The Cervicofacial Flap in Cheek

Reconstruction: A Guide for Flap

Design
Al Haitham Al Shetawi, DMD, MD,* Anastasiya Quimby, DDS, MD,y
and Rui Fernandes, DMD, MDz
Purpose: The cervicofacial (CF) flap is a random-pattern flap that provides an excellent match for cheek
reconstruction. The design of the CF flap varies between different cheek subunits. In this report, the
authors review their experience with this flap and present a guide for flap design for different cheek
subunits.
Materials and Methods: Patients who had cheek reconstruction were screened using the database of
the surgical procedures from 2011 to 2016. Seventy-four patients were identified. Data on patient demo-
graphics, diagnosis, defect type, and outcome were retrospectively reviewed. Patients who did not have a
clear description of the defect or flap design were excluded from the study. The authors divided the cheek
into 3 zones and created a guide for flap design for each zone.
Results: Twenty-eight patients with CF flap for cheek reconstruction met the inclusion criteria (21 male
[75%] and 7 female [25%]; mean age, 57 yr; range, 8 to 88 yr). Fifty-seven percent had zone A defects, 18%
had zone B1 defects, 14% had zone B2 defects, and 11% had multiple-zone defects. Mean follow-up was
4.6 months (0 to 17 months). Ninety-three percent had a successful outcome. Only 2 patients developed
wound complications.
Conclusion: The CF flap is a versatile flap that provides excellent skin color, thickness, and texture
match in cheek reconstruction. Planning the flap design is essential to achieve a good outcome. The pre-
sent algorithm provides a straightforward method to reliably design the CF flap for cheek reconstruction.
Ó 2017 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 75:2708.e1-2708.e6, 2017

The most important elements in cheek reconstruction
are restoring facial esthetics and maintaining func-
tion.1 When faced with the sequelae of traumatic
injury or ablative surgery, the reconstructive surgeon
strives to restore the uniformity of skin color, texture,
and contour, preserve the function of the facial nerve,
and minimize facial scars.2
Cheek defects can be reconstructed with different
local, regional, and free flaps. The choice usually de-
pends on intrinsic wound characteristics, such as
size, depth, and anatomic location, and extrinsic
characteristics, such as adjacent anatomic structures
and the patient’s general health and ability to with-
stand long procedures. In addition to these consider-
ations, the surgeon’s creativity plays an essential role
in flap selection. In general, cheek defects are
preferably reconstructed with tissue from adjacent
units, such as the neck, submental area, or chest,
using local or regional flaps to maintain skin color
and texture.3,4

Received from the Department of Oral and Maxillofacial Surgery, facial Surgery, University of Florida Health. Jacksonville, FL 32209;
University of Florida Health, Jacksonville, FL. e-mail: Rui.fernandes@jax.ufl.edu
*Fellow, Head and Neck Surgical Oncology and Microvascular Received June 28 2017
Reconstruction, Division of Head and Neck Surgery. Accepted August 5 2017
yResident, Oral and Maxillofacial Surgery. Ó 2017 American Association of Oral and Maxillofacial Surgeons
zChief, Division of Head and Neck Surgery. 0278-2391/17/31065-0
Conflict of Interest Disclosures: None of the authors have a rele- http://dx.doi.org/10.1016/j.joms.2017.08.006
vant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Fernandes:
Division of Head and Neck Surgery, Department of Oral and Maxillo-

2708.e1
AL SHETAWI, QUIMBY, AND FERNANDES 2708.e2

Table 1. PATIENT DEMOGRAPHICS, DIAGNOSIS, AND

DEFECT TYPE (N = 28)

