RECONSTRUCTIVE

Simplifying Cheek Reconstruction: A Review of

over 400 Cases
Emily D. Rapstine, B.A.
William J. Knaus II, M.D.
James F. Thornton, M.D.
Dallas, Texas
Downloaded from https://journals.lww.com/plasreconsurg by hynvGtHKPWJ9v028bghVPhuYg6HY3KDz5aC4mec1p3LBMZdpIrhiKUrlNe4v9/tDRMjUDJ0nNodDb+8MCwekRzeMl55B4Xb1e+YYRvogwG5IBhfu2KEgHGJyullztdY2 on 06/23/2019
Background: The cheek is a vast, well-vascularized facial subunit defined by the
preauricular crease laterally, the mandible inferiorly, the lips and nasolabial fold
medially, and the orbit-cheek crease and zygomatic arch superiorly. Reconstruction
of the cheek commonly takes advantage of skin laxity in older patients and the
relaxed skin tension lines of the face. Poor reconstructive techniques can cause or

exacerbate significant deformities, especially in the oral and ocular regions.

Methods: Four hundred twenty-two cases of post-Mohs’ cheek reconstruction
were reviewed retrospectively. All cases were performed sequentially over 10
years by the senior author (J.F.T.). Indications, techniques, postoperative care,
complications, and patient characteristics (e.g., age, sex, medical history, defect
size, and skin quality) were taken into consideration for each case.
Results: The procedures used for cheek reconstruction included direct closure
(53 percent), cervicofacial advancement flaps (19 percent), perialar crescentic
advancement flaps (8 percent), full-thickness skin grafting (8 percent), V-Y
advancement flaps (2 percent), and free flaps (1 percent). Although no attempt
was made to modify patients’ anticoagulation status before surgery, no hema-
tomas were reported. Nine patients had multiple procedures for cancer recur-
rence or new defects, and all but four operations were performed at a university
hospital outpatient surgery center. Seventeen total complications were noted
from distal flap necrosis (n ⫽ 2), ectropion (n ⫽ 7), wound healing (n ⫽ 7),
and compromised vascular supply (n ⫽ 1).
Conclusion: Knowledge of aesthetic considerations and appropriate use of
operative techniques yield optimum cheek reconstruction defined by suc-
cessful wound closure, thoughtful scar placement, and minimal postopera-
tive complications. (Plast. Reconstr. Surg. 129: 1291, 2012.)

F
requently involved in Mohs’ resection for skin
cancer, the cheek has several unique qualities
that lend themselves well to successful post-
Mohs’ resection reconstruction. This article reviews
over 400 consecutive cheek reconstructions, all per-
formed by the senior author (J.F.T.). We reviewed
indications; techniques; and patient characteristics
such as age, sex, medical history, defect size, skin
characteristics, and aesthetic preference. Postoper-
ative care and complications were also reviewed.
The cheek is a large expanse of well-vascular-
ized skin that often becomes lax in the elderly
population. The redundancy of skin in older in-
dividuals lends itself to both providing sufficient
tissue for repairing defects and concealing scars in
the deepened relaxed skin tension lines. The
From the University of Texas Southwestern Medical Center.
Received for publication September 30, 2011; accepted De-
cember 21, 2011.
Copyright ©2012 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e31824ecac7
cheek is essentially defined by its borders—later-
ally, the preauricular crease; inferiorly, the man-
dible; medially, the lips and nasolabial fold; and
superiorly, the orbit-cheek crease and zygomatic
arch. The vastness of the cheek makes it a unique
subunit, yet it is similar to other facial subunits in
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
Supplemental digital content is available for
this article. Direct URL citations appear in the
printed text; simply type the URL address into
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able links to the material are provided in the
HTML text of this article on the Journal’s Web
site (www.PRSJournal.com).

