Modified Rhomboid Flap For Facial Reconstruction

JCD
Adil Gandevivala et al 10.5005/jp-journals-10031-1162

Case Report
Modified Rhomboid Flap for Reconstruction of Defect of

Cheek after Excision of Basal Cell Carcinoma
1
Adil Gandevivala, 2Dinesh H Shah, 3Sunil Sidana, 4Akram Khan
ABSTRACT knowledge of cheek anatomy is necessary before perform-

The cheek is a very important part of the human face because it ing specific flap design, which allows safe and successful
is the largest part and is essential in terms of both esthetics and operative reconstruction procedure.
functionality. Basal cell carcinomas (BCCs) are most common The facial artery is the main artery of face and origi-
skin malignancy found in Caucasians and rarely in Asians. nates from the external carotid artery and supplies pre-
Treatment can range from topical medications, curettage, Mohs
micrography, cryosurgery, laser surgery and excision. Defect dominantly the cheek region. A course of facial artery in
left after excision can be cosmetically disfiguring. Options for face is tortuous, and it crosses the mandible at the facial
reconstruction after excision of the lesion are skin graft and notch then courses under the muscles of facial expression.
local flaps. We present a case of BCC of the cheek which was Facial artery is oriented axially, giving rise to perforating
reconstructed with modified rhomboid flap.
vessels that supplies the subdermal plexus. An axial type
Keywords: Cheek defect, Reconstruction, Rhomboid flap. of flap is based on a named vessel, such as the supraor-
How to cite this article: Gandevivala A, Shah DH, Sidana S, bital or superficial temporal arteries.2 Random based
Khan A. Modified Rhomboid Flap for Reconstruction of Defect
local flaps get supply from the area of subdermal plexus.
of Cheek after Excision of Basal Cell Carcinoma. J Contemp
Dent 2016;6(2):154-156. An important fibrous network, called the superficial
Source of support: Nil
musculoaponeurotic system (SMAS), interlinks the
muscles of facial expression. The SMAS lies under the
Conflict of interest: None
subcutaneous fat, and its extension is continuous superi-
orly with the superficial temporal fascia (temporoparietal
INTRODUCTION
fascia) and inferiorly with the platysma.
The cheek is a very important part of the human face Dissection of a cheek flap usually is performed in a
because it is the largest part and is essential in terms of layer of subcutaneous plane to preserve facial nerve and
both esthetics and functionality. Cheek defects after exci- the subdermal vascular plexus. In some cases of larger
sions, basal cell carcinoma (BCC) can range from small to defects, elevation below SMAS plane may be required for
medium size which can be reconstructed by using a full adequate vascularity of the flap.
thickness skin grafts or defects local flaps. Disadvantages
with skin graft are second donor site required for skin graft CASE REPORT
and mismatch in color. Local flaps have the advantage of
A 65-year-old man presented for evaluation of a progres-
same-site donor tissue and good color match of skin from
sively enlarging plaque on the left lateral cheek. Physical
adjacent site of the lesion. However, donor-site morbidity
examination revealed a sclerotic, yellow, depressed plaque
and further scarring in an already cosmetically sensitive
of the upper left cheek measuring 1.8 × 1.3 cm (Fig. 1).
area may occur after most types of flap repair.1
Punch biopsy confirmed it to be a BCC. The lesion was
excised with 6 mm margin. Primary closure of excised
CHEEK ANATOMY
lesion would have led to ectropion of left lower eyelid
The cheeks constitute a substantial portion of the face (Fig. 2). Modified rhomboid flap was then designed adja-
and contain several important structures. A complete cent to the defect. The flap was elevated in a subcutane-
ous plane and rotated into the defect. Skin closure was
done with 5–0 ethilon (Fig. 3). Histopathology revealed
1
Lecturer, 2Postgraduate Student, 3Professor, 4Private Practitioner
nodular cystic variant of BCC. Three month after the
1-3
Department of Oral and Maxillofacial Surgery, MGM Dental surgery, healing was satisfactory with minimal linear
College and Hospital, Navi Mumbai, Maharashtra, India
4
scar (Fig. 4).
Dr. Khan's Dental Clinical Mumbai, Navi Mumbai, Maharashtra
India
DISCUSSION
Corresponding Author: Adil Gandevivala, Lecturer, Department
of Oral and Maxillofacial Surgery, MGM Dental College Face represents complete personality of a human being.
and Hospital, Navi Mumbai, Maharashtra, India, Phone: Therefore, adequate cosmetic correction of facial defects
+919096815606, e-mail: [email protected]
arising due to various injuries and lesions is very important.
154
JCD
Modified Rhomboid Flap for Reconstruction of Defect of Cheek after Excision of Basal Cell Carcinoma
Fig. 1: Inner circle depicts the BCC, outer circle marked with Fig. 2: Primary closure of excised lesion would have resulted in
6 mm margin (modified rhomboid flap designed laterally) ectropion of lower eyelid
Fig. 3: After suture placement Fig. 4: Three months after surgery
“Reconstruction ladder” exists in current surgical practice In the face malignant tumor are BCC, squamous cell
