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Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e6
Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties Xiaorong Liu a,*, Yusheng Liu a, Keqiong Chen a, Yan Gao a, Weilong Huang a, Wenwei Yuan a, Qian Cai b a Department of Plastic and Cosmetic Surgery, Dongguan People’s Hospital, No.3 Wandao Road, Wanjiang District, Dongguan 523018, China b Department of Otolaryngology-Head and Neck, Sun Yat-sen Hospital, Sun Yat-sen University, 107, Yan Jiang West Road, Guangzhou 510120, China
Received 19 May 2015; accepted 12 July 2015
KEYWORDS Cheek; Rotation flap; Z-plasty; Skin defect
Summary Background: Cervicofacial flaps are commonly used in the reconstruction of skin defects in regions such as the medial cheek and lower eyelid. However, their drawbacks include long flap incision, extensive undermining, and a high possibility of postoperative complications including distal flap necrosis and lower eyelid ectropion. Methods: Nine cases of reconstruction of skin defects in the medial cheek and adjacent areas were performed using a lateral cheek rotation flap in combination with Z-plasties between October 2009 and August 2014. In the surgery, the defect was trimmed into a downwardpointing triangle, with the flap incision line starting from the bottom edge of the defect and extending outward in the lateral orbital direction in an arc until before the sideburn. After the flap was undermined, double or quadruple Z-plasties were performed along the lateral orbital incision line to elongate the flap. Results: All flaps survived without the occurrence of complications such as hematoma, wound infection, distal flap necrosis, and lower eyelid ectropion. During the follow-up period, the flaps exhibited good color and texture. A natural looking cheek was restored without obvious scars. Conclusions: A lateral cheek rotation flap in combination with Z-plasty is an optimal method for reconstruction of skin defects in the medial cheek and lower eyelid region. Compared to conventional cervicofacial flaps, the lateral cheek rotation flap was shown to have a variety
* Corresponding author. Tel.: þ86 769 28636535. E-mail address: [email protected] (X. Liu). http://dx.doi.org/10.1016/j.bjps.2015.07.014 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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X. Liu et al. of advantages, including a simpler operation, shorter flap incision, minimal undermining, and effective prevention of complications such as lower eyelid ectropion and distal flap necrosis. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction The Mustarde flap1 and its derivatives, the cervicofacial2e13 or cervicothoracic14 flaps, have been reported in the reconstruction of skin defects in the areas of the medial cheek and lower eyelid. However, these types of flaps involve a long incision and extensive undermining and have a higher incidence of postoperative complications such as distal flap necrosis and lower eyelid ectropion. Belmahi et al. used a temporoparietal scalp rotation flap to reconstruct the preauricular donor area of the Mustarde flap. This method reduced the undermining area of the Mustarde flap and decreased the incidence of complications including hematoma, distal flap necrosis, and lower eyelid ectropion. However, the sideburns are moved downward after the surgery, producing an unnatural look, especially in female patients.9,10 In this study, reconstruction of skin defects in the medial cheek and adjacent areas were performed in nine patients using a lateral cheek rotation flap in combination with Z-plasty and achieved desirable results, which are reported below.
Patients and methods This group of patients consisted of four males and five females, aged between 18 and 83 years old, with an average age of 48 years. The etiologies included five cases of basal cell carcinoma, one case of skin and soft tissue sarcoma, one case of vascular malformation, one case of cicatrix, and one case of skin defects from trauma. The locations of the skin defects included six cases of the medial cheek, two
Figure 1 The excision area of the skin tumor was marked with Methylene blue.
cases of the medial cheek and lower eyelid, and one case of the medial cheek, paranasal area, and medial canthus. The largest area of a skin defect was 7.0 cm 6.0 cm, the smallest area was 2.0 cm 2.0 cm, and the average area was 4.5 cm 3.8 cm. Three patients underwent double Zplasties, and six patients received quadruple Z-plasties.
