Cheek Reconstruction: Current Concepts in Managing Facial Soft Tissue Loss

ABSTRACT

Significant defects of the cheek present a reconstructive challenge due to their extremely visible site, as well as limited local tissue supply. In addition, the cheek abuts several structures of expressive function, such as the eye, mouth, and local facial musculature. To achieve satisfactory functional and aesthetic results, reconstruction of such defects requires careful three-dimensional restoration of all missing components, adequate texture matching, as well as functional restoration. Aesthetic reconstruction of facial defects should adhere to the priority goals of first preserving function and second achieving cosmesis. According to the size of the defect, location on the cheek, relationship to adjacent structures, available donor tissue, and existing skin tension lines, a host of techniques is available for closure. As a well-established principle in facial reconstructive surgery, one should use local tissue whenever possible to provide the best tissue for color and contour restoration. However, thoughtful reliance upon the “reconstructive ladder,” including direct closure, skin grafting, local flap creation, regional flap placement, and free-flap repair, will invariably guide the surgeon in an optimal approach to cheek reconstruction.

KEYWORDS

Considerations for cheek reconstruction - free-tissue transfer - free-flap repair - skin grafting - flap placement

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Editor's Comments

Drs. Heller, Cole, and Kaufman from Baylor College of Medicine in Houston have written an excellent article on cheek reconstruction that illustrates extensive clinical experience.

I am happy to see their endorsement of skin grafting for reconstruction of selected cheek defects. Quite frequently skin grafting of cheek defects is considered an inferior or “palliative” technique. However, in the appropriate patient, a color matched skin graft can provide very acceptable aesthetic results and should always be considered as a viable reconstruction option.

The next comment regarding local flaps is to remember the cheek often has, particularly in the elderly patient, tremendous laxity. Even quite large defects can be closed by a simple linear vertical closure with meticulous dog-ear excision. This results in a scar that follows ideal aesthetic lines leaving a very acceptable aesthetic result.

Also, regarding lip retraction during repair; understand that the lip is surrounded by a dynamic muscular unit, the orbicularis oris, and even a moderate degree of lip retraction resulting from a closure of a cheek defect will resolve over a short period of time leaving no long-term defect.

Again, the authors are to be commended for writing a very thorough and well-illustrated clinical paper.

James F. Thornton, M.D.

Figure 1 Full-thickness color matched skin graft reconstruction of a large cheek defect in an elderly patient.

Figure 2 Linear closure of a large central cheek defect.

Figure 3 Spontaneous resolution of significant perioperative lip retraction.