Cheek Defects Research Articles

Anatomical study and clinical application of medial sural artery perforator flap for oral cavity reconstruction

The present study aims to provide anatomical evidence for clinical application of the medial sural artery perforator (MSAP) flap. The current study investigated the vascular anatomy of the flap, evaluated the postoperative appearance and function of the donor and recipient sites, and investigate the clinical value in reconstruction of oral cavity. Six lower limbs of Chinese adult cadavers were microsurgically dissected. The locations and courses of the medial sural artery perforators were identified and recorded, which provided an anatomical basis for clinical application. Then, 16 clinical cases employing this flap were evaluated, ranging from 3×4cm to 6×8cm, and were employed for defects in the oral cavity region. Sixteen clinical cases with intraoral soft tissue defects, which included four clinical cases with inner cheek defects, were successfully followed up for 10–47 months (24 months on average). The donor site function, contour of recipient site and oral function recovery were evaluated as acceptable or better in cases with intraoral soft tissue defect, which were further verifying the value of clinical application of MSAP in repairing oral cavity defects. Moreover, two typical clinical cases were described in detail. To conclude, the MSAP flap is a favorable choice for small- to medium-size defects based on minor donor site morbidity, satisfactory oral function recovery, perforator stability and adaptation of the pedicle for anastomosis in the oral cavity region.

A Simple Approach for the Repair of Intermediate-to-Large Cheek Defects.

Surgical management of cheek congenital melanocytic nevus (CMN) remains a huge challenge because of undesirable defects in repair. The use of direct closure is often limited to defect reconstruction with a diameter less than 4 cm. This study aimed to evaluate the safety and efficacy of direct vertical closure combined with extensive subcutaneous tissue undermining boundaries for intermediate-to-large cheek defects. A retrospective review was conducted to evaluate patients with cheek CMN who underwent the aforementioned procedure. Projected adult size, defect size, and incision length were measured. The Vancouver scar scale and visual analog scale were applied to assess scar formation and postoperative appearance. Complications within 1 year postoperatively were recorded. A total of 35 patients with CMN >3.5 cm underwent the procedure. Patients' age ranged from 3 to 36 years. The average projected adult size of the facial CMN was 5.5 ± 1.6 cm. The mean Vancouver scar scale and visual analog scale scores were 2.6 ± 1.0 and 8.0 ± 0.7, respectively. There were 2 cases of dog ear deformity (5.7%) and 1 case of hematoma (2.9%). This simple algorithm yields satisfying results with low complication rate in the repair of intermediate-to-large cheek defects and may become a useful alternative to cheek reconstruction.

Effects of free anterolateral femoral or medial calf flaps in the repair of severe facial burns

Objective: To explore the effects of free anterolateral femoral or medial calf flaps in the repair of severe facial burns. Methods: From January 2014 to October 2017, 18 patients with severe facial burns were admitted to Zhengzhou First People's Hospital, including 12 males and 6 females, aged 15-78 years. Autologous intermediate split-thickness skin grafts were transplanted to replace oral mucosa in 4 patients with perforating cheek defects, and 8 patients underwent early vacuum sealing drainage and autologous intermediate split-thickness skin grafting to reduce the wound area to 14 cm×6 cm-22 cm×14 cm before flap transplantation. The wounds of 15 patients were repaired with free anterolateral femoral flaps, and the wounds of the other 3 patients were repaired with free medial calf flaps. The area of flaps ranged from 16 cm×7 cm to 24 cm×17 cm. The facial artery or superficial temporal artery was anastomosed end-to-end with lateral femoral circumflex artery or posterior tibial artery under microscope routinely and manually, and the two accompanying veins were anastomosed end-to-end by Coupler microvascular anastomat. The donor site was sutured or transplanted with autologous intermediate split-thickness skin graft. The anastomosis time of veins was recorded. The patency rate of vascular was calculated. The survival status of flaps were observed. The recovery of recipient area was observed during follow-up. Results: The anastomosis time of two veins in this group was 6-10 minutes, with an average of 8.5 minutes. The patency rates of veins and arteries were 100%. There was no vascular crisis due to the anastomosis problem. The free flaps survived well in 16 patients; one patient had hemorrhage under the flap 6 hours after operation, and the blood circulation of flaps turned well after hemostasis by surgical exploration; the other patient had 3 cm necrosis at the distal end of flap after operation, and the wound was closed after dressing change and autologous intermediate split-thickness skin grafting. The patients were followed up for 2 to 24 months after discharge. Most of the five senses function recovered. The color and texture of the flaps were not consistent with those of the normal facial skin. Some flaps were slightly swollen. Oral integrity was restored in 4 patients with perforating cheek defect with mouth opening of 2.2-3.5 cm. Conclusions: Free anterolateral thigh flaps or medial calf flaps can repair severe facial burn wounds. It takes less time to anastomose venous vessels by microvascular anastomat during operation and can ensure the quality of venous anastomosis.