Surgical procedure Surgery was performed under local or general anesthesia. Methylene blue was used to mark the excision area of the skin tumor, vascular malformation, and cicatrix (Figure 1). Tumor resection required intraoperative frozen section analysis to confirm complete removal of the tumor with negative margins. The defect was trimmed into a downward-pointing triangle, with the flap incision line starting from the bottom edge of the defect and extending outward in the lateral orbital direction in an arc until before the sideburn. According to the size of the defect, double or quadruple Z-plasties were designed along the lateral orbital incision line, which was the incision line between the outer canthus and the sideburn (Figure 2). The cheek flap incision was performed, followed by subcutaneous undermining of the flap to 3 cm below the defect using electrocautery. After undermining, the cheek flap was pushed toward the defect to estimate the flap tension. Z-plasty incisions were made one by one until the distal end of the cheek flap could be translocated to the defect without any tension. The inside of the cheek flap was
Figure 2 The defect was trimmed into a downward-pointing triangle, quadruple Z-plasties were designed along the lateral orbital incision line, which was the incision line between the outer canthus and the sideburn.
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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Reconstruction of skin defects in the medial cheek
Figure 3 The postoperative 7 days view showing the position of Z-plasty flap ① was exchanged with it of Z-plasty flap ②,and the position of Z-plasty flap ③ was exchanged with Z-plasty flap ④. The indent on the flap caused by bone anchoring sutures disappeared after two months.
anchored to the lateral orbital periosteum with silk suture. The positions of the Z-plasty flaps were exchanged with each other (Figure 3). A drainage sheet was placed beneath the cheek flap, and the incision was closed layer by layer.
Results All flaps survived without the occurrence of complications such as hematoma, wound infection, distal flap necrosis, and lower eyelid ectropion. The follow-up period ranged from six months to five years. One patient died from cardiovascular disease two years after the surgery. No tumor relapse was observed in patients with tumors. The flaps exhibited good color and texture. A natural-looking cheek was restored without obvious scars. (Figure 4eFigure 7)
Discussion In the reconstruction of medial cheek skin defects due to trauma and the removal of skin tumors and scars, the
3 sources of tissue for reconstruction are limited because the medial cheek abuts the lower eyelid superiorly and is adjacent to the nose and lip medially. Improper reconstruction leads to deformities such as lower eyelid ectropion, lateral shifting of the nasal sidewall, alar splaying, and oral commissure dislocation.15 Therefore, reconstruction of skin defects in the medial cheek presents unique challenges for plastic surgeons. Minor skin defects in the medial cheek are usually closed directly. However, moderate or large skin defects require skin grafts or skin flap transfers. Skin grafting often causes a ‘patch-like’ appearance that leads to a disfigured look, and skin graft contraction at later stages can result in deformities such as lower eyelid ectropion and oral commissure dislocation. Local flaps include the rhomboid flap,16 bilobed flap,17 VeY advancement flap,15,16,18 and hatchetskin flap.19 These skin flaps yield desirable restoration but are normally used in the reconstruction of small or mediumsized skin defects. Pedicle flaps mainly include the submental flap,20,21 hemiforehead flap,22 nasal flap,23 retroangular flap,24 orbicularis oculi myocutaneous flap in the temporal area,25 and the recently reported reverse superior labial artery flap.26 These flaps require dissection of the vascular pedicle, which is associated with timeconsuming surgery and scars left in the donor area. Free flaps require vascular anastomosis, and the color and texture of the flaps are different from the skin in the cheek. Expanded flaps require staged surgery, which increases costs and patient suffering, and they are not suitable for patients who need immediate reconstruction due to tumor or trauma. Cervicofacial flaps are commonly used in the reconstruction of medium-to large-sized skin defects in regions such as the medial cheek and lower eyelid. The color and texture of cervicofacial flaps are consistent with the skin in the cheek, which results in a well-restored appearance. Cervicofacial flaps can be anteriorly or posteriorly based, and they can be elevated in the subcutaneous or sub-superficial musculoaponeurotic system (sub-SMAS) plane.5,10 Subcutaneous cervicofacial flaps involve a wide pedicle, long flap incision, and extensive undermining, and they are susceptible to complications such as distal flap necrosis and lower eyelid ectropion. Although sub-SMAS cervicofacial flaps can increase the blood supply of the
Figure 4 (Left) Preoperative frontal view of a 38-year-old woman with recurrent basal cell carcinoma in her left infraorbital area. (Middle and right) Late postoperative frontal view and oblique views (two years).
