Approaches to Cheek Reconstruction following Mohs Surgery

Abstract

The native features of the cheek allow for a variety of approaches when considering reconstruction following Mohs surgery. Selecting the best approach requires consideration of deficit size and location, skin laxity, surrounding anatomy, aesthetic outcomes, and specific patient factors. Reconstruction options vary based on the zone of the cheek affected, but direct closure remains the gold standard. When direct closure is not suitable, the use of the cervicofacial advancement flap, biologic agents, or a combination of the two should adequately address the majority of cheek deficits resulting from Mohs surgery. During cheek reconstruction, great care should be taken to maintain and support the surrounding anatomy, most notably the lower eyelid. Postoperative management is mostly comprised of scar management, as immediate, urgent complications are rare. Options to address postoperative scarring range from silicone sheeting to revisional surgery, but most deficits will settle well if given adequate time and are properly cared for with noninvasive measures.

Keywords

cheek reconstruction - direct closure of cheek - cervicofacial advancement flap - Integra - NovoSorb BTM

Properties of the Cheek

The cheek, due to its exposed location and broad surface area, is highly susceptible to ultraviolet damage, making it a common site for skin cancer. Reconstruction options vary based on the size, depth, and location of the deficit. However, its reconstruction is typically successful due to the cheek's vascularity, laxity, and relatively featureless surface.[1] [2] These characteristics allow for ideal incision placement along native tension lines, resulting in favorable postoperative scars.

There are significant functional and aesthetic considerations when determining the most suitable reconstructive approach. Functionally, maintaining the native eyelid, lip, and hairline positioning is of utmost importance.[1] [2] [3] While some techniques can adequately address the deficit, they may simultaneously distort the surrounding anatomy leading to unfavorable results. Aesthetically, the cheek is one of the most visible and prominent facial features and its cosmesis has a significant impact on patient's quality of life.[3] The aesthetic goals of cheek reconstruction focus on restoring the natural features of the cheek, such as the malar prominence, and utilizing natural tension lines to conceal scars.

This article will discuss techniques to address cheek deficits following Mohs excision based on location, the effect on surrounding anatomy, and patient factors. The concepts covered include direct closure, the details of the cervicofacial flap, and then, finally, the addition of biologic agents in reconstruction.

Cheek Reconstruction

The cheek is defined by several key anatomical landmarks: the preauricular crease, the mandible, the lips and the nasolabial fold, and, most notably, the orbit–cheek crease and zygomatic arch. The proximity of the superior border to the lower eyelid can potentially lead to eyelid distortion.[1] [4] [5] Extrinsic ectropion of the lower eyelid is a significant complication of cheek reconstruction and is the result of undue tension on the lower eyelid. This condition rarely resolves on its own and often requires additional surgical intervention, making perioperative eyelid support essential.[6] [7]

Zones of the Cheek

The cheek is divided into three zones ([Fig. 1]), as defined by Roth et al, each with unique characteristics that guide reconstruction.[2]

Fig. 1 Zones of the cheek. (Reproduced with permission from UT Southwestern)

• Zone I (suborbital subunit): defined by the superior border of the eyelid, this zone poses an increased risk of eyelid complications. However, the superior border can effectively conceal incision lines within the orbit–cheek crease, contributing to a successful aesthetic outcome. The medial border similarly utilizes the nasolabial fold to hide incisions. Reconstructive planning of the suborbital subunit is centered on recreating the malar prominence and the importance of eyelid position.[3]

• Zone II (preauricular subunit): this zone offers favorable conditions for direct closure by recruiting skin from the inferior and medial regions. Additionally, the lateral and inferior borders allow for the recruitment of neck tissue if the anterior/posterior defect distance is too large and direct closure cannot be achieved. However, the lack of anterior/posterior laxity near the preauricular region can complicate reconstruction, risking distortion of the hairline and beard.

• Zone III (buccomandibular subunit): this zone borders the lower lip and the convexity of the chin. Similarly to zone II, neck tissue can be utilized for additional laxity if needed providing opportunities for direct closure. However, this zone requires a large amount of tissue excess for reconstruction and carries the risk of lip distortion requiring special attention to avoid ectropion.

Cheek Reconstruction

In the largest series of cheek reconstructions to date, more than half of the cases were managed with direct closure, while the remaining majority underwent reconstruction with a cervicofacial advancement flap.[1] Specifically, 53% of defects were closed directly, and 19% were reconstructed with a cervicofacial flap, demonstrating that the majority of cheek defects can be effectively managed with these techniques. However, the evolution of skin substitutes such as Integra collagen-chondroitin silicone (CCS) or NovoSorb biodegradable temporizing matrix (BTM) has provided a highly acceptable and minimally invasive alternative.[8]

Direct Closure

Direct closure is a viable option across all cheek zones, particularly in zones I and II, where inherent laxity and vascularity promote healing and aesthetic outcomes. It should be noted that there is no advantage of a local transposition flap, as the initial defect rarely provides a favorable flap design and only provides inferior scar placement. Key considerations for direct closure include meticulous eyelid support, dog-ear excision, and postoperative scar management. With the addition of postoperative scar management, this technique can yield excellent cosmetic results[9] ([Fig. 2]).

Fig. 2 Direct closure. Left: Direct closure of zone I at 4 days post-op. Right: Result at 3 months post-op with the addition of silicone sheeting.

