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Free flap reconstruction of the cheek
FREE FLAP RECONSTRUCTION OF THE CHEEK PETER G. CORDEIRO, MD, and ERIC SANTAMARIA, MD
Free flaps are primarily indicated for reconstruction of large cheek defects involving the external skin, inner lining, or full thickness. The radial forearm flap is our first option for reconstruction of such defects because of its thin pliable skin paddle with minimal soft tissue. The lateral arm or anterior thigh fasciocutaneous flaps provide larger amounts of skin and soft tissue volume and are therefore used for larger cheek defects. Once masticatory muscles, the parotid gland, and/or the maxilla or mandible are included with the resection, cheek defects become more complex, and larger soft tissue or composite free flaps are mandatory for reconstruction. The rectus abdominis myocutaneous free flap has proved to be very useful for reconstruction of these massive defects, and the scapular or latissimus dorsi free flap are secondary alternatives. Cheek defects including the ascending ramus of the mandible are best reconstructed using an osteocutaneous scapular or radial forearm flap. Full-thickness cheek defects that include the oral commissure and lips are more challenging to reconstruct. We advocate using a lip-switch procedure to provide a functional stoma and using a free flap with two separate skin islands for lining and cover, but not for reconstruction of the oral commissure. Copyright 9 1999 by W.B. Saunders Company KEY WORDS: cheek reconstruction, free flaps
Facial contour depends to a large extent on the soft tissues of the cheeks and subjacent bony structure. Each cheek is composed of an external skin layer and an internal surface, which is part of the oral mucosa. The parotid gland, facial nerve, and masticatory and muscles of facial expression are contained between these two layers. The elasticity of the cheek skin and mucosa creates its unique functional capabilities--it contributes to oral competence as well as the ability to act as a reservoir for liquids and solids. The cheek is limited superiorly by a horizontal line that extends from the infraorbital rim to the root of the auricular helix. Laterally, the cheek extends over the anterior border of the ear and continues inferiorly along the mandibular border. The medial margin of the cheek is the lateral nasal wall and nasolabial crease (Fig 1). Tumors involving the cheek m a y arise from a variety of different tissue components that make up this complicated structure. Tumors m a y arise from the skin externally, the mucosa internally, or the muscles and the parotid gland in between. If the skin or mucosa is resected, the defects are more likely to require some form of plastic reconstruction. These reconstructive problems become m u c h more difficultif multiple layers of the cheek are involved, and even more complex if adjacent structures such as the eyelid, nose, lips, commissure, and mandible or maxilla are involved. The vast majority of small- and medium-size defects of the cheek m a y be closed primarily using local or regional flaps. Free flaps are usually reserved only for reconstruc-
From the Department of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY. Address reprint requests to Peter G. Cordeiro, M.D., Room C-1189, 1275 York Ave., New York, NY 10021. Copyright 9 1999 by W.B. Saunders Company 1071-0949/99/0604-0006510.00/0
tion of large defects involving external skin, intraoral lining, or both (full-thickness defects). They are usually essential if the resections include the upper or lower jaw with soft tissue and skin. Free tissue transfer has also been described for improvement of contour deformities that m a y be congenital or acquired in nature. 1 This particular group of deformities will not be addressed in this article.
INDICATIONS FOR FREE TISSUE TRANSFER As with any reconstructive procedure, the simplest technique is usually selected if it will adequately achieve the objectives of the reconstruction. When methods such as skin grafts, local flaps, or regional flaps are unavailable or inadequate, a free flap becomes the m e t h o d of choice. After applying these parameters for reconstruction, the principal indications for using a free flap for cheek reconstruction include: 1) resurfacing of extensive external skin defects; 2) resurfacing of extensive intraoral defects; 3) moderate to large through-and-through defects; 4) extensive contour deformities; and 5) smaller defects where local flaps are unreliable due to previous surgery, compromised blood supply, or radiation therapy.
GENERAL CONSIDERATIONS There are several basic principles that must be applied to reconstruction of the three layers of the cheek (external skin, internal lining, soft tissue fill). Resurfacing external cheek skin is principally an esthetic endeavor, and issues such as contour, color match, texture, and appearance are of primary concern. The principle of facial units should be adhered to as much as possible to optimize esthetic results
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thin pliable skin in addition to multiple skin islands. These flaps can restore intraoral lining and cheek skin in one stage, without a major increase in bulk.
