Medial Cheek Research Articles

Simultaneous Cheek and Lower Eyelid Reconstruction With Combinations of Local Flaps

Cheek defects are common facial defects, especially after tumor ablation. Although primary repair yields the best aesthetic outcome, wide defects require flap resurfacing. Among the flap techniques, the cervicofacial rotation/advancement flap is one of the most common. In cases with eyelid involvement, it is very unlikely that a local flap would single-handedly resurface the defect and additional flaps must be used.This article presents our clinical experience with 14 patients with cheek defects for whom cervicofacial rotation/advancement flaps were used. In 3 of the 14 patients, local flaps that include the laterally based Tripier flap, the Fricke flap, the nasojugal flap, and the median forehead flap were combined with the cervicofacial flap to reconstruct the lower eyelid defects in accordance with the principle of individually reconstructing different anatomic subunits. All infraorbital defects were resurfaced with residual cheek and cervical skin with a good color and texture match. In patients whose eyelids were intact, no malposition was observed.Posteriorly based cervicofacial rotation/advancement flaps offer a very reliable and convenient method for resurfacing infraorbital and medial cheek defects. When a lower eyelid defect is also present, its individual reconstruction as a separate facial subunit needs to be considered using a combination of smaller local flaps.

Single stage turn in perforator infraorbital artery island flap for nasal ala reconstruction.

ABSTRACTBackground:The reconstruction of fullthickness nasal alla defects is challenging procedure. Use of local flaps is acceptable approach. Flap based on infraorbital artery could be used for primary reconstruction of nasal ala defects.Methods:The prospective study include consecutive series of 15 patients with advanced skin carcinoma of the nasal ala and medial cheek staged T4 by TNM, in whom the turn in infraorbital flap was used. The patient characteristics, type of carcinoma and complications were analyzed.Results:The turn in infraorbital flap was used mostly in male patients (80%), mean age 64 years. The basal cell skin carcinoma was found in 60%. Skin layer was skin grafted. All flaps survived, but in one case a partial wound dehiscence in one partial skin graft loss was found, and in two patients partial nasal obstruction occurred. These three complications were solved as secondary procedures under local anesthesia.Conclusion:Full-thickness defect of the nasal ala can be properly reconstructed using flap based on infraorbital artery providing exceptional esthetic and functional results, as single stage procedure.

Use of a Patient and Observer Scar Assessment Scale to Evaluate the V-Y Advancement Flap for Reconstruction of Medial Cheek Defects

The V-Y advancement flap (VYF) is not commonly used to reconstruct defects located on the medial cheek. The quantitative assessment of VYF for this indication has not been reported. In evaluation of surgical scarring, the Patient and Observer Scar Assessment Scale (POSAS) has been validated for use in burn and breast surgery scars, but its usefulness in dermatologic surgery has not been determined. To present our experience with the use of the POSAS to assess the success of VYF reconstruction for surgical defects on the medial cheek. Fourteen patients with medium to large (>5cm(2) ) medial cheek Mohs defects reconstructed using VYF were assessed. Final cosmetic and functional results were analyzed after a follow-up of 6months to 2years (mean follow-up 21months) using the POSAS. Observers using the POSAS gave a mean score for VYF reconstructions of 9.1±2.3 (5 represents normal skin, 50 represents worst imaginable scar). Patients using the POSAS gave a mean score for VYF reconstructions of 10±4 (6 representing normal skin, 60 representing worst imaginable scar). VYF reconstruction of medium to large defects of the medial cheek is a useful option. The POSAS may be a helpful tool for evaluating reconstructive results in dermatologic surgery.

Modified Flap Design for Symmetric Reconstruction of the Apical Triangle of the Upper Lip

The apical triangle is the superior portion of the cutaneous upper lip lying between the medial cheek and alar margin. Defects involving this subunit are often repaired without taking into consideration the aesthetic implications of its potential loss or reduction. We present a simple option for repair of apical triangle defects to address this concern. We collected a series of 69 patients with apical triangle defects treated from 2002 to 2008 with Mohs micrographic surgery. Their defects were reconstructed using various flaps (advancement, rotation, island pedicle, or M-plasty). A subset of 27 patients was identified who had undergone a standard cheek advancement flap or a modified flap. The modified design introduces an incision extending from the alar crease onto the nasal sill along the cutaneous upper lip, creating a second sliding flap to assist in recreating the apical triangle. A modified flap design introduced the ability to transfer adjacent tissue of the cutaneous upper lip to reconstruct the apical triangle subunit. This flap modification is a simple and efficient method of repairing peri-alar defects that restores the apical subunit, preserving facial symmetry.