The cervicofacial flap

Surgical and traumatic defects of the face present a reconstructive challenge to restore facial symmetry. The cervicofacial flap is a rotational and advancement flap with random blood supply utilized to close moderate- to large-sized defects of the cheek. Subcutaneous dissection of the cervical region allows for a large amount of tissue mobilization. Depending on the location of the cheek defect, the flap can be pedicled either anteriorly or posteriorly. This article presents the authors’ preferred surgical technique as well as reported surgical variations. Routine postoperative care and management of potential complications are discussed.

Comparison of the reconstruction of through-and-through cheek defects involving the labial commissure following tumor resection using four types of local and pedicle flaps

BackgroundThe reconstruction of through-and-through cheek defects involving the labial commissure following cancer ablation is a surgical challenge.MethodsThis study evaluated 35 patients with buccal squamous cell carcinoma (SCC) involving the labial commissure who underwent Abbe–Estlander (A-EF), folded extended supraclavicular fasciocutaneous island (SFIF), folded pectoralis major muscle (PMMF), or folded extended vertical lower trapezius island myocutaneous (TIMF) flap reconstruction of through-and-through cheek defects involving the labial commissure following radical resection.ResultsThe A-EF and SFIF groups differed significantly (P < 0.05) from the PMMF and TIMF groups in terms of tumor clinical stage and type of treatment. The inner PMMF (median 6.3 × 4.5) and TIMF (median 9.8 × 6.7) skin paddle dimensions were larger than those of the A-EF (median 1.8 × 2.2) and SFIF (median 5.5 × 4.3) groups (P < 0.05). The outer PMMF (median 6.3 × 6.6) and TIMF (median 9.8 × 13.2) dimensions were larger than those of the A-EF (median 1.8 × 3.8) and SFIF (median 5.5 × 4.6) groups (P < 0.05). The esthetic results, orbicularis oris function, and speech function were significantly (P < 0.05) better in the A-EF group than in the SFIF, PMMF, and TIMF groups. The patients were followed for 6–38 months (median 26.8, 25.0, 22.1, and 20.8 months in the A-EF, SFIF, PMMF, and TIMF groups, respectively). At the final follow-up, 4 (80.0%) patients in the A-EF, 7 (87.5%) in the SFIF, 5 (55.6%) in the PMMF, and 5 (38.4%) in the TIMF groups were alive with no disease; 1 (20.0%), 1 (22.2%), 2 (22.2%), and 4 (30.8%) patients, respectively, were alive with disease; and 2 (22.2%) patients in the PMMF and 4 (30.8%) in the TIMF group had died of local recurrence or distant metastases at between 9 and 38 months. There was a significant survival difference in the A-EF and SFIF groups compared with the PMMF and TIMF groups (P < 0.05).ConclusionsThe A-EF is suitable for reconstructing defects of clinical stage II disease; the SFIF for clinical stage II or III disease; the PMMF for clinical stage III or IV; and the TIMF for clinical stage rCS III or rCS IV disease.

