Cheek Advancement Flap for Paranasal Reconstruction

EDITORIAL COMMENT

This is an excellent and reliable flap for defects in the paranasal area. One should always remember not to extend the flap into the nose; by doing so, the rules of the aesthetic unit will be broken, resulting in an unacceptable outcome that will require secondary revision.

The cheek enjoys an obvious prominence in the architecture of the face. In older patients, there is an area of relative redundancy of tissue extending from the medial canthus of the eye to the inferior border of the mandible, providing for more available skin for the reconstructive procedures often required in this age group. With the use of cheek advancement flaps for paranasal reconstruction, important considerations include the anatomic complexity of the region (1, 2, 3), the avoidance of excess skin excision and resultant scarring and contracture, and careful flap design to avoid the transfer of hair-bearing skin (2). It is also important to match flap thickness as closely as possible to that of the original defect to achieve the most pleasing aesthetic outcome (4).

INDICATIONS

Cheek advancement flaps are useful for coverage of the paranasal region, when there is a full-thickness defect in this area, or when bone is exposed at the nasomaxillary junction or maxilla. Split-thickness skin grafts do not usually provide satisfactory coverage, since the contraction associated with wound healing tends to pull the lower-eyelid margin inferiorly. Full-thickness skin grafts taken from the postauricular, preauricular, or supraclavicular region will provide excellent texture, color match, and resilient skin; however, they will be noticeable as patches in an otherwise unscarred face (4), when applied to defects greater than 5 mm in depth.

ANATOMY

There is a rich vascular anastomotic network supplying the cheek skin, which is based on branches of the external carotid artery, with a smaller contribution from the internal carotid artery. The facial artery, which courses superomedially from the lower border of the mandible toward the modiolus near the buccal angle, constitutes the main blood supply. Other contributions are received from the transverse facial artery (a branch of the superficial temporal artery), the buccal and infraorbital branches of the internal maxillary artery, and the zygomatic branch of the lacrimal artery (a branch of the ophthalmic artery).

Venous drainage of the cheek parallels the arterial system. Lymphatic drainage is achieved via the superficial and deep parotid nodes, the buccal nodes surrounding the facial vein, and the submandibular nodes, ultimately to empty into the cervical chain of lymph nodes (5, 6, 7, 8).

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