Operative Technique in Plastic Surgery – Kevin C.Chung

■ Placing the Tarsal Strip
■ Use a double-armed 5-0 Prolene suture or double-armed 5-0 Vicryl or
equivalent (TECH FIG 3A).3
■ First, pass the suture through the tarsus from superior to inferior,
perpendicular to the eyelid margin.
■ Then, pass one arm of the suture from posterior to anterior at the inferior
border of the tarsal strip. Pass the second arm from posterior to anterior at the
superior border of the strip.
■ The suture passed from posterior to anterior will place the strip in the best
anatomical position on the inner aspect of the orbital rim once tied.
■ Pass the superior suture through the periosteum at the orbital rim. This is
most easily achieved by placing the suture on the rim, passing it backward
until the tip trips inside the rim, and then passing forward to catch the
periosteum on the inner aspect of the orbital rim.
■ Check the eyelid and canthal position. Adjust the vertical position of the
suture to the orbital rim if incorrect.
■ Place the second inferior suture 2 mm lower on the orbital rim (TECH FIG
3B).
■ If using 5-0 Prolene, tie five knots with the needles still attached. Then, bury
the end of the suture by passing the needle posteriorly and laterally from the
knot to exit (TECH FIG 3C). Trim at exit.
■ If using 5-0 Vicryl, tie and cut as normal.
■ Close the orbicularis with a deep 6-0 Vicryl suture if required.
■ Close the lateral canthus and skin with two or three interrupted 6-0 Vicryl
sutures (TECH FIG 3D).

TECH FIG 3 • A. Pass a double-armed suture
posteriorly to anteriorly through the tarsal strip. B.
Anchor the suture to the inner aspect of the orbital rim.
C. Bury the ends of the suture. D. Close the angle and
skin with interrupted sutures.
PEARLS AND PITFALLS
Granuloma formation
■ Discharge the contents of the meibomian glands within
the tarsal strip.
Bruising
■ Avoid the marginal arcades when injecting local
anesthesia and maintaining meticulous hemostasis.
Irritation from deep
suture
■ Knot with needles attached and use the needle to pass
the end of the suture flat and posteriorly.
Asymmetry
■ Careful preop marking and intraoperative adjustment
of suture placement to the orbital rim.
Pulling the lower lid
inferiorly on the globe
■ Beware negative vector patients with prominent eyes.

POSTOPERATIVE CARE
■ Topical antibiotic ointment is applied daily to the eye and the sutures until
sutures are removed or dissolve.
■ Ice packs are used for the first 24 to 48 hours to reduce inflammation.
OUTCOMES
■ Tarsal strip canthoplasty results in high patient satisfaction with effective
outcomes in 87% to 96% of patients.4,5
COMPLICATIONS
■ Infection
■ Chemosis
■ Bruising
■ Visible scar
■ Asymmetry
■ Suture granuloma
■ Prolonged tenderness over deep suture
REFERENCES
1. Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol.
1979;97(11):2192-2196.
2. Carruthers J, Carruthers A. Botox: beyond wrinkles. Clin Dermatol.
2004;22(1):89-93.
3. Hsuan J, Selva D. The use of a polyglactin suture in the lateral tarsal strip
procedure. Am J Ophthalmol. 2004;138(4):588-591.
4. Kam KY, Cole CJ, Bunce C, et al. The lateral tarsal strip in ectropion surgery:
is it effective when performed in isolation? Eye (Lond). 2012;26(6):827-832.
5. Lee H, Park M, Chang M, et al. Clinical characteristics and effectiveness of
the lateral tarsal strip and medial spindle procedure. Ann Plast Surg.
2015;75(4):369.

25
CHAPTER
Section VIII: Cheek
Cheek Reconstruction With
Laterally or Medially Based
Cervicofacial Flap
Sammy Sinno and Barry M. Zide
DEFINITION
■ Local tissue from the cheek and upper neck provide the best tissue for cheek
reconstruction; several techniques have been described including submental
and sternocleidomastoid flaps.1,2
■ Laterally, or posteriorly, based cervicofacial flaps are most useful for small to
moderate full-thickness skin and subcutaneous defects of the anterior and
inferior cheek. These flaps take advantage of the loose neck skin to provide a
large amount of coverage with local/regional tissue borrowed from the lateral
face, neck, and even chest. Laterally based flaps avoid incisions below the
eyelid; however, crossing the anterior mandibular border may require a Z-
plasty (FIG 1).
■ Medially, or anteriorly, based cervicofacial flaps are also useful for moderate
sized full-thickness skin and subcutaneous defects of the anterior and upper
cheek. These flaps also take advantage of the loose preauricular and neck skin
and avoid incisions on the mandible.

FIG 1 • Lateral-based and medial-based cheek flaps.
ANATOMY
■ The cheek is a laminated structure consisting of skin, subcutaneous tissue, and
the superficial musculoaponeurotic system (SMAS). These structures overlie
the facial nerve, parotid gland, buccal fat bad, and mandible.
■ The arterial supply to the cheek is provided by the facial, superficial temporal,
and transverse facial arteries originating from the external carotid artery.
Venous drainage may parallel the arterial system though variations are
common (FIG 2).
■ Techniques of deep-plane elevation or tissue expansion can be used to improve
the blood supply and reliability of the flap.2–5
■ The cheek can be subdivided into overlapping zones to categorize lesions and
organize the reconstructive strategy (FIG 3).

PATIENT HISTORY AND PHYSICAL FINDINGS
■ The cheeks are often exposed to trauma and sun damage leading to a frequent
requirement for reconstruction.
FIG 2 • Arterial blood supply of the cheek.

FIG 3 • The three reconstructive zones of the cheek.
Red border between zones 1 and 2 marks a vertical line
dropped from the midpupil. Zone 1, lateral cheek; zone
2, central cheek; zone 3, inferomedial cheek. Laterally
(posteriorly) based cheek flaps work best for zone 3
defects. Medially (anteriorly) based flaps are best for
zone 1 and 2 defects.
■ The defect size, depth, and location must be evaluated in addition to the
surrounding skin quality, tone, and texture.
■ Hairlines should also be noted, particularly sideburns in women, as this will
affect flap design due to the need to avoid hair transposition onto the cheek.
■ Patients should be encouraged to stop smoking as this increases the risk of
distal flap necrosis.
■ For skin cancer defects, consider delaying the reconstruction until the

resection margins are proven clear by histological analysis.
■ The effect of radiation therapy must also be taken into account when
applicable.
■ Ensure that the blood supply to the face is intact by evaluating neck and facial
scars.
■ Specifically evaluate the area where the facial and superficial temporal
arteries are located. Pay particular attention to prior sentinel lymph node
biopsy scars in the face and cheek.
IMAGING
■ No imaging is required other than that indicated by a preoperative clearance
workup.
SURGICAL MANAGEMENT
Preoperative Planning
■ Smaller cervicofacial flaps may be performed under local anesthesia or deeper
anesthetic techniques.
■ Assess the mobility and laxity of the skin surrounding the defect and
determine which facial structures may be distorted by flap movement.
■ Scars should be positioned at the border of aesthetic units (nasal-facial
junction, nasolabial fold, infraorbital rim) or along the hairline when possible,
which may require sacrifice of additional tissue.
■ If it is not possible to place the scar at the border of aesthetic units, scars
should be aligned parallel to relaxed skin tension lines (these are curvilinear
on the cheek).
Positioning
■ Patient is positioned supine on the operative table with the head turned to the
contralateral side from the defect.
■ The ipsilateral face, neck, and chest are prepped into the field. Alternatively,
the entire face may be prepped into the field to assess symmetry
intraoperatively.
Approach
■ Depending on the size and location of the defect, decisions must be made
regarding plane of flap elevation (subcutaneous or sub-SMAS), extent of