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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Figure 5 (Above) An 83-year-old woman with basal cell carcinoma in her right infraorbital area. (Below, left) Preoperative frontal view. (Below, middle) Postoperative frontal view (three months). (Below, right) Postoperative oblique views (three months).
flaps, they also carry a risk of damage to facial nerve branches and are susceptible to lower eyelid ectropion. Belmahi et al. used a temporoparietal scalp rotation flap in combination with a Mustarde flap to reconstruct infraorbital skin defects. This method reduced the undermining area of the Mustarde flap and decreased the incidence rates of hematoma and distal flap necrosis. In addition, the suspension function of the scalp flap helped to avoid the occurrence of lower eyelid ectropion. However, this method used a scalp flap with hair to repair preauricular defects, producing an unnatural look, especially in female patients.9,10 In this study, skin defects in the medial cheek were reconstructed with a lateral cheek rotation flap. Meanwhile, Z-plasties were performed along the lateral orbital flap incision line. After the Z-plasties were completed, the length of the flap was significantly elongated, and the medial reach range of the flap was broadened. Rohrich et al. reported that 60-degree Z-plasty could theoretically increase the length of the flap by 70% and that no significant difference was observed regarding flap length increases between multiple small Z-plasties and a single large Z-plasty.27 If the length of the incision line from the lateral canthus to the sideburn was X, then the flap length would be increased by 0.7X after the Z-plasties. Previously, Z-plasty was mainly used to lengthen scars, change scar
direction, correct soft tissue deformities, and improve function.27 Using Z-plasty to elongate skin flaps has not been reported in the literature, and this report adds a new application for Z-plasty. The advantages of the surgical method reported here are summarized as follows. (1) The main issue in using anteriorly based cervicofacial rotation flaps for the reconstruction of medial cheek skin defects is excessive horizontal tension in the flap. Sometimes, to reconstruct a medium-sized defect, the incision has to be extended to the postauricular region, occipital hairline, and even the thoracic region. Extensive flap undermining leads to a reduction in the distal blood supply and an increased risk of bleeding. Z-plasty was performed along the lateral orbital incision, which makes efficient use of vertically relaxed cervicofacial skin. This technique compensates for the shortage of horizontally oriented skin and decreases the undermining area and the incidence rate of distal flap necrosis and hematoma. (2) Using Z-plasty for flap reconstruction in the presideburn area avoids the dislocation of the sideburn and lateral canthus and eases the problem of closing the Mustarde flap in the preauricular donor area.9 (3) Following flap transposition in Z-plasty, the incision line at the lateral canthus was nearly in a vertical direction, and scar contraction pulled the skin upward, which further
Figure 6 (Left) Preoperative frontal view of a 24-year-old woman with soft tissue sarcoma in her left medial cheek. (Middle and right) Late postoperative frontal and oblique views (two years).
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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Reconstruction of skin defects in the medial cheek
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Figure 7 (Left) Preoperative frontal view of a 71-year-old woman with basal cell carcinoma in her left medial cheek and lower eyelid. The tumor involved the eyelid margin but not the tarsal plate. The flap incision was first made in the gray line, extending just through the lateral canthus and continuing superiorly into the lateral orbital area, finally ending just before the sideburn. (Middle and right) Early postoperative frontal and oblique views (two months).