www.PRSJournal.com 1291
 Plastic and Reconstructive Surgery • June 2012

its visible bilateral symmetry, which is imperative cheek into three unique zones as illustrated by
to recreate and/or retain when reconstructing. Roth et al.2 a useful planning tool, with the fol-
Many potentially significant functional deformi- lowing considerations (Fig. 1).
ties may be induced by poor reconstructive tech- Zone I has relatively little laxity, and the eyelid
niques, especially those involving oral incompe- is an important superior border. In cheek recon-
tence and extrinsic ectropion of the eyelid, which struction, eyelid complications yield the most pro-
may require correction by further procedures. found overall complications. Inappropriate ten-
sion on the lower lid may lead to ectropion.
RESULTS Although there are many challenges associated
Our results were based on a retrospective chart with the superior portion of zone I, some incisions
review. After obtaining institutional review board can be remarkably hidden in the orbit-cheek
approval and written consent from patients, 422 crease near the infraorbital rim, leading to a pleas-
consecutive cases were reviewed over a 10-year ing aesthetic result. Incisions in the medial area of
span. Two hundred women and 213 men consti- zone I may be camouflaged in the nasolabial fold.
tuted the patient base. Nine of the patients un- Difficulties can occur at the malar prominence, an
derwent multiple procedures: two for melanoma essentially convex surface that can be challenging
recurrences and the other seven for defects in to recreate because of the tissue bulk needed to
addition to their primary presentation. Roughly restore the appropriate convexity.
25 percent of the patients reviewed were smokers. Zone II provides the most opportunity to use
The individuals ranged in age from 12 to 92 years, direct closure. However, it should be noted that
with both the average and median age being 60 there are limitations imposed by the relative lack
years. Size of the defect needing reconstruction, of skin laxity in the direct preauricular area, lim-
available reconstructive techniques, and complica- iting the availability of skin that can be advanced
tions were noted. Patients who underwent Mohs’ anteriorly from the ear for closure. Skin inferior
surgery were offered same-day reconstruction. All and medial to defects in this region may be used
but four of the patients were treated in an outpatient for closure, but use of superior skin may distort the
surgery setting in a university hospital under mon- temporal hairline. Also, great care must be taken
itored sedation or general anesthesia. The remain- in the portion of zone II bordering the mandible
ing patients were treated on an inpatient basis. to avoid distorting the beard pattern in men.
The American Society of Anesthesiologists Zone III provides ample opportunities for direct
classification range was from 1 to 4, and no post- closure as well, but reconstruction in this area can
operative complications were noted from anesthe-
sia. Frequently, patients presented fully anticoag-
ulated for comorbid disease, and no attempt was
made to modify or change their anticoagulation
status before or after surgery. The 2005 survey by
Kirkorian et al. of Mohs’ surgeons found that peri-
operative continuation of medically necessary an-
ticoagulants is becoming more common among
surgeons involved with Mohs’ cases.1
After closure, patients were followed postop-
eratively. Most of the postoperative care was fo-
cused on minimizing any scarring the patient ex-
perienced. Scar management consisted of silicone
sheeting worn daily for 3 months and optional
daily application of Bio-Oil (Pacific World Corp.,
Irvine, Calif.) for scar softening. Dermabrasion
under topical anesthesia was offered up to three
times beginning 6 weeks after their procedure
during a postoperative clinic visit if more aggres-
sive scar management was needed. Patients with
hypertrophic scaring were offered Kenalog intra-
lesional injections (Bristol-Myers Squibb, New
York, N.Y.) in a clinic setting. With regard to cheek
reconstruction, we consider the division of the Fig. 1. The three unique zones considered in cheek reconstruction.

