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CHEEK RECONSTRUCTION

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SUMMARY

  • The cheek is the largest subunit of the face, and reconstruction aims to restore its soft contours, avoid distortion of the adjacent eyelid, nose, and mouth, and preserve underlying critical anatomic structures.

  • While cheek reconstruction benefits from a robust blood supply and ample tissue reservoir, the presence of free margins around its borders, as well as the parotid gland, duct, and facial nerve branches at its deep aspect, makes an appreciation of the underlying anatomy of vital importance.

image Beginner Pearls

  • The contours of the cheek reflect the shape of the underlying fat pads. These contours change with age.

  • The cheek skin is anchored by osseocutaneous ligaments that affect contour and mobility of skin flaps.

  • Primary closure with side-to-side approximation of the edges of a fusiform wound is the most common reconstruction method for cheek defects.

image Expert Pearls

  • Rotation and advancement flaps are useful for larger cheek defects or those abutting cosmetic subunit boundaries.

  • SMAS plication can be very useful when closing larger defects, as it both shifts tension deep and substantially reduces defect size.

image Don’t Forget!

  • Skin grafts are used only infrequently on the cheeks.

  • The parotid may appear similar to fat.

  • Large defects and those approaching the lower eyelid may benefit from repair with two adjoining flaps or a flap and a graft, rather than a single reconstructive modality.

image Pitfalls and Cautions

  • The potential for cheek closures to push skin against free margins, such as the lower eyelid, should always be considered.

  • While V-Y island pedicle flaps are used frequently on the cheeks, meticulous suturing is critical in order to minimize the unsightly appearance of a triangular shaped scare that does not conform to cosmetic unit boundaries.

image Patient Education Points

  • Always gauge a patient’s willingness to undergo and recover from an extensive procedure before it is initiated.

  • Some patients may prefer a small partial closure or healing by secondary intention to a more involved and much larger flap.

image Billing Pearls

  • Random pattern single stage flaps on the cheeks are coded with 14040 or 14041, and these codes include the excisional component; it is not appropriate to bill both an excision and a flap repair code simultaneously, except for Mohs excision codes.

  • When coding a flap, graft, or linear repair, medical necessity is the ultimate arbiter of appropriateness.

INTRODUCTION

The cheek is the largest subunit of the face, and reconstruction aims to restore its soft contours, avoid distortion of the adjacent eyelid, nose, and mouth, and preserve underlying critical anatomic structures.

While cheek reconstruction benefits from a robust blood supply and ample tissue reservoir, the presence of free margins around its borders, as well as the parotid gland, duct, and facial nerve branches at its deep aspect, makes an appreciation of the underlying anatomy of vital ...

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