prevented the occurrence of lower eyelid ectropion. (4) The surgical method described here is in compliance with the principles of “replace like with like” and “for both appearance and function, use tissues from less important areas to reconstruct wounds in important areas”. The medial cheek is adjacent to the center of the face and functions in supporting the lower eyelid and nasolabial structures. Meanwhile, the lateral cheek is in the peripheral region of the face, with less impact on supporting other structures. In addition, deformities appear more evident when they are closer to the center of the face. Thus, compared to the lateral cheek, the medial cheek is more important for maintaining the facial appearance and function. (5) The flap was elevated in the subcutaneous plane, which avoids damage to the facial nerve and its branches and makes the surgical procedure easier. (6) This surgical procedure is also suitable for defects in the anterior lamella of the lower eyelid and for defects involving the eyelid margin (see Figure 7). The disadvantage of this surgical procedure is the introduction of an incision in the normal skin in the lateral orbital area, which may aggravate incision scars in the lateral orbital area. However, long-term follow-up indicated that the scars from the lateral orbital incision were inconspicuous. Furthermore, this surgical procedure is only suitable for the reconstruction of skin defects located medial to the lateral canthus. Skin defects located beyond the lateral canthus should be repaired using other methods.
Conclusions A lateral cheek rotation flap in combination with Z-plasty is an optimal method for reconstruction of skin defects in the medial cheek and lower eyelid region. Compared to conventional cervicofacial flaps, the lateral cheek rotation flap was shown to have a variety of advantages, including a simpler operation, shorter flap incision, minimal undermining, and effective prevention of complications such as lower eyelid ectropion and distal flap necrosis. The authors suggest using the method in patients with skin defects located medial to the lateral canthus.
Ethical approval The study was approved by the ethical committee of the Dongguan people’s Hospital. Written informed consent to use preoperative, intraoperative, and postoperative photographs was obtained from the patients who appear in this report.
Funding None.
Conflicts of interest None declared.
References 1. Mustarde JC. The use of the flaps in the orbital region. Plast Reconstr Surg 1970;45:146e50. 2. Juri J, Juri C. Advancement and rotation of a large cervicofacial flap for cheek repairs. Plast Reconstr Surg 1979;64:692e6. 3. Kroll SS, Reece GP, Robb G, Black J. Deep-plane cervicofacial rotation-advancement flap for reconstruction of large cheek defect. Plast Reconstr Surg 1994;94:88e93. 4. Longaker MT, Glat PM, Zide BM. Deep-plane cervicofacial “hike”:anatomic basis with dog-ear blepharoplasty. Plast Reconstr Surg 1997;99:16e21. 5. Menick FJ. Reconstruction of the cheek. Plast Reconstr Surg 2001;108:496e505. 6. Boutros S, Zide B. Cheek and eyelid reconstruction:the resurrection of the angle rotation flap. Plast Reconstr Surg 2005; 116:1425e30. 7. Tan ST, Mackinnon CA. Deep plane cervicofacial flap:a usefuland versatile technique in head and neck surgery. Head Neck 2006;28:46e55. 8. Austen Jr WG, Parrett BM, Taqhinia A, Wolfort SF, Upton J. The subcutaneous cervicofacial flap revisited. Ann Plast Surg 2009; 62:149e53. 9. Belmahi A, Oufkir A, Bron T, Ouezzani S. Reconstruction of cheek skin defects by the ‘Yin-Yang’ rotation of the Mustarde
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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X. Liu et al. flap and the temporoparietal scalp. J Plast Reconstr Aesthet Surg 2009;62:506e9. Jowett N, Mlynarek AM. Reconstruction of cheek defects: a review of current techniques. Cur Opin Otolaryngol Head Neck Surg 2010;18:244e54. D’Arpa S, Cordova A, Pirrello R, Zabbia G, Kalbermatten D, Moschella F. The face lift SMAS plication flap for reconstruction of large temporofrontal defects: reconstructive surgery meets cosmetic surgery. Plast Reconstr Surg 2011;127:2068e75. Huang AT, Tarasidis G, Yelverton JC, Burke A. A novel advancement flap for reconstruction of massive forehead and temple soft-tissue defects. Laryngoscope 2012;122:1679e84. Rapstine ED, Knaus WJ, Thornton JF. Simplifying cheek