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Fig 1. The esthetic units of the face (A) and subunits of the cheek (B). These are subdivided into: 1) suborbital, 2) preauricular, and 3) buccomandibular. in cheek reconstruction. 2 The cheek may be considered a single total facial unit or may be divided into three smaller overlapping subunits: 1) suborbital, 2) preauricular, and 3) buccomandibular (Fig 1). Although it may be occasionally necessary to sacrifice adjacent normal tissue, final results are far superior when scars follow facial subunits, thus minimizing the appearance of a "patch." Restoration of intraoral cheek mucosa is essential to maximize the functional aspects of speech and mastication. With the introduction of microsurgical techniques, our ability to reconstruct massive intraoral defects has improved substantially over the last two decades. 3 More recently, the importance of sensation for adequate function and meaningful quality of life after flap intraoral reconstruction has been emphasized. 4-7 The capability to sense ingested food in the mouth facilitates mastication and enhances swallowing function; it also favors gustatory delectation, prevents pooling and drooling of saliva, and increases quality of speech. For this reason, surgical techniques to provide sensate free tissue transfer and appropriate rehabilitation in oromandibular reconstruction are becoming more popular. Full-thickness cheek defects represent a difficult reconstructive challenge, because both esthetic and functional issues must be addressed. 8 Regional flaps are usually not large enough to provide both intraoral lining and external skin. Although a combination of two regional flaps has been described for reconstruction of through-and-through defects, these are usually extensive procedures that require two or more stages and frequently create a bulky cheek that has poor function and poorer aesthetic results? Free flaps have become the preferred method for reconstructing such extensive defects; they can provide large quantities of 266
SITE SELECTION
The choice of free flap is dictated by the requirements of the defect. The defect should first be evaluated with regard to: 1) the amount of external skin; 2) intraoral lining requirement; and 3) soft tissue bulk required. There are a variety of different skin and soft tissue flaps that can be used to reconstruct these complex defects. The following free flaps tend to be the most useful for reconstruction of the cheek. Radial Forearm Flap The radial forearm free flap is a fasciocutaneous flap that is based on the radial artery, venae commitantes, and the cephalic vein. The cutaneous segment of the flap is hairless on the volar aspect, but can be quite hairy, particularly in men, on the radial aspect of the forearm. It provides a relatively poor color and texture match when compared with the skin of the cheek. It does, however, provide an extensive quantity of thin, pliable skin that is highly vascularized and very reliable. Multiple separate skin islands can be designed along the length of the forearm, and the flap can be effectively folded to provide the various surfaces that are necessary. Portions of the flap can also be de-epithelialized to provide soft tissue fill and contouring of the cheek. Sensation to this flap is provided by the lateral antebrachial cutaneous nerve, which can thereby provide a potentially sensate reconstruction. 4-7 The large-diameter, long vascular pedicle provides easy access to recipient vessels in the neck. The donor site is usually skin-grafted with acceptable results in most patients, with minimal to no functional deficit. Lateral Arm Flap The lateral arm fasciocutaneous flap is based on the radial collateral artery and its venae commitantes. Sensation to the skin of the flap is provided by the posterior cutaneous nerve of the forearm, which can be harvested with the flap, potentially making this a sensate flap. The skin is reasonably hairless, but somewhat thicker and less pliable than the skin of the cheek. This flap usually provides a moderate amount of subcutaneous tissue, which is useful if there is a soft tissue deficit such as after parotid resection. The vascular pedicle is usually adequate to anastomose to vessels on the neck, but the vessels are of small diameter; this can be a technically challenging flap. The lateral arm flap cannot be used for reconstructions requiring multiple skin islands. The donor site can usually be closed primarily only if it is less than 6.0 cm in width, and can be quite unattractive if skin-grafted. Anterolateral Thigh Flap The anterolateral thigh fasciocutaneous flap is based on the descending branch of the lateral circumflex femoral artery and accompanying vein. This flap can provide a huge skin island with a fairly extensive amount of soft tissue, CORDEIROAND SANTAMARIA
particularly in the heavy patient. The skin is fairly thick and minimally pliable. The blood vessels can be sometimes difficult to dissect and can be of small diameter, unless the pedicle is dissected fairly proximally in the thigh. This can then become difficult to position spatially when anastomoses to vessels in the upper neck are required. The donor site can be unattractive, particularly in the young female.
Scapular/ParascapularFlap The scapular flap is a fasciocutaneous flap based on the circumflex scapular vessels. This flap can provide large amounts of skin, as well as moderate amounts of soft tissue. The blood vessels are highly reliable and the skin is extremely well vascularized and dependable. It is usually not possible to create multiple skin islands unless a parascapular flap is raised simultaneously. The flap can be elevated with an osseous component and is useful when small amounts of bone (such as the ascending ramus of the mandible) must be reconstructed in combination with external skin and subcutaneous tissue. The skin is quite thick but tends to provide a reasonable color match for the skin of the cheek. In addition, the donor site may be closed, primarily leaving a relatively inconspicuous scar. The main drawback of this flap is that it requires a change of position of the patient during surgery, and flap dissection cannot be performed simultaneously with tumor resection. Thus, it tends to be used less often for reconstruction of the cheek. Rectus Abdominis Flap
The rectus abdominis myocutaneous flap is based on the inferior epigastric vessels. This flap can provide large quantities of skin as well as subcutaneous tissue and muscle, with multiple skin islands. The vessels are highly reliable and of good diameter. The pedicle can be lengthened up to 18 to 20 cm, which is very useful if recipient vessels are required in the contralateral neck. 1~ The main drawback of this flap is its bulk; it is therefore generally used only for the largest composite defects of the cheek and neck.