posterior incision (preauricular, postauricular, chest), and need for preoperative
tissue expansion.
■ If the surgeon decides to go sub-SMAS, it is critical to spread obliquely so
the nerves stay on the downside.
■ The senior author rarely performs sub-SMAS dissection for posteriorly based
flaps.
■ Incisions should follow the nasolabial fold and can continue to the submental
crease.
■ Larger defects may require an incision that extends posteriorly toward the
sternocleidomastoid muscle.
■ Patients (especially nonsmokers) with smaller defects and significant skin
laxity that allows for defect closure under minimal tension are good candidates
for cervicofacial flaps elevated in the subcutaneous plane.
■ Large defects, poor skin laxity/quality, and a positive smoking history are
additional indications for tissue expansion or deep-plane elevation of the
cervicofacial flap to minimize the risk of distal flap necrosis.
■ Deeper defects may also benefit from deep-plane elevation (including the
platysma muscle in the neck) as the greater flap tissue bulk prevents contour
depression over the defect that may be seen with only skin and subcutaneous
tissue coverage.
T E C H N I Q U E S
■ Laterally Based Cervicofacial Flap
■ The defect is outlined, and flap is drawn to place scars along the borders of
aesthetic subunits (TECH FIG 1A).
■ After completion of the flap design, dilute 0.5% lidocaine with 1:200 000
epinephrine is infiltrated in the subcutaneous plane.
■ Using sharp and blunt dissection, the entire flap is elevated in a
subcutaneous plane (TECH FIG 1B).
■ Support of the flap may be required, and anchors, periosteal sutures, and
sutures around the medial canthal tendon can aid greatly.
■ After obtaining hemostasis, the flap inset begins anteriorly with buried deep
dermal 5-0 PDS suture and rotating the flap superiorly and anteriorly.

■ Working anteriorly, each advancement point is secured with buried deep
dermal 5-0 PDS suture.
■ Excision of any dog ear at this point is crucial. When the scar crosses the
mandibular border, a Z-plasty or W-plasty is often required below the
mandible.
■ Scar placement should rest without excess tensions along the nasolabial fold.
■ A drain is placed.
■ The skin incision is closed with running and interrupted 6-0 Prolene sutures.
TECH FIG 1 • A. The defect is outlined, and the flap is
marked. Note the incision along the nasolabial fold
with, in this case, a posterior back cut. The inferior
incision should be “cut as you go.” B. Flap elevation in
the subcutaneous plane. Note that a deep plane can
be used if there are concerns for flap ischemia.
■ Medially Based Cervicofacial Flap
Creating the Flap
■ Similar to the laterally based flaps, the cheek defect is outlined and drawn to
place scars along the borders of aesthetic subunits (TECH FIG 2A).
■ The flap markings begin at the superior and lateral edge of the defect and, if
possible, can be placed at the junction between the cheek and eyelid. In some

cases (TECH FIG 2B), the excision includes the lower eyelid skin in which
case the flap incision is placed within the lower eyelid itself.
■ It should be remembered, however, that the closer the incision is to the lid
margin, the higher the risk of ectropion.
■ The marking of the lateral portion of the apex of the flap is placed
approximately 1 cm superior to the lateral canthus. This helps to suspend the
cheek flap above the lateral canthus, thus decreasing the risk of ectropion.
■ The flap edges are infiltrated with a dilute solution lidocaine with
epinephrine as outlined above.
■ Skin incisions are performed and the skin flap is elevated in the
subcutaneous plane.
■ Care must be taken to avoid raising excessively thin flaps as this increases
the risk of flap necrosis.
■ Similarly, care must be taken to avoid injury to the facial nerve with
excessively deep dissections.
■ The flap may be elevated using a no. 10 blade or with a fine-tipped
electrocautery (eg, Colorado needle) at a low setting (15).
■ The dissection continues medially until the defect is reached.
■ The medial and inferior borders of the defect are similarly elevated in the
subcutaneous plane.
■ Flap dissection is then continued inferiorly down to the neck, taking care to
avoid injury to the great auricular nerve over the sternocleidomastoid muscle
(TECH FIG 2C).
■ The extent of the dissection depends on the patient’s skin laxity and the
amount of excess skin in the neck. This can be judged by periodically gently
pulling the skin flap over and analyzing the tension on the flap.
■ Meticulous hemostasis is achieved with bipolar electrocautery.
Insetting the Flap
■ Once adequate dissection has been performed, a back cut on the flap is
performed to decrease tension on it.

TECH FIG 2 • A. Melanoma in situ with 0.2-mm deep
lesion in center. The wound is dressed after getting
clear margins on step sections. The flap is elevated in
the sub-SMAS plane with oblique spreading of
scissors to avoid nerve injury. The flap design: the
incision goes straight back or up slightly the distance
of the width of the lesion removed. It then moves to
the mid tragus and downward to the lobule. The
incision goes straight back about 3.5 cm and an angle
opened 60 to 70 degrees is marked in B. The
incisions are well hidden and the sub-SMAS
dissection guarantees reliability not found in the
Mustarde-type flap. C. Final result.

■ The patient’s face/neck is then placed in the extreme lateral position to
maximize the length of flap that is necessary to close the wound with no
tension. Temporary sutures are placed in the superolateral portion of the
defect (ie, the area that is at greatest tension) to the flap minimizing tension
on the flap as much as possible.
■ The remainder of the flap is inset with temporary sutures again aiming to
minimize tension on the flap.
■ Particular attention should be placed in the preauricular area as closure of
the flap defect at this area can result in excessive tension on the flap. If this
is the case, a small triangular area in front the ear can be left open and skin
grafted with a full-thickness graft harvested from the excess portions of the
flap.
■ The inferomedial portion of the flap usually has a small dog-ear from the
flap rotation.
■ Excision of this dog-ear is marked in such a way to avoid narrowing of the
flap base (TECH FIG 3).
■ In some cases, a secondary revision may be necessary.

TECH FIG 3 • Dog-ear excision in the inferomedial
portion of the flap. Note angulation of the dog-ear to
avoid narrowing of the flap base (arrow).
PEARLS AND PITFALLS
Incision
placement
■ Incisions should be placed along borders of facial aesthetic units
whenever possible. This may require excision of additional tissue
surrounding the defect.
■ Avoid vertical incisions in the central cheek anterior to a line
dropped down from the lateral canthus (Z-line).
■ Dog-ears do not settle down no matter how long you look at
them. The flap should be completely flat at the time of surgery. If
flap viability may be jeopardized, tell the patient about the
potential residual dog-ear before the first stage.
■ Excise dog-ears in a manner that does not narrow the flap base.
Flap choice
■ Laterally based cervicofacial skin flaps survive better than
medially based flaps because the transverse branches of the
facial and superficial temporal arteries are preserved.
Skin cancer
■ Consider delaying the reconstruction until the margins of
resection are proven clear by histological analysis.
Flap
suspension
■ Larger defects require longer incisions with wider elevation and
undermining. Larger flaps frequently have tension at the cheek
closure that may compromise blood supply and are vulnerable to
flap ptosis.
■ Suspend to the medial canthal tendon if required.
■ Leave dog-ears if necessary.
Flap
readvancement
■ Similar to other rotational flaps, these may be readvanced for
serial excisions, positive margins, or partial flap loss.
POSTOPERATIVE CARE
■ Patients should rest with their head elevated for the first few days
postoperatively.
■ Skin sutures should be removed 5 to 10 days postoperatively.

