In addition, scars crossing the mandibular border may be difficult to hide or result in contracture. The use of Z-plasty incisions to cross the mandibular border may obviate this problem.

FIGURE 35.8. Inferiorly based cervicofacial rotation flap closure of Mohs resection for basal cell cancer. Note the excision of dog-ear along nasolabial fold. A. Planned resection. B. Defect and flap design. C and D. Postoperative appearance.

In an effort to improve the blood supply and reliability of the cheek rotation flap, several authors have described a composite dissection of the skin flap.3,6 This dissection is performed in the deep plane by elevating the skin together with the SMAS. The flap is elevated with vertical spreading below the SMAS, and the facial nerve branches are preserved. This modification enables larger flap design and may be more reliable in smokers and patients with poor skin quality. In addition, the use of these thicker flaps enables repair of deeper defects without resultant contour abnormalities. Conversely, these flaps may require secondary revision (thinning) if used for the repair of simple excisions.

Cervicopectoral Flaps. Cervicopectoral flaps use the excess skin of the neck and chest to cover lower lateral cheek defects. The upper border of the defects suitable for cervicopectoral flap reconstruction can be estimated by drawing a line connecting the tragus to the lateral commissure. Reconstruction of defects extending significantly above this line may be complicated by skin necrosis. The incisions are marked along the posterior aspect of the defect, around the ear lobe, and along the retroauricular hairline. The incision is continued in the neck approximately 2 to 3 cm behind the anterior border of the trapezius and across the clavicle at the deltopectoral groove. A back-cut may be performed as necessary. Larger defects may require further dissection of the flap by running along the border of the pectoralis muscle and extending across the chest (Figure 35.10). This flap is based primarily on the internal mammary perforating vessels with variable contribution from perforators emanating from the thoracoacromial artery and vein. Cervicopectoral flaps are raised subcutaneously over the cheek and lower mandible and enter the deep plane below the platysma approximately 3 to 4 cm below the mandibular border. The platysma can be safely transected at this level to improve the reach of the flap. The flap is advanced and rotated into the defect, and the donor area of the flap lateral to the pectoralis muscle is closed in a V-to-Y fashion. Skin grafting of the donor site is occasionally necessary to provide tension-free closure. The head is lightly immobilized postoperatively using rolled sheets to avoid violent movements.

FIGURE 35.9. Laterally based cervicofacial rotation flap. Skin flaps are raised in the subcutaneous plane and rotated/advanced to fill in the defect. A. Defect and flap design. B. After flap transfer.

Local Composite Flaps

Pectoralis Major Flap. The pectoralis major flap is occasionally useful for the repair of lower lateral cheek defects. The pectoralis muscle is supplied by the pectoral branches of the thoracoacromial vessels that are located along a line drawn from the acromion to the xiphoid process. The vessels emerge from below the clavicle and can be located easily using a Doppler probe. The skin of the pectoralis flap is reliable and rarely undergoes total necrosis; however, partial skin necrosis can occur if the flap is not elevated meticulously. The flap tends to be bulky and is primarily used for complex reconstructions, involving the skin, subcutaneous tissues, parotid, and masseter. Although a folded pectoralis major myocutaneous flap has been described for repair of through-and-through cheek defects to provide both intraoral and extraoral coverage, this option is significantly disfiguring because of excessive bulk and should probably be avoided except in extenuating circumstances. The flap may be transferred as a muscle-only flap, or together with an overlying skin paddle. The skin paddle is usually designed as an ellipse medial to the nipple–areola complex. A width of approximately 6 to 7 cm is usually closed without excessive tension. The superior extent of the skin paddle ideally avoids the internal mammary perforating vessels saving the option for a future deltopectoral flap. Closure of this defect may cause significant distortion of the breast. An alternative is a skin paddle below the nipple. This skin paddle has longer reach and a better scar; however, the blood supply may be tenuous. In addition, extensive undermining in a female patient may lead to breast or nipple necrosis. The muscle may be thinned proximally to avoid an unsightly bulge in the lower neck. In addition, near-complete disinsertion of the muscle may prevent postoperative neck contracture and torticollis. Care is taken when tunneling the flap into the defect to avoid avulsion of the skin paddle, kinking or excessive twisting of the pedicle, or external compression from an inadequate tunnel.

