FIGURE 36.1 This is a 62-year-old woman who has undergone resection of a maxillary sinus squamous cell carcinoma (SCC) that involved the cheek subunit. This is an intraoperative view of the left lateral face. The blue paper template has been made for the external skin paddle. Eight marks have been placed on the template for transfer to the donor site to facilitate the inset. The defect includes all three lamellae of the cheek. The angle of the mouth requires suspension of the modiolus. The nerve to the upper lip orbicularis oris was stimulated and was felt not to require additional nerve grafting.

HISTORY

As with any history, the assessment has to take into account prior treatment, the extent of the defect, and the patient’s goals relative to what the reconstructive intervention can accomplish. If the patient had a significant radiation or smoking history, the likelihood of a wound complication or late tissue atrophy increases. Therefore, a thicker, higher volume reconstruction may require customization of the flap or choice of an alternative donor site. Prior trauma or surgery to possible donor sites needs to be assessed. It is best to have a primary and secondary donor site discussed with the patient prior to the surgery. It is important to know about prior surgery or trauma to the site to understand the risk to the facial nerve, for example, prior local excision, parotid procedures, local flaps, facelift, facial trauma, or idiopathic facial nerve weakness. It is important to take a history about prior eye surgery or trauma, because this is an adjacent subunit and can be impacted by cheek reconstruction. It is important to support the lower eyelid with the reconstruction. If there is a preexisting ectropion, or the cheek defect extends to the eyelid subunit, an oculoplastics consultation should be considered.

PHYSICAL EXAMINATION

Assessment of the extent of the disease is essential for the surgeon to plan the defect, help prepare for tissue transplantation, and help to educate the patient. In the case of prior trauma, burns, or surgery, the degree of contracture of the involved subunits is important to assess to allow for compensation with skin paddle design. The goal of the assessment is to determine the extent and depth of the cheek subunit involvement. Specifically, assessment of the involvement of the adjacent eyelid and nasal subunits, the involvement of the deeper lamellae of the cheek that include the SMAS, the facial nerve, the buccinator muscle, the parotid duct, and the buccal mucosa. Bimanual palpation is helpful to assess the depth of tumor involvement. Intraoral examination of the buccal mucosa is good for assessing the extent of intraoral involvement. Palpation of the infraorbital rim is good for assessing lid mobility and deep extension. Observing the face in repose in addition to eye closure, angle of mouth elevation, and lip closure is useful to determine SMAS or facial nerve involvement. Testing of cheek sensation is useful for determining involvement of the infraorbital nerve.

INDICATIONS

Local flaps such as cervical facial rotation flaps are the reconstruction of first choice for cheek defects. Microsurgical reconstruction of cheek defects is for patients who have inadequate local donor tissue for a local rotational, advancement, or interpolation flaps. These situations arise when there has been extensive tissue loss such as in burns, trauma, or necrotizing fasciitis, in situations where the defect is deep and the essential elements of the SMAS, facial nerve, lower eyelid, and/or the buccal mucosa have been lost. The goals of cheek reconstruction are to prevent ectropion, maintain the position of the corner of the mouth, restore the soft tissue contour of the midface, prevent rotation and contracture of the nose into the reconstructed cheek, and maintain jaw opening by providing adequate intraoral lining.

CONTRAINDICATIONS

It is important to assess the local tissue options and not immediately move to a microsurgical option. There are few contraindications because patients tolerate cheek reconstruction well. As with any major surgical procedure, patients need adequate preoperative clearance.

PREOPERATIVE PLANNING

Radiology

The need for radiology varies greatly depending on the etiology of the defect, depth of the defect, and prior treatment. For superficial lesions, the need for preoperative imaging is limited. Imaging is important for patients with neoplastic disease extending to the SMAS, who have facial nerve weakness, who have had prior treatment, or whose disease crosses outside the cheek anatomic subunit, to anticipate the extent of the defect. CT scan with contrast is useful for assessment of the fascial planes of the SMAS, buccinator, pterygomandibular raphe, nasal facial groove, and the orbital septum. If there are facial nerve findings that are more extensive than the primary lesion would suggest, then an MRI can be helpful to assess perineural invasion. This would help anticipate the extent of nerve grafting that would be necessary. As with any reconstructive microsurgery case, the recipient artery and vein have to be a part of the reconstructive plan. If the patient had prior neck exploration or dissection, consideration of a CT angiogram to aid in identification of recipient artery can be helpful so that a donor site with adequate pedicle length can be chosen.

For cheek reconstruction, color and contour match are important when choosing the donor site. A patient’s body habitus and skin color will affect the choice of donor site. Also, when choosing the adipose tissue used for contouring, it should be from a site that will not become ptotic when inset into the recipient site. For many patients, the lateral arm and the parascapular/latissimus site provide the best color match, are good for contouring, have fewer problems with ptosis, and are my first choice sites. The lateral arm is also a good donor site for nerve grafts, particularly the posterior antebrachial cutaneous nerve (PACN) of the forearm. Despite these advantages, the lateral arm site has a very short, very small-caliber pedicle and will rarely reach past the facial or occipital artery recipient sites and, for this reason, is less commonly used. The parascapular/latissimus donor site has a longer, larger caliber pedicle, has well-compartmentalized adipose tissue, and good skin color match, but the harvest is from the lateral thorax, and this makes the elevation more difficult when the extirpation is being performed. To overcome this, I place the patient in a semidecubitus position for the extirpation and reconstruction.

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