Cheek Advancement Flap with Retained Standing Cone for Reconstruction of a Defect Involving the Upper Lip, Nasal Sill, Alar Insertion, and Medial Cheek

Cheek Advancement Flap with Retained Standing Cone for Reconstruction of a Defect Involving the Upper Lip, Nasal Sill, Alar Insertion, and Medial Cheek

Burned Unilateral Half-Cheek Resurfacing Techniques

Postburn cheek deformities are a tragedy for patients and pose a great challenge to surgeons due to a limited number of well-matching donor sites. In cases of unilateral half-cheek deformity, the flap's skin should match the contralateral cheek and the residual skin of the deformed cheek. The skin of a distant flap does not match the facial skin and resembles a patch. The most suitable skin type is the neck's skin and residual cheek's skin transposed on the defect with special techniques. Seventy-six patients with unilateral cheek scars covering nearly half of cheek's surface (total cheek deformities are not included in this series) were personally operated. The deformities were divided into four types or forms: lower cheek, lateral, medial, and upper. The flaps and techniques were designed for each type. The cervical skin, residual cheek skin, and periauricular skin (most matching the cheek's skin) was used in form of different flaps, depending on the scar location on the cheek. The basic flap used was the cervical split flap which could include A) a thoracic adipose-cutaneous layer (cervico-thoracic flap); B) periauricular fasciocutaneous layer (cervico-periauricular and cervico-thoraco-periauricular flaps); C) residual healthy facial adipocutaneous layer (cervico-facial, cervico-facio-periauricular, and cervico-thoraco-facioperiauricular flaps). Cervical flap has axial circulation and is elevated without platysma; it is transposed on the cheek with some tension. The lower and lateral cheek deformities were eliminated most successfully with the cervico-thoraco-periauricular flap by one-stage procedure. Medial and upper cheek deformities were eliminated with the cervico-facio-thoraco-periauricular flap. The facial segment can be expanded (usually in cases of upper cheek reconstruction); in such cases, the thoracic region is not included in the flap (cervico-facio-periauricular flap). The cheeks were reconstructed in all patients without serious complications. The flap's skin matched the contralateral cheek and surrounding healthy skin; the donor site's damage was minimal; operation scars' line was maximally shortened. The use of cervical split flap in combination with thoracic, facial, and periauricular adipose-cutaneous layer opens, in author's opinion, a reliable and most successful way for postburn half-cheek resurfacing.

The Apical Triangle: An Overlooked Aesthetic Facial Subunit

A patient was referred for surgical reconstruction of a left facial defect after Mohs surgery that resulted in loss of the apical triangle, more than half of the lateral superior ala, and 4 to 5 mm of the medial cheek (Figure 1). After a medial advancement flap to reconstruct the aesthetic subunit of the cheek and a paramedian forehead flap over an auricular cartilage batten graft to re-create the ala, distortion and loss of the apical triangle occurred. The overall result of the reconstruction could be considered reasonably successful, but the patient’s face still did not appear completely symmetrical, particularly when attention was directed to the left apical triangle region. An inferior-medial displacement of the melolabial crease marked the distortion of this subunit (Figure 2). How would you repair this subunit?