FIGURE 35.10. Cervicopectoral rotation flap. Preoperative (A, B), intraoperative (C, D), and postoperative (E, F) photographs of cervicopectoral rotation flap for large cheek defect resulting from basal cell cancer excision. The flap is elevated in the subcutaneous plane until a point approximately 2 cm below the angle of the mandible at which point the platysma is included with the flap (dark arrow in C). A small skin graft was necessary below the hairline to obtain tension-free closure (arrow in D). Note the good contour and acceptable final scar.

Trapezius Flap The trapezius flap is similar to the pectoralis major flap in that it is occasionally useful for complex lower lateral cheek defects. The arterial and venous anatomy of the trapezius (Mathes and Nahai type II vascular pattern) is variable and can be a potential pitfall in dissection. The dominant pedicle is the transverse cervical artery and vein, which in most instances are branches of the thyrocervical trunk (80%). The distal portions of the muscle receive a variable contribution from the dorsal scapular artery and vein, which course deep to the rhomboid muscles. These vessels are usually branches of the transverse cervical artery and vein, but may arise separately from the subclavian vessels, leading to distal ischemia if divided. Three distinct musculocutaneous flaps based on the trapezius system are available (superior, lateral, and lower). The lower and lateral flaps are more useful for cheek reconstruction because of their arc of rotation. The lower flap is designed with the patient in the lateral decubitus position. The skin flap is marked between the midline and the medial border of the scapula overlying the inferior aspect of the trapezius muscle. The lower extent of the skin paddle is variable, although the inferior border of the scapula is in general reliable. Skin, subcutaneous tissues, and fibers of the trapezius muscle are incised and the flap is elevated above the plane of the rhomboid muscles. If a large dorsal scapular artery is encountered, the contribution of this vessel to the skin flap perfusion should be assessed using a microvascular clamp. If the dorsal scapular vessels are critical for perfusion of the distal aspect of the flap, these vessels can be mobilized by incising a cuff of rhomboid muscle and ligating their deep branches. Careful dissection can enable the preservation of the spinal accessory nerve branches to the upper trapezius muscle, thus preserving its function.

Tissue Expansion. When timing of reconstruction is not critical (i.e., excision of a benign lesion), tissue expansion (Chapter 10) may represent an alternative option. In addition, this technique may be useful in secondary revision of existing scars, skin grafts, or excision of skin paddles of previously performed free flaps. In these settings, tissue expansion has the advantage of transferring potentially sensate skin that is of similar color, texture, and hair-bearing status while minimizing donor defects.

Although simple in concept, tissue expansion of the cheek is highly technical and can be associated with high rates of complications.7 Despite these difficulties, however, the expanded skin is salvageable in most instances, and successful reconstruction is usually achieved. Careful preoperative planning with regard to patient selection, expander size, and incisions used for expander and fill-valve placement are critical determinants of success.8 No expander is placed before the surgeon has decided exactly what incisions will eventually be required to transfer the expanded skin at the second stage.

Wieslander8 has outlined guidelines for tissue expansion of the head and neck based on his experience with more than 100 patients over a 6-year period. These guidelines include the following: the width and length of the expander are at least as large, preferably larger, than the defect; the access incisions are kept small and as far away from the lesion as possible; access incisions are oriented perpendicular to the lesion; expansion of the lesion should be avoided; straight incisions bordering the defect are avoided; fill-valves are placed away from (>7 cm) and below or lateral to the expander pocket; expanders are filled intraoperatively to the safest maximal amount to avoid seroma/hematoma; postoperative expansion should be delayed for 10 to 14 days; overexpansion by 30% to 50% is recommended; and the capsule is incised but capsulectomy is avoided at the time of flap transposition.

Microsurgical Reconstruction

Microsurgical reconstruction is an important option for complex defects involving multiple tissue layers. These techniques are also useful for resurfacing massive skin resections and in patients in whom local flaps are not available (e.g., previous neck dissection and facial burns) or advisable (contaminated wounds and history of radiation therapy). Resurfacing of extensive intraoral or through-and-through defects and contour deformities are additional potential indications for the use of microsurgical tissue transfer.

Although a number of flap options have been described, the radial forearm, parascapular, rectus abdominus, anterolateral thigh flap, and free fibula flap have been the most useful in our experience. The choice of free flap is dependent on the amount of external skin, intraoral lining, and soft-tissue contour requirements. In addition, the availability and location of the recipient vessels must be carefully determined.