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Volume 129, Number 6 • Simplifying Cheek Reconstruction
easily distort the lips. For certain defects, skin can be
borrowed from the neck to provide sufficient tissue
for closure, especially if the patient has some laxity
in the neck. The chin itself presents unique recon-
struction challenges that are discussed separately.
TECHNIQUES
Several techniques were used to reconstruct
the defects in this review. Over half of the cases
were closed directly, followed by cervicofacial ad-
vancement flaps, which constituted 19 percent of
the procedures. Perialar crescentic advancement
flaps, full-thickness skin grafting, and V-Y advance-
ment flaps were also used to lesser extents. Each
of these techniques is discussed in detail (Table 1).
Direct Closure
As discussed in our Plastic and Reconstructive
Surgery article, “The Rationale for Direct Linear
Closure of Facial Mohs’ Defects,”3 our preferred
method of closure for many cheek defects is pri-
mary closure. Approximately 53 percent (n ⫽ 222)
of the reconstructions in this review consisted of
direct primary closure. When followed by metic-
ulous postoperative scar management, excellent
cosmetic results can be achieved (Fig. 2).
Any cheek defect can be considered for pri-
mary direct closure. The inherent laxity of the
cheek, specifically in zones I and II, presents the
option of undermining the boundaries of the de-
fect to increase soft-tissue availability for advance-
ment and closure. In addition, the excellent vas-
cular supply of the cheek enhances wound healing
and the final cosmetic appearance.
The patient should be positioned in an upright
setting to ensure that there is no extrinsic ectropion
from the direct closure before proceeding with this
technique. The practitioner then places a suture and
attempts closure both with and against relaxed skin
tension lines. Using clinical judgment, the surgeon
will see which position yields the most laxity and the
best opportunity for primary closure. Soft-tissue de-
fects in zone I at the cheek/lid junction, particularly
in the elderly patient, present ideal opportunities for
Table 1. Techniques Used for Cheek Reconstruction
Repair Technique No. of Cases (%)
Direct closure 222 (53)
Cervicofacial advancement 82 (19)
Perialar crescentic advancement 35 (8)
Full-thickness skin graft 32 (8)
V-Y advancement 7 (2)
Free flap 4 (1)
Other 40 (9)
Total 422 (100)
primary closure, as one can take advantage of the
lower eyelid skin laxity that is frequently seen. An
essential component of this closure is to ensure that
there is sufficient soft tissue for closure by perform-
ing a tailor-tack of the wound. At the point of slight-
est lid retraction noted during the tailor-tacking,
these sutures are removed and another technique
should be attempted. A wide range of defects
can be closed both vertically and horizontally in
zones I and II (Fig. 3).
The tenets of closure are limited; undermin-
ing is used only as needed, and meticulous dog-ear
excisions are made at the time of closure. It has
been our experience that dog-ears do not settle
with time on areas of relative tissue laxity, such as
the cheek.3 In addition, the risks of tissue loss and
hematomas are minimized with direct closure.
We prefer, when possible, to avoid geometric
flap closures, including bilobed or rhombic flaps,
which have been historically popular in the litera-
ture for closure of cheek defects.4 –7 Our rationale for
avoiding these flaps is that their use results in un-
avoidable scars that are oriented perpendicular to
relaxed skin tension lines, and the final result often
yields a geometric shape that is not found on the
native face. We feel that our algorithm provides su-
perior closure with significantly less tissue dissection
compared with traditional geometric flaps.
Perialar Crescentic Advancement
Our next level of closure is that of a perialar
crescentic advancement flap as outlined by
Jackson.7 More recent studies have argued for its
use in upper lip and nasolabial fold defects.8,9 This
technique uses a subcutaneous cheek advancement
flap with planned dog-ear excisions that follow the
relaxed skin tension lines of the nasolabial fold or
the nasal sidewall. Zone I defects abutting the na-
solabial fold or the lip can be successfully recon-
structed with a perialar crescentic advancement flap
with favorable scar placement. In this technique, the
defect is extended in a crescent shape along the
proposed scar line. Undermining is performed lat-
erally. The defect is then closed by bisecting the
halves and sharply excising the dog-ear defect (Fig. 4).
It should be noted that even with direct clo-
sure or perialar crescentic advancement flap, a
degree of lip retraction can be tolerated on the
table that should rapidly resolve postoperatively.
Over several weeks, the actions of the orbicularis
oris compensate for minor retraction, as noted
in Figure 4. However, the same is not true of
eyelid retraction, and any extrinsic ectropion
from direct closure or an advancement flap must
1293