Repair of a Medial Cheek Defect

Repair of a Medial Cheek Defect

Facial Acne Scarring

Facial Acne Scarring

Demodex folliculorum: Requirements for Understanding Its Role in Human Skin Disease

Correspondence: Michael S. Christensen, Springhouse Skin Research, Inc., 215 Springhouse Lane, Merion Station, Pennsylvania 19066, USA. E-mail: mikesenior@verizon.net was then pressed against the medial cheek, causing the glue to spread to a thin film the width of the slide (1 inch) and approximately half its length (1.5 inch). The slide was left in place for 5 minutes while the cyanoacrylate hardened as it polymerized. Before removal, an outline of the slide was drawn with a Sharpie permanent marker, leaving a demarcated area on which a second cyanoacrylate-coated slide was applied. Two sequential surface biopsy samples were thus obtained, taken from precisely the same site, a procedure that caused minimal discomfort and erythema. Slides were placed face up on the stage of a stereomicroscope for quantitative assessment of horny casts and determination of mite density per square centimeter. A second biopsy is shown in Supplementary Figure 1. To quantify mite densities, with the slide in place the microscope stage was moved under the objective lens to generate five distinct representative fields. The casts in each were counted separately, and a mean of the five values was used to calculate casts per square centimeter. To liberate the mites from the casts, a drop of olive oil was placed on the slide, sufficient to cover the entire sample. Casts (a total of 20, randomly selected) were then disrupted individually with a fine needle. As each cast was disrupted, the number of mites released was immediately counted while the mites swam freely in the olive oil medium (Supplementary Figure 2). Mites remained mobile in the olive oil for nearly 3 hours, in contrast to less than 2 hours in mineral oil, before becoming motionless and more difficult to distinguish from cellular debris. Even when large numbers of casts were found on a biopsy, not all casts contained mites, so we determined two factors after counting: the percentage of casts infested and the mean number of mites per infested cast. Using these two factors and the number of casts per square centimeter, we calculated the number of mites per square centimeter The data and text commentary herein were drawn posthumously from labor atory notebooks and writings found in Dr. Kligman’s study and bedroom. Comments in brackets were added by Barbara A. Gilchrest (Department of Dermatology, Boston University School of Medicine) and James J. Leyden (Department of Dermatology, University of Pennsylvania School of Medicine). Demodex folliculorum was first described independently by two investigators nearly 170 years ago. Human beings are the sole host for this mite (Supplementary Figure 1 online), which resides exclusively in sebaceous follicles and has been repeatedly but inconclusively implicated in rosacea by more than 1,000 peer-reviewed papers, approximately half of them published since 1990. Sometimes visible within follicles in routine cross-sectional biopsy sections, Demodex is more reliably detected in “skin surface biopsies,” a technique first employed by Marks and Dawber (1971) and modified by Mills and Kligman (1983). The purpose of this investigation is to further refine the technique to make it more accurate, reproducible, and quantitative— characteristics necessary for implicating the mites in skin disease. [One of Kligman’s characteristics was to periodically start over and assume everything previously said or published was probably wrong, even if it was he who had said or published it. At times in the past he had dismissed the possibility that Demodex has a role in skin disease, but at the end of the trail he reversed his position and determined to seek data in support of the possibility. Thus, with his longtime collaborator, Mike Christensen, Kligman embarked on a bottom-up re-exploration of whether Demodex plays a role in skin disease. True to his lifelong approach, Kligman decided to begin by improving, if possible, the technique for quantifying Demodex.This methodology is described online.]

Secondary Intention Healing after Excision of Nonmelanoma Skin Cancer of the Head and Neck: Statistical Evaluation of Prognostic Values of Wound Characteristics and Final Cosmetic Results

Most data on secondary intention healing of skin cancer defects in the head and neck are empirical and descriptive. This study statistically evaluates the prognostic value of several wound characteristics and location on the final cosmetic result of skin defects left to heal by secondary intention after tumor removal. A chart review of all facial reconstructions using secondary intention healing performed in one center between 1992 and 2001 was undertaken. Patient and wound characteristics were analyzed. For analysis of cosmetic outcome, the most recent photographs of the scars were assessed by three independent raters using a categorical judgment scale. There were a total of 89 patients with 95 wounds. Forty-three percent of the wounds (41 of 95) healed with an "excellent" outcome. In the univariate analysis, the rating excellent was given more often to scars derived from wounds that were small and superficial and that were located in concave areas of the face, in particular, near the medial canthus and medial cheek. Multivariable logistic regression revealed independent associations of an excellent cosmetic outcome with wound size and contour of wound surface only. This is the first study presenting statistical evidence of what has been known empirically for a long time: wounds in concave areas of the face that are left to heal by secondary intention have a high chance of healing with an excellent cosmetic outcome, especially if these wounds are small, superficial, and located near the medial canthus and medial cheek.