■ Large flaps with wide undermining extending onto the inferior neck may
require placement of a closed suction drain.
■ Postoperative antibiotic coverage is not necessary.
OUTCOMES
■ Laterally and medially based cervicofacial flaps provide excellent color and
texture match with the ability to camouflage scars in the cheek borders.
■ Proper patient selection, appropriate flap design, gentle tissue handling, and
hemostasis minimize complication rates (FIGS 4 and 5).
■ Two major drawbacks to cervicofacial flaps include unpredictable distal tip
perfusion and anterior skin excess requiring excision as a vertical dog-ear.
■ Incidence of distal tip necrosis has been reported in 14.5% of cases; this is
reduced with sub-SMAS elevation.6
COMPLICATIONS
■ As noted, distal tip necrosis is a problem. However, the incidence of this
complication can be minimized by avoiding tension on the flap, elevation of
the flap in a thick subcutaneous or, in some cases, submuscular plane, and
meticulous attention to hemostasis.
■ Contour deformities, dog-ears, and scarring can occur particularly in large,
deep defects. These may require revision surgery such as scar revision, dog-ear
excision, or resurfacing.
■ Hematomas occur commonly after facelifts and cheek flaps due to the
excellent blood supply of the face. Meticulous hemostasis is therefore
necessary.
■ In addition, if general anesthesia is used, it is important to have a calm
emergence and avoidance of hypertension during extubation.
■ Infection is rare but can occur and should be treated aggressively.
■ Facial nerve injury is also rare but can occur in thin patients or in cases where
submuscular dissection is performed.

FIG 4 • A. The melanoma just under 1 mm is removed
full thickness. The anterior margin is moved to the
nasojugal fold and along the nasolabial fold. The
Schrudde designed flap is lifted sub smas preserving
nerves by oblique spreading of scissors. The flap
design goes straight back the width of the lesion and
the distance to the nasojugal fold and then down to mid
tragus. A 70-degree flap is designed under the ear.
After closure, the ear lobule is left to auto tube to
preserve correct lobule shape. B. The final result is well
supported. The flap design does not require the usual
upswing of the flap behind the defect as the Schrudde
design already does this. The ear lobule has auto
tubed.
FIG 5 • A. Preoperative image of patient who underwent

laterally based cervicofacial flap. Immediate (B) and 12-
month (C) postoperative views.
REFERENCES
1. Patel UA, Bayles SW, Hayden RE. The submental flap: a modified technique
for resident training. Laryngoscope. 2007;117(1):186-189.
2. Avery CM. The sternocleidomastoid perforator flap. Br J Oral Maxillofac
Surg. 2011;49(7):573-575.
3. Boutros S, Zide BM. Cheek and eyelid reconstruction: the resurrection of the
angle rotation flap. Plast Reconstr Surg. 2005;116:1425-1429.
4. Kroll SS, Reece GP, Robb G, Black J. Deep-plane cervicofacial rotation-
advancement flap for reconstruction of large cheek defects. Plast Reconstr
Surg. 1994;94:88-93.
5. Roth DA, Longaker MT, Zide BM. Cheek surface reconstruction: best choices
according to zones. Oper Tech Plast Reconstr Surg. 1998;5:26-36.
6. Sakellariou A, Salama A. The use of cervicofacial flap in maxillofacial
reconstruction. Oral Maxillofac Surg Clin North Am. 2014;26:389-400.

26
CHAPTER
Cheek Reconstruction With
Tissue Expanders
John T. Stranix and Barry M. Zide
DEFINITION
■ Tissue expansion is a proven technique for generating additional cutaneous
tissue to reconstruct facial defects when local coverage options are otherwise
inadequate.
■ Skin adjacent to, or near, the surgical defect is stretched over time to produce
adequate local tissue of similar color and texture for coverage without
creation of a donor-site defect.
■ Expansion is achieved through placement of a buried prosthesis that is
gradually filled with saline via a distant port.
■ As the volume of saline increases, the prosthesis enlarges and stretches the
overlying tissue to cause expansion.
ANATOMY
■ Skin expansion results from mechanical stress applied over time through both
mechanical creep (cellular stretch) and biologic creep (increased cellular
proliferation).
■ Thickening of the epidermis occurs with concurrent thinning of the dermis and
alignment of collagen fibrils.
■ Angiogenesis occurs in response to ischemia generated by tissue expansion,
increasing both the number and caliber of blood vessels in the expanded tissue.
This is similar to the increased vascularity seen with the delay phenomenon
and expanded flaps can be considered delayed flaps.
■ Skin of the anterolateral neck shares essentially the same color, texture, and
dermal appendages as the skin covering the majority of the cheek. This
excellent match makes the neck an ideal donor site for cheek reconstruction

with tissue expansion.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Tissue expansion is performed over 3 to 4 months, requiring office visits 5 to 7
days apart. This requires a motivated, well-informed, and compliant patient and
family. Sometimes, twice-weekly fills can expedite expansion.
■ In some cases, parents and/or patients can do the fillings with proper
instruction.
■ Tissue expansion has a higher complication rate in children compared to
adults.1 Smokers also have an increased risk of complications.2
■ Facial tissue expansion must take into account the location, size, shape, and
type of defect (nevus, burn, trauma, oncologic).
■ Expansion under scars or radiated tissue should not be done.
■ Consideration should be given to the aesthetic subunits involved, adjacent
specialized structures that may be disrupted/distorted, skin quality, pre-existing
scars, and any additional areas with reconstructive needs.
■ Available donor sites for expansion must be evaluated as this will determine
the size and type of expander possible.
SURGICAL MANAGEMENT
■ The increased vascularity of expanded lateral cheek and neck tissue enables
the design of unique advancement, rotation, or transposition flaps specific to
individual cheek defects.
■ There are three general approaches to tissue expansion for coverage of cheek
lesions:
■ Expansion of tissue immediately adjacent to the defect (which thins the skin)
■ Cervicofacial flap expansion and/or neck expansion for cervicofacial flap
donor-site coverage
■ Direct expansion from below the lesion to allow excision and primary
closure
■ An expander placed in the upper neck (as opposed to an expander placed
immediately adjacent to the defect) is preferred because this approach results in
decreased skin thinning.
■ Transillumination of the expander in situ is a helpful technique because this
approach identifies the major blood vessels of the flap by enabling the surgeon
to perform back cuts more accurately.
■ The Schrudde angle rotation flap adapts well to an expander placed in the