APPROACH TO CHEEK RECONSTRUCTION BASED ON TYPE OF DEFECT External Defects External Skin Only. These defects potentially require a large surface area of thin pliable skin with minimal soft tissue. In a majority of these cases, the radial forearm fasciocutaneous flap provides the ideal quantitiy of skin, with minimal bulk. To maximize esthetic results for these type of defects, it is best to keep the facial subunit concept in mind. If necessary, the defect should be extended to the junction lines between different facial subunits. 2 In many cases, the radial forearm flap provides poor color and texture match. One option to improve these esthetic results is to remove the skin at a later date, and to apply full-thickness supraclavicular skin grafts over the subcutaneous portion of the flap, to provide better color and texture match. FREE FLAP RECONSTRUCTION OF THE CHEEK
External Skin Plus Soft Tissue. These defects tend to require both extensive skin surface area as well as soft tissue volume. Many patients in this category have undergone parotidectomy in combination with resection of the skin. In some cases, the facial nerve may be resected. If technically feasible, the nerve should always be primarily grafted and then covered with the free flap. The choice of free flap ranges from a radial forearm flap to a lateral arm flap, anterolateral thigh flap, or scapular flap, depending on the increasing amount of soft tissue bulk that is required (Figs 2 and 3). In general, it is best to volume-overcorrect these defects and then, if necessary, to revise them secondarily with traditional liposuction. We have found the lateral arm flap to be most useful for radical parotidectomy defects (Fig 2). External Skin/Soft Tissue/Bone. If the resection includes bone, the bone does not necessarily need to be reconstructed. If the lateral aspect of the maxilla is missing, soft tissue coverage alone will usually provide adequate contour restoration. If the ascending ramus of the mandible is resected, then a combination of vascularized bone with skin and soft tissue is necessary. The scapular flap provides the idea] solution to this complicated problem, because the bone is usually adequate to reconstruct the mandible, and the skin/subcutaneous portion of the flap serves to cover the rest of the defect (Fig 4). Internal Lining Defects Mucosal Defects. Most small mucosal defects of the cheek can be closed primarily. Defects that involve the entire lining of the cheek, extending from maxillary to mandibular sulci, will usually require a free flap. These defects require a large surface area of very thin pliable skin; the radial forearm fasciocutaneous flap remains the flap of choice (Fig 5). Many of these resections include a marginal mandibulectomy, and in these situations, the flap can be sutured directly to the lingual mucosa inferiorly. Care must be taken to inset just the right amount of flap. Too much flap will create an insensate bulky mass in the oral cavity that may interefere with mastication. Too little flap may create difficulties with mouth opening and functional trismus. It is felt by many authors that skin undergoes "mucosalization" phenomena, which allow chewing without disruption of the oral lining integrity. The hair on the forearm flap can sometimes become an esthetic problem, and we have found that electrolysis for hair removal can be a useful adjunct to improving the final result. For patients with resection of the ascending ramus of the mandible in combination with the intraoral and pharyngeal lining, the forearm osteocutaneous flap provides an excellent solution, n The minimal amount of bone that is provided by the radius is usually adequate for reconstruction of the mandibular defect, and the skin provides excellent intraoral lining. Full-thickness (Through-and-Through) Defects These are usually extensive tumors that involve the intraoral lining, cheek soft tissues, plus external skin. The ideal flap for reconstruction of this type of defects is the radial 267
Fig 2. (A) A 64-year-old man with a basal carcinoma invading the parotid gland, showing limits of tumor excision. (B) Design of a lateral arm flap, used for reconstruction of the cheek defect. (C) Immediate postoperative result showing adequate facial contour with acceptable color match. This could be further improved with liposuction and flap revision.
forearm fasciocutaneous flap (Fig 6). The thin pliable skin provides both internal lining and external coverage when the flap is folded on itself, s,12,13 It usually provides adequate thickness and bulk to maintain the contour of the cheek. The major drawback of this type of reconstruction is the poor quality of the skin and the fact that the patient is usually left with a pin-cushioned type deformity externally as a result of the circumferential nature of the defect. We have not found a good method to improve on the esthetic result of this type of reconstruction (Fig 6); however, it does provide a good functional result. If the commissure of the mouth is resected, we generally do not advocate using a portion of the flap to reconstruct the commissure. 14-17Instead, we recommend restoration of
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continuity by suturing the lip to itself and then using the free flap to provide intraoral closure and external lining, is
Mucosa/Soft Tissue/Skin/Bone. These defects tend to be massive. Most of these patients have full-thickness resection of the cheek in combination with segmental mandibulectomy, as well as portions of the maxilla/orbit. These reconstructions require a flap that provides both extensive skin surface area as well as substantial soft tissue bulk. 19 There are basically two ways to approach this problem. A soft tissue reconstruction alone can be provided. If the patient is not too obese, a rectus flap will provide multiple
CORDEIRO AND SANTAMARIA
Fig 3. (A) A 62-year-old man with parotid carcinoma involving the cheek skin. (B) Because a large surface/moderate soft tissue bulk was created after tumor excision, an anterolateral thigh flap with a 12 x 27 skin island was used for reconstruction. (C) Postoperative result 8 months after surgery, before revision, showing adequate resurfacing of the cheek skin. Note that the color of the skin in this flap usually does not match that of the face.
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Fig 4. (A) A 49-year-old woman with a recurrent parotid tumor after receiving radiation therapy. She underwent excision of the cheek skin, parotid gland, facial nerve, masticatory muscles, and the ascending ramus of the mandible. (B) The defect was reconstructed using an osteocutaneous scapular free flap. Note that this flap provides an extensive amount of skin and subcutaneous tissue, in addition to the lateral border of the scapula, which is used for reconstruction of the ascending ramus of the mandible. (C) Postoperative result at 2 years, showing excellent contour and color match of the cheek reconstruction.
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CORDEIRO AND SANTAMARIA
Fig 5. (A) Preoperative photo of an intraoral carcinoma arising from the buccal mucosa in a 35-year-old man. (B) The approach to tumor excision was through a cheek flap reflected laterally to completely expose the cheek inner lining. Resurfacing of the cheek mucosa was performed using a radial forearm fasciocutaneous flap, sutured to the remaining mucosa. (C) Postoperative result 6 months after surgery, showing adequate contour and "mucosalization" of the cheek mucosa.