Radial Forearm Flap. The radial forearm flap is a fasciocutaneous flap based on the radial artery. The flap is an excellent source of thin, pliable skin with a long, reliable pedicle. The flap has dual venous drainage via the cephalic vein and radial vena comitans. Sensate reconstructions may be performed using the lateral antebrachial cutaneous nerve. The forearm flap is an excellent choice for defects requiring a thin coverage of skin (Figure 35.11). In addition, the flap may be folded upon itself to provide more bulk or to provide coverage of through-and-through cheek defects (Figure 35.12). Multiple skin islands may be designed along the length of the flap, and the flap may be de-epithelialized or thinned to allow soft-tissue contouring. A short segment of the radial bone may be harvested as vascularized bone with the flap. The main drawbacks of this flap include donor-site scarring and color/texture mismatch with local tissues. In addition, the flap may be hair-bearing in some men.

FIGURE 35.11. Radial forearm free flap. Intraoperative (A, B, C) and postoperative (D, E) photographs of a free radial forearm flap used for reconstruction of deep, wide, central cheek defect resulting from resection of a desmoplastic melanoma. The flap was folded upon itself medially to correct the volume deficiency. Note the postoperative ectropion (D) despite intraoperative canthoplasty and flap suspension.

Parascapular Flap. The parascapular flap is a fasciocutaneous flap based on the circumflex scapular vessels. This flap has more bulk than the radial forearm flap and is useful in reconstruction of composite resections such as radical parotidectomy (Figure 35.13). The flap may be harvested with a segment of scapular bone (up to 14 cm). In addition, the latissimus dorsi muscle can be harvested on a common pedicle, resulting in a large amount of soft tissues useful in reconstruction of massive defects. In general, this flap has a better color match with facial skin than most other microvascular flaps and is associated with minimal functional deficits, although the donor-site scar tends to widen if large flaps are designed. The flap is not usually useful for through-and-through defects and its pedicle length is shorter and more difficult to dissect than the radial forearm flap. In addition, parascapular and scapular flap dissection require lateral positioning of the patient, making simultaneous flap harvest and tumor resection difficult.

Rectus Abdominus Flap. The rectus abdominus myocutaneous flap is a workhorse flap for facial reconstruction. The use of this flap for cheek reconstruction is more limited, however. The flap is usually designed with a vertical skin paddle, and its primary indications are reconstruction of complex defects including multiple layers. The pedicle vessels are the deep inferior epigastric artery and vein and are highly reliable. Pedicle length may be lengthened through intramuscular dissection and may be as long as 14 to 15 cm. The flap may be bulky, particularly in obese patients, and secondary revisions with liposuction and direct excision may be required. The flap can be folded upon itself for reconstruction of through-and-through defects of the cheek, but is too bulky in most patients. The amount of muscle harvested with the flap can be tailored to fit the defect and is particularly useful for obliterating radical resections involving the maxillary sinus and the overlying cheek skin. Perforator flaps (deep inferior epigastric perforator flap) that include only perforating vessels without harvesting rectus muscle have become more popular for the head and neck reconstruction. These flaps have the advantage of being less bulky and may be associated with less donor-site pain and abdominal wall laxity or hernias (Chapter 62). The potential drawbacks to the use of the rectus flap for cheek reconstruction include donor-site complications and bulkiness of the flap necessitating secondary revisions.

FIGURE 35.12. Folded radial forearm flap. Preoperative (A) and intraoperative (B, C, D) photographs of a folded radial forearm flap for intraoral and external coverage of a complex cheek defect. Note that lip continuity was restored using lip rotation flaps (right,Karapandzic; left, Estlander), thereby avoiding interposition of the radial forearm flap in the lip defect.