neck. This flap incorporates an angular subcutaneous flap below the ear and
backward. When the flap is brought up and forward, it fills the area in front of
the ear, which would have a defect otherwise.
■ The size of the required expander can be calculated directly based on the
length and width of the expected defect. When using a single expander, the
length of the expander should be equal to or greater than the longest side of the
lesion. The width of the expander should be the maximum possible according
to anatomy.
■ The timing required to reach full expansion and the amount of fluid needed for
expansion vary based on the quality and quantity of skin. Similarly, the timing
of transfer after adequate fill has been obtained varies based on the condition
of the skin and the amount of expansion that has been done. However, in
general, once full expansion has been obtained, the transfer can be safely
scheduled after 1 to 2 weeks.
Preoperative Planning
■ Careful flap planning should incorporate the expander placement incision(s)
and align scars with borders of aesthetic units when feasible.
■ For large expanders, multiple access incisions may be required to allow for
adequate expander pocket dissection. Incisions are usually preauricular or open
V shaped in the scalp or along the Schrudde infra-auricular incision.
■ If re-expansion and readvancement may be required for serial excisions, this
should also be incorporated into flap choice and design. Serial expansions and
excisions are associated with a higher extrusion rate during subsequent
expansions.3 The author rarely re-expands the face.
■ Actual or anticipated defect size must be determined to select the appropriate
number, size, and orientation of tissue expander(s). Location of remote port
placement should be distant from the expander and secured in situ.
■ Donor-site selection plays an important role with the goal of providing a good
soft tissue match in color, texture, and contour. For cheek reconstruction, the
lateral cheek and neck provide an excellent match.
Positioning
■ The procedure can be performed under sedation with monitored anesthesia
care or full general anesthesia with the patient positioned supine on the
operative table.
■ The head is turned toward the contralateral side from the defect, and the

ipsilateral face, neck, and chest are prepped into the field.
■ Administration of an antibiotic with skin flora coverage 30 to 60 minutes prior
to incision is recommended.
Approach
■ Size, shape, and number of the expanders
■ As stated earlier, in cases in which a single expander is used, the length of the
expander should be longer than the length of the incision required to replace
the intended area, whereas the width of the expander should be roughly equal
to the width of the expected defect. In practice, we use the widest expander
possible based on anatomic constraints.
■ Using the largest expander possible within the limitations of donor-site
anatomy will reduce the number of expanders (and total expansion) required.
■ Compared to the expander base area, expander volume is less important due
to the minimal risk of hyperinflation up to 10 times above the manufacturer’s
stated nominal capacity.4
■ Using multiple expanders allows more rapid expansion with fewer
complications than single expanders and should be considered when feasible.2
■ Soft, flat, rectangular silicone expanders with rounded corners are
recommended for expansion of head and neck tissue. In the face and neck,
floppy bag expanders are avoided due to knuckling and extrusion problems.
■ Port placement
■ Remote filling ports are preferred in the head and neck over integrated filling
valves and are typically placed in the postauricular scalp or neck.
■ External filling valves may be helpful in children, but the port egress site
must be dependent to allow for periprosthetic fluid drainage and should be far
from the expander (greater than 6 cm) as they are associated with a higher
infection risk.5
■ Ports must be secured to prevent drift.
■ Incision placement
■ Incisions for expander placement should not interfere with subsequent flap
advancement or compromise the blood supply to the expanded tissue. Ideally,
placement incisions are either incorporated into the subsequent flap design
(like the Schrudde infra-auricular V), placed within the area to be excised, or
distant like the scalp.
■ Access incisions should be kept away from the expansion process (greater

than 2–3 cm) and never oriented parallel to expander edges as this increases
exposure risk. Incisions should be either perpendicular to the expander or in
the shape of a V or W with the broad base directed toward the expander.
■ Flap incisions and tissue transposition
■ Simply cutting around the advancing edge of the expander base does not take
full advantage of the expanded tissue.
■ The following flap designs enable the most efficient use of expanded local
tissue for coverage:
• The single back-cut flap is ideal for triangular defects. The single back cut
allows the flap to be advanced and/or transposed and is a workhorse
technique. The flap can be shaped or contoured in a way to recreate a side
burn or exactly tailored to a defect.
• The double back-cut flap provides maximal gain of soft tissue advancement
and is best for round or rectangular lesions. These flaps are amenable to re-
expansion for serial excisions.
• Over-the-top advancement flap allows for simple calculation of the amount
of soft tissue available in the flap. This type of advancement is used when
the expander was larger than the square-shaped defect. It does require
sacrifice of some adjacent normal tissue over the lateral edges of the
expander, and the required dog-ear excisions cause the flap to narrow when
advanced.
■ Expanded cervicofacial flap
■ A powerful technique for coverage of large cheek defects (greater than 3 cm)
incorporates tissue expansion into the design of cervicofacial
rotation/advancement flaps.
■ Benefits of cervicofacial flap expansion include the following:
• Improved flap vascularity, which may obviate the need for sub-SMAS flap
elevation
• Allows coverage high onto the temporal area and farther medially and
inferiorly
• Facilitates tension-free closure
• Transillumination demonstrates axial blood supply, enabling utilization of
the maximal flap back cut to optimize rotation/advancement
• Remote expander placement away from the defect reduces exposure risk,
with access incisions directly incorporated into flap design.
■ Direct expansion and closure

■ For nonexpansile lesions of the cheek, direct expansion from underneath the
defect itself enables excision and primary closure.
■ This technique minimizes the degree of undermining necessary and has the
benefit of resulting in a straight line scar that can be favorably oriented along
resting skin tension lines.
T E C H N I Q U E S
■ Tissue Expander Insertion
■ Once the flap design and implant position are determined, mark out the
access incision, remote port location, and planned expander pocket.
■ Infiltrate a dilute solution of 1:200,000 to 1:400,00 epinephrine in a
subcutaneous plane throughout the marked areas.
■ After a period of 7 to 12 minutes for vasoconstriction, make the access
incision (usually 2–3 cm long) into subcutaneous tissue.
■ Develop the expander pocket with a combination of blunt and sharp
dissection in the subcutaneous plane staying above the superficial
musculoaponeurotic muscular system (cheek) and platysma (neck).
■ Make sure the pocket is far enough away from the incision so the expander
is about 2 cm from the access point.
■ With the same technique, create a superficial pocket for the remote fill port
that is separate from the expander pocket but accessible through the same
incision.
■ Hemostasis should be checked and the pocket should be irrigated.
■ Prior to insertion, trim the port tubing to the appropriate length to avoid
redundancy that may lead to kinking and check the expander for leaks.
■ After rolling and inserting the expander into the pocket, attach a 16-gauge
plastic angiocath to the expander tubing, completely deflate the expander,
and then clamp the tube.
■ The connector is placed and tied with two 3-0 Tevdek or Ethibond sutures on
each side to prevent detachment. The port is also secured so it does not drift.
The tubing to the expander must be on the down side.
■ Make sure the skin overlying the port is loose and the tubing does not kink.
■ When you are satisfied with port position and palpability, place a suture