Single-Skin Paddle Anterolateral Thigh Free Flap with Ileotibial Tract for Internal Lining in Reconstruction of Full-Thickness Cheek Defect.

Single-Skin Paddle Anterolateral Thigh Free Flap with Ileotibial Tract for Internal Lining in Reconstruction of Full-Thickness Cheek Defect.

Modified Cervicofacial Flap for Large Cheek Defect Reconstruction under Local Anesthesia

The cervicofacial flap was first described in 1969. For the past several years, it has been the flap of choice for the reconstruction of facial defects especially cheek defects. In recent years, with the advent of microvascular free flap tissue transfer, the use of a cervicofacial flap has been sparse. This article highlights the importance and application of locoregional flaps such as a cervicofacial flap in the reconstruction of soft tissue defects on a face. This case was unique from the reconstruction point of view. An 81-year-old patient presented to us with a long standing ulcerated growth in his left cheek which was neglected due to lack of symptoms and his poor financial condition. Clinically, the extent was defined from the suborbital skin region till the mid cheek region and medially from the lateral nasal crease up to the cheek prominence area. An initial biopsy suggested basal cell carcinoma. The lesion was excised, and a 4.5 × 5.5 cm defect was reconstructed using a modified “cervicofacial” flap under local anesthesia. Our experience shows that this technique is a reliable, easy to harvest flap with good outcomes. Moreover, it can be utilized in those candidates not suitable for a free flap procedure under general anesthesia.

Versatility of cervicofacial flaps: Cervical‐medial cheek flap for reconstruction in cutaneous substance loss of the inner cheek

Preservation of facial harmony is a major challenge in reconstruction after resection of head and neck skin tumors. For large medial cheek-skin defects, we used a derived posterior-based cervicofacial flap, or cervical-medial cheek flap (CMCF). We present a retrospective review of cases treated at a university-based cancer center. Patient characteristics, surgical technique, and complication rates are described. Eighteen patients were treated between 2014 and 2017 with reconstruction for integumentary cheek defect after skin tumor surgery using CMCF. Mean defect size was 5.7 cm in length and 3.9 cm in width. The main histological subtype was lentigo maligna (33.3%). We report no flap necrosis but 4 minor complications occurred over a mean follow-up of 14.4 months. At last follow-up, satisfaction rate was very high (88.9%) with no evidence of recurrence. The CMCF is a promising yet infrequently used option in medial cheek reconstruction, with excellent cosmetic and functional outcomes.

Reconstruction of a subtotal upper lip defect with a facial artery musculomucosal flap, kite flap, and radial forearm free flap: a case report

BackgroundFor reconstructive surgeons, massive midface defects, including large, full-thickness wounds on the upper lip, can be very challenging. Although there are many methods for reconstruction of upper lip defects, it is difficult to obtain satisfactory restoration of oral functions and good cosmetic results.Case presentationThis case report presents a man with massive midface defects, including upper lip, left nose, and cheek defects. Over the previous 2 years, the patient had three reconstructions with sequential free flaps for the resection of recurrent tumors, the first of which was in March of 2016; this resulted in the patient having massive midface defects, including an upper lip defect, a defect on the left side of the nose, and one on the left cheek. The defects were reconstructed using a radial forearm free flap (RFFF), a facial artery musculomucosal (FAMM) flap, and a kite flap. In June 2016, he underwent a second reconstruction, this time of the left nose defect, using a left anterolateral thigh (ALT) flap. In March of 2017, the patient underwent a third reconstruction with the use of a free ALT on the left intraoral cheek and the defects on the neck. All flaps survived. No complications were encountered postoperatively. The patient regained good oral sphincter function with no reports of drooling. Although the patient underwent three surgeries, the reconstruction results were acceptable.ConclusionsFor massive midface defects, including large, full-thickness wounds on the upper lip, the combination of a FAMM flap, kite flap, and RFFF promotes the reconstruction of the complex midface structure and improves the resulting functionality.

