Middle Facial Reconstruction

Clinical Presentation

A 51-year-old White male had a basal cell cancer over his left medial cheek and nasal sidewall. Mohs surgery was performed by our dermatological surgeon and the skin resection margins were all negative. The patient had a 6 × 2.5 cm skin defect involving the medial cheek and nasal sidewall near the medial canthus ( Fig. 3.1 ). The plastic surgery service was asked to close this complex skin defect after a definitive cancer resection. The patient was also a heavy smoker and was unable to stop smoking prior to surgery.

Operative Plan and Special Considerations

Based on an analysis of the defect involving the medial cheek and nasal sidewall, the medial cheek advancement could be designed to cover the cheek defect and a portion of the nasal sidewall defect and a full thickness skin graft could also be used to cover the rest of the defect in the nasal sidewall.

Operative Procedures

The medial cheek advancement flap was designed superiorly parallel to the lower eyelid and medial to the nasolabial fold ( Fig. 3.2 ). The flap area was infiltrated with 1% lidocaine with 1:100,000 epinephrine.

The flap was elevated under direct vision at the subcutaneous tissue plane and the area of the skin flap elevation measured 15 × 10 cm ( Fig. 3.3 ). With a scissor dissection, the medial cheek skin flap was elevated and advanced to cover the entire medial cheek defect along with some of the inferior portion of the nasal sidewall ( Fig. 3.4 ). Several tacking sutures were used with 4-0 nylon suture to hold the skin flap and facilitate closure of the defect. On the nasal side wall, the skin flap was also approximated to the nasal sidewall skin with 4-0 nylon sutures in half-buried horizontal mattress fashion. Some excess skin was excised for better donor site closure. The medial inferior portion of the flap was sutured to the nasal labial fold skin with 4-0 nylon sutures in simple interrupted fashion. The lower eyelid incision closure was done in the deeper dermal layer with 5-0 Monocryl sutures in a simple interrupted fashion, followed by the 5-0 nylon sutures for skin closure in a simple running fashion.

The excess portion of the distal flap was excised. This portion of the skin, which measured 2 × 1 cm, was defatted and placed over the left nasal side wall defect and secured with multiple 5-0 chromic sutures ( Fig. 3.5 ). The skin graft was sutured to the wound bed and then secured with a tie-over dressing for skin graft immobilization.

Follow-Up Results

The patient did well postoperatively without any complications related to the medial cheek advancement flap. He was observed overnight in the hospital and discharged home the next day. His tie-over dressing was removed at postoperative day 5. The flap and skin graft sites both healed well. There was no entropion over his left lower eyelid ( Figs. 3.6A–C ).

Final Outcome

The medial cheek advancement flap to the medial cheek defect and full thickness skin graft to the nasal sidewall defect healed well without any issues. The patient has had a reasonably good cosmetic outcome and minimal scarring ( Fig. 3.7A and B ). He returned to normal life and has been followed by our demonologist for routine skin cancer follow-up.

Pearls for Success

The medial cheek advancement flap can be elevated to cover a medial cheek and even a portion of the nasal sidewall defects if the patient has some skin laxity in the cheek. The flap is elevated at the subcutaneous tissue plane above the fascia of the superficial musculoaponeurotic system. Superiorly it is parallel to the lower eyelid and medially it follows the nasolabial fold. Attention should be paid not to traumatize the orbicularis oculi muscle. Preoperative evaluation of the lower eyelid position may be helpful to predict whether the patient would need a lateral canthopexy. In a smoker, the distal portion of the flap may not be reliable. For this case, it was converted to a full thickness skin graft. With proper immobilization postoperatively, the full thickness skin graft can heal well and provide even better contour of the nasal sidewall for reconstruction.