A Philosophy for Treating Complex Nasal Defects

Plastic and Reconstructive Surgery Defects of the Nose, Lip, and Cheek: Rebuilding the Composite Defect Frederick J. Menick, MD Background: The face can be divided into regions (units) with characteristic skin quality, border outline, and three-dimensional contour. A defect may lie entirely within a single major unit or encompass several adjacent units, creating unique problems for repair. Composite defects overlap two or more facial units. Nasal defects often extend into the adjacent lip and cheek. The simplest solution may appear to be [sic] to simply “fill the hole”—just replace the missing bulk. Poor contour, incorrect dimension, malposition, asymmetry, poor blending into adjacent normal tissues, and a patch-like repair often follow. Methods: The following principles of regional unit repair were applied to guide these complex reconstructions: (1) reconstruct units, not defects; (2) alter the wound in site, size, shape, and depth; (3) consider using separate grafts and flaps for each unit and subunit, if appropriate; (4) use “like” tissue for “like” tissue; (5) restore a stable platform; (6) build in stages; (7) use distant tissue for “invisible” needs and local skin for resurfacing; and (8) disregard old scars. Results: Clinical cases of increasing composite complexity were repaired with local, regional, and distant tissues. Excellent aesthetics and function were obtained. Conclusions: Careful visual analysis of the normal face and the defect can direct the choice, timing, and technique of facial repair. Regional unit principles provide a coordinated approach to the vision, planning, and fabrication of these difficult wounds. The entire repair should be intellectually planned, designed step by step, and laid out in a series of coordinated steps, with general principles applied to successfully repair composite defects of the nose, lip, and cheek. Plast Reconstr Surg. 2007;120(4):887-898.

PR31 A LITTLE GIRL WITH A GIANT NAEVUS. A CASE REPORT

Purpose The treatment of congenital giant hairy naevi remains controversial and it can present a challenge for the reconstructive surgeon. Recent publications promote the use of curettage and laser treatment, however they show incomplete clearance. In this atmosphere we present a case of surgical resection involving serial excision, skin grafts and tissue expansion with early good cosmetic results.Methodology Now aged 2 year old girl was born with extensive congenital melanocytic naevi of her face, involving lower forehead, glabella, medial eyelids, nasal bridge and medial cheeks bilaterally. Lower back and right calf were also involved. No associated anomalies were recorded. At one week of age she had curettage of the facial naevus, when the surface naevus containing most of pigment and naevus cells was removed in London. She was left with the left eye ectropion due to a small scar. She moved to NZ and underwent further treatment. There was no role for laser treatment so surgical excision at the age of 12 months was performed, followed by insertion of tissue expanders, bilateral cheek and forehead advancement and full thickness graft to defects post serial excisions. A literature review was performed and our findings compared with historical results from other centres.Results Multiple treatment techniques have been used over the last few decades. Surgical approach provides stable long term results in terms of cosmesis and function and early good results are shown in our case. We will continue further reconstructions in the future to achieve the best appearance and function.

Cheek and Eyelid Reconstruction: The Resurrection of the Angle Rotation Flap

Reconstruction of larger cheek and eyelid defects may pose a dilemma for surgeons, since flaps used in reconstruction may be difficult to design, be unreliable, require extensive dissection, and result in neck scarring. Consequently, the authors wish to simplify and expand an overlooked flap, the angle rotation flap, which moves tissue in both a medial and upward direction. Twenty patients with cheek and eyelid defects were treated by the angle rotation flap. In this flap design, the angle designed below the ear was closed primarily and the neck tissue previously there was rotated upward and forward to lie in front of the ear. The portion of the flap that was in front of the ear was transposed to the lower lid/cheek area. This flap was modified in several patients by elevation in the deep plane and first-stage tissue expansion. In all cases, good coverage was provided for medial cheek and lower eyelid defects with minimal scarring on the neck. There were no flap losses of any kind. There were no major complications, and all minor incidences were treated by minimal procedures without long-term sequelae. The modified angle rotation flap is a useful tool for cheek and eyelid defects.

