Bilobed‐modified cervicofacial flap for reconstruction of an extensive surgical defect of the cheek

Large surgical defects of the cheek represent a reconstructive challenge due to its important role in facial expression and aesthetics. One of the most effective options is the cervicofacial flap (CF), which uses a random advancement and rotation flap technique based on the skin laxity of the cheek, preauricular region, and neck. Modifications extending to the chest when necessary have been documented.1 However, the size and location of defects are variable, sometimes too large to be reconstructed with the conventional CF flap. In this case report we present a solution to close such defects by design modification. A 71-year-old male presented with a recurrent morpheaform basal cell carcinoma of the left cheek. After tumor excision with clear margins by Mohs micrographic surgery, reconstruction was planned using a modified CF flap with a bilobed design. This modification incorporated a preauricular skin rotation lobe with a retroauricular skin transposition lobe (Figure 1). Under general anesthesia, incisions were made along the zygomatic, preauricular, and retroauricular regions, followed by a subcutaneous dissection above the superficial musculoaponeurotic system (SMAS). Dissection was extended to the supraclavicular area to facilitate flap advancement and rotation. Subsequently, the flap was anchored to the periosteum of the zygomatic bone and sutured (Figure 2). The patient experienced no postoperative complications, and no evidence of tumor recurrence was observed after a five-year follow-up (Figure 3). Reconstructing large cheek defects is challenging due to the limited skin remaining after tumor excision. Several options are available to address this issue. First, local flaps from the temporal skin and/or nasolabial fold, such as the versatile bilobed flap, could be a solution.2 However, this technique alters multiple anatomical subunits and carries the risk of visible scarring with the well-known "trap door" effect. Another alternative is employing a vascularized free flap. While this technique offers potential advantages, it is notably more complex, requires specialized techniques such as vascular anastomosis and may hinder the detection of tumor recurrence. Finally, using a total skin graft is also a possibility. However, this approach may result in an aesthetically undesirable outcome. The CF flap offers an excellent combination of color and texture matching, making it a preferred choice for facial reconstruction. Its single-stage execution minimizes the risk of open wounds and delays in adjuvant radiation therapy if necessary. Numerous modifications have been introduced to enhance its versatility, mainly by extending the dissection beyond the cervical area.1-3 In the case presented, we propose a modification involving a horizontal extension of the CF design to incorporate the skin on both sides of the ear. In addition to rotating the preauricular skin, transposing the retroauricular skin provides a notable advantage due to its unexposed nature and rich vascularity from the inclusion of perforating branches of the occipital and posterior auricular arteries. Furthermore, this modification allows for discreet concealment of scars from the donor area.4 During execution, it is crucial to consider the anatomical structures beneath the SMAS, to avoid potential risks of damage. The SMAS represents an organized fibrous network comprising the platysma muscle, parotid fascia, and a fibromuscular layer covering the cheek, facilitating the connection of facial muscles to the dermis.5 It is vascularized by the transverse facial artery, which also supplies blood to a broad region of the lateral malar area. Careful attention to these structures is essential to ensure successful flap execution and minimize complications.6 Some authors have proposed incorporating the SMAS in flap dissection to ensure adequate vascularization.7 However, a dissection at the subcutaneous level has been demonstrated to provide enough blood supply through the subdermal plexus. Moreover, elevation of the SMAS could increase the risk of transverse facial artery transection and facial nerve injury, particularly its temporal and marginal branches due to lack of collateral innervation. Therefore, given the high success rate of the subcutaneous approach, the need for incorporating the SMAS may be questioned. Similarly, the traditional description of the cervical plane as subplatysmal has been suggested.1-3 During flap elevation, only the perforators from the submental artery are preserved.3-7 Thus, considering the absence of significant additional vascular supply provided by deep dissection and the viability of the subcutaneous plane, this approach could be recommended.8-10 In conclusion, we propose a modification of the classic CF flap incorporating retroauricular skin transposition as a versatile reconstructive option for closing large cheek defects. The choice of dissection plane should be based on patient characteristics and surgeon experience. However, given the lack of substantial advantages and the associated risks with deep dissection, an execution at the subcutaneous plane may be preferred. We thank the patient for granting permission to report the case and publish the results. None.