reconstruction: a review of over 400 cases. Plast Reconstr Surg 2012;129:1291e9. Moore BA, Wine T, Netterville JL. Cervicofacial and cervicothoracic rotation flaps in head and neck reconstruction. Head Neck 2005;27:1092e101. Raklyar E, Zloty DM. Use of a patient and observer scar assessment scale to evaluate the V-Y advancement flap for reconstruction of medial cheek defects. Dermatol Surg 2012; 38:1968e74. Chandawarkar RY, Cervino AL. Subunits of the cheek: an algorithm for the reconstruction of partial-thickness defects. Br J Plast Surg 2003;56:135e9. Yenidunya MO, Demirseren ME, Ceran C. Bilobed flap reconstruction in infraorbital skin defects. Plast Reconstr Surg 2007; 119:145e50. Sugg KB, Cederna PS, Brown DL. The V-Y advancement flap is equivalent to the Mustarde flap for ectropion prevention in the
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reconstruction of moderate-size lid-cheek junction defects. Plast Reconstr Surg 2013;131:28ee36e. Zhi-guo W, Quan-chen, Rui-xia K, Zhen-yu C, Ran H. Principles of hatchet-skin flap for repair of tissue defects on the cheek. Aesthetic Plast Surg 2012;36:163e8. Li P, Fang QG, Luo RH, et al. Reconstruction of full-thickness buccal defects with submental island flap. J Craniofac Surg 2015;26:e104e6. Chow TL, Choi CY, Ho LI, Fung SC. The use of bipaddled submental flap for reconstructing composite buccal defect. J Maxillofac Oral Surg 2014;13:75e7. Fujiwara M, Nagata T, Fukamizu H. Hemiforehead flap for reconstruction of composite facial defects. J Craniofac Surg 2012;23:e369e71. Seyhan T. The radix nasi island flap: a versatile musculocutaneous flap for defects of the eyelids, nose, and malar region. J Craniofac Surg 2009;20:516e21. Chen WL, Wang YY, Zhang DM, Chai Q, Wang HJ, Wang L. Use of the contralateral retroangular island flap for reconstructing midfacial defects after skin cancer ablation. Head Neck 2011; 33:1765e8. Zhou G, Chen GY, Teng L, Liu C, Qiao Q, Li G. Clinical experience with orbicularis oculi myocutaneous flaps in the temporal area. Plast Reconstr Surg 1998;101:1796e802. Turan A, Kostakoglu N, Tuncel U. Reverse superior labial artery flap in reconstruction of nose and medial cheek defects. Ann Plast Surg 2015;74:418e21. Rohrich RJ, Zbar RI. A simplified algorithm for the use of Zplasty. Plast Reconstr Surg 1999;103:1513e7.
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) xx, 1e6
Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties Xiaorong Liu a,*, Yusheng Liu a, Keqiong Chen a, Yan Gao a, Weilong Huang a, Wenwei Yuan a, Qian Cai b a Department of Plastic and Cosmetic Surgery, Dongguan People’s Hospital, No.3 Wandao Road, Wanjiang District, Dongguan 523018, China b Department of Otolaryngology-Head and Neck, Sun Yat-sen Hospital, Sun Yat-sen University, 107, Yan Jiang West Road, Guangzhou 510120, China
Received 19 May 2015; accepted 12 July 2015
KEYWORDS Cheek; Rotation flap; Z-plasty; Skin defect
Summary Background: Cervicofacial flaps are commonly used in the reconstruction of skin defects in regions such as the medial cheek and lower eyelid. However, their drawbacks include long flap incision, extensive undermining, and a high possibility of postoperative complications including distal flap necrosis and lower eyelid ectropion. Methods: Nine cases of reconstruction of skin defects in the medial cheek and adjacent areas were performed using a lateral cheek rotation flap in combination with Z-plasties between October 2009 and August 2014. In the surgery, the defect was trimmed into a downwardpointing triangle, with the flap incision line starting from the bottom edge of the defect and extending outward in the lateral orbital direction in an arc until before the sideburn. After the flap was undermined, double or quadruple Z-plasties were performed along the lateral orbital incision line to elongate the flap. Results: All flaps survived without the occurrence of complications such as hematoma, wound infection, distal flap necrosis, and lower eyelid ectropion. During the follow-up period, the flaps exhibited good color and texture. A natural looking cheek was restored without obvious scars. Conclusions: A lateral cheek rotation flap in combination with Z-plasty is an optimal method for reconstruction of skin defects in the medial cheek and lower eyelid region. Compared to conventional cervicofacial flaps, the lateral cheek rotation flap was shown to have a variety
