When large surgical defects involve multiple aesthetic units—the nasal sidewall, medial cheek or infraorbital region—it is essential to preserve anatomical features, nasal grooves and cosmetic subunits. Optimal reconstruction minimizes distortion of key structures—the eyelid margin, alar rim—while restoring function and concealing scars within natural skin creases.1-3 The cheek advancement flap is an effective reconstructive technique for nasal sidewall and medial cheek defects, as it preserves aesthetic subunits and avoids complications like nasal distortion, alar retraction and lower eyelid ectropion. The flap design advances adjacent cheek tissue to close the defect, with closure lines placed along natural creases—the lower eyelid–cheek junction and the nasolabial fold—enhancing both functional and cosmetic results. Upwards and medial mobilization allows complete defect coverage, but several technical considerations are essential for successful outcomes.4, 5 After tumour excision, tissue mobility should be assessed and the defect segmented, placing closure lines along cosmetic units' borders to prevent crossing into adjacent aesthetic subunits. The flap design relies on two lateral curvilinear incisions: a superior incision along the lower eyelid–cheek junction and an inferior one along the nasolabial fold. Preserving the periorbital subunit during the superior incision is crucial, as improper placement may lead to ectropion. A curved incision (Figures 1a -o- and 2a -o-) aligned with orbicularis oculi fibres is preferred over a straight-line incision, as it closely follows the curvature of the periorbital anatomy, reduces tension and postoperative oedema and improves cosmetic results. Excess tissue in the temple region should be removed by designing a Burow's triangle along the relaxed skin-tension lines, positioned at the level of the lateral canthus (Figure 1a − + −), at the junction between periorbital and temple subunits. Positioning it outside the periocular region helps preserve lymphatic drainage, reducing the risk of postoperative oedema and chemosis. An alternative to a Burrow's triangle in this region is a semilunar excision within the lower eyelid–cheek junction (Figure 2a -§-). Inferiorly, a traditional Burow's triangle should be avoided, as it invades the perioral subunit at the upper lip level, leading to noticeable scarring. Instead, a semilunar excision in the opposite direction of a typical Burow's triangle positioned within the nasolabial fold (Figures 1a -*- and 2a -*-) allows adequate tissue advancement while preserving adjacent aesthetic units.6 The flap should be undermined at the upper level of the subcutaneous fat, mobilized and advanced medially with a surgical hook (Figures 1b and 2b). Haemostasis with atraumatic pinpoint electrocoagulation is essential. Suspension 4/0 absorbable sutures should be placed to secure the advanced subcutaneous tissue to the periosteum at the nasal sidewall—infraorbital cheek subunit junction (Figures 1c and 2c). These sutures preserve the natural contour of the sulcus, guide the flap towards a preferred closure line at the junction of aesthetic subunits, and prevent the ‘tent-pole’ effect, in which elevated tension causes protrusion. Skin edges should be approximated with a 5/0 or 6/0 continuous mattress suture along the lower eyelid–cheek junction and the nasolabial fold. Continuous mattress suture uses a simple suture bite followed by a reverse bite adjacent to the first to create a single broad suture that achieves wound approximation and epidermal eversion without constricting the wound edge. In the perialar region, 5/0 or 6/0 single mattress horizontal or vertical sutures should be used to restore the alar profile (Figures 1d and 2d). The cheek advancement flap represents a simple and aesthetically favourable reconstructive option for extensive defects involving the nasal sidewall, medial cheek or infraorbital region. When performed in accordance with the principles outlined above, it achieves excellent functional and aesthetic results (Figures 1e,f and 2e,f). The authors have nothing to report. None declared. This study was carried out in accordance with the Declaration of Helsinki. Ethics committee approval was waived because the study affected neither routine diagnostic nor therapeutic management. This retrospective review of patient data did not require ethical approval in accordance with local/national guidelines. The patients in this manuscript have given written informed consent to the publication of their case details. All data were de-identified before use. The data related to the cases described in this letter are available from the corresponding author upon reasonable request.
Paradisi et al. (Tue,) studied this question.