skin islands to restore intraoral/palatal closure as well as a second skin island to resurface externally. The bulk of the flap will often provide a surprisingly reasonable contour, despite the fact that mandibulectomy has been performed (Fig 7). Many of these patients require revisionary procedures to improve contour. A second approach to this type of problem is to reconstruct both the bony deficit as well as the intraoral and external lining. In this situation, a double free flap is the only solution to the problem. The fibula osteocutaneous free flap can be used to reconstruct the mandibular segmental deficit, with the skin used externally. A forearm flap can then be used to reline the cheek introrally. In general, these massive defects will have poor esthetic results, but still function remarkably well. FREE FLAP RECONSTRUCTION OF THE CHEEK
CONCLUSION The algorithm for reconstruction of complex defects of the cheek using microsurgical techniques is driven purely by the type of defect. External skin resurfacing or intraoral lining is best restored with a very thin pliable flap, such as the forearm fasciocutaneous flap. Full-thickness cheek defects are also best restored with a folded forearm flap. More extensive external defects that have larger soft tissue requirements are best reconstructed with thicker fasciocutaneous flaps such as the lateral arm, anterolateral thigh, and scapular flap. Full-thickness defects involving the upper and or lower jaw are reconstructed with soft tissue flaps such as the rectus abdominis myocutaneous flap, scapular osteocutaneous flap, or multiple free flaps. 271
Fig 6. (A) Intraoperative photo after excision of a recurrent squamous cell carcinoma in the perioral region, showing a through-and-through cheek defect. Note the opening of the oral commissure to allow better access for tumor excision and flap fixation. (B) Reconstruction of the defect was performed using a two-island radial forearm fasciocutaneous free flap, folded on itself. (C) The free flap has been inset using the proximal skin island to reline the inner mucosa and the distal skin island for external coverage. (D) Postoperative result showing an acceptable cheek contour. Note the presence of a pin-cushioned deformity over the cheek skin, which is secondary to the circumferential nature of the defect.
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CORDEIRO AND SANTAMARIA
Fig 7. (A) Intraoperative defect in a 61-year-old man with recurrent squamous cell carcinoma of the right cheek, who underwent resection of the right cheek, orbital contents, hemimandible, maxilla, and palate extending to the midline and the lateral cranial base. (B) A lower lip-switch flap was used to reconstruct the oral commissure and upper lip, and a rectus abodminis free flap with two islands was used to reconstruct the intraoral/palatal defect and to provide external resurfacing of the cheek unit in one stage. (C) Postoperative result 3 years later, after one revision of the free flap to decrease bulk. The patient has good rnasticatory function, adequate oral competence, and has very intelligible speech (From Cordeiro PG, Santamaria E: Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg 103:1850, 1999; reprinted with permission.)
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REFERENCES 1. Upton J, Albin RE, Mulliken JB, et al: The use of scapular and parascapular flaps for cheek reconstruction. Plast Reconstr Surg 90:959-971, 1992 2. Menick FJ: Facial reconstruction in aesthetic units: Reconstructive philosophy and subunit principles, in Kroll SS (ed): Reconstructive Plastic Surgery for Cancer. St. Louis, MO, Mosby, 1996, pp 166-183 3. Bunkis J, Mulliken JB, Upton J, et al: The evolution of techniques for reconstruction of full-thickness defects. Plast Reconstr Surg 70:319327, 1982 4. Boyd B, Mulholland S, Gullane P, et al: Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: Are we making sense? Plast Reconstr Surg 93:1350-1359, 1994 5. Vriens JPM, Acosta R, Soutar DS, et al: Recovery of sensation in the radial forearm free flap in oral reconstruction. Plast Reconstr Surg 98:649-656, 1996 6. Cordeiro PG, Schwartz M, Neves RI, et ah A comparison of donor and recipient site sensation in free tissue reconstruction of the oral cavity. Ann Plast Surg 39:461-468, 1997 7. Santamaria E, Wei F-C, Chen I-H: Sensation recovery on innervated radial forearm flap for hemiglossectomy reconstruction using different recipient nerves. Plast Reconstr Surg 103:450-457, 1999 8. Freedman AM, Hidalgo DA: Full-thickness cheek and lip reconstruction with the radial forearm free flap. Ann Plast Surg 25:287-294, 1990 9. Strasnick L, Calcaterra TC: Reconstruction of full-thickness cheek defects with combined cervicopectoral and pectoralis major myocutaneous flaps. Laryngoscope 99:757-760, 1989
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10. Cordeiro PG, Santamaria E: The extended pedicle rectus abdominus free tissue transfer for head and neck reconstruction. Ann Plast Surg 39:53-59, 1997 11. Zenn MR, Hidalgo DA, Cordeiro PG, et al: Current role of the radial forearm free flap in mandibular reconstruction. Plast Reconstr Surg 99:1012-1017, 1997 12. Savant DN, Patel SG, Deshmukh, SP, et al: Folded free radial forearm flap for reconstruction of full-thickness defects of the cheek. Head Neck 17:293-296, 1995 13. Niranjan NS, Watson DP: Reconstruction of the cheek using a "suspended" radial forearm free flap. Br J Plast Surg 43:365-366,1990 14. Katou, F, Shirai N, Kamakura S, et ah Full-thickness reconstruction of cheek defect involving oral commissure with forearm tendinocutaneous flap. Br J Oral Maxillofac Surg 34:26-27,1996 15. Furuta A, Sakaguchi Y, Iwasawa M, et al: Reconstruction of the lips, oral commissure and full thickness cheek with a composite radial forearm plamaris longus free flap. Ann Plast Surg 33:544-547, 1994 16. Naasan A, Quaba AA: Reconstruction of the oral commissure by vascularised toe web transfer. Br J Plast Surg 43:376-378,1990 17. Khazanchi RK. A new design for reconstruction of composite defects of cheek and lips [Letter]. Plast Reconstr Surg 98:370-371, 1995 18. Cordeiro PG, Santamaria E: Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg 103:1850-1856, 1999 19. Cordeiro PG, Santamaria E: A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg (in press)