* Corresponding author. Tel.: þ86 769 28636535. E-mail address: [email protected] (X. Liu). http://dx.doi.org/10.1016/j.bjps.2015.07.014 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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X. Liu et al. of advantages, including a simpler operation, shorter flap incision, minimal undermining, and effective prevention of complications such as lower eyelid ectropion and distal flap necrosis. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction The Mustarde flap1 and its derivatives, the cervicofacial2e13 or cervicothoracic14 flaps, have been reported in the reconstruction of skin defects in the areas of the medial cheek and lower eyelid. However, these types of flaps involve a long incision and extensive undermining and have a higher incidence of postoperative complications such as distal flap necrosis and lower eyelid ectropion. Belmahi et al. used a temporoparietal scalp rotation flap to reconstruct the preauricular donor area of the Mustarde flap. This method reduced the undermining area of the Mustarde flap and decreased the incidence of complications including hematoma, distal flap necrosis, and lower eyelid ectropion. However, the sideburns are moved downward after the surgery, producing an unnatural look, especially in female patients.9,10 In this study, reconstruction of skin defects in the medial cheek and adjacent areas were performed in nine patients using a lateral cheek rotation flap in combination with Z-plasty and achieved desirable results, which are reported below.
Patients and methods This group of patients consisted of four males and five females, aged between 18 and 83 years old, with an average age of 48 years. The etiologies included five cases of basal cell carcinoma, one case of skin and soft tissue sarcoma, one case of vascular malformation, one case of cicatrix, and one case of skin defects from trauma. The locations of the skin defects included six cases of the medial cheek, two
Figure 1 The excision area of the skin tumor was marked with Methylene blue.
cases of the medial cheek and lower eyelid, and one case of the medial cheek, paranasal area, and medial canthus. The largest area of a skin defect was 7.0 cm 6.0 cm, the smallest area was 2.0 cm 2.0 cm, and the average area was 4.5 cm 3.8 cm. Three patients underwent double Zplasties, and six patients received quadruple Z-plasties.
Surgical procedure Surgery was performed under local or general anesthesia. Methylene blue was used to mark the excision area of the skin tumor, vascular malformation, and cicatrix (Figure 1). Tumor resection required intraoperative frozen section analysis to confirm complete removal of the tumor with negative margins. The defect was trimmed into a downward-pointing triangle, with the flap incision line starting from the bottom edge of the defect and extending outward in the lateral orbital direction in an arc until before the sideburn. According to the size of the defect, double or quadruple Z-plasties were designed along the lateral orbital incision line, which was the incision line between the outer canthus and the sideburn (Figure 2). The cheek flap incision was performed, followed by subcutaneous undermining of the flap to 3 cm below the defect using electrocautery. After undermining, the cheek flap was pushed toward the defect to estimate the flap tension. Z-plasty incisions were made one by one until the distal end of the cheek flap could be translocated to the defect without any tension. The inside of the cheek flap was
Figure 2 The defect was trimmed into a downward-pointing triangle, quadruple Z-plasties were designed along the lateral orbital incision line, which was the incision line between the outer canthus and the sideburn.
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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Reconstruction of skin defects in the medial cheek
Figure 3 The postoperative 7 days view showing the position of Z-plasty flap ① was exchanged with it of Z-plasty flap ②,and the position of Z-plasty flap ③ was exchanged with Z-plasty flap ④. The indent on the flap caused by bone anchoring sutures disappeared after two months.
anchored to the lateral orbital periosteum with silk suture. The positions of the Z-plasty flaps were exchanged with each other (Figure 3). A drainage sheet was placed beneath the cheek flap, and the incision was closed layer by layer.