Clinical application of folded free radial forearm flaps for reconstruction of full-tickness cheek defects after resection of buccal carcinoma

Objective:To investigate the therapeutic effect of folded free radial forearm flaps (RFF) for reconstruction of full-tickness cheek defects after the resection of buccal carcinoma.Method:Seventeen cases of buccal carcinoma received radical neck dissection with cheekectomy and mandibulectomy, and the folded RFF to reconstruct full-tickness cheek defects simultaneously. Preoperative Allen test, ultrasonic doppler blood flow meter examination or computed tomography angiography confirmed good vascular condition of the forearm. Result: RFF were obtained from all patients, and completely survived. During the follow-up period of 6-36 months, the lateral morphology of the cheek was restored well and the mouth opening is normal. Language and swallowing function recovered well, without salivation or cheek biting. There were no obvious complications in the donor site. One case（T₃N₁M₀）died of pulmonary metastatic carcinoma a year later. Conclusion:The success rate is high and the morphology and function recovered well of the folded RFF for reconstruction of full-tickness cheek defects, so it is a reliable method to reconstruct full-tickness cheek defects after the resection of buccal carcinoma.

Standard morphology of the oral commissure and changes resulting from reconstruction for defects involving the commissure

The aim of this study was to characterize the standard morphology of the oral commissure and to describe the changes after reconstruction in patients with through-and-through cheek defects involving the oral commissure. Indices for the morphological analyses of the commissure were derived from examinations of 50 normal Japanese volunteers. Ten patients with full-thickness cheek defects involving the commissure were then evaluated. All of these patients underwent free flap reconstruction with vermilion advancement flaps from the remaining vermilion. The morphology of the commissure with the mouth closed was classified based on the point of entrance of the vermilion into the oral cavity. In normal volunteers, the commissure pattern consisting of the entrance of the upper vermilion into the oral cavity before the lower vermilion and just prior to forming the oral commissure was considered to be the standard. However, in the reconstructed cases, there was an increase in the pattern in which the lower vermilion enters the oral cavity before the upper vermilion for the remaining commissure postoperatively, especially when the lower lip defects were greater than those of the upper lip. It is important to refer not only to the standard morphology of the commissure, but also to the changes according to the extent of resection and the method of reconstruction.

Total Cheek Reconstruction Using the Pre-Expanded Medial Arm Flap With Functional and Aesthetic Donor Site Closure.

This clinical study aimed at introducing a reconstructive method for total cheek soft tissue defects using the pre-expanded medial arm flap and to maximally reduce donor site morbidities simultaneously. A retrospective review of data was performed for 3 patients requiring the pre-expanded medial arm flap to reconstruct total cheek defects. The donor site in the medial arm was primarily closed using a pedicle parascapular or thoracodorsal artery perforator flap. All patients had a total unilateral cheek defect after lesion removal. Three pre-expanded medial arm flaps measuring 17 × 11 cm, 22 × 15 cm, and 20 × 15 cm were separately used for cheek defect reconstruction. The donor sites in the medial arm were closed using a pedicle parascapular flap, measuring 22 × 9.5 cm, and 2 pedicle thoracodorsal artery perforator flaps, measuring 22 × 10 cm and 23 × 10 cm. No major complications occurred in any patient. Patients were followed up for 3, 12, and 18 months. Patients (and/or their family members) were satisfied with the final outcomes. Total cheek defect reconstruction using a pre-expanded medial arm flap, with the donor site closed using a pedicle axial back flap, can not only provide sufficient tissue for cheek resurfacing, but also guarantee primary donor site closure and could be an alternative reconstructive option for patients who have a total cheek defect.

Approach to Reconstruction of Cheek Defects.