Anterolateral Thigh Flap. The anterolateral thigh flap is a fasciocutaneous flap based on the perforating vessels of the descending branch of the lateral circumflex femoral artery and vein. The flap may be thin and pliable, depending on the patient’s body habitus, and is useful for providing a large amount of skin together with a variable amount of vastus lateralis muscle to fill complex defects (Figure 35.14). The flap may be thinned somewhat at the time of flap harvest; however, aggressive thinning may be associated with partial flap necrosis. Alternatively, secondary revisions with liposuction and direct excision may be required. Thin patients may be good candidates for reconstruction of through-and-through cheek defects based on the dissection of multiple perforating branches. Pedicle dissection is more difficult than the radial forearm flap because of anatomic variability; however, large-caliber vessels are available in most instances. Dissection of the pedicle vessels to their origin can result in a lengthy pedicle that enables microvascular anastomosis to the neck vessels while avoiding vein grafting. The advantages of this flap include more favorable donor-site scarring than the radial forearm flap, potential for simultaneous flap harvest and tumor ablation, and the ability to tailor the thickness of the flap by altering the amount of vastus lateralis muscle resection. Knee extension is rarely affected unless there is inadvertent injury to the femoral nerve. Color match to the facial skin is poor, however, as is the hair pattern.

FIGURE 35.13. Parascapular flap. Preoperative (A) and intraoperative (A, B, C, D) and postoperative (E, F) photographs of a free parascapular flap for reconstruction of a complex cheek defect resulting from resection of a recurrent malignant melanoma of the right parotid gland. Facial nerve repair was performed using sural nerve grafts. Postoperative photographs were taken 1 year postoperatively without further revision. Note the good color match and contour.

FIGURE 35.14. Anterolateral thigh flap. Intraoperative (A, B, C), and postoperative (D, E) photographs of a massive cheek and neck defect resulting from resection of osteoradionecrosis and infection of the right mandible. The patient had a previous parotid tumor treated with wide resection, radical neck dissection, and maximal doses of external beam radiation therapy. Note the severe atrophy of the surrounding tissues. A thin anterolateral thigh flap together with a small portion of the vastus lateralis muscle (C) was used to cover the cheek defect and close the small intraoral defect resulting from resection.

FIGURE 35.15. Summary of reconstructive technique for acquired cheek defects. See text for details. FTSG, full-thickness skin graft.

Fibula Osteocutaneous Flap. The fibula osteocutaneous flap (Chapter 37) is an excellent source of vascularized bone (up to 30 cm) and a variable amount of skin and soft tissues. Portions of the soleus muscle and flexor hallucis longus muscle can be harvested as vascularized muscle. The flap is based on the peroneal vessels and is useful for reconstruction of segmental mandibular defects with or without external skin resections. The flap may be harvested at the time of tumor ablation, and the skin paddle may be folded upon itself to provide both intra- and extra-oral lining. The fibula skin paddle is most reliable in the distal portions of the leg where the perforating vessels tend to follow a septocutaneous pattern. Care must be taken during flap harvest to avoid injury to the neurovascular structures of the lower extremity and to preserve adequate bone proximally and distally to avoid knee and ankle instability, respectively. In addition, the vascular supply of the leg should be carefully evaluated preoperatively, either by physical examination or in combination with radiologic studies, to avoid lower extremity ischemia.


Reconstruction of cheek defects requires careful planning and execution. Although the choice of surgical options must be individualized, an overall guide for the practitioner is summarized in Figure 35.15.


1.  Zide, B, Longaker, M. Cheek surface reconstruction: best choices according to zones. Oper Tech Plast Reconstr Surg.1998;5:26.

2.  Jackson I. Local Flaps for Head and Neck Reconstruction. St. Louis, MO: Quality Medical Publishing; 2002.

3.  Longaker M, Glat P, Zide BM, et al. Deep-plane cervicofacial “hike”: anatomic basis with dog-ear blepharoplasty. Plast Reconstr Surg. 1997;99:16.

4.  Chadawarkar R, Cervino A. Subunits of the cheek: an algorithm for the re-construction of partial-thickness defects. Br J Plast Surg. 2003;56:135-139.

5.  Al-Shunnar B, Manson P. Cheek reconstruction with laterally based flaps. Clin Plast Surg. 2001;28:283.

6.  Kroll S, Reece G, Robb G, et al. Deep-plane cervicofacial rotation-advancement flap for reconstruction of large cheek defects. Plast Reconstr Surg. 1994;94:88.

7.  Antonyshyn O, Gruss J, Zuker R, et al. Tissue expansion in head and neck reconstruction. Plast Reconstr Surg. 1988;82:58.

8.  Wieslander J. Tissue expansion in the head and neck. Scand J Plast Reconstr Hand Surg. 1991;25:47.