Cheek Reconstruction Ppt

Cheek reconstruction Dr. Diyar A. Salih Plastic Surgery Resident February, 2009 KURDISTAN, SLEMANI

Problematic  Its prominence and central position.  Its unique characteristics as an anatomic subunit.

3 subunits   

Suborbital Preauricular, and Buccomandibular.

Cheek wounds  2. 3. 4.

Classified by depth into: Superficial Full-thickness, and Subcutaneous contour deficits.

Reconstruction challenging 1. Cheek contour is paramount to facial

2. 3.

aesthetics. No existing reconstructive option can universally recreate the volume loss created by a subcutaneous tissue defect. The dynamic function of the cheek is not easily reproduced. Reconstruction can alter or obliterate the lines that divide facial subunits.

Etiology • • •

Neoplasia Burns, and Trauma. Etiology  affect presurgical planning: For example: Skin graft: considered: Full-thickness burn. History of radiation Acne as teenagers Multiple skin cancers. Traumatic defect  primary closure or local flap.

Indications of reconstruction

 Congenital  Traumatic, and  Mohs surgery defects. Subsequent soft tissue deficit can be corrected with various techniques.

Anatomy

Extension  Extends from the inferior orbital rim superiorly to the mandibular rim inferiorly and from the lateral nasal sidewall and nasolabial crease medially to the preauricular area posteriorly.

Arterial supply  External

carotid artery (ECA)  The greatest contribution is from the facial artery.

Venous drainage  Facial vein, which

subsequently communicates with the internal jugular (IJ) vein.  However, substantial drainage via the ophthalmic, infraorbital, and deep facial veins communicates with the cavernous sinus.  This venous system is valveless, which can lead to bacterial spread from a localized skin infection and subsequent cavernous sinus thrombosis.

Lymphatic drainage  Is primarily 2. 3. 4.

directed to: Intraparotid LN Submandibular LN, and Submental LN.

Nerve supply  Divided into sensory and motor systems.  Sensation: second (maxillary) and third (mandibular) divisions of the trigeminal nerve.  Motor: the facial nerve (cranial nerve VII) provides innervation to the muscles of facial expression.

Facial nerve anatomy  Stylomastoid  

 

foramen. Travels through the parotid gland. Branches into upper (zygomaticofacial) and lower (cervicofacial) divisions. Upper division: temporal and zygomatic branches. Lower division: buccal, marginal mandibular, and cervical branches.

Muscles of facial expression 1. Zygomaticus major & minor 2. O occuli M 3. OOM 4. Levator labii sup. 5. Platysma. 6. Risorius m.

SMAS  Is a continuous fascial covering known as the superficial musculoaponeurotic system (SMAS) covers each of facial expression muscles.  The branches of the facial nerve lie deep to the SMAS as they course more superficially in the anterior face.  The more medial and anterior areas of the face have the most superficial facial nerve branches.

Reconstruction

Healing by secondary intention 1. Concave surfaces, such as the temple and medial canthus. 2. Defects that are small and superficial and are not closely associated with the eyelid or lip.

 Exercise needed because wound contracture in the

cheek can lead to distortion of the lower eyelid or upper lip.

 An occlusive dressing and some form of antibiotic ointment.

Surgical Therapy 1. Primary closure:  Wide undermining.  Small defects (<2 cm,

central).  The degree of surrounding skin laxity predicates this closure.  Older patients (ideal candidate).  Final scar, should rest parallel to or within a relaxed skin tension line (RSTL).

2. Skin grafts  least cosmetically satisfying forms of correction because of the poor tissue match of the donor site skin with the sun-exposed cheek area.  Indications: (1) large (>4 cm) defect (2) a high-grade skin neoplasm with questionable margins or perineural invasion. (3) poor tolerance of prolonged periods of anesthesia. (4) a third-degree burn over substantial portions of the face.

3. Local flaps: Advancement flaps

 are typically random.  relying on the subdermal plexus for blood supply.

V-Y advancement flap

Cervicofacial flap (upper cheek)

3. Local flaps: Transposition flaps

Transposition flaps (Banner F)

Transposition flaps (Bilobed F)

Transposition flaps (Rhomboid F)

Cont.

3. Local flaps: Rotation flaps.

Cervicofacial flaps (Inf. Based)

Cervicofacial flaps (Lat. Based)

Cervicopectoral flap

Cervicopectoral flap, cont.

3. Local flaps: Local composite flaps:  Pectoralis major flap.  Trapezius flap.

3. Local flaps: Tissue expansion:  Benign lesions.  Secondary scar revision.

 High rate of complications.

Free tissue transfer  Radial forearm flap.

 Parascapular flap:

 Anterolateral thigh flap

 Rectus abdominis flap.  Fibula osteocutaneous flap.

Complications  Hematoma, most serious & within the first     

12 hours: leading to flap necrosis. Ecrtopion or lower eyelid edema. Distal flap necrosis. Hair bearing shift. Asymmetry Scarring

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