Staged Treatment of a Traumatic Cheek and Jowl Avulsion: Using a Purse-String Technique, Rhombic Flap, and Rhytidectomy

Abstract

Introduction: This article describes a 3-stage treatment modality for a traumatic cheek and jowl avulsion consisting of a purse-string technique, rhombic flap, and face-lift. This approach has not been previously published. Materials and Methods: This case report and literature review discusses the management of a complex left cheek wound consisting of a 6-cm-diameter avulsion and a 5-cm-linear extension. Primary closure was not possible, and a staged treatment modality was selected. The avulsed portion was reduced with a purse-string suture. Primary closure was achieved 3 weeks later with a rhombic flap. Asymmetry was addressed at 6 months postinjury with bilateral rhytidectomy and liposculpture. Successful outcome was determined through patient satisfaction, clinical examination, and comparison of perioperative photographs. Results: The initial defect was reduced in size by more than one-half, from 6 cm to 2.5 cm in diameter, with the purse string. Primary repair was achieved with a smaller local flap, preserved facial landmarks and central oval, and a satisfactory scar. Jowl and nasolabial fold symmetry was effectively restored with bilateral rhytidectomy. No major complications occurred, including flap necrosis, infection, or facial nerve injury. Conclusions: For facial soft-tissue avulsions that are not amenable to primary closure, a purse-string technique allows for circumferential tissue recruitment, creep, and expansion. This creates a smaller defect and potentiates a more conservative definitive closure. Residual nasolabial and jowl asymmetry may be improved with bilateral rhytidectomy. Patients must be fully informed of the complexities of staged treatment including multiple surgeries, increased wound care and appointments, and delayed results.