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Subunits andAnatomical Considerations
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ab c
Fig. 9.19 Wedge excision and primary closure. (a) Markings for excision, (b) Excision defect, (c)
Final closure
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Suggested Algorithm
Concha
Partial Thickness
1. Healing by secondary intention
2. Skin graft
Partial Thickness/Full Thickness
1. Revolving door ap
2. Post-auricular island ap
3. Post-auricular transposition ap
4. Pre-auricular transposition ap
Antihelix/Helix
Partial Thickness
1. Healing by secondary intention (antihelix)
2. Skin graft (antihelix)
Full Thickness
1. Wedge excision
2. Helical rim advancement
3. Superiorly based pre-auricular ap
4. Two-stage post-auricular ap
9 Auricular Reconstruction
Triangular Fossa
1. Healing by secondary intention
2. Skin graft
3. Superiorly based pre-auricular ap
Tragus
1. Superiorly based pre-auricular ap
2. Advancement ap
Suggested Algorithm
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Posterior Surface ofPinna
1. Healing by secondary intention
2. Primary closure
3. Skin graft
4. Post-auricular advancement/transposition ap
5. Rhombic ap
Lobule
1. Primary closure
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Cheek Defects
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Subunits andAnatomical Considerations
The cheek is the largest aesthetic unit in the face. It has an undulating contour and
is dened by the nasofacial, melolabial and mentolabial folds medially, infra-orbital
rim and zygomatic arch superiorly, pinna and angle of the mandible posteriorly and
the lower border of the mandible inferiorly. It can be divided into medial, buccal,
infra-orbital, zygomatic, lateral and mandibular subunits (Fig.10.1).
Fig. 10.1 Subunits of the
cheek
© Springer Nature Switzerland AG 2024
V. Ilankovan et al., Local Flaps in Facial Reconstruction,
https://doi.org/10.1007/978-3-031-49464-2_10
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10 Cheek Defects
The medial subunit consists of skin adjacent to the nasofacial, melolabial and
mentolabial folds. The buccal subunit encompasses the central cheek area lateral to
the medial unit. The infra-orbital unit represents the area below the lower eyelid.
The lateral subunit is the area adjacent to the pinna and angle of the mandible. The
zygomatic subunit is between the buccal, infra-orbital unit and temple and overlies
the zygomatic prominence. The mandibular subunit encompasses the area overlying
the body of the mandible.
The facial artery and vein course the cheek unit obliquely from the lower border
of the mandible, just anterior to the insertion of the masseter muscle up to the medial
canthus region. They lie deep to the muscles of facial expression. The branches of
the facial nerve emerge from the anterior border of the parotid gland and supply the
muscles of facial expression and lie on their deep surface. The nerve is relatively
unprotected in the cheek and mandibular subunits. The infra-orbital nerve provides
sensory supply to most of the cheek and emerges from the infra-orbital foramen,
deep to the orbicularis oculi and levator labii superioris.
The skin in the subunits of the cheek varies in their characteristics. Reconstructive
options should take into account adjacent tissue laxity and the likelihood of distorting the surrounding landmarks (eyelids, nose, lips and pinna).
Scars are best placed along the aesthetic borders, and consideration should be
given to extending the defect, especially in the medial and lateral subunits. When
this is inappropriate, scars are best designed to be parallel to the RSTL. The RSTLs
in the cheeks are curvilinear or radially fan out from the lateral canthus area (crow’s
foot) and offer excellent camouage for the scars. The skin creases are more prominent in the elderly and can be made more obvious by requesting the patient to smile
and shut their eyes tight (Fig.10.2).
Subunits andAnatomical Considerations
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Fig. 10.2 Orientation of
RSTL’s in the cheek
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10 Cheek Defects
Medial Subunit
Primary Closure
Indications: Small and medium defects.
Technique: The defect is modied into an ellipse to lie along the axis of the
nasofacial, melolabial and mentolabial folds. The adjacent wound margins are
undermined in the subcutaneous plane and closed in layers (Fig.10.3a–c, d–f, g–i).
Tips: Asymmetric undermining, with greater undermining in the lateral aspect
often allows the scars to be placed in the most advantageous position.
Medial Subunit
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a
c
b
d
Fig. 10.3 Excision and primary closure. (a) Markings for excision, (b) Excision defect, (c) Final
closure, (d) Markings for excision, (e) Excision defect, (f) Final closure, (g) Markings for excision,
(h) Excision defect, (i) Final closure
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10 Cheek Defects
Fig. 10.3 (continued)
Medial Subunit
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Fig. 10.3 (continued)
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i
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