around the tubing but under the skin adjacent to the dome to secure the port
in place.
■ The port tubing must be sutured in place to prevent drift into the larger
pocket.
■ Place a small closed suction drain that is tunneled to a separate, remote stab
incision for egress.
■ Use a 23-gauge needle to transcutaneously access the port and partially fill
the expander with injectable saline (about 10% volume). This initial fill
unfurls the expander, obliterates dead space caused by undermining the
pocket, and allows assessment of the connection between the port and
expander.
■ Check to make sure the insertion of the port tubing into the expander is on
the downside.
■ Make sure the expander lies flat in the pocket after the partial fill by pushing
on the overlying skin—no edges should be felt. If the pocket needs
adjustment, pull out the expander first, or else, it may be cut in the procedure.
■ Once adequate expander position is obtained, close the access incision(s) in
layers.
■ Expanded Flap Elevation and Inset
■ Following adequate expansion, design a flap that will provide defect
coverage and draw it in marker over the expanded tissue (TECH FIG 1A,B).
■ When designing the back cut, transilluminate the flap to identify and mark
the location of axial blood vessels (TECH FIG 1C).
■ Division of these should be avoided and will determine the maximal extent
of your back cut.
■ Infiltrate a dilute solution of 1:2-400 000 epinephrine in a subcutaneous
plane throughout the marked areas.
■ Perform the marked incisions through the dermis.
■ Using cautery, elevate the flap in a subcutaneous plane until the expander
capsule is encountered.
■ Cautery will not cut the expander and thus avoids a flood of saline into the
field.
■ Incise the expander capsule the entire length of the incision.
■ Additional capsulotomy and subcutaneous undermining of this proximal

tissue should be performed as needed for adequate movement.
■ Although the capsule edge may be removed if it prevents motion,
significant capsulectomy should not be performed as this may compromise
flap blood supply.
■ If excessive tension is present, the back cuts may be extended up to the first
axial vessels encountered on transillumination to provide additional rotation.
■ Rotate and inset the flap (TECH FIG 1D,E).
■ Place a small closed suction drain that is tunneled to a separate, remote stab
incision for egress (can use the same stab incision previously used with
expander placement).

TECH FIG 1 • A,B. Markings for a Schrudde design
flap wherein a triangle placed under the ear allows the
flap to move without worry of needing to fill the defect
from flap movement. The flap should not go right
under the eyelid unless the lid is supported by fascial
slings. C. The expanded flap is transilluminated so the
back cuts do not interrupt blood supply. With the lights
out in the OR, the vessels are easily visible. D. The
flap should be supported by sutures to periosteum or
fascia, indicated by arrows. E. Completed flap inset.
■ Expanded Cervicofacial Flap
■ Refer to the chapter Cheek Reconstruction With the Angle Rotation Flap for
flap design. The flap is designed in exactly the same manner, except
expansion is performed prior to elevation and advancement.

■ Expansion of the cervicofacial flap is usually done with a neck expander and
may avoid sub-SMAS flap elevation.
■ A subcutaneous implant pocket is designed 1 cm larger in all dimensions.
Expander insertion is performed through the preauricular flap incision, which
may be extended cranially to facilitate exposure. A submental counterincision
may also be helpful for pocket dissection.
■ The remote fill port can be placed in the scalp or behind the ear.
■ Perform the incisions and expander removal in the same manner as the
subcutaneous flaps above.
■ Additional subcutaneous dissection should be performed for complete flap
elevation. Flap advancement, inset, and superomedial support should be
performed according to the techniques detailed in the chapter Cheek
Reconstruction with the Angle Rotation Flap.
■ Take full advantage of the improved vascularity and quantity of soft tissue.
Align planned incisions with aesthetic subunit borders, sacrificing some
residual normal tissue from the medial cheek if necessary (TECH FIG 2).
■ There is usually a vertical dog-ear medially that requires excision.
■ In addition to the cutaneous inset of the above flaps, these larger flaps
require suspension from periosteum, bone anchors, and temporal fascia.

TECH FIG 2 • A. An OR fire burned this woman. The
graft to the lower eyelid was too small, the cheek had
an expander attempt, and it became exposed. The red
line indicates the delay incisions made at the time of
expansion placement. The green line shows the
incision for the final flap. B. Flap inset.
■ Neck Expansion for Donor-Site Coverage of Large
Cervicofacial Flaps
■ For larger cheek defects, deep-plane cervicofacial flap elevation may be
performed in conjunction with neck soft tissue expansion for donor-site
coverage (TECH FIG 3A,B).
■ This provides the maximum possible flap vascularity by combining the
sub-SMAS elevation with tissue expansion delay phenomenon and enables
primary donor-site closure with pliable neck tissue.
■ The tissue expander is placed in the subcutaneous (preplatysmal) plane
inferior to the mandibular border using the above technique (TECH FIG
3C).
■ Following adequate neck tissue expansion, the cervicofacial flap is designed
with transillumination used to identify axial vessel location and incorporate
them into the backcut limitations.
■ Removal of edge of expander scars and proper back cut will maximize the
gain.

TECH FIG 3 • A large AVM extending from the
superomedial cheek to the superior ear required
excision down to deep temporal fascia. A. The flap
(indicated in yellow) will go thinly under the lid, as
shown by the green arrow. B. The AVM will be
removed to deep temporal fascia. The ear will be
reduced. The upper brow will be supported by anchors
(arrows) as the frontal branches are removed. C. Flap
design. The neck expander was placed via a
preauricular incision to provide additional soft tissue
and allow primary donor-site closure for the deep-
plane angle rotation cervicofacial flap.
PEARLS AND PITFALLS

Incisions
■ Keep placement incisions at least 2–3 cm away from the
expansion process.
■ Inverted V incisions work well for insertion and allow for
expansion to begin at 10 d; must be kept away from base of
the proposed flaps.
■ Use back cuts with transillumination to maximize tissue gain
and avoid flap devascularization.
Expander
selection
■ Rectangular expanders are preferred because you can figure
out mathematically when the expander is close to ready.
■ Choose size according to base length dimensions that are
slightly larger than the defect (not according to expander
volume, as they can be significantly overinflated).
■ Avoid hard-backed, floppy bag, or integrated fill port
expanders on the face and neck.
■ Multiple expanders may allow for more rapid expansion but
also increase the chance of problems. Expanders, if multiple,
should be chosen according to the shape/extent of the defect
and what each expander will accomplish.
Expander
placement
■ Infiltrate semitumescent dilute epinephrine prior to pocket
formation.
■ Make sure the expander lies flat in the pocket after insertion,
no edges should be palpable, and the port connection must be
on the downside.
■ Make sure the remote port is loose in its pocket, or the
overlying skin will necrose, and always secure the port in
place.
■ Use a closed suction drain that egresses from a distant site.
Tissue expansion
■ Avoid trying to predict exactly how long expansion takes
since this is highly variable.
■ In certain instances, teach appropriate family members to do
the expansions at home.
■ Expand until you have approximately 20% more tissue than
needed to cover the defect when possible.
Implant
exposure/infection
■ Consider temporary deflation, drain any periprosthetic fluid,
and start antibiotics if evidence of infection.
■ May save a seemingly infected implant. Drainage from the
most dependent portion of the expander and Betadine
irrigations can save the day… sometimes.
■ If almost fully expanded, try to incorporate the area of
exposure into the back cut of the flap.

POSTOPERATIVE CARE
■ Postoperative antibiotics are not required, and the drain is removed within 24
to 48 hours.
■ Filling begins at the first postsurgical visit, typically at 7 to 10 days.
■ If the expander was inserted through an incision that may be affected by the
expansion, it will be necessary to delay filling for 3 weeks.
■ Filling should be performed after sterilizing the skin over the port to prevent
contamination.
■ It is important to use a 23-gauge or smaller needle to prevent port leakage
(although the companies say it will work with a 21-gauge needle). A butterfly
needle is particularly useful as it allows for slight patient movement without
dislodging.
■ In children, it may be helpful to apply a topical local anesthetic 20 minutes
prior to each filling session.
■ Subsequent filling amounts vary but are usually about 5% of the nominal
expander volume with intervals between fillings ranging from 4 days to 1
week.
■ The expander should be compressible to 1 cm after filling.
■ Frequent small-volume inflations are better tolerated, approximately every 5
days.
■ When guardians or significant others can be trained or designated as fillers,
they can usually fill every 5 days.
■ Expansion is complete when the cutaneous tissue generated is able to cover a
surface area approximately 20% greater than the defect itself to accommodate
for primary flap contraction after expander removal.
OUTCOMES
■ Follow-up patient photos are shown in FIG 1.