Fig. 2. A 77-year-old woman presented with a 1.6 ⫻ 1.1-cm defect after squamous cell carcinoma excision (left). The defect was
closed primarily (center). (Right) The patient is shown 10 months after the procedure.
Fig. 3. The areas of the defects to be reconstructed.
be corrected on the table as, in our experience,
it does not improve postoperatively without an
additional operation.
Cervicofacial Advancement
For large defects, defects that are unable to be
closed directly, and for patients who can tolerate
the procedure, cervicofacial advancement flaps
are the preferred choice. This technique has been
popularized over the past 30 years because of its
superb color and texture matching of the cheek by
mobilizing skin from an adjacent facial subunit.10
1294
Plastic and Reconstructive Surgery • June 2012
Several technical points should be noted re-
garding their use. The incision is made at the
cheek/eyelid junction, with no attempts made at
subciliary incisions. Our preference is to use the
principles of like-to-like tissue reconstruction. The
thickened cheek skin is a poor match for the very
thin, distinct lower eyelid skin, and we avoid any
attempt to recreate the lower eyelid skin with
cheek skin. For this reason, incisions are made
following the cheek/lid junction with a superior
excision and extension into the hairline and along
the preauricular area down onto the neck if re-
quired. It should be noted that in zone II, partic-
ularly in elderly patients, there is often a tremen-
dous amount of lax skin along the cheek and
temple that can be advanced into the wound, with
no requirement for further preauricular incisions.
The plane of dissection remains subcutaneous
throughout. Although popularized in other case
series, no attempts were made at a deep plane,
submuscular, or sub–superficial musculoaponeu-
rotic system dissection for expediency of the pro-
cedure and for our reliability of skin-only flaps as
demonstrated in this series.11
By performing meticulous hemostasis during
surgery and liberally applying a topical hemostatic
agent such as Surgicel (Ethicon, Inc., Somerville,
N.J.) or Avitene (Davol, Inc., Warwick, R.I.) in the
wound field on coagulated vessels, we had zero
postoperative hematoma complications in both
inpatient and outpatient populations, with no at-
tempts made to modify patients’ anticoagulation
status. Drains were used sparingly (n ⫽ 7) and
Volume 129, Number 6 • Simplifying Cheek Reconstruction

Fig. 4. An 88-year-old man presented with a 4.1 ⫻ 4.0-cm defect after melanoma excision (above,
left). (Above, right) Temporary tailor-tacking of the wound ensured adequate tissue mobility without
excessive tension before closure. Slight lip retraction was seen while still in the operating room
(below, left), but it resolved within 2 months postoperatively (below, right).

were all removed within 3 postoperative days. To
avoid lower eyelid ectropion, great care was
taken to provide a superior vector of redundant
tissue at the lateral eyelid/temple area. This
provides a crowding of skin along the cheek/
eyelid junction and prevents late ectropion com-
plications (Fig. 5).
No periosteal anchoring sutures were used at
the leading edge of the cheek/eyelid junction, as
we feel that this, although well described by pre-
vious authors,12–14 contributes to distal flap loss
and is an unnecessary step if adequate redundant
soft tissue is advanced and secured with a lateral
supporting stitch as a superior vector, as described
above. All wounds were closed in a complex mul-
tilayer fashion with interrupted Vicryl (Ethicon),
Monocryl (Ethicon), and overlying simple nylon
or gut sutures. Flaps that had any appearance of
vascular compromise were treated immediately
postoperatively with a 2% nitroglycerin ointment
as described by Rohrich et al.15 (Fig. 6).
Full-Thickness Grafting
Under specific conditions, full-thickness, col-
or-matched skin grafting of the cheek can be a
suitable reconstruction choice. For the cheek, the
authors agree that this is a less preferable method
of reconstruction because of concerns of wound
contraction and poor color and texture matching.
However, two instances occur where a full-thick-
ness skin graft is the best repair option. The first
example is for small, medial defects involving the
cheek/eyelid junction. Small, full-thickness, color-
matched grafts can be placed at the medial can-
thus abutting the cheek/lid junction without fur-
ther incisions needed along the eyelid or cheek/
lid junction. [See Figure, Supplemental Digital

