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CHEEK RECONSTRUCTION ppt

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Powerpoint presentation of Cheek reconstruction. By Dr. Diyar Abdulwahid Salih, plastic surgery resident.
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Cheek Cheek reconstruction reconstruction Dr. Diyar A. Salih Dr. Diyar A. Salih Plastic Surgery Resident Plastic Surgery Resident February, 2009 February, 2009 KURDISTAN, SLEMANI KURDISTAN, SLEMANI
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Page 1: CHEEK RECONSTRUCTION ppt

Cheek reconstructionCheek reconstruction

Dr. Diyar A. SalihDr. Diyar A. Salih

Plastic Surgery ResidentPlastic Surgery Resident

February, 2009February, 2009

KURDISTAN, SLEMANIKURDISTAN, SLEMANI

Page 2: CHEEK RECONSTRUCTION ppt

ProblematicProblematic

Its prominence and central position.Its prominence and central position. Its unique characteristics as an anatomic Its unique characteristics as an anatomic

subunit.subunit.

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3 subunits3 subunits

SuborbitalSuborbital Preauricular, andPreauricular, and Buccomandibular.Buccomandibular.

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Cheek woundsCheek wounds

Classified by depth into:Classified by depth into:

1.1. SuperficialSuperficial

2.2. Full-thickness, andFull-thickness, and

3.3. Subcutaneous contour deficits.Subcutaneous contour deficits.

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Reconstruction challengingReconstruction challenging

1.1. Cheek contour is paramount to facial Cheek contour is paramount to facial aesthetics. No existing reconstructive aesthetics. No existing reconstructive option can universally recreate the option can universally recreate the volume loss created by a subcutaneous volume loss created by a subcutaneous tissue defect.tissue defect.

2.2. The dynamic function of the cheek is not The dynamic function of the cheek is not easily reproduced.easily reproduced.

3.3. Reconstruction can alter or obliterate the Reconstruction can alter or obliterate the lines that divide facial subunits.lines that divide facial subunits.

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EtiologyEtiology

1.1. NeoplasiaNeoplasia2.2. Burns, andBurns, and3.3. Trauma.Trauma. Etiology Etiology affect presurgical planning affect presurgical planning::

For example:For example:Skin graftSkin graft: considered:: considered:Full-thickness burn.Full-thickness burn.History of radiationHistory of radiationAcne as teenagersAcne as teenagersMultiple skin cancers.Multiple skin cancers.Traumatic defect Traumatic defect primary closure or local flap. primary closure or local flap.

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Indications of reconstructionIndications of reconstruction

CongenitalCongenital Traumatic, and Traumatic, and Mohs surgery defects.Mohs surgery defects.

Subsequent soft tissue deficit can be Subsequent soft tissue deficit can be corrected with various techniques.corrected with various techniques.

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AnatomyAnatomy

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ExtensionExtension

Extends from the Extends from the inferior orbital rim inferior orbital rim superiorly to the superiorly to the mandibular rim mandibular rim inferiorly and from the inferiorly and from the lateral nasal sidewall lateral nasal sidewall and nasolabial crease and nasolabial crease medially to the medially to the preauricular area preauricular area posteriorly.posteriorly.

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Arterial supplyArterial supply EExternal xternal

carotid carotid arteryartery (ECA)(ECA)

The The greatest greatest contribution contribution is from the is from the facial facial artery.artery.

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Venous drainageVenous drainage Facial veinFacial vein, which , which

subsequently communicates subsequently communicates with the internal jugular (IJ) with the internal jugular (IJ) vein.vein.

However, substantial drainage However, substantial drainage via the ophthalmic, infraorbital, via the ophthalmic, infraorbital, and deep facial veins and deep facial veins communicates with the communicates with the cavernous sinus. cavernous sinus.

This venous system is This venous system is valveless, which can lead to valveless, which can lead to bacterial spread from a bacterial spread from a localized skin infection and localized skin infection and subsequent cavernous sinus subsequent cavernous sinus thrombosis.thrombosis.

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Lymphatic drainageLymphatic drainage

Is primarily Is primarily directed to:directed to:

1.1. Intraparotid LNIntraparotid LN

2.2. Submandibular Submandibular LN, and LN, and

3.3. Submental LN.Submental LN.

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Nerve supplyNerve supply

Divided into sensory and motor systems.Divided into sensory and motor systems. SensationSensation: second (maxillary) and third : second (maxillary) and third

(mandibular) divisions of the trigeminal (mandibular) divisions of the trigeminal nerve. nerve.

MotorMotor: the facial nerve (cranial nerve VII) : the facial nerve (cranial nerve VII) provides innervation to the muscles of provides innervation to the muscles of facial expression.facial expression.

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Facial nerve anatomyFacial nerve anatomy Stylomastoid

foramen. Travels through the

parotid gland. Branches into upper

(zygomaticofacial) and lower (cervicofacial) divisions.

Upper division: temporal and zygomatic branches.

Lower division: buccal, marginal mandibular, and cervical branches.

