Islands on the Cheek: Island Flaps on the Cheek and a Modified Oblique-Sigmoid Flap

Abstract

Cutaneous island flaps have long been used in plastic and dermatologic surgery to reconstruct cheek defects following excision of skin cancers. One of the first to use such an island flap was the German Surgeon, Ernst Blasius (1802–1875), who described this technique in the closure of skin defects in 1850 [1]. As we know, The design of a V-Y flap is very simple. The principle is to use skin from an area of relative excess to fill an area of deficiency. A “V”-shaped flap is incised adjacent to and advanced into the defect [2]. However, one of the major problems with the V-Y advancement flap when used as a cheek advancement flap is the vertical scar, which violates the relaxed skin tension lines of the cheek [3]. Therefore it is best reserved for lesions alongside creases such as the nasolabial fold. Defects involving the lower eyelid region on the cheek can be challenging because of the unique anatomical arrangements of the structures in this region. One of the risks of using V-Y advancement flaps are poor scars and ectropion of the lower lids [4]. It is important to assess this risk pre-operatively. The “pinch test” and “snap back test” are used to detect the presence of lower lid laxity. The result is abnormal if the lid can be distended more than 6 mm from the globe or does not briskly returns to its natural position [5]. Gravity may also exert a pull on the lower eyelid leading to delayed ectropion formation in inferiorly based island flaps on the cheek. Therefore it is often advisable to anchor the flap to the periosteum of the lower orbit [2]. Standard technique in such situations is to anchor the flap dermis to the periosteum of the infraorbital rim with permanent sutures. While some surgeon use absorbable sutures, I prefer to use 4.0 nylon or polypropylene permanent sutures in this situation.