Cheek Advancement

Description

This is a laterally based random-pattern sliding skin-subcutaneous flap; several variations are described (31). Wide subcutaneous undermining is necessary, creating a

Figure 23 Nasolabial island flap for total columellar reconstruction: intraoperative sequence.

cervicofacial flap that can be advanced into the defect. Incisions should be placed along topographical borders such as the melolabial and preauricular sulci. The elevated cheek flap is heavy and dermal retaining sutures to immovable landmarks such as the malar periosteum can prevent surrounding structures from being distorted, such as the lower eyelid.

Indications

Cheek flaps are applied most often for reconstructing defects medially on the face, near the melolabial fold or nasal sidewall.

Advantages

Cheek advancements take advantage of the large surface area and loose cheek skin-subcutaneous unit. Large defects (2-3 cm) adjacent to the nose are amenable to repair using this flap. No incisions are necessary in the cheek itself, which is very beneficial since these incisions are often obvious.

Disadvantages

Tension medially can blunt the natural nasal-cheek crease. This can be minimized with dermal-periosteal sutures to the nasal sidewall. Inferolaterally based flaps for defects near the lower lid may result in ectropion. This problem may be avoided by using oversized lower eyelid cartilage grafts and subdermal-to-periosteal fixation sutures to lateral canthal area.

INTRAORAL AND MISCELLANEOUS FLAPS Buccinator Musculomucosal

Description

The buccinator musculomucosal flap (BMF) was originally described for reconstruction of defects of the hard palate. Experience with intraoral tumor extirpations expanded its use for surgical defects of the posterior oral cavity that were too small to justify a regional flap (32). The flap is based on the buccal neurovas-cular pedicle and includes cheek mucosa and the buccinator muscle (Fig. 24). Cadaveric studies demonstrate the consistent isolation of the buccal artery, and India ink injections demonstrate the generous blood supply from this artery to the overlying cheek mucosa. The buccal nerve is adjacent to the buccal artery and is easily included with the flap to maintain sensation in the overlying mucosa.

The tumor is extirpated by an intraoral approach and the defect sized. Sten-sen's duct is identified and the superior margin of the flap is outlined, keeping at least 5 mm inferior to the duct papilla. The anterior limit of the flap is one cm -g behind the oral commissure. The maximal graft size possible is 4 cm in a superior-inferior direction and 7 cm in an anterior-posterior direction. The buccal mucosa ยป

and the buccinator muscle are incised to the level of the buccopharyngeal fascia working in an anterior to posterior direction (Fig. 25). A loose areolar plane exists ^

between the buccinator muscle and the buccopharyngeal fascia, facilitating elevation of the flap with blunt dissection. The buccopharyngeal fascia should be preserved for two reasons: to prevent buccal fat pad herniation into the field of dis- o section and to avoid injury to branches of the facial nerve. Small branches from the facial artery may require ligation as may venous tributaries from the pterygoid @

Facial Artery Ligation

plexus. The neurovascular pedicle may be isolated to create an island flap to facilitate rotation, but this is not usually necessary. The flap is then transferred into the defect and secured with long-lasting absorbable sutures and the donor site is closed primarily.

Indications

In the past, these flaps were used primarily for reconstruction of cleft palate defects. This versatile local flap should be considered for reconstruction of defects of the floor of mouth, retromolar trigone, and soft palate.

Neurovascular Anatomy

The buccal artery and nerve arise laterally at the posteroinferior aspect of the buccinator muscle. The neurovascular bundle arises between the ramus of the mandible and medial pterygoid muscle.

Buccal Artery

Advantages

The BMF is a reliable, easily harvested local flap, useful for reconstruction of lesions involving the floor of mouth, retromolar trigone, and soft palate. It obviates the need for an intraoral bolster or harvesting of tissue beyond the oral cavity. The BMF is raised within 30 min without the use of magnification, thus minimizing total intraoperative time. There are no adverse affects secondary to harvesting the muscle, particularly with respect to mastication, oral continence, or facial nerve function. When tested over the area of reconstruction in the early postoperative period, patients report fine touch perception, which may be an aid to oral rehabilitation.

The BMF has several advantages over typical alternative reconstructive methods including skin grafts, tongue flaps, and nasolabial flaps. Skin grafts "take" poorly over exposed bone and require placement of a bolster that may be technically difficult in this area. Tongue flaps usually require two stages and speech and swallowing may be adversely affected. The nasolabial flap requires an external excision and may not reach the retromolar trigone. Regional flaps (such as the temporalis muscle flap) or free flaps (such as the radial forearm) involve extensive extraoral dissection and are better reserved for more extensive defects.

Disadvantages

Although this flap can be used in previously irradiated fields, the risk of partial loss may be higher. In addition, external carotid artery resection or thrombosis may also preclude use of this flap.

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