CORDEIRO AND SANTAMARIA
Free flaps are primarily indicated for reconstruction of large cheek defects involving the external skin, inner lining, or full thickness. The radial forearm flap is our first option for reconstruction of such defects because of its thin pliable skin paddle with minimal soft tissue. The lateral arm or anterior thigh fasciocutaneous flaps provide larger amounts of skin and soft tissue volume and are therefore used for larger cheek defects. Once masticatory muscles, the parotid gland, and/or the maxilla or mandible are included with the resection, cheek defects become more complex, and larger soft tissue or composite free flaps are mandatory for reconstruction. The rectus abdominis myocutaneous free flap has proved to be very useful for reconstruction of these massive defects, and the scapular or latissimus dorsi free flap are secondary alternatives. Cheek defects including the ascending ramus of the mandible are best reconstructed using an osteocutaneous scapular or radial forearm flap. Full-thickness cheek defects that include the oral commissure and lips are more challenging to reconstruct. We advocate using a lip-switch procedure to provide a functional stoma and using a free flap with two separate skin islands for lining and cover, but not for reconstruction of the oral commissure. Copyright 9 1999 by W.B. Saunders Company KEY WORDS: cheek reconstruction, free flaps
Facial contour depends to a large extent on the soft tissues of the cheeks and subjacent bony structure. Each cheek is composed of an external skin layer and an internal surface, which is part of the oral mucosa. The parotid gland, facial nerve, and masticatory and muscles of facial expression are contained between these two layers. The elasticity of the cheek skin and mucosa creates its unique functional capabilities--it contributes to oral competence as well as the ability to act as a reservoir for liquids and solids. The cheek is limited superiorly by a horizontal line that extends from the infraorbital rim to the root of the auricular helix. Laterally, the cheek extends over the anterior border of the ear and continues inferiorly along the mandibular border. The medial margin of the cheek is the lateral nasal wall and nasolabial crease (Fig 1). Tumors involving the cheek m a y arise from a variety of different tissue components that make up this complicated structure. Tumors m a y arise from the skin externally, the mucosa internally, or the muscles and the parotid gland in between. If the skin or mucosa is resected, the defects are more likely to require some form of plastic reconstruction. These reconstructive problems become m u c h more difficultif multiple layers of the cheek are involved, and even more complex if adjacent structures such as the eyelid, nose, lips, commissure, and mandible or maxilla are involved. The vast majority of small- and medium-size defects of the cheek m a y be closed primarily using local or regional flaps. Free flaps are usually reserved only for reconstruc-
From the Department of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY. Address reprint requests to Peter G. Cordeiro, M.D., Room C-1189, 1275 York Ave., New York, NY 10021. Copyright 9 1999 by W.B. Saunders Company 1071-0949/99/0604-0006510.00/0
tion of large defects involving external skin, intraoral lining, or both (full-thickness defects). They are usually essential if the resections include the upper or lower jaw with soft tissue and skin. Free tissue transfer has also been described for improvement of contour deformities that m a y be congenital or acquired in nature. 1 This particular group of deformities will not be addressed in this article.
INDICATIONS FOR FREE TISSUE TRANSFER As with any reconstructive procedure, the simplest technique is usually selected if it will adequately achieve the objectives of the reconstruction. When methods such as skin grafts, local flaps, or regional flaps are unavailable or inadequate, a free flap becomes the m e t h o d of choice. After applying these parameters for reconstruction, the principal indications for using a free flap for cheek reconstruction include: 1) resurfacing of extensive external skin defects; 2) resurfacing of extensive intraoral defects; 3) moderate to large through-and-through defects; 4) extensive contour deformities; and 5) smaller defects where local flaps are unreliable due to previous surgery, compromised blood supply, or radiation therapy.
GENERAL CONSIDERATIONS There are several basic principles that must be applied to reconstruction of the three layers of the cheek (external skin, internal lining, soft tissue fill). Resurfacing external cheek skin is principally an esthetic endeavor, and issues such as contour, color match, texture, and appearance are of primary concern. The principle of facial units should be adhered to as much as possible to optimize esthetic results
Operative Techniques in Plastic and Reconstructive Surgery, Vol 6, No 4 (November), 1999: pp 265-274
265
thin pliable skin in addition to multiple skin islands. These flaps can restore intraoral lining and cheek skin in one stage, without a major increase in bulk.