1295

Fig. 5. Illustration demonstrates the redundant skin crowding
at the lateral eyelid/temple junction to prevent later lower lid
ectropion. A lateral supporting stitch is placed to provide a
superior vector for the redundant tissue.
Content 1, which shows a 41-year-old male smoker
with a 1.5 ⫻ 2.5-cm defect at the medial canthus
abutting the cheek/eyelid junction after basal cell
carcinoma resection, http://links.lww.com/PRS/A495. A
small, color-matched, full-thickness skin graft was
inset (center). (Right) The patient is shown at 6
months after the procedure.]
Fig. 6. A 68-year-old woman presented with a 4.3 ⫻ 2.5-cm defect after melanoma removal (left). The completed cervicofacial
advancement flap is shown (center). (Right) The patient is shown 10 months after the procedure.
1296
Plastic and Reconstructive Surgery • June 2012
Another example where full-thickness grafting
proves to be a viable repair option is on patients
with significant comorbid disease and very large
cheek defects that require coverage but in whom
comorbid disease precludes an extensive cervico-
facial advancement flap. Large, color-matched or
non– color-matched, full-thickness grafts will pro-
vide adequate functional coverage but not ideal
aesthetic results (Fig. 7).
Free Flaps
In our series, free flaps were used sparingly [n ⫽
4 (1 percent)]. These cases involved either com-
bined defects of both the cheek and lateral lid with
exposed bone or such large, thick defects of the
cheek that sufficient soft-tissue bulk was required
for reconstruction. The limitations of free flap
coverage include the inability to provide color-
matched skin and oftentimes bulky reconstruc-
tion. Free flap reconstruction had the highest
postoperative complication rate.
V-Y Advancement Flaps
First described by Esser, V-Y flaps have re-
cently begun to be frequently used for cheek
reconstruction.16 –18 V-Y advancement flaps provide
excellent color and texture match for reconstruc-
tion. Ideally, the flaps are designed to follow the
relaxed skin tension lines with one limb, preferably
the common limb of the Y, being along the relaxed
nasolabial fold for concealed scar placement.19 This
technique is especially useful for very medial cheek
defects. Careful examination using Doppler ultra-
Volume 129, Number 6 • Simplifying Cheek Reconstruction

Fig. 7. (Left) A 75-year-old man presented with a 9.5 ⫻ 4.5-cm defect after melanoma in situ removal. A color-matched full-thickness
skin graft was used (center). (Right) The patient is shown 2 months after the procedure.

sound is used to ensure the planned incisions in-
clude at least one robust perforator. The remaining
V-shaped flap should be developed in the deep sub-
cutaneous plane. The flap is then mobilized by me-
ticulous sharp and blunt dissection. The amount of
advancement available from the flap depends on the
vertical attachment between the subcutaneous pedi-
cle and the underlying facial structures, and skin
laxity.7,20 The use of a V-Y advancement flap pro-
duces less tension in a problematic location than
would a direct closure for the same defect. Very large
flaps can be elevated with a generous level of ad-
vancement, given the maintenance of a single per-
forator. [See Figure, Supplemental Digital Content
2, which shows a 70-year-old man with a 2.5 ⫻ 2.0-cm
defect after melanoma in situ resection that abuts
the vermilion and extends down to the orbicularis
oris, http://links.lww.com/PRS/A496. A V-Y advance-
ment flap was chosen to provide sufficient native
soft-tissue bulk. The incisions were not able to be
placed within the nasolabial fold, so they were po-
sitioned within relaxed skin tension lines. (Right)
The patient is shown at 10 months postoperatively.]
Chin Reconstruction
The chin is a unique area in that it is essentially
a convex surface with very limited laxity available
for primary closure. Grafts are uniformly unsuit-
able for the chin, and there is significant risk of

Fig. 8. A cheek repair algorithm summarizing the authors’ experience with cheek reconstruction.