Age (yr)
Mean 57
Range 8-88
Gender
Male 21
Female 7
Diagnosis
SCC 11
BCC 6
Melanoma 2
GSW 3
Inclusion cyst 2
MEC 1
MVA 1
Neurofibromatosis 1
Dog bite 1
Defect zones
A 16
B1 5
B2 4
Combination 3
Tobacco 11
Radiation 3
Complications 2
FIGURE 1. Cheek zones.
Abbreviations: BCC, basal cell carcinoma; GSW, gunshot Al Shetawi, Quimby, and Fernandes. Cervicofacial Flap in Cheek
wound; MEC, mucoepidermoid carcinoma; MVA, motor Reconstruction. J Oral Maxillofac Surg 2017.
vehicle accident; SCC, squamous cell carcinoma.
Al Shetawi, Quimby, and Fernandes. Cervicofacial Flap in Cheek
Reconstruction. J Oral Maxillofac Surg 2017.
and flap design were identified. Data on patient demo-
graphics, diagnosis, defect type, and outcome were
collected (Table 1).
The literature is rich in algorithms for cheek recon-
Based on their experience with this flap, the authors
struction.5-8 A common flap used in cheek
divided the cheek into 3 zones and created a guide for
reconstruction is the cervicofacial (CF) flap. The CF
flap design for each zone. The cheek was divided by a
flap is a random-pattern flap that provides excellent
vertical line bisecting a line from the lateral canthus to
skin color, thickness, and texture match.9 The design
the root of the helix into 2 zones. Zone A is anterior to
of the CF flap varies among different cheek subunits.
this line, and zone B is posterior to it (Fig 1). Zone B
In this report, the authors review their experience
was further subdivided by a horizontal line from the
with this flap and present a guide for flap design for
tragus into B1 and B2. Zone B1 is superior to the line
different cheek subunits.
and zone B2 is inferior to the line (Fig 1).
All defects were reconstructed with an anteriorly
based CF flap. The design of the CF flap was modified
Materials and Methods
based on the zone of the defect. In zone A, the incision
The study was approved by the institutional review was started at the superior lateral corner of the defect
board. Patients who underwent cheek reconstruction and passed posteriorly to the ear through the sideburn
were screened using the database of the surgical pro- area, and then carried inferiorly in a preauricular
cedures performed from 2011 to 2016. Seventy-four crease, around the earlobe, and then inferiorly to
patients with cheek reconstruction were identified the neck in a cervical crease (Figs 2, 3). In zone B1,
and the operative reports were reviewed. Patients the incision was started at the inferior posterior
who did not have a clear description of the defect or corner of the defect and extended along the
flap design were excluded from the study. Twenty- preauricular crease, around the earlobe, and then
eight patients with detailed description of the defect carried inferiorly to the neck in the cervical crease
2708.e3
FIGURE 2. Zone A. The dotted line outlines the distal ‘‘dog-ear’’
excision.
Al Shetawi, Quimby, and Fernandes. Cervicofacial Flap in Cheek
Reconstruction. J Oral Maxillofac Surg 2017.
(Figs 4, 5). In zone B2, the incision was started at the
inferior posterior corner of the defect and extended
along a preauricular crease, around the earlobe and
superiorly to include the skin overlying the mastoid,
and then carried inferiorly to the neck in the cervical
crease (Figs 6, 7).
The flap was elevated superficial to the superficial
musculoaponeurotic system (SMAS) in the parotid re-
gion and deep to the platysma in the neck. When
the anterior margin of the parotid gland was reached,
care was taken to avoid injuring the facial nerve
branches. The greater auricular nerve was preserved
during flap elevation. A wedge excision of skin medi-
ally was required to remove the dog-ear deformity.
Results
Twenty-eight patients with CF advancement flap for
cheek reconstruction were included (21 male [75%]
and 7 female [25%]; mean age, 57 yr; range, 8 to
88 yr). Eleven patients used tobacco and 3 patients
had a history of radiation. The pathology consisted
CERVICOFACIAL FLAP IN CHEEK RECONSTRUCTION
of squamous cell carcinoma (SCC; 39%), basal cell car-
cinoma (21%), gunshot wounds (11%), melanoma
(7%), inclusion cyst (7%), mucoepidermoid carcinoma
(3.5%), motor vehicle accident (3.5%), neurofibroma-
tosis (3.5%), and dog bite (3.5%). The mean defect
size was 44.5 cm2 (range, 9 to 80 cm2). Fifty-seven
percent had zone A defects, 18% had zone B1 defects,
14% had zone B2 defects, and 11% had multiple-zone
defects. The mean follow-up was 4.6 months (0 to
17 months). One patient was lost to follow-up after su-
ture removal. Only 2 patients developed wound com-
plications: 1 patient had flap necrosis that required
secondary reconstruction with a supraclavicular flap,
and 1 patient had wound dehiscence that required
minor revision.
Discussion
The cheek is the largest unit in the face. It is
bounded superiorly by the infraorbital rim and zygo-
matic arch, medially by the nasofacial junction, nasola-
bial fold, and labiomandibular crease, inferiorly by the
border of the mandible, and laterally by the preauricu-
lar crease.6 Cheek defects present a considerable
challenge to the reconstructive surgeon to achieve
the best esthetic and functional outcome.
Numerous options are available for reconstruction,
such as healing by secondary intention, primary
closure, skin grafts, and local, regional, and free flaps.
Asymmetry in this unit is less noticeable compared
with centrally located units such as the nose. This is
because visual comparison with the contralateral
side in the primary gaze is not readily available
compared with the central units.3
The first form of cheek flap was introduced by
Esser10 in 1918. Several modifications to the flap
were seen over the years until Juri and Juri11 described
the advancement of the rotational CF flap. This flap
can be anteriorly based, supplied by the facial and sub-
mental arteries, or posteriorly based, supplied by the
superficial temporal artery and preauricular vessels
in the face.4 The flap has a random-pattern blood
supply. Inclusion of the platysma transforms the flap
into a composite musculocutaneous flap vascularized
by branches of the facial artery and augments the
blood supply of anteriorly based flaps.4
The CF flap is the mainstay of reconstruction for
medium and large cheek defects.12 The flap is
elevated in the supra-SMAS plane in the parotid re-
gion and in the subplatysmal plane in the neck. For
very large defects, the incision can be extended in
the subplatysmal plane to the chest as a cervicopec-
toral flap with additional arterial supply arising
AL SHETAWI, QUIMBY, AND FERNANDES 2708.e4

