Cheek defects: causes, symptoms, diagnosis, treatment

Etiological factors of cheek defects can be: accidental trauma, previous inflammatory process (for example, noma) or surgical intervention.

Defects of the cheeks can be through and superficial, sometimes only a defect of the mucous membrane of the cheek is observed.

From a topographic-anatomical point of view, a distinction is made between isolated defects of the cheek and those combined with defects:

• lips or both lips
• opposite cheek;
• nose;
• soft tissues of the parotid region and auricle;
• half of the face and its area on the opposite side.

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Symptoms of cheek defects

Based on the clinical picture, cheek defects can be divided (Yu. I. Vernadsky, 1973-1988) into the following groups:

1. Gaping defects that widely expose the oral cavity, in which the mouth can be opened completely or almost completely (enough for unimpeded food intake).
2. Gaping extensive defects, in which there is cicatricial contracture of the lower jaw, which greatly complicates eating and requires surgical intervention.
3. Extensive defects, narrowed by the growth of scar tissue, which to a certain extent masks the defect of the cheek.
4. Defects completely filled with scar tissue, i.e. masked by it. In this case, the true dimensions of the defect can be fully determined only after excision of the scar tissue.
5. Superficial defects of the cheek skin that arise as a result of the removal of superficial tumors (angioma, pigment spot, etc.) and excision of superficial scars formed after burns, frostbite, radiation damage, mechanical injuries.
6. Defects of the mucous membrane of the cheek that arise as a result of burns with alkalis or acids, ulcerative stomatitis or noma, gunshot wounds and removal of neoplasms;
7. A combination of several of the above symptoms.

Treatment of cheek defects

If there is a cicatricial contracture, it is first eliminated, and then the enlarged cheek defect is replaced. The skin of the abdomen, neck, or shoulder-chest flap can be used as a plastic material. Let us list the main methods of cheek plastic surgery (meloplasty).

The Israel Method

In the neck area, from the corner of the lower jaw to the collarbone, a long tongue-shaped skin flap is cut out with its base facing the angle of the lower jaw. The separated flap is turned upward by 180° (with the skin surface in the oral cavity). In the area of the edges of the defect, a blind incision is made to refresh them and the edge of the mucous membrane is separated. The end of the flap is sutured to the refreshed edges of the cheek defect. The wound surface on the neck is sutured, avoiding pinching the flap pedicle in the upper pole of the wound. After 9-10 days, i.e. after the flap has taken root, its pedicle is cut off on the neck, turned upward, forward and spread out on the granulating surface of the anterior end of the flap, thereby creating a duplicate of the skin in the area of the cheek defect. The wound on the neck is sutured tightly.

The disadvantages of the method are the two-stage nature and the need to leave the flap surface for granulation. Therefore, N. N. Milostanov proposed using a round stem for meloplasty, which he forms on the neck. However, this method does not relieve the patient from the second stage of the operation.

Method of N. A. Almazova

A wide (4.5-7 cm) skin-muscle flap is prepared on the neck, including the subcutaneous muscle of the neck (Fig. 203 a) and expanding at the clavicle.

The length of the flap can reach 15 cm (depending on the length of the neck and the size of the defect). After separation, the flap is turned upward and forward, inserted into the oral cavity through an incision in front of the masseter muscle. The wound on the neck is sutured, trying not to pinch the leg of the flap.

The scars are excised, and the flap is placed with the wound surface on the inner exposed surface of the cheek to replace the mucous membrane.

The end of the flap is doubled, forming a duplicate of the skin in the defect area. The edges of the outer layer of the duplicate are sutured to the edges of the skin in the defect area of the cheek.

After engraftment, the flap is cut off at the posterior bend, the wound on the neck is sutured along its entire length, using excess skin tape at the bend.

The subsequent stages, as with the Israel method, are reduced to the formation of the corner of the mouth from the transplanted duplicate skin.

Method of A.E. Rauer-N. M. Mikhelson

Its essence lies in the fact that from two flaps (one - a bridge - on the chest, the second - on the inner surface of the shoulder) a duplicate of the skin is created, which is subsequently transferred on a leg to the area of the defect.

In everyday work, the methods of Israel, N. A. Almazova or A. E. Rauer-N. M. Mikhelson should be preferred over closing the defect with local tissues.

To close a large bone and cheek defect after resection of the upper jaw together with adjacent soft tissues, N. M. Aleksandrov (1974, 1975) recommends epidermizing the wound bottom with a split skin flap, and then cutting out a large tongue-shaped flap in the pre-auricular region and lateral neck region, the shape and size of which allow it to be rotated to the area of the cheek defect. Before this movement, the wound in the area of the flap is epidermized with a split skin graft (from the thigh), the size of which corresponds to the defect of the mucous membrane of the cheek. Then the duplicated flap is fixed to the edges of the postoperative cheek defect and sutures are applied to the donor base.

In cases where it is impossible to close the cheek defect by mobilizing its edges, the inner lining of the cheek is created from local tissues (by inverting skin flaps on a stalk into the oral cavity), and the outer part of the duplication is created by freely transplanting a thick or split skin flap from the anterior abdominal wall or chest.

Method of F. M. Khitrov

To eliminate an extensive cheek defect, it is better to use the Filatov stem, using the scheme of surgical interventions developed by F. M. Khitrov, or the method of O. P. Chudakov, but not the methods of Israel or N. A. Almazova. This is due to the fact that the Filatov stem is more viable than the Israel or N. A. Almazova flaps, is more convenient for suturing and has a sufficiently long leg, which allows the patient's hand to be given a comfortable position.

If necessary, the Filatov stem can be grafted to the edges of the defect with both legs, and then cut transversely in its middle part and doubled, as a result of which a sufficient amount of plastic material is obtained.

Whatever method the surgeon uses for lip or cheek plastic surgery, he must remember that scarring of transplanted tissues can lead to contracture of the lower jaw. Therefore, when performing plastic surgery, it is necessary to use forming prostheses (for example, made according to M. P. Barchukov); after the completion of plastic surgery, mechanotherapy of the lower jaw and physiotherapy softening scars are prescribed.

Such defects lead not only to severe disfigurement, speech and nutritional disorders, but also to dehydration of the body, eczematous lesions of the skin of the neck and chest. As a result of the contraction of the masticatory muscles and the muscles of the floor of the mouth or the formation of scars in this area, the lateral fragments of the lower jaw are pulled up and to the midline, squeezing the tongue from the sides and from below.