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Introduction
CHAPTER 42 Reconstruction of the
Cheeks
Christopher J. Miller Thuzar M. Shin Jeremy R. Etzkorn Eduardo K. Moioli Joseph F. Sobanko
SUMMARY
The cheek is the largest subunit of the face, and reconstruction aims to restore its
soft contours, avoid distortion of the adjacent eyelid, nose, and mouth, and preserve underlying critical anatomic structures.
While cheek reconstruction benefits from a robust blood supply and ample tissue
reservoir, the presence of free margins around its borders, as well as the parotid
gland, duct, and facial nerve branches at its deep aspect, makes an appreciation of the underlying anatomy of vital importance.
Beginner Pearls
The contours of the cheek reflect the shape of the underlying fat pads. These contours
change with age.
The cheek skin is anchored by osseocutaneous ligaments that affect contour and
mobility of skin flaps.
Primary closure with side-to-side approximation of the edges of a fusiform wound is
the most common reconstruction method for cheek defects.
Expert Pearls
Rotation and advancement flaps are useful for larger cheek defects or those abutting
cosmetic subunit boundaries.
SMAS plication can be very useful when closing larger defects, as it both shifts
tension deep and substantially reduces defect size.
Donโt Forget!
Skin grafts are used only infrequently on the cheeks.
The parotid may appear similar to fat.
Large defects and those approaching the lower eyelid may benefit from repair with
two adjoining flaps or a flap and a graft, rather than a single reconstructive modality.
Pitfalls and Cautions
The potential for cheek closures to push skin against free margins, such as the lower
eyelid, should always be considered.
While V-Y island pedicle flaps are used frequently on the cheeks, meticulous suturing
is critical in order to minimize the unsightly appearance of a triangular shaped scare that does not conform to cosmetic unit boundaries.
Patient Education Points
Always gauge a patientโs willingness to undergo and recover from an extensive
procedure before it is initiated.
Some patients may prefer a small partial closure or healing by secondary intention to a
more involved and much larger flap.
Billing Pearls
Random pattern single stage flaps on the cheeks are coded with 14040 or 14041, and
these codes include the excisional component; it is not appropriate to bill both an excision and a flap repair code simultaneously, except for Mohs excision codes.
When coding a flap, graft, or linear repair, medical necessity is the ultimate arbiter of
appropriateness.
CHAPTER 42 Reconstruction of the