FIGURE 3. A, Zone A defect. B, Flap elevation. Flap shows good texture and color match C, immediately and D, 3 months postoperatively.
Al Shetawi, Quimby, and Fernandes. Cervicofacial Flap in Cheek Reconstruction. J Oral Maxillofac Surg 2017.
2708.e5
FIGURE 4. Zone B1. The dotted line outlines the distal ‘‘dog-ear’’
excision.
Al Shetawi, Quimby, and Fernandes. Cervicofacial Flap in Cheek
Reconstruction. J Oral Maxillofac Surg 2017.
from internal mammary perforators.4 When
designing the flap, the position of the lower eyelid,
the vermillion-cutaneous junction, and the nostril
margin must be taken into account.13 The incisions
should be placed in natural skin creases and
parallel to the relaxed tension skin lines.13 Vertical
FIGURE 5. Postoperative photograph of zone B1 reconstruction.
Al Shetawi, Quimby, and Fernandes. Cervicofacial Flap in Cheek
Reconstruction. J Oral Maxillofac Surg 2017.
CERVICOFACIAL FLAP IN CHEEK RECONSTRUCTION
FIGURE 6. Zone B2. The dotted line outlines the distal ‘‘dog-ear’’
excision.
Al Shetawi, Quimby, and Fernandes. Cervicofacial Flap in Cheek
Reconstruction. J Oral Maxillofac Surg 2017.
incisions anterior to the line drawn from the lateral
canthus are best avoided in the central face,
because such scars are distracting in the frontal
view.14 When possible, incisions are best placed be-
tween facial units or hidden along the hairline or
contour lines. Menick3 pointed out that the
FIGURE 7. Postoperative photograph of zone B2 reconstruction.
Al Shetawi, Quimby, and Fernandes. Cervicofacial Flap in Cheek
Reconstruction. J Oral Maxillofac Surg 2017.
AL SHETAWI, QUIMBY, AND FERNANDES
presence and position of facial scarring are less
important in the peripheral units.
Subdivisions to the cheek unit have been proposed
in treatment algorithms. Roth and Zide15 divided the
cheek into 3 zones to help determine the method of
cheek reconstruction. Dobratz and Hilger6 divided
the cheek esthetic region into 4 subunits based on
the bony and soft tissue anatomy of the region. These
subunits include the medial, zygomatic, buccal, and
lateral units.6 Chandawarkar and Cervino5 divided
the cheek into 4 subunits based on the anatomic con-
tour and function and neurovascular distribution.
In this study, the cheek was divided into 3 zones to
organize a straightforward strategy for CF flap design.
All zones were successfully reconstructed using this al-
gorithm except in 1 patient who had flap necrosis. He
was an 82-year-old man and former tobacco user with
cheek SCC. The defect was in zone A and measured
6  4 cm. He required secondary reconstruction using
a supraclavicular flap. As in most patients undergoing
reconstructive surgery, identifying patients with risk
factors for flap failure is important.
There are limitations to this study. First, the
number of patients in this study does not accurately
reflect the total number of CF flaps performed from
2011 to 2016. This was because the operative re-
ports were used to identify the patients who had
CF flaps and excluded those who did not have a
clear description of the defect or flap design in
the operative dictation. Second, this was a retro-
spective analysis with all outcomes collected after
implementing this treatment algorithm. Despite
these limitations, the study clearly presents the
2708.e6
versatility of this flap in restoring cheek defects. It
also provides a straightforward algorithm to reliably
design the CF flap for cheek reconstruction.
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