The ???Pixie??? Ear Deformity following Face Lift Surgery Revisited

The "pixie" ear deformity can be recognized by its "stuck on" or "pulled" appearance, which is caused by the extrinsic pull of the medial cheek and jawline skin flaps at the earlobe attachment point, the otobasion inferius. The tension results in migration of the otobasion inferius from a posterior cephalad position to an anterior caudal position. Although this deformity has been described clinically, it has yet to be objectively defined. Recently, the two components of the earlobe, the attached cephalic segment (intertragal to otobasion inferius distance) and the free caudal segment (otobasion inferius to subaurale distance), were shown to be essential in evaluating for earlobe ptosis and pseudoptosis. These two components can be used to designate an objective criterion for the pixie ear deformity. The deformity, as defined by the authors' parameters, was assessed in 44 patients who had undergone rhytidectomy. A simple and accurate surgical treatment is demonstrated by a cadaver dissection and a clinical case. The deformity can be defined as an increase in the attached cephalic segment (intertragal to otobasion inferius distance) and a decrease in the free caudal segment (otobasion inferius to subaurale distance) to 0 mm following rhytidectomy. The incidence of pixie ear deformity was 5.7 percent in the authors' series of patients. A medially based triangular excision over the attached cephalic segment is presented as a simple and accurate surgical treatment of pixie ear deformity. A more accurate and objective designation may allow for improved detection, avoidance, and treatment of this deformity.

The use of the melolabial Burow's graft in the reconstruction of combination nasal sidewall-cheek defects.

Combination defects involving both the nasal sidewall or ala and cheek can be challenging to reconstruct. Patients with skin cancers involving the nasal sidewall or ala and medial cheek treated with Mohs micrographic surgery were reconstructed using a cheek advancement flap in combination with a melolabial Burow's graft. This technique provides a simple, reproducible, and cosmetically excellent method of repairing these defects. The use of this repair provides superb tissue matches and maintains natural aesthetic subunits, yielding an excellent result with minimal morbidity.

The Use of the Melolabial Burowʼs Graft in the Reconstruction of Combination Nasal Sidewall–Cheek Defects

BACKGROUND Combination defects involving both the nasal sidewall or ala and cheek can be challenging to reconstruct. METHODS Patients with skin cancers involving the nasal sidewall or ala and medial cheek treated with Mohs micrographic surgery were reconstructed using a cheek advancement flap in combination with a melolabial Burow's graft. RESULTS This technique provides a simple, reproducible, and cosmetically excellent method of repairing these defects. CONCLUSION The use of this repair provides superb tissue matches and maintains natural aesthetic subunits, yielding an excellent result with minimal morbidity.

Repair of the Left Nasal Sidewall, Nasofacial Sulcus, and Medial Cheek

Repair of the Left Nasal Sidewall, Nasofacial Sulcus, and Medial Cheek

Triple-Flap Technique for Reconstruction of Large Nasal Defects

Triple-Flap Technique for Reconstruction of Large Nasal Defects

Carbon Dioxide Laser Abrasion

To evaluate the effectiveness of the carbon dioxide laser for treatment of facial acne scarring and to determine if certain regions of the face would respond more favorably to carbon dioxide laser resurfacing than other areas of the face. Twenty-five patients with facial acne scarring were treated with the carbon dioxide laser with the flash-scanning attachment. Physician and patient evaluations were performed at postoperative follow-up. The face was evaluated for improvement by 5 anatomic regions: medial and lateral cheeks, perioral region, temple, and forehead. Office ambulatory surgery center. Patients demonstrated overall improvement with the carbon dioxide laser. However, certain areas, such as the lateral cheek and temple, responded less favorably than other areas, such as the medial cheek, perioral region, and forehead. These findings were found to be statistically significant (P < .001) for physician and patient assessments. No long-term complications were reported. The carbon dioxide laser is an effective modality for the treatment of facial acne scarring. Physician and patient satisfaction is high. Nevertheless, multiple treatments may be necessary to achieve improvement, especially in the temple and lateral cheek areas; these anatomic sites respond less favorably to laser resurfacing than the medial cheek, perioral region, and forehead.