1297

providing extrinsic lip ectropion with resulting
poor aesthetic outcomes or functional incompe-
tence of the lower lip. Our approach for chin
defects was direct closure, either horizontally or
superiorly as dictated by the chin laxity, or a bi-
lobed flap that took advantage of the laxity of the
neck skin to provide a suitable reconstruction. For
larger defects or defects that also involve the ver-
milion, a V-Y advancement flap as outlined in the
article by Thornton and Reece can provide suit-
able coverage options.21
COMPLICATIONS
Seventeen complications (4 percent) were
noted in this series. Two cases of distal flap necrosis
occurred in patients with cervicofacial advancement
flaps. One patient healed by secondary intention,
but the other required an additional full-thickness
skin graft at a later date. Seven cases of ectropion
were recorded, five for cervicofacial advancement
procedures and two for free flap procedures. Seven
wound healing difficulties also occurred— one after
a perialar crescentic advancement, one following a
direct closure, one after a full-thickness skin graft,
and four following cervicofacial advancements.
None required additional procedures.
Overall, 35 percent (n ⫽ 6) of patients en-
countering problems were smokers. Sixty-five per-
cent (n ⫽ 11) of the patients with complications
had received cervicofacial advancements. The
overall complication rate for this series (4 per-
cent) compares very favorably to previously pub-
lished series.22–26
ALGORITHM
Our approach as outlined should provide a
simple and rational algorithm for cheek recon-
struction (Fig. 8).
SUMMARY
Optimal cheek reconstruction, defined by suc-
cessful wound closure, careful scar placement, and
minimal postoperative complications, may be ac-
complished by taking advantage of the inherent
characteristics of the cheek and using the follow-
ing basic tenets:
• Use of a limited number of simple, rapid, and
reliable surgical techniques.
• Favoring subtarsal incisions over subciliary in-
cisions for cervicofacial advancement flaps.
• Careful attention to lateral cervicofacial flap
support and avoidance of periosteal anchoring
sutures to minimize complications with cervi-
cofacial advancement flaps.
1298
Plastic and Reconstructive Surgery • June 2012
Although it was not one of the original intents
of this review, we have found that procedures can
be safely performed on anticoagulated patients
with no increase in bleeding complications, as
demonstrated by this case review.
CODING PERSPECTIVE (FIGURE 6)
This information prepared by Dr. Raymond
Janevicius is intended to provide coding guidance.
14301 Adjacent tissue transfer, 30.1 to
60 cm2
• A cervicofacial flap is a random-pattern
flap, which is reported as an adjacent tissue
transfer, 14301.
• Adjacent tissue transfers are reported by de-
fect size. The defect size is the sum of areas
of the primary defect, the defect resulting from
the ablation, and the secondary defect, which is
the defect created by the flap.
• The primary defect in Figure 6 measures 4 ⫻ 3
cm ⫽ 12 cm2. The lateral flap, when ele-
vated, leaves a secondary defect measuring 6 ⫻
5 cm ⫽ 30 cm2. The total defect is the sum
of the primary and secondary defects; thus
12 ⫹ 30 ⫽ 42 cm2.
• If the total defect of the cheek measures less
than 30 cm2, use the appropriate code:
14040 Adjacent tissue transfer, cheek, up
to 10 cm2
14041 Adjacent tissue transfer, cheek,
10.1 to 30 cm2
• If the total defect measures greater than 60
cm2, use, in addition to 14301, the add-on
code 14302 for each 30 cm2 above 60 cm2.
Thus, a 110 cm2 cervicofacial flap is reported
as follows:
14301 Adjacent tissue transfer, 30.1 to
60 cm2
14302 Adjacent tissue transfer, each
additional 30 cm2
14302 Adjacent tissue transfer, each
additional 30 cm2
• The adjacent tissue transfer codes include ex-
cisions of cutaneous lesions, so the excision of
the cheek tumor is not separately reportable.
• Excision of dog-ears is included in the
global flap codes.
Volume 129, Number 6 • Simplifying Cheek Reconstruction
James F. Thornton, M.D.
1801 Inwood Road
Dallas, Texas 75390
james.thornton@utsouthwestern.edu
PATIENT CONSENT
Patients provided written consent for the use of their
images.
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