The cheek is the largest facial unit with a prominent position on the face. Trauma, burns, and the resection of skin cancers constitute common sources of injury, potentially resulting in defects that, through natural healing, produce noticeable scarring. Surgical repair focuses on the reformation of three-dimensional geometries, proper establishment of symmetry, and the minimization of color and texture discrepancies to the surrounding. Defects located in this region may extend to the orbital, nasal, or buccal units and cause unique structural and functional disturbances. Furthermore, without appropriate repair, full-thickness defects involving the buccal mucosa may result in oral dysfunction. In this article, the authors provide a framework to approach various cheek defects and provide a review of the host of ideologies and techniques.

Tripaddled Anterolateral Thigh Flap for the Reconstruction of Extensively Full-Thickness Cheek Defects by Stacking Two Skin Paddles as Kiss Pattern.

Extended anterolateral thigh (ALT) flap can provide a large amount of skin to reconstruct the extensively full-thickness defects of cheek. However when the width of 1 skin paddle exceeds 8 cm, it always results in that the donor site cannot be closed primarily and need to be covered by split-thickness skin grafting, which delivers lots of impacts on the functional and cosmetic outcome of the thigh. The aim of this study was to introduce the authors' modification of stacking 2 skin paddles of the tripaddled ALT flap to reconstruct the extensive full-thickness defects in the cheek after the radical ablasion of advanced buccal squamous cell carcinoma. Ten patients of advanced buccal squamous cell carcinoma between March 2014 and December 2016 were enrolled in the authors' hospital. All the patients were received the soft-tissue reconstructions for the extensively full-thickness cheek defects by using the tripaddled ALT chimeric flaps. Among 3 skin paddles, the distal paddle was used to reconstruct the inner mucosa defect, and the other 2 large skin paddles were stacked side by side for outer mega cheek defect. The mean area of the intraoral defect was 32.2 cm and the mean area of the extraoral defect was 106.34 cm. The mean width of the outer skin defect was 9.5 cm. All the flaps survived and all the donor sites were closed primarily. So, stacking 2 skin paddles of a tripaddled ALT flap as a kiss pattern is a novel modification on conventional flap design to provide customized coverage for extensive and full-thickness buccal defects while minimizing donor-site morbidity.

Cervicofacial Rotation Advancement Flap in Cheek Reconstruction

Introduction: The Cervicofacial rotation advancement flap (CRAF) is a random-pattern flap that provides an excellent match for cheek reconstruction. In this report, the authors review their experience with this flap and present their advantages in order to expand the awareness and promote the application.Methods: A retrospective analysis of reconstruction of cheek defects using CRAF was performed in 12 patients. Data on patient demographics; diagnosis, defect type, and outcome were collected. Results: These patients included 07 male and 05 female; they ranged in age from 56 to 88 years, with a mean age of 67 years.05 patients used tobacco and one patient had a history of radiation. On histopathological examinations of the specimen, 03patients had squamous cell carcinoma, and 09 patients had basal cell carcinoma. The mean defect size was 40cm² [range 10 to 67cm²]. The mean follow-up was 06 months [0 to 24 months]. One patient was lost to follow-up after suture removal. As complication 01 patient had flap necrosis No facial nerve injury was observed. All patients were pleased with the outcome of the Cosmetic results. Conclusion: Cervicofacial flap provides a technically simple, reliable, safe, efficient, and cosmetic means to reconstruct defects of the cheek.

Reconstruction of full‐thickness cheek defect with chimeric facial artery free flap: A case report

Full-thickness cheek defects represent a difficult challenge for reconstructive surgeons. Multiple techniques have been described, including local, regional, and free flaps. In this report, the reconstruction of a through and through left cheek defect, resulting from a self-inflicted gunshot injury, with a chimeric facial artery free flap is presented. The patient underwent reconstruction with a chimeric full-thickness facial artery free flap, with 9 × 3 cm diameter skin paddle and a 6 × 5 cm myomucosal paddle, was harvested on the contralateral cheek with a 7-cm length of facial pedicle. The flap was transferred via a microsurgical technique and an end-to-end microsurgical anastomosis was performed between the donor and the contralateral facial vessels. The flap was transplanted successfully and there were no donor or recipient site complications with a satisfactory esthetic result 5 years after surgery. This technique may be a good reconstructive option for medium size, full-thickness, cheek defects allowing a "like with like" reconstruction with minimal donor-site morbidity.