FIG 1 • A,B. Follow-up photos of the patient in TECH
FIG 1. She will need additional work for the epicanthal
fold, residual nevus on lip, and tightness around the
commissure. C. Follow-up photo of the patient in TECH
FIG 2. The lower lid position is excellent as a graft was
used under the margin of the lid. The flap would be too
heavy without support. The commissure was repaired
later. D. Follow-up photo of the patient in TECH FIG 3.
The anchor scar is indicated by an arrow.
COMPLICATIONS
■ Complication rates with tissue expansion vary widely and are directly related
to the experience of the individual surgeon.6
■ Most complications that occur with tissue expansion are technique specific and
do not interfere with completion of the planned multistage procedures.2
■ Late infections are usually related to iatrogenic contamination during the
course of inflation. These infections should be managed with port
externalization, irrigation, and antibiotic therapy. Late infections may be
salvaged with immediate intervention and antibiotic therapy.
■ Implant exposure usually occurs through necrosis of the overlying skin,
trauma, a dehiscent and malpositioned incision, or a fold in the implant.
Inadequate pocket dissection or too rapid inflation can lead to implant
extrusion as well.
■ Major complications are rare but include the following:
■ Infection
■ Implant exposure
■ Flap ischemia and/or necrosis
■ Hematoma
■ Minor
■ Transient pain with expansion
■ Seroma
■ Widening of scars
■ Dog-ears at donor site
REFERENCES

1. Elias DL, Baird WL, Zubowicz VN. Applications and complications of tissue
expansion in pediatric patients. J Pediatr Surg. 1991;26:15-21.
2. Zide BM, Karp NS. Maximizing gain from rectangular tissue expanders. Plast
Reconstr Surg. 1992;90:500-504.
3. Hudson DA, Lazarus D, Silfen R. The use of serial tissue expansion in
pediatric plastic surgery. Ann Plast Surg. 2000;45:589-593.
4. Hallock GG. Safety of clinical overinflation of tissue expanders. Plast
Reconstr Surg. 1995;96:153-157.
5. Lozano S, Drucker M. Use of tissue expanders with external ports. Ann Plast
Surg. 2000;44:14-17.
6. Manders EK, Schenden MJ, Furrey JA, et al. Soft-tissue expansion: concepts
and complications. Plast Reconstr Surg. 1984;74:493-507.

27
CHAPTER
Cheek Reconstruction With
Free Radial Forearm Flap
John G. Fernandez
DEFINITION
■ Cheek and face defects commonly occur secondary to trauma, burns, or tumor
resection.
■ Most cheek defects can be treated with primary closure, skin grafts, or local
flaps.1
■ Less commonly, reconstruction of cheek defects requires free flap transfer.
These defects are more complex, often involve a large area of the skin, or are
composite defects involving the cheek skin and underlying tissues.
■ Free flap coverage is necessary owing to lack of local tissues from previous
surgery or radiation.2
■ Some patients require free tissue transfer because the facial vessels are
ligated during the course of concomitant neck dissection.
■ The radial forearm flap (RFF) is an excellent option in these situations due to
its long pedicle, thin and pliable skin paddle, and the potential to transfer
multiple skin paddles to line composite through-and-through cheek defects.
■ Other flaps are also useful for cheek defects. These include the anterolateral
thigh flap, scapular and parascapular flaps, lateral arm flap, fibula flap, and the
rectus abdominis flap.
■ Flap selection is based on multiple factors including volume of tissue loss
and subsequent functional and aesthetic reconstruction needs.
■ This process is individualized for the patient and the defect to be
reconstructed.
■ No clear evidence supports one flap over the use of another.
■ The flap must appropriately match the color and thickness of the surrounding

cheek soft tissue and have a reliable blood supply with adequate vessel
diameter and length.
■ The advantage of RFF is its flexibility in design and its ability to be
fashioned as a fasciocutaneous flap, as an osteocutaneous flap involving
unicortical short segment of radius, or as composite flaps, including palmaris
longus tendon (for lip reconstruction), as well as its ability to be de-
epithelialized and folded to reconstruct the intraoral lining and external skin
defects.2
ANATOMY
■ The borders of the cheek include laterally the preauricular crease, medially the
nasal-cheek junction, nasolabial fold and lip, inferiorly the lower border of the
mandible, and superiorly the orbital-cheek junction (FIG 1A).1
■ The main arterial supply to the cheek is from branches of the external carotid
artery with the greatest contribution arising from the facial artery.
■ The branches of the facial nerve lie deep to the SMAS.
■ The RFF venous drainage is primarily from the venae comitantes, secondary
drainage from the cephalic vein (FIG 1B).3
■ RFF dominant arterial supply is the radial artery.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The history should identify patient factors that may increase the risk of
complications, including smoking history, hypertension, obesity, diabetes, and
prior radiation therapy.
■ Elicit personal or family history of clotting abnormalities, strokes, coronary
artery disease, or cerebrovascular disease.
■ A personal or family history of clotting abnormalities may warrant a
hematology consult to rule out familial causes of hypercoagulability or
bleeding diathesis.
■ A directed physical examination of the head and neck includes a detailed
assessment of the tumor or traumatic defect; nodal involvement; quality of the
surrounding cheek skin including laxity, scars, and fine wrinkles; and
assessment of facial nerve function.
■ Preoperative plan for resection should be determined in consultation with the
oncologic surgeons.
■ Orbital-cheek junction and periorbital reconstruction may result in eye-related
complications including ectropion, scleral show, dry eye, and chemosis.4

Therefore, a preoperative and postoperative visual field exam and periorbital
assessment may be necessary for lesions that encroach on the eyelid.
■ The preoperative evaluation for patients who will undergo cheek
reconstruction with an RFF flap includes gathering pertinent patient history
such as hand dominance, prior upper extremity surgery, history of trauma, or
fractures.
■ Consider the body habitus and thickness of the donor tissue and its potential
effect on the overall aesthetic and functional outcome.
■ An Allen test should be performed to assess ulnar and radial artery perfusion
to the hand. Motor and sensory examination of the hand should be performed.
■ Patients should be instructed to avoid blood draws or intravenous line
placement in the arm to be used for RFF harvest.
IMAGING
■ X-ray of the forearm and hand is indicated if an osteocutaneous flap is
planned.
FIG 1 • A. Outlines of the zones of the cheek. Note
overlap of zones. B. Arterial and venous anatomy of the
forearm.
SURGICAL MANAGEMENT
■ The goal of surgical management is to re-establish the normal anatomy of the
face; provide stable soft tissue coverage; allow for normal speech and
swallowing, thereby improving quality of life; and maximize aesthetics.
■ An RFF is an excellent option for complex defects of the cheek and can be
performed to provide external coverage or as a folded flap to repair through-
and-through cheek defects.
Preoperative Planning
■ Consider the size of the anticipated defect of the aesthetic subunit (suborbital,
preauricular, and buccomandibular) and intraoral component (if any).
■ Maxillectomy defects often result in periorbital skin defects, whereas
mandibulectomies and buccal tumors often include the buccomandibular