\
FREE FLAP DONOR
S~ S sS I
2 r
l 1
! I
Fig 1. The esthetic units of the face (A) and subunits of the cheek (B). These are subdivided into: 1) suborbital, 2) preauricular, and 3) buccomandibular. in cheek reconstruction. 2 The cheek may be considered a single total facial unit or may be divided into three smaller overlapping subunits: 1) suborbital, 2) preauricular, and 3) buccomandibular (Fig 1). Although it may be occasionally necessary to sacrifice adjacent normal tissue, final results are far superior when scars follow facial subunits, thus minimizing the appearance of a "patch." Restoration of intraoral cheek mucosa is essential to maximize the functional aspects of speech and mastication. With the introduction of microsurgical techniques, our ability to reconstruct massive intraoral defects has improved substantially over the last two decades. 3 More recently, the importance of sensation for adequate function and meaningful quality of life after flap intraoral reconstruction has been emphasized. 4-7 The capability to sense ingested food in the mouth facilitates mastication and enhances swallowing function; it also favors gustatory delectation, prevents pooling and drooling of saliva, and increases quality of speech. For this reason, surgical techniques to provide sensate free tissue transfer and appropriate rehabilitation in oromandibular reconstruction are becoming more popular. Full-thickness cheek defects represent a difficult reconstructive challenge, because both esthetic and functional issues must be addressed. 8 Regional flaps are usually not large enough to provide both intraoral lining and external skin. Although a combination of two regional flaps has been described for reconstruction of through-and-through defects, these are usually extensive procedures that require two or more stages and frequently create a bulky cheek that has poor function and poorer aesthetic results? Free flaps have become the preferred method for reconstructing such extensive defects; they can provide large quantities of 266
SITE SELECTION
The choice of free flap is dictated by the requirements of the defect. The defect should first be evaluated with regard to: 1) the amount of external skin; 2) intraoral lining requirement; and 3) soft tissue bulk required. There are a variety of different skin and soft tissue flaps that can be used to reconstruct these complex defects. The following free flaps tend to be the most useful for reconstruction of the cheek. Radial Forearm Flap The radial forearm free flap is a fasciocutaneous flap that is based on the radial artery, venae commitantes, and the cephalic vein. The cutaneous segment of the flap is hairless on the volar aspect, but can be quite hairy, particularly in men, on the radial aspect of the forearm. It provides a relatively poor color and texture match when compared with the skin of the cheek. It does, however, provide an extensive quantity of thin, pliable skin that is highly vascularized and very reliable. Multiple separate skin islands can be designed along the length of the forearm, and the flap can be effectively folded to provide the various surfaces that are necessary. Portions of the flap can also be de-epithelialized to provide soft tissue fill and contouring of the cheek. Sensation to this flap is provided by the lateral antebrachial cutaneous nerve, which can thereby provide a potentially sensate reconstruction. 4-7 The large-diameter, long vascular pedicle provides easy access to recipient vessels in the neck. The donor site is usually skin-grafted with acceptable results in most patients, with minimal to no functional deficit. Lateral Arm Flap The lateral arm fasciocutaneous flap is based on the radial collateral artery and its venae commitantes. Sensation to the skin of the flap is provided by the posterior cutaneous nerve of the forearm, which can be harvested with the flap, potentially making this a sensate flap. The skin is reasonably hairless, but somewhat thicker and less pliable than the skin of the cheek. This flap usually provides a moderate amount of subcutaneous tissue, which is useful if there is a soft tissue deficit such as after parotid resection. The vascular pedicle is usually adequate to anastomose to vessels on the neck, but the vessels are of small diameter; this can be a technically challenging flap. The lateral arm flap cannot be used for reconstructions requiring multiple skin islands. The donor site can usually be closed primarily only if it is less than 6.0 cm in width, and can be quite unattractive if skin-grafted. Anterolateral Thigh Flap The anterolateral thigh fasciocutaneous flap is based on the descending branch of the lateral circumflex femoral artery and accompanying vein. This flap can provide a huge skin island with a fairly extensive amount of soft tissue, CORDEIROAND SANTAMARIA
particularly in the heavy patient. The skin is fairly thick and minimally pliable. The blood vessels can be sometimes difficult to dissect and can be of small diameter, unless the pedicle is dissected fairly proximally in the thigh. This can then become difficult to position spatially when anastomoses to vessels in the upper neck are required. The donor site can be unattractive, particularly in the young female.
Scapular/ParascapularFlap The scapular flap is a fasciocutaneous flap based on the circumflex scapular vessels. This flap can provide large amounts of skin, as well as moderate amounts of soft tissue. The blood vessels are highly reliable and the skin is extremely well vascularized and dependable. It is usually not possible to create multiple skin islands unless a parascapular flap is raised simultaneously. The flap can be elevated with an osseous component and is useful when small amounts of bone (such as the ascending ramus of the mandible) must be reconstructed in combination with external skin and subcutaneous tissue. The skin is quite thick but tends to provide a reasonable color match for the skin of the cheek. In addition, the donor site may be closed, primarily leaving a relatively inconspicuous scar. The main drawback of this flap is that it requires a change of position of the patient during surgery, and flap dissection cannot be performed simultaneously with tumor resection. Thus, it tends to be used less often for reconstruction of the cheek. Rectus Abdominis Flap
The rectus abdominis myocutaneous flap is based on the inferior epigastric vessels. This flap can provide large quantities of skin as well as subcutaneous tissue and muscle, with multiple skin islands. The vessels are highly reliable and of good diameter. The pedicle can be lengthened up to 18 to 20 cm, which is very useful if recipient vessels are required in the contralateral neck. 1~ The main drawback of this flap is its bulk; it is therefore generally used only for the largest composite defects of the cheek and neck.
