Cheek defects: causes, symptoms, diagnosis, treatment
Last reviewed: 23.04.2024
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The etiological factors of cheek defects may be: accidental trauma, an inflammatory process (eg, nome), or surgical intervention.
Defects of the cheeks can be through, superficial, sometimes there is a defect only of the mucous membrane of the cheek.
From the topografical and anatomical point of view, isolated cheek defects are distinguished and combined with defects:
- lips or both lips
- the opposite cheek;
- nose;
- soft tissues of the parotid region and auricle;
- half of the face and its site on the opposite side.
[Symptoms of cheek defects
According to the clinical picture, the defects of the cheeks can be divided (Yu. I. Vernadsky, 1973-1988) into the following groups:
- Yawning defects, wide exposures of the oral cavity, at which it is possible to open the mouth completely or almost completely (quite enough for unobstructed food intake).
- Yawning extensive defects, in which there is scarring contracture of the lower jaw, severely hampering food intake and requiring surgical intervention.
- Extensive defects, narrowed due to the growth of scar tissue, which to some extent masks the defect of the cheek.
- Defects completely filled with scar tissue, i.e., disguised by it. In this case, the true size of the defect can be fully determined only after excision of scar tissue.
- Surface defects of the cheek skin, resulting from the removal of superficially located tumors (angioma, pigment spot, etc.) and excision of superficial scars formed after burns, frostbite, radiation injuries, and mechanical injuries.
- Defects of the mucous membrane of the cheeks, caused by burns with alkalis or acids, diseases of ulcerative stomatitis or nome, gunshot wounds and removal of tumors;
- Combination of several of the above symptoms.
Treatment of cheek defects
In the presence of cicatricial contracture, it is first eliminated and then the replacement of the enlarged cheek defect is replaced. As a plastic material, you can use the skin of the abdomen, neck or shoulder-thoracic flap. We list the main methods of plasty of the cheek (meloplastics).
The Israel method
In the neck area from the bottom of the mandible to the collar bone, a long tongue-shaped skin flap is turned, facing the corner of the lower jaw. The patched flap is turned upward by 180 ° (the dermal surface into the oral cavity). In the region of the edges of the defect, for their refreshing, an incision is made blind and the edge of the mucosa is cut off. The end of the flap is hemmed to the freshened edges of the cheek defect. The wound surface on the neck is sutured, avoiding the infringement of the flap leg in the upper pole of the wound. After 9-10 days, i.e., after engrafting the flap, cut off his leg on the neck, turn up, forward and spread on the granulating surface of the front end of the flap, thereby creating a duplicate skin in the area of the defect of the cheek. The wound on the neck is tightly sealed.
Disadvantages of the method are two-stage and the need to leave the surface of the flap for granulation. Therefore NN Milostanov proposed using a round stalk for meloplasty , which he forms on the neck. However, this method does not relieve the patient of the second stage of the operation.
The method of NA Almazova
On the neck, a wide (4.5-7 cm) musculocutaneous flap is prepared, including the hypodermic neck muscle (Figure 203a) and widening at the collarbone.
The length of the flap can reach 15 cm (depending on the length of the neck and the size of the defect). After the cutting, the flap is turned up and forward, injected into the oral cavity through the incision in front of the masticatory muscle. The wound is sewn on the neck, trying not to pinch the flap leg.
Scars are excised, the flap is placed wound surface on the inner naked surface of the cheek to replace the mucous membrane.
The end of the flap is doubled, forming a duplicate skin in the defect area. The edges of the outer layer of the duplicate are hemmed to the edges of the skin in the region of the cheek defect.
After engrafting, the flap is cut off at the rear inflection, the wound on the neck is sutured throughout its entire length, using an excess of dermal tape at the inflection point.
The subsequent stages, like the Israel method, are reduced to the formation of the angle of the mouth from the transplanted duplicate skin.
Method A.E. Rauer-N. M. Michelson
Its essence lies in the fact that of two flaps (one - the bridge - on the chest, the second - on the inner surface of the shoulder) create a duplicate skin, which is later transferred to the leg on the foot of the defect.
In everyday work, one should prefer the methods of Israel, NA Almazova or AE Rauera-N. M. Michelson, and not the closure of the defect by local tissues.
To close a large defect in the bone and cheek after resection of the upper jaw along with adjacent soft tissues NM Aleksandrov (1974, 1975) recommends epidermisation of the bottom of the wound with a split skin flap, and then in the anterior region and lateral region of the neck to cut out a large tongue-shaped flap, the dimensions of which allow it to be rotated to the region of the defect of the cheek. Before this movement, the wound in the region of the flap is epidermalized by a split skin graft (from the hip), whose dimensions correspond to a defect in the mucous membrane of the cheek. Then the duplicated flap is fixed to the edges of the postoperative defect of the cheek and stitches are applied to the donor base.
In cases where it is impossible to cover a cheek defect by mobilization of its edges, internal lining of the cheek (by tipping the cutaneous flaps on the pedicle) is created from the local tissues, and the outer part of the duplicate is created by free transplantation of a thick or split skin flap from the anterior the walls of the abdomen or chest.
The method of FM Khitrova
To eliminate the extensive defect of the cheek, it is better to use the Filatov stalk, using the scheme of surgical interventions developed by FM Khitrov, or the method of O. P. Chudakov, but not the methods of Israel or NA Almazova. This is due to the fact that Filatov's stem is more viable than the flaps of Israel or NA Almazova, it is more convenient for sewing and has a fairly long leg, which makes it possible to give the patient's hand a comfortable position.
If necessary, the Filatov's stem can be engrafted to the edges of the defect with both legs, and then cut transversely in its middle part and double, resulting in a sufficient amount of plastic material.
Whichever method the surgeon applies for lip or cheek plastic surgery, he must remember that scarring of transplanted tissues can lead to contracture of the lower jaw. Therefore, when carrying out the plastic, it is necessary to use forming prostheses (for example, manufactured according to MP Barchukov); at the end of the plastics appoint a mechanotherapy of the lower jaw and softening scars physiotherapy.
Such defects lead not only to severe disfigurement, speech and nutrition disorders, but also to dehydration of the body, eczematous damage to the skin of the neck and chest. As a result of the reduction of the masticatory muscles and muscles of the bottom of the oral cavity or the formation of scars in this region, lateral fragments of the lower jaw are pulled upward and to the midline, squeezing the tongue from the sides and from below.