subunit.
■ Isolated tumors of the buccal mucosa or advanced/recurrent parotid gland
tumors may also result in through-and-through defects.
■ Melanomas involving the cheek, particularly desmoplastic melanomas, may
result in large skin defects in combination with a unilateral neck dissection
thereby limiting the potential for reconstruction using local flaps (eg,
cervicofacial flap).
■ A free RFF is a good option in these circumstances.
■ Consider the reconstructive needs and goals to help decide the proper
reconstructive technique.
■ Perform an Allen test again in the preoperative holding room or operating
room to confirm clinic findings. For most accurate results, use a pulse oximeter
on the thumb while occluding the radial artery.
■ Make sure no blood draws or IV lines are placed in the nondominant arm (use
of limb alert bracelet is helpful).
Positioning
■ The patient is placed supine on the operating room table with the arm extended
90 degrees on a hand table.
■ The head of bed is turned 180 degrees and centered under the lights.
■ All pressure points are inspected and protected, and preoperative antibiotics
are given within 60 minutes of the incision.
■ Corneal eye protectors and sequential compression devices are placed
bilaterally.
■ Alternatively, the eyelids can be sutured together after application of
ointment using a fine nylon suture that is removed after the operation.
■ The arm is prepped circumferentially to the level of the axilla. A sterile
tourniquet is padded and inflated when the flap is ready to be harvested.
Approach
■ The flap is raised under tourniquet control in a distal to proximal fashion.
■ It can be raised either subfascial or suprafascial.
■ If the fascia is included in the flap, care is taken to preserve the paratenon on
the tendons to ensure skin graft take.
■ The flap can safely be raised on the superficial venous system, the deep
system,3 or both.

T E C H N I Q U E S
■ Flap Design
■ Evaluate the specimen and design the flap based on the postablative oral
mucosa and/or skin defect measurements (TECH FIG 1A).
■ Mark the radial artery, cephalic vein, palmaris longus tendon, and FCR.
■ Design skin paddle centered over the radial artery and cephalic vein.
■ If a small flap is needed, the cephalic vein can be excluded from the initial
design and the flap is centered over the radial vessels. In these cases, it is
helpful to incise the distal aspect of the flap first and ensure that the vena
comitans of the radial artery is of adequate size for microsurgical
anastomosis (TECH FIG 1B).
TECH FIG 1 • A. Evaluate the specimen and design
the flap based on the postablative oral mucosa and/or

skin defect measurements. B. Design skin paddle
centered over the radial artery and cephalic vein.
■ Flap Dissection
■ Elevate the extremity and inflate the tourniquet.
■ The flap is incised circumferentially.
■ When making the distal incision, care must be taken to avoid injury to the
radial nerve branches as they are superficial in the distal region of the wrist.
■ Similarly, injury to the cephalic vein should be avoided when making the
proximal incision (TECH FIG 2).
■ Subfascial dissection is the safest approach to the flap vessels and can be
performed expeditiously. However, care must be taken to avoid injury to the
superficial radial nerve.
■ The simplest way to avoid this problem is to identify the radial nerve trunk
as it exits below the brachioradialis muscle.
■ The branches can then be traced distally and dissected out of the flap.
■ Small branches entering the skin flap are sharply transected.
TECH FIG 2 • Incision is made with a 10 blade. Incise
fascia with knife and raise edges using Adson forceps.
Spread with hemostat in the direction parallel to
nerves.

■ Subfascial Dissection
■ The radial artery and vena comitans are identified distally and ligated.
■ The radial vessels are dissected in a subfascial plane from distal to proximal,
taking care to avoid injury to the skin-perforating vessels.
■ Small perforators to the muscles and radial bone are cauterized or suture
ligated (TECH FIG 3A).
■ Follow the pedicle as it dives under the brachioradialis tendon (TECH FIG
3B).
■ Move back and forth between radial and ulnar sides to ensure
circumferential view of the radial artery.
■ As you move proximally, use a blunt retractor like a Weitlaner to spread
the brachioradialis and FCR (TECH FIG 3C).
■ Dissect the cephalic vein proximally for additional venous outflow as
necessary.
■ Incise proximal skin last and be sure to dissect on top of the cephalic vein.
■ Mark pedicle orientation with methylene blue or a marking pen.
■ Deflate tourniquet and use bipolar cautery for hemostasis.
■ Allow the flap to reperfuse for 20 to 30 minutes prior to harvesting for inset
and microanastomosis.
■ Donor site is closed with skin graft.

TECH FIG 3 • A. In subfascial plane, dissect with knife
from distal to proximal. Using the no. 10 blade pointed
away from the flap, dissect in subfascial plane staying
on the sensory branches of the radial nerve. B.
Spread under the pedicle perpendicular to the pedicle
and bipolar cauterize the tissue. There are multiple
perforating branches from the pedicle to the
underlying muscle and bone. These small vessels are
easily cauterized with a bipolar. C. Incise proximal skin
last, and be sure to dissect on top of the cephalic vein.
As you move proximally, use a blunt retractor to
spread the brachioradialis and FCR. This maneuver
exposes the radial artery and VC.

■ Flap Inset
■ Divide flap pedicle to start ischemia time.
■ Transfer flap to the defect and tunnel pedicle vessels to the neck.
■ Inset flap at key points to set the pedicle length.
■ If a through-and-through defect is present, then inset the intraoral
component first with absorbable sutures (eg, Vicryl) (TECH FIG 4A).
■ De-epithelialize folded portion of flap with a no. 10 blade.
TECH FIG 4 • A. Transfer flap to the defect and inset
flap with an absorbable suture such as 2-0 Vicryl
interrupted sutures for the intraoral lining. De-
epithelialize folded portion of flap with a no. 10 blade.
Inset external skin to flap skin with 4-0 Vicryl for the
dermis and 6-0 nylon for the skin. B. Vein
anastomosis with a coupler device or hand sewn with
10-0 nylon. C. Arterial anastomosis is performed with

interrupted 9-0 nylon circumferentially.
■ Microsurgical anastomosis is then performed.
■ The recipient arteries most commonly used in the neck are the facial,
superior thyroid, or lingual artery, and the recipient veins are the internal
jugular or branches of the internal jugular and the facial vein (TECH FIG
4B,C).
■ The neck and wounds are irrigated with warm saline or antibiotic solution,
and hemostasis is ensured.
■ A neck drain is placed if necessary.
■ Care should be taken to avoid compression of the pedicle with the drain.
This can be done by simply sewing the drain loosely to the
sternocleidomastoid muscle.
■ The neck skin and platysma, as well as the cheek skin, are closed in a
layered fashion.
PEARLS AND PITFALLS
Indications
■ Free flap reconstruction is indicated for through-and-through
cheek defects, requiring intraoral lining and external skin
coverage. Free flaps are also useful for large defects of the cheek
that cannot be closed with local options or skin grafts.
Flap
selection
■ No evidence supports one flap over another flap. The flap must
match tissue thickness and color and have a reliable blood supply
and vascular pedicle.
Postoperative
monitoring
■ Free flap survival for head and neck reconstruction is greater than
95%. Frequent clinical observation and Doppler checks are
essential for early detection of compromised vascular flow.
Donor site
■ Volar resting splint and negative pressure therapy to skin graft for
5 days. Subsequently, Ace wrap and arm elevation for 3–6 weeks.
POSTOPERATIVE CARE
■ The most important factor in flap salvage is thorough monitoring and early
detection of compromised vascular flow.