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Muscles of facial expressionMuscles of facial expression

1.1. Zygomaticus Zygomaticus major & minormajor & minor

2.2. O occuli MO occuli M

3.3. OOMOOM

4.4. Levator labii sup.Levator labii sup.

5.5. Platysma.Platysma.

6.6. Risorius m. Risorius m.

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SMASSMAS Is a continuous fascial covering known as the Is a continuous fascial covering known as the

superficial musculoaponeurotic system (SMAS) superficial musculoaponeurotic system (SMAS) covers each of facial expression muscles. covers each of facial expression muscles.

The branches of the facial nerve lie deep to the The branches of the facial nerve lie deep to the SMAS as they course more superficially in the SMAS as they course more superficially in the anterior face. anterior face.

The more medial and anterior areas of the face The more medial and anterior areas of the face have the most superficial facial nerve have the most superficial facial nerve branches.branches.

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ReconstructionReconstruction

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Healing by secondary Healing by secondary intentionintention

1.1. Concave surfaces, such as the temple and medial Concave surfaces, such as the temple and medial canthus. canthus.

2.2. Defects that are small and superficial and are not Defects that are small and superficial and are not closely associated with the eyelid or lip. closely associated with the eyelid or lip.

ExerciseExercise needed because wound contracture in the needed because wound contracture in the cheek can lead to distortion of the lower eyelid or upper cheek can lead to distortion of the lower eyelid or upper lip. lip.

An occlusive dressing and some form of antibiotic An occlusive dressing and some form of antibiotic ointmentointment..

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Surgical TherapySurgical Therapy

1.1. Primary closure:Primary closure:

Wide undermining.Wide undermining. Small defects (<2 cm, Small defects (<2 cm,

central). central). The degree of The degree of

surrounding skin laxity surrounding skin laxity predicates this closure. predicates this closure.

Older patients (ideal Older patients (ideal candidate).candidate).

Final scar, should rest Final scar, should rest parallel to or within a parallel to or within a relaxed skin tension line relaxed skin tension line (RSTL).(RSTL).

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Page 21: CHEEK RECONSTRUCTION ppt

2. Skin grafts2. Skin grafts least cosmetically satisfying forms of correction least cosmetically satisfying forms of correction

because of the poor tissue match of the donor because of the poor tissue match of the donor site skin with the sun-exposed cheek area. site skin with the sun-exposed cheek area.

IndicationsIndications: :

(1) large (>4 cm) defect(1) large (>4 cm) defect

(2) a high-grade skin neoplasm with (2) a high-grade skin neoplasm with questionable margins or perineural invasion.questionable margins or perineural invasion.

(3) poor tolerance of prolonged periods of (3) poor tolerance of prolonged periods of anesthesia.anesthesia.

(4) a third-degree burn over substantial (4) a third-degree burn over substantial portions of the face.portions of the face.

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3. 3. Local flaps:Local flaps:

Advancement flapsAdvancement flaps

are typically random.are typically random. relying on the subdermal plexus for blood relying on the subdermal plexus for blood

supply.supply.

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V-Y advancement flapV-Y advancement flap

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Cervicofacial flap (upper cheek)Cervicofacial flap (upper cheek)

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3. 3. Local flaps:Local flaps:

Transposition flapsTransposition flaps

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Transposition flaps (Banner F)Transposition flaps (Banner F)

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Transposition flaps (Bilobed F)Transposition flaps (Bilobed F)

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Transposition flaps (Rhomboid F)Transposition flaps (Rhomboid F)

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Cont.Cont.

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3. 3. Local flaps:Local flaps:

Rotation flaps.Rotation flaps.

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Cervicofacial flaps (Inf. Based)Cervicofacial flaps (Inf. Based)

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Cervicofacial flaps (Lat. Based)Cervicofacial flaps (Lat. Based)

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Cervicopectoral flapCervicopectoral flap

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Cervicopectoral flap, cont.Cervicopectoral flap, cont.

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3. 3. Local flaps:Local flaps:

Local composite flaps:Local composite flaps: Pectoralis major flap.Pectoralis major flap. Trapezius flap.Trapezius flap.

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3. 3. Local flaps:Local flaps:

Tissue expansion:Tissue expansion: Benign lesions.Benign lesions. Secondary scar revision.Secondary scar revision.

High rate of complications.High rate of complications.

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Free tissue transferFree tissue transfer

Radial forearm flap.Radial forearm flap.

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Parascapular flap:Parascapular flap:

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Anterolateral thigh flapAnterolateral thigh flap

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Rectus abdominis flap.Rectus abdominis flap. Fibula osteocutaneous flap.Fibula osteocutaneous flap.

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ComplicationsComplications

HematomaHematoma, most serious & within the first , most serious & within the first 12 hours: leading to flap necrosis.12 hours: leading to flap necrosis.

Ecrtopion or lower eyelid edema.Ecrtopion or lower eyelid edema. Distal flap necrosis.Distal flap necrosis. Hair bearing shift.Hair bearing shift. AsymmetryAsymmetry ScarringScarring

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Thank youThank you


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