The Combined Platysma And Temporalis Flap: An Alternative Method Of Reconstructing The Cheek Defect

Introduction: Reconstruction of the primary defect following resection of primary tumour is part of the surgical treatment of head and neck cancer. The present paper reports a case of reconstruction of medium size through and through defect of the cheek with the transverse platysma myocutaneous flap combined with the temporalis flap. Materials and Methods: A 78 years old Chinese male with presented with biopsy proven squamous cell carcinoma of the cheek mucosa. After excision a medium size (about 4cm by 5cm) through and through defect of the cheek was present. A posteriorly based platysma flap and temporalis flap was harvested and used to reconstruct the defect. The donor site was closed primarily. Results: Overall aesthetic results was good. There was no necrosis of flap, dehiscence or fistula. Flap contracture was the main complication. Conclusion(s): The combined platysma and temporalis flap is a good method to reconstruct a medium sized through and through defect of cheek.

Bilateral Submental Flap: An Innovative Modification.

Early management of premalignant lesions like oral submucous fibrosis cannot be underestimated in context of prevention and control of oral malignancies. Soft tissue reconstruction of the oral cavity and face is a complex undertaking. Several flaps local and distant as well as microvascular are available, each with their pros and cons. Microvascular free flaps lay a considerable burden on resources, expertise, increased operating time, and logistics. Simple and technically reproducible alternatives are needed to tackle these issues, more so in developing countries like ours. Submental flap is based on a large branch of the facial artery and was initially described in 1993 by Martin et al as an excellent option in head and neck reconstruction. We describe innovative modification of the submental flap based on concept of bilateral presence of facial and submental vasculature and thus can be used for bilateral cheek reconstruction. We use pedicled bilateral submental flap (BSF) by dividing the oval skin paddle obliquely, maintaining needed length. The best use of the BSF is in reconstruction of cheek defect, after surgical release of grade IV oral submucous fibrosis, a debilitating affliction commonly affecting young productive adults and seen in Indian subcontinent. The technique was used successfully in 20cases with minor complications.

Reconstruction design before tumour resection: A new concept of through-and-through cheek defect reconstruction

ObjectiveTo explore a new method of reconstruction of through-and-through cheek defects and to evaluate this method’s efficacy and patient prognosis. Materials and methodsThis retrospective study included 70 patients who underwent reconstruction of through-and-through cheek defects. The surgical approach, design of facial skin incisions, selection and design of flaps, postoperative quality of life and prognosis of patients were recorded and reported. ResultsPostoperative quality of life gradually increased over time, and the mean scores of University of Washington Quality of Life (UW-QOL) Questionnaire was more than 80 at 1-year postoperatively. The appearance, oral competence, chewing, swallowing, speech and other oral functions were well recovered in about 90% of patients at 1-year postoperatively. ConclusionThis new idea of reconstruction before tumour resection, brings the effect of plastic and reconstructive surgery to a new height.

Reconstruction of the Three-Dimensional Mandibulofacial Defects Using a Single Cutaneous Perforator-Based Fibula Osteocutaneous Flap.

The reconstruction of the mandibulofacial defects is a difficult task when there are full-thickness cheek defects involving mandible, inner mucosa and outer skin. There are several reconstructive options for the coverage of large defects, but most of the methods are complicated, and time- and effort-consuming. We hereby present a case of fibula osteocutaneous flap based on a single peroneal artery perforator in the reconstruction of a three-dimensional mandibulofacial defects.