APPROACH TO CHEEK RECONSTRUCTION BASED ON TYPE OF DEFECT External Defects External Skin Only. These defects potentially require a large surface area of thin pliable skin with minimal soft tissue. In a majority of these cases, the radial forearm fasciocutaneous flap provides the ideal quantitiy of skin, with minimal bulk. To maximize esthetic results for these type of defects, it is best to keep the facial subunit concept in mind. If necessary, the defect should be extended to the junction lines between different facial subunits. 2 In many cases, the radial forearm flap provides poor color and texture match. One option to improve these esthetic results is to remove the skin at a later date, and to apply full-thickness supraclavicular skin grafts over the subcutaneous portion of the flap, to provide better color and texture match. FREE FLAP RECONSTRUCTION OF THE CHEEK
External Skin Plus Soft Tissue. These defects tend to require both extensive skin surface area as well as soft tissue volume. Many patients in this category have undergone parotidectomy in combination with resection of the skin. In some cases, the facial nerve may be resected. If technically feasible, the nerve should always be primarily grafted and then covered with the free flap. The choice of free flap ranges from a radial forearm flap to a lateral arm flap, anterolateral thigh flap, or scapular flap, depending on the increasing amount of soft tissue bulk that is required (Figs 2 and 3). In general, it is best to volume-overcorrect these defects and then, if necessary, to revise them secondarily with traditional liposuction. We have found the lateral arm flap to be most useful for radical parotidectomy defects (Fig 2). External Skin/Soft Tissue/Bone. If the resection includes bone, the bone does not necessarily need to be reconstructed. If the lateral aspect of the maxilla is missing, soft tissue coverage alone will usually provide adequate contour restoration. If the ascending ramus of the mandible is resected, then a combination of vascularized bone with skin and soft tissue is necessary. The scapular flap provides the idea] solution to this complicated problem, because the bone is usually adequate to reconstruct the mandible, and the skin/subcutaneous portion of the flap serves to cover the rest of the defect (Fig 4). Internal Lining Defects Mucosal Defects. Most small mucosal defects of the cheek can be closed primarily. Defects that involve the entire lining of the cheek, extending from maxillary to mandibular sulci, will usually require a free flap. These defects require a large surface area of very thin pliable skin; the radial forearm fasciocutaneous flap remains the flap of choice (Fig 5). Many of these resections include a marginal mandibulectomy, and in these situations, the flap can be sutured directly to the lingual mucosa inferiorly. Care must be taken to inset just the right amount of flap. Too much flap will create an insensate bulky mass in the oral cavity that may interefere with mastication. Too little flap may create difficulties with mouth opening and functional trismus. It is felt by many authors that skin undergoes "mucosalization" phenomena, which allow chewing without disruption of the oral lining integrity. The hair on the forearm flap can sometimes become an esthetic problem, and we have found that electrolysis for hair removal can be a useful adjunct to improving the final result. For patients with resection of the ascending ramus of the mandible in combination with the intraoral and pharyngeal lining, the forearm osteocutaneous flap provides an excellent solution, n The minimal amount of bone that is provided by the radius is usually adequate for reconstruction of the mandibular defect, and the skin provides excellent intraoral lining. Full-thickness (Through-and-Through) Defects These are usually extensive tumors that involve the intraoral lining, cheek soft tissues, plus external skin. The ideal flap for reconstruction of this type of defects is the radial 267
Fig 2. (A) A 64-year-old man with a basal carcinoma invading the parotid gland, showing limits of tumor excision. (B) Design of a lateral arm flap, used for reconstruction of the cheek defect. (C) Immediate postoperative result showing adequate facial contour with acceptable color match. This could be further improved with liposuction and flap revision.
forearm fasciocutaneous flap (Fig 6). The thin pliable skin provides both internal lining and external coverage when the flap is folded on itself, s,12,13 It usually provides adequate thickness and bulk to maintain the contour of the cheek. The major drawback of this type of reconstruction is the poor quality of the skin and the fact that the patient is usually left with a pin-cushioned type deformity externally as a result of the circumferential nature of the defect. We have not found a good method to improve on the esthetic result of this type of reconstruction (Fig 6); however, it does provide a good functional result. If the commissure of the mouth is resected, we generally do not advocate using a portion of the flap to reconstruct the commissure. 14-17Instead, we recommend restoration of
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continuity by suturing the lip to itself and then using the free flap to provide intraoral closure and external lining, is
Mucosa/Soft Tissue/Skin/Bone. These defects tend to be massive. Most of these patients have full-thickness resection of the cheek in combination with segmental mandibulectomy, as well as portions of the maxilla/orbit. These reconstructions require a flap that provides both extensive skin surface area as well as substantial soft tissue bulk. 19 There are basically two ways to approach this problem. A soft tissue reconstruction alone can be provided. If the patient is not too obese, a rectus flap will provide multiple
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Fig 3. (A) A 62-year-old man with parotid carcinoma involving the cheek skin. (B) Because a large surface/moderate soft tissue bulk was created after tumor excision, an anterolateral thigh flap with a 12 x 27 skin island was used for reconstruction. (C) Postoperative result 8 months after surgery, before revision, showing adequate resurfacing of the cheek skin. Note that the color of the skin in this flap usually does not match that of the face.
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Fig 4. (A) A 49-year-old woman with a recurrent parotid tumor after receiving radiation therapy. She underwent excision of the cheek skin, parotid gland, facial nerve, masticatory muscles, and the ascending ramus of the mandible. (B) The defect was reconstructed using an osteocutaneous scapular free flap. Note that this flap provides an extensive amount of skin and subcutaneous tissue, in addition to the lateral border of the scapula, which is used for reconstruction of the ascending ramus of the mandible. (C) Postoperative result at 2 years, showing excellent contour and color match of the cheek reconstruction.
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Fig 5. (A) Preoperative photo of an intraoral carcinoma arising from the buccal mucosa in a 35-year-old man. (B) The approach to tumor excision was through a cheek flap reflected laterally to completely expose the cheek inner lining. Resurfacing of the cheek mucosa was performed using a radial forearm fasciocutaneous flap, sutured to the remaining mucosa. (C) Postoperative result 6 months after surgery, showing adequate contour and "mucosalization" of the cheek mucosa.
