Case 7: Cervicofacial Flap for Cheek Reconstruction Post Excision of Pigmented Solid Basal Cell Carcinoma
Bertha Kawilarang1, Agus Roy Rusly Hariantana Hamid1, I Gusti Putu Hendra Sanjaya1
- 1Department of Plastic Reconstructive and Aesthetic Surgery. Prof. dr. I.G.N.G. Ngoerah General Hospital, Bali, Indonesia
Abstract
Keywords: cervicofacial flap, reconstruction, basal cell carcinoma, facial, cheek Authors: Bertha Kawilarang, MD, Agus Roy Rusly Hariantana Hamid, MD, I Gusti Putu Hendra Sanjaya, MD. Institution: Department of Plastic Reconstructive and Aesthetic Surgery. Prof. dr. I.G.N.G. Ngoerah General Hospital, Bali, Indonesia Abstract Background: Basal cell carcinoma (BCC) is the most common skin malignancy, with the pigmented solid subtype being a rare variant. Surgical excision with clear margins remains the mainstay of treