JAMA Facial Plastic Surgery Journal Club Slides: Local Flaps

1. JAMA Facial Plastic SurgeryJournal Club Slides:Local Flaps Pepper J-P, Baker SR. Local flaps: cheek and lip reconstruction. JAMA Facial Plast Surg. 2013;15(5):374-382.

2. Introduction • Reconstruction of cutaneous defects of the cheek and lip is a foundational topic with which facial plastic and reconstructive surgeons should be well versed. • Important advances have been made in the understanding of the soft tissue and vascular anatomy of the cheek that enhance our ability to reconstruct these regions. • The V-Y subcutaneous tissue pedicle island advancement flap has been used with increased frequency, particularly for larger defects, and merits careful understanding. • Lastly, pedicled perforator flaps will likely see increased application for facial reconstruction in the near future.

3. Purpose • To review new findings that have an impact on the planning and understanding of local flaps for the reconstruction of cutaneous defects of the cheek and upper lip. Recent research in facial soft-tissue anatomy and vascular anatomy is integrated into a discussion of local flap reconstruction.

4. Relevance to Clinical Practice • Facial deformities affect the impression of an individual, with greater cognitive import given to deformities of the central face compared with those located more laterally. Observers are more likely to find even small centrally located deformities of the face to be bothersome and disfiguring in comparison with similar abnormalities located peripherally. • Small defects may still be perceived by both the patient and society as highly disfiguring. • Prominent scars of the cutaneous lip are often more obvious during speech and emotive expression.

5. Description of Evidence • A Medline search of scientific literature was conducted, with an emphasis on 1980 to the present. Search terms included cheek, lip, reconstruction, vascular anatomy, soft-tissue anatomy, aging face, outcomes, and perforator flap. • Cadaveric studies were sought for anatomic review, and comparison group outcome studies were preferentially cited over clinical case series. However, the vast majority of the literature is case series or expert opinion. There were no randomized trials or meta-analyses for review.

6. Terminology

7. Description of Anatomy

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9. Description of Anatomy Aging midface and subunits

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12. Description of Anatomy

13. Highlights & Clinical Insights • The zygomatic osteocutaneous ligament is the strongest soft-tissue retaining ligament in the face. • The orbicularis oris is not a simple sphincter; it has highly complex insertions and 3-dimensional anatomy, particularly on sagittal view. • The cheek is predominantly perfused by the transverse facial artery. • The highest density of musculocutaneous perforators from the facial artery is approximately 1.5 cm lateral to the oral commissure. • For large medial cheek and cutaneous lip defects, the V-Y subcutaneous tissue pedicle island advancement flap is an important reconstructive technique. • Trapdoor deformity is a possible complication of these flaps. • Anticipate more revision surgery when using this technique for defects that are larger than 4 cm2.

14. Comment • For resident teaching purposes, it is highly recommended that presenters include facial defects and discuss the reconstructive options for the given defect.

15. Conclusions • Outcomes analyses for local flap reconstruction are in high demand. • Detailed knowledge of soft-tissue anatomy of the cheek and lip is critical to accurate surgical planning in local flap reconstruction. • The V-Y subcutaneous tissue pedicle island advancement flap has proven valuable in the reconstruction of medial cheek and cutaneous upper lip defects.

16. Contact Information • If you have questions, please contact the corresponding author: • Jon-Paul Pepper, MD, Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar St, Ste 204M, Los Angeles, CA 90033 (jonpaulpepper@gmail.com). Conflict of Interest Disclosures • None reported.