skin islands to restore intraoral/palatal closure as well as a second skin island to resurface externally. The bulk of the flap will often provide a surprisingly reasonable contour, despite the fact that mandibulectomy has been performed (Fig 7). Many of these patients require revisionary procedures to improve contour. A second approach to this type of problem is to reconstruct both the bony deficit as well as the intraoral and external lining. In this situation, a double free flap is the only solution to the problem. The fibula osteocutaneous free flap can be used to reconstruct the mandibular segmental deficit, with the skin used externally. A forearm flap can then be used to reline the cheek introrally. In general, these massive defects will have poor esthetic results, but still function remarkably well. FREE FLAP RECONSTRUCTION OF THE CHEEK
CONCLUSION The algorithm for reconstruction of complex defects of the cheek using microsurgical techniques is driven purely by the type of defect. External skin resurfacing or intraoral lining is best restored with a very thin pliable flap, such as the forearm fasciocutaneous flap. Full-thickness cheek defects are also best restored with a folded forearm flap. More extensive external defects that have larger soft tissue requirements are best reconstructed with thicker fasciocutaneous flaps such as the lateral arm, anterolateral thigh, and scapular flap. Full-thickness defects involving the upper and or lower jaw are reconstructed with soft tissue flaps such as the rectus abdominis myocutaneous flap, scapular osteocutaneous flap, or multiple free flaps. 271
Fig 6. (A) Intraoperative photo after excision of a recurrent squamous cell carcinoma in the perioral region, showing a through-and-through cheek defect. Note the opening of the oral commissure to allow better access for tumor excision and flap fixation. (B) Reconstruction of the defect was performed using a two-island radial forearm fasciocutaneous free flap, folded on itself. (C) The free flap has been inset using the proximal skin island to reline the inner mucosa and the distal skin island for external coverage. (D) Postoperative result showing an acceptable cheek contour. Note the presence of a pin-cushioned deformity over the cheek skin, which is secondary to the circumferential nature of the defect.
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Fig 7. (A) Intraoperative defect in a 61-year-old man with recurrent squamous cell carcinoma of the right cheek, who underwent resection of the right cheek, orbital contents, hemimandible, maxilla, and palate extending to the midline and the lateral cranial base. (B) A lower lip-switch flap was used to reconstruct the oral commissure and upper lip, and a rectus abodminis free flap with two islands was used to reconstruct the intraoral/palatal defect and to provide external resurfacing of the cheek unit in one stage. (C) Postoperative result 3 years later, after one revision of the free flap to decrease bulk. The patient has good rnasticatory function, adequate oral competence, and has very intelligible speech (From Cordeiro PG, Santamaria E: Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg 103:1850, 1999; reprinted with permission.)
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REFERENCES 1. Upton J, Albin RE, Mulliken JB, et al: The use of scapular and parascapular flaps for cheek reconstruction. Plast Reconstr Surg 90:959-971, 1992 2. Menick FJ: Facial reconstruction in aesthetic units: Reconstructive philosophy and subunit principles, in Kroll SS (ed): Reconstructive Plastic Surgery for Cancer. St. Louis, MO, Mosby, 1996, pp 166-183 3. Bunkis J, Mulliken JB, Upton J, et al: The evolution of techniques for reconstruction of full-thickness defects. Plast Reconstr Surg 70:319327, 1982 4. Boyd B, Mulholland S, Gullane P, et al: Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: Are we making sense? Plast Reconstr Surg 93:1350-1359, 1994 5. Vriens JPM, Acosta R, Soutar DS, et al: Recovery of sensation in the radial forearm free flap in oral reconstruction. Plast Reconstr Surg 98:649-656, 1996 6. Cordeiro PG, Schwartz M, Neves RI, et ah A comparison of donor and recipient site sensation in free tissue reconstruction of the oral cavity. Ann Plast Surg 39:461-468, 1997 7. Santamaria E, Wei F-C, Chen I-H: Sensation recovery on innervated radial forearm flap for hemiglossectomy reconstruction using different recipient nerves. Plast Reconstr Surg 103:450-457, 1999 8. Freedman AM, Hidalgo DA: Full-thickness cheek and lip reconstruction with the radial forearm free flap. Ann Plast Surg 25:287-294, 1990 9. Strasnick L, Calcaterra TC: Reconstruction of full-thickness cheek defects with combined cervicopectoral and pectoralis major myocutaneous flaps. Laryngoscope 99:757-760, 1989
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10. Cordeiro PG, Santamaria E: The extended pedicle rectus abdominus free tissue transfer for head and neck reconstruction. Ann Plast Surg 39:53-59, 1997 11. Zenn MR, Hidalgo DA, Cordeiro PG, et al: Current role of the radial forearm free flap in mandibular reconstruction. Plast Reconstr Surg 99:1012-1017, 1997 12. Savant DN, Patel SG, Deshmukh, SP, et al: Folded free radial forearm flap for reconstruction of full-thickness defects of the cheek. Head Neck 17:293-296, 1995 13. Niranjan NS, Watson DP: Reconstruction of the cheek using a "suspended" radial forearm free flap. Br J Plast Surg 43:365-366,1990 14. Katou, F, Shirai N, Kamakura S, et ah Full-thickness reconstruction of cheek defect involving oral commissure with forearm tendinocutaneous flap. Br J Oral Maxillofac Surg 34:26-27,1996 15. Furuta A, Sakaguchi Y, Iwasawa M, et al: Reconstruction of the lips, oral commissure and full thickness cheek with a composite radial forearm plamaris longus free flap. Ann Plast Surg 33:544-547, 1994 16. Naasan A, Quaba AA: Reconstruction of the oral commissure by vascularised toe web transfer. Br J Plast Surg 43:376-378,1990 17. Khazanchi RK. A new design for reconstruction of composite defects of cheek and lips [Letter]. Plast Reconstr Surg 98:370-371, 1995 18. Cordeiro PG, Santamaria E: Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg 103:1850-1856, 1999 19. Cordeiro PG, Santamaria E: A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg (in press)
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