Results All flaps survived without the occurrence of complications such as hematoma, wound infection, distal flap necrosis, and lower eyelid ectropion. The follow-up period ranged from six months to five years. One patient died from cardiovascular disease two years after the surgery. No tumor relapse was observed in patients with tumors. The flaps exhibited good color and texture. A natural-looking cheek was restored without obvious scars. (Figure 4eFigure 7)
Discussion In the reconstruction of medial cheek skin defects due to trauma and the removal of skin tumors and scars, the
3 sources of tissue for reconstruction are limited because the medial cheek abuts the lower eyelid superiorly and is adjacent to the nose and lip medially. Improper reconstruction leads to deformities such as lower eyelid ectropion, lateral shifting of the nasal sidewall, alar splaying, and oral commissure dislocation.15 Therefore, reconstruction of skin defects in the medial cheek presents unique challenges for plastic surgeons. Minor skin defects in the medial cheek are usually closed directly. However, moderate or large skin defects require skin grafts or skin flap transfers. Skin grafting often causes a ‘patch-like’ appearance that leads to a disfigured look, and skin graft contraction at later stages can result in deformities such as lower eyelid ectropion and oral commissure dislocation. Local flaps include the rhomboid flap,16 bilobed flap,17 VeY advancement flap,15,16,18 and hatchetskin flap.19 These skin flaps yield desirable restoration but are normally used in the reconstruction of small or mediumsized skin defects. Pedicle flaps mainly include the submental flap,20,21 hemiforehead flap,22 nasal flap,23 retroangular flap,24 orbicularis oculi myocutaneous flap in the temporal area,25 and the recently reported reverse superior labial artery flap.26 These flaps require dissection of the vascular pedicle, which is associated with timeconsuming surgery and scars left in the donor area. Free flaps require vascular anastomosis, and the color and texture of the flaps are different from the skin in the cheek. Expanded flaps require staged surgery, which increases costs and patient suffering, and they are not suitable for patients who need immediate reconstruction due to tumor or trauma. Cervicofacial flaps are commonly used in the reconstruction of medium-to large-sized skin defects in regions such as the medial cheek and lower eyelid. The color and texture of cervicofacial flaps are consistent with the skin in the cheek, which results in a well-restored appearance. Cervicofacial flaps can be anteriorly or posteriorly based, and they can be elevated in the subcutaneous or sub-superficial musculoaponeurotic system (sub-SMAS) plane.5,10 Subcutaneous cervicofacial flaps involve a wide pedicle, long flap incision, and extensive undermining, and they are susceptible to complications such as distal flap necrosis and lower eyelid ectropion. Although sub-SMAS cervicofacial flaps can increase the blood supply of the
Figure 4 (Left) Preoperative frontal view of a 38-year-old woman with recurrent basal cell carcinoma in her left infraorbital area. (Middle and right) Late postoperative frontal view and oblique views (two years).
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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Figure 5 (Above) An 83-year-old woman with basal cell carcinoma in her right infraorbital area. (Below, left) Preoperative frontal view. (Below, middle) Postoperative frontal view (three months). (Below, right) Postoperative oblique views (three months).