■ Clinical observation to assess skin color, temperature, and capillary refill and
Doppler sonography are extremely effective in flap monitoring.
■ Flap monitoring is performed most frequently in the first 6 hours after
surgery (eg, every 1 hour) and gradually decreases over time (Q2 hours × 4
hours; Q4 hours × 48 hours).
■ Postoperative antibiotics are generally not necessary and are used for a short
duration (5 days).
■ A preoperative dose of antibiotics within 60 minutes of incision has been
shown to reduce surgical site infections.
■ Deep venous thrombosis prophylaxis includes early mobilization, bilateral
sequential compression devices, and subcutaneous Lovenox daily.
OUTCOMES
■ The free RFF is a highly reliable flap, able to be folded for intraoral lining and
external skin coverage.
■ Free flap success rates in head and neck reconstruction is higher than 95%.
COMPLICATIONS
■ Donor site wound breakdown or skin graft breakdown leading to tendon
exposure
■ Poor donor site cosmetic outcome
■ If bone is harvested, risk of fracture and potential functional loss
■ Ischemic hand
■ Partial or total flap loss
■ Intraoral leak or fistula
■ Infection
REFERENCES
1. Rapstine ED, Knaus WJ II, Thorton JF. Simplifying cheek reconstruction: a
review of over 400 cases. Plast Reconstr Surg. 2012;129:1291-1299.
2. Cordeiro PG, Chen CM. A 15-year review of midface reconstruction and total
and subtotal maxillectomy. Part 1. Algorithm and outcomes. Plast Reconstr
Surg. 2012;129:124-136.
3. Demirkan F, Wei FC, Lutz BS, et al. Reliability of the venae comitantes in the
venous drainage of the free radial forearm flap. Plast Reconstr Surg.
1998;102:1544-1548.
4. Rogers-vizena CR, Lalonde DH, Menick FJ, Bentz ML. Surgical treatment

and reconstruction of nonmelanoma facial skin cancers. Plast Reconstr Surg.
2015;135:895-908.

28
CHAPTER
Cheek Reconstruction With
Skin Grafts
Farooq Shahzad and Babak J. Mehrara
DEFINITION
■ The cheeks are the largest aesthetic unit of the face.
■ The boundaries of the cheek are medially the nasofacial groove and
nasolabial fold, inferiorly the mandibular border, laterally the preauricular
crease, and superiorly the infraorbital rim and the line joining the lateral
canthus to the helical root.
■ The cheek is subdivided into three aesthetic subunits: suborbital, preauricular,
and buccomandibular (FIG 1).1
■ These subdivisions are useful for planning reconstruction.
ANATOMY
■ The face has an abundant blood supply with a rich collateral network. The
arterial supply to the cheek is via branches of the external carotid artery. The
principal supply is via three sources (FIG 2):
■ Facial artery and its continuation, the angular artery
■ Transverse facial artery, which is a branch of the superficial temporal artery
■ Infraorbital artery, which is a branch of the internal maxillary artery
■ The veins accompany the arteries.

FIG 1 • Aesthetic subunits of the cheek: (1) suborbital;
(2) preauricular; (3) buccomandibular.
■ The lymphatics of the cheek drain to the parotid, submandibular, and
submental nodes. Additional drainage occurs to the jugular nodes.
■ Sensory innervation to the cheek is via three sources:
■ Maxillary division (V1) of the trigeminal nerve via the infraorbital and
zygomaticofacial nerves
■ Mandibular division (V3) of the trigeminal nerves via the buccal, mental, and
auriculotemporal nerves
■ Cervical plexus (C2, C3) via the greater auricular and transverse cervical
nerves
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Cheek defects occur most frequently following skin cancer resection but may
also occur after trauma or other causes.

■ Skin cancers on the cheek can be removed by conventional methods or using
Mohs micrographic surgery.
■ Assessment of margins is important and should be discussed with the patient.
■ If margin status is in doubt, it is often more prudent to proceed with
reconstruction only when the final pathology is reviewed and negative
margins are assured.
■ Many skin cancer excisions or traumatic injuries of the cheek may be repaired
primarily. In other cases, local flap reconstruction or skin grafts are more
appropriate.
■ Skin grafts are useful in patients with significant comorbidities in whom
facial flaps may be contraindicated, situations in which the blood supply to
local flaps has been compromised, large defects that are not amenable to
reconstruction with local tissues, or cases in which local flap closure may
result in distortion of the adjacent structures such as the eyelid or nose.
■ For example, skin grafts may be useful in young patients with large
superficial cheek skin defects. These patients have tight skin without much
redundancy, and thus, attempts to reconstruct larger defects with local flaps
will cause distortion of contour or pull on adjacent structures like eyelids.
■ Skin grafts are also helpful in some cases for men because facial flaps in
these patients may change the distribution of hair growth resulting in a
noticeable and difficult-to-treat problem.
■ Infrequently, skin grafts may be useful for reconstruction of aggressive or
recurrent tumors in which there is a high risk of local recurrence that is more
suitable for applying skin grafts to facilitate surveillance.
■ Finally, skin grafts may be used in combination with flap closures to extend
the reach or avoid tension on the base of the flap or to provide coverage for
adjoining anatomic regions (eg, eyelid).
FIG 2 • A. Arterial and venous anatomy of the cheek. B.
Sensory and motor nerve anatomy of the face.
■ The defect is analyzed for the following:
■ Location, size, and depth of the defect
■ Involvement of deeper structures (eg, facial nerve, parotid duct, and oral

mucosa)
■ Proximity of the defect to lower eyelid, nasal ala, and lip
■ Previous radiation and radiation changes. Heavily radiated or compromised
wounds may not be amenable to local flaps or skin grafts and may require
vascularized tissue transfer depending on the exposed structures and
complexity of the wound.
NONOPERATIVE MANAGEMENT
■ Areas of the face with a concave surface heal well with secondary intention
healing.
■ The cheek is convex, and therefore, secondary healing results in aesthetically
unpleasing results.
■ Exceptions are small preauricular defects and very small medial defects at the
alar groove that heal well with local wound care.
SURGICAL MANAGEMENT
■ Patient selection for skin graft reconstruction is as discussed above.
■ Full-thickness skin grafts taken from within the face and neck (cranial to the
clavicles) will have better color and texture match.
■ Common donor sites are the preauricular or postauricular areas, neck, upper
eyelid, and supraclavicular region.
■ Scars are ideally placed at the borders of the cheek.
■ In general, however, subunit principle and excision of normal skin are not
necessary or advised. In rare circumstances, the margins of the graft may be
adjusted to blend into normal anatomic structures (eg, nasolabial fold or lower
eyelid-cheek margin).
Preoperative Planning
■ The condition of the wound bed is examined. Contaminated wounds or those
with eschars will need debridement and dressing changes until an appropriate
bed is available for skin grafting.
■ If possible, skin grafting should be delayed until the wound has granulated
enough to decrease contour deformities that may result from deep excisions. In
practice, this is not always possible, however, because of contracture and
deformity of adjacent structures.
■ One potential solution is the use of decellularized dermis or other material
(eg, Integra) to promote wound filling and granulation, thereby avoiding