for management of such defects on face with healing by carcinoma (SCC), and melanoma.4 Basal cell carcinomas
secondary intention and granulation formation at one end are the most common forms of skin cancer. They most
of spectrum and reconstruction by microvascular surgery commonly occur on sun-exposed area of the body as
at the other end of spectrum. Local flaps in the recon- slow growing tumor. Face is the most common location
struction of defects falls in-between this spectrum with for these lesion. It is well known that recurrence rates are
intention of achieving best cosmetic results comparable to higher for larger and previously recurrent tumors as well
microvascular surgery and also feasibility of the technique as for more aggressive histologic subtypes.5
at secondary referral center where, many a time, expertise In the past 20 years, reconstructive techniques have
for microvascular surgery is not available.3 greatly advanced the approach to cheek reconstruction;
however, several factors continue to play a important
role in reconstructive outcome.4 Various reconstructive
Cheek Esthetic Unit
options are available for closure of cheek defect, include
The anatomic location of a lesion should be evaluated primary closure, healing by secondary intention, skin
within the area of facial esthetic units. Specific land- grafting, local flaps, regional flap, and distant flap.
marks that are used for assessment of the cheek define In elderly patients with lax skin, a large defect can be
the borders of these esthetic units. Medially this is bor- closed primarily using relaxed skin tension lines (RSTL)
dered by the nasofacial groove, melolabial crease, and with minimal wound closure tension. In our case, defect
labiomental sulcus; laterally by the preauricular crease; was present just beneath lateral to the lower eyelid region,
superiorly by the infraorbital rim and superior border of and primary closure would result into ectropion of lower
the zygomatic arch; and inferiorly by the inferior man- eyelid.
dibular border. It is also subdivided into four subunits Secondary intention is the safest option if the malig-
named as the medial, zygomatic, buccal, and lateral.2 nancy is removed with questionable margins, which
Journal of Contemporary Dentistry, May-August 2016;6(2):154-156 155
Adil Gandevivala et al
requires prolonged daily wound care and frequent two-thirds the length of the diameter of the defect. The
observation. This technique is not suitable as the healing second side is equal in length to the first side. In our study,
wound distorts the surrounding structures. Skin graft- we used this modified rhomboid flap on cheek where
ing is also a commonly used method for reconstruction. creases are not prominent, skin is thinner, and resulting
A disadvantage of skin grafting is suboptimal color and scar tends to blend better with adjacent skin.3
texture matching between the grafts and surrounding
tissue. CONCLUSION
A local flap consists of a tongue-like protrusion of
Reconstruction of facial defects by local flaps is easy
tissue which is made up of skin and a variable amount of
and cost-effective technique, easy to learn, and takes
the underlying subcutaneous tissue. Classification of flap
minimum time to perform good esthetic results.
is based on their vascular supply, composition, method
of transfer, and design.3 In the face rectangular advance-
ment flap by Burrow’s triangle, bilobed flap, rhomboid REFERENCES
flap, and forehead rotation flap are most commonly used 1. Zhi-guo W, Quan-chen X, Rui-xia K, Zhen-yu C, Ran H.
in current practice.3 Principles of hatchet-skin flap for repair of tissue defects on
the cheek. Aesthetic Plast Surg 2012 Feb;36(1):163-168.
The rhomboid flap is a type of a complex transposi-
2. Tollifson T, Murakami CM, Kriet JD. Cheek repair. Otolar-
tion flap with a strict geometrical design introduced by
yngol Clin North Am 2001 Jun;34(3):627-646.
Limberg in 1946. For a rhomboid design, the lesion is 3. Gujrathi AB, Ambulgekar V. Reconstruction of facial skin
excised as rhomboid with internal angles of 60° and 120°. defect by various flaps: our experience. J Evid Based Med
It also depends on location of the defect, the skin thick- Healthc 2015 Aug 10;2(32):4701-4708.
ness of the donor site, and the orientation of the RSTL. In 4. Heller L, Cole P, Kaufman Y. Cheek reconstruction: current
concepts in managing facial soft tissue loss. Semin Plast Surg
our case, as the defect was circular, modified rhomboid
2008 Nov;22(4):294-305.
flap/rhombic flap was used in our case. In modified 5. Darwish AMA. The role of wider safety margins in the
rhomboid flap, around a circular defect, two sides are prognosis of the basal cell carcinoma of the face and scalp.
drawn with apex forming 60°. The length of first side is J Surg 2014;2(1):3.
156

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JCD

Adil Gandevivala et al 10.5005/jp-journals-10031-1162

Modified Rhomboid Flap for Reconstruction of Defect of

ABSTRACT knowledge of cheek anatomy is necessary before perform-

Fig. 3: After suture placement Fig. 4: Three months after surgery

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