flaps, they also carry a risk of damage to facial nerve branches and are susceptible to lower eyelid ectropion. Belmahi et al. used a temporoparietal scalp rotation flap in combination with a Mustarde flap to reconstruct infraorbital skin defects. This method reduced the undermining area of the Mustarde flap and decreased the incidence rates of hematoma and distal flap necrosis. In addition, the suspension function of the scalp flap helped to avoid the occurrence of lower eyelid ectropion. However, this method used a scalp flap with hair to repair preauricular defects, producing an unnatural look, especially in female patients.9,10 In this study, skin defects in the medial cheek were reconstructed with a lateral cheek rotation flap. Meanwhile, Z-plasties were performed along the lateral orbital flap incision line. After the Z-plasties were completed, the length of the flap was significantly elongated, and the medial reach range of the flap was broadened. Rohrich et al. reported that 60-degree Z-plasty could theoretically increase the length of the flap by 70% and that no significant difference was observed regarding flap length increases between multiple small Z-plasties and a single large Z-plasty.27 If the length of the incision line from the lateral canthus to the sideburn was X, then the flap length would be increased by 0.7X after the Z-plasties. Previously, Z-plasty was mainly used to lengthen scars, change scar
direction, correct soft tissue deformities, and improve function.27 Using Z-plasty to elongate skin flaps has not been reported in the literature, and this report adds a new application for Z-plasty. The advantages of the surgical method reported here are summarized as follows. (1) The main issue in using anteriorly based cervicofacial rotation flaps for the reconstruction of medial cheek skin defects is excessive horizontal tension in the flap. Sometimes, to reconstruct a medium-sized defect, the incision has to be extended to the postauricular region, occipital hairline, and even the thoracic region. Extensive flap undermining leads to a reduction in the distal blood supply and an increased risk of bleeding. Z-plasty was performed along the lateral orbital incision, which makes efficient use of vertically relaxed cervicofacial skin. This technique compensates for the shortage of horizontally oriented skin and decreases the undermining area and the incidence rate of distal flap necrosis and hematoma. (2) Using Z-plasty for flap reconstruction in the presideburn area avoids the dislocation of the sideburn and lateral canthus and eases the problem of closing the Mustarde flap in the preauricular donor area.9 (3) Following flap transposition in Z-plasty, the incision line at the lateral canthus was nearly in a vertical direction, and scar contraction pulled the skin upward, which further
Figure 6 (Left) Preoperative frontal view of a 24-year-old woman with soft tissue sarcoma in her left medial cheek. (Middle and right) Late postoperative frontal and oblique views (two years).
Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014
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Figure 7 (Left) Preoperative frontal view of a 71-year-old woman with basal cell carcinoma in her left medial cheek and lower eyelid. The tumor involved the eyelid margin but not the tarsal plate. The flap incision was first made in the gray line, extending just through the lateral canthus and continuing superiorly into the lateral orbital area, finally ending just before the sideburn. (Middle and right) Early postoperative frontal and oblique views (two months).
prevented the occurrence of lower eyelid ectropion. (4) The surgical method described here is in compliance with the principles of “replace like with like” and “for both appearance and function, use tissues from less important areas to reconstruct wounds in important areas”. The medial cheek is adjacent to the center of the face and functions in supporting the lower eyelid and nasolabial structures. Meanwhile, the lateral cheek is in the peripheral region of the face, with less impact on supporting other structures. In addition, deformities appear more evident when they are closer to the center of the face. Thus, compared to the lateral cheek, the medial cheek is more important for maintaining the facial appearance and function. (5) The flap was elevated in the subcutaneous plane, which avoids damage to the facial nerve and its branches and makes the surgical procedure easier. (6) This surgical procedure is also suitable for defects in the anterior lamella of the lower eyelid and for defects involving the eyelid margin (see Figure 7). The disadvantage of this surgical procedure is the introduction of an incision in the normal skin in the lateral orbital area, which may aggravate incision scars in the lateral orbital area. However, long-term follow-up indicated that the scars from the lateral orbital incision were inconspicuous. Furthermore, this surgical procedure is only suitable for the reconstruction of skin defects located medial to the lateral canthus. Skin defects located beyond the lateral canthus should be repaired using other methods.
Conclusions A lateral cheek rotation flap in combination with Z-plasty is an optimal method for reconstruction of skin defects in the medial cheek and lower eyelid region. Compared to conventional cervicofacial flaps, the lateral cheek rotation flap was shown to have a variety of advantages, including a simpler operation, shorter flap incision, minimal undermining, and effective prevention of complications such as lower eyelid ectropion and distal flap necrosis. The authors suggest using the method in patients with skin defects located medial to the lateral canthus.
Ethical approval The study was approved by the ethical committee of the Dongguan people’s Hospital. Written informed consent to use preoperative, intraoperative, and postoperative photographs was obtained from the patients who appear in this report.
Funding None.
Conflicts of interest None declared.
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Please cite this article in press as: Liu X, et al., Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties, Journal of Plastic, Reconstructive & Aesthetic Surgery (2015), http://dx.doi.org/10.1016/j.bjps.2015.07.014