Cervicofacial Flap

Direct closure may be unsuitable for medium to large full-thickness defects or defects that span multiple subunits, thus making the cervicofacial flap the next logical choice[10] ([Fig. 3]). For successful reconstruction, the incision should follow the cheek–lid junction, extending superiorly into the hairline and along the preauricular crease ([Fig. 3]). If the arc of rotation is under significant tension, a back cut can be extended onto the neck at the area of maximum tension.[3] An additional incision aligned with the nasolabial fold may be necessary to avoid a standing cone deformity along the medial cheek.

Fig. 3 Cervicofacial advancement flap. Top left: The preoperative defect spanning zone I, overlapping into zone II. Top right: Incision following the cheek–lid junction, into the hairline, and along the preauricular crease. Temporary placement of silk sutures was done to evaluate the tension of the closure. Bottom left: Immediate postoperative sutures. Bottom right: 2.5-year postoperative result status after scar revision.

Proper support for the lower eyelid ([Fig. 4]) is crucial to prevent ectropion, which can be achieved with a lateral supporting stitch to suspend the lateral canthus and create redundant soft tissue under the eyelid.[6] While previous techniques utilized anchoring sutures at the cheek–eyelid junction's leading edge, recent reconstructions suggest that lateral periosteal sutures alone are sufficient when there is adequate soft tissue and do not carry the additional risk of distal flap loss.[10] The dissection plane should remain deep subcutaneous throughout, and meticulous hemostasis is essential for a safe postoperative course. Hemostasis with the use of cautery and topical hemostatic agents, such as Avitene, provides a safe, hematoma-free, postoperative course and is sufficient, even for fully anticoagulated patients.[1]

Fig. 4 Lateral periosteal stitch. Left: Immediate postoperative sutures. The black arrow indicates the lateral supporting stitch used to create redundant soft tissue for eyelid support. Middle: Photograph at the 3-week postoperative follow up with some residual fullness of the left eye. Right: Photograph at 6 months postoperatively after scar management and adequate time for the tissue to settle.

Biologic Agents

Biologic agents such as Integra or NovoSorb BTM offer a safe alternative to traditional skin grafting, particularly for patients with large defects, comorbid conditions that preclude anesthesia, insufficient tissue, or limited laxity.[11] These synthetic alternatives serve as an acellular scaffolding to promote revascularization and dermal regeneration.[12] They can be applied under local anesthetic, are well tolerated, and require minimal postoperative care. Patients are able to shower on the third postoperative day and do not require subsequent wound management aside from applying antibiotic ointment to the wound edges. If given adequate time, deficits managed with biologic agents can often heal secondarily ([Fig. 5]). However, the addition of split- or full-thickness grafting can offer an expeditious, predictable course ([Fig. 6]).

Fig. 5 Zone I coverage with Integra. Top left: Preoperative markings for excision of squamous cell carcinoma. Top right: Initial defect within zone I. Bottom left: Photograph of Integra incorporation at 2 weeks postoperatively. Bottom right: Photograph at 15 weeks postoperatively.

Fig. 6 Integra with delayed split-thickness skin grafting. Top left: Photograph of Integra 4 weeks postoperatively prior to split-thickness grafting. Top right: Split-thickness graft inset. Bottom: Photograph at the 3-month follow up.

Combining Cervicofacial Flap with Biologics

Combining the cervicofacial advancement flaps with the use of biologic agents provides an even more robust adjunct for continued healing. Biologics provide the surgeon with a degree of safety and comfort if the flap design does not adequately address the deficit. This combination is especially useful in closures with a high degree of tension or inadequate flap coverage. The technique entails the development of a standard cervicofacial advancement flap. When attempting closure, the tension of the wound should be evaluated. If the inset is determined to be too tight, there is concern for ectropion, or flap survival is questionable, then the preauricular sutures can be released. Subsequently, a biologic can be placed, which allows the area to heal secondarily ([Fig. 7]).

Fig. 7 Combination of the cervicofacial advancement flap with Integra. Top: Photographs taken at 1 week postoperatively following cervicofacial advancement flap with preauricular Integra placement. Bottom: Photographs taken at 6 months postoperatively.

Postoperative Complications and Management

Complications such as bleeding, infection, and wound dehiscence can be seen with all the approaches discussed. However, immediate postoperative complications of cheek reconstruction are rare.[5] Eyelid ectropion is perhaps the most profound functional complication of cheek reconstruction and is most common with suborbital subunit reconstructions and the cervicofacial advancement flap.[1] [3] [6] [13] If adequate soft-tissue support is not obtained intraoperatively, patients often require subsequent surgical intervention to restore eyelid integrity.[7]

Bandage position is maintained for the first 72 hours. Patients can then remove their dressings and shower. Postoperative care is minimal and consists of topical antibiotic ointment application on the suture lines. If nonabsorbable sutures are used, patients can follow up in 1 week for removal.[13]

Wound Optimization

Postoperative wound management is customized to the patient's goals and may address issues such as scar hypertrophy, pigmentation, or depression. Techniques for scar management include laser therapy, silicone sheeting, steroid injections, dermabrasion, or Dermapen along the incision line.[1] [4] [9] After 2 to 3 months, once the wound has typically settled, asymmetry of the cheeks can be corrected using standard scar revision techniques such as direct excision and closure, as well as dermal or fat grafting.

Conclusion

The functional and aesthetic requirements of the cheek mandate a methodical approach to reconstruction. Considering the zone of the defect and the surrounding anatomy is essential to determine the appropriate method. By utilizing these techniques—linear closure, cervicofacial advancement flaps, or biologic agents—surgeons can provide safe and reliable coverage for the majority of cheek defects while simultaneously restoring cosmesis.

Conflict of Interest

None declared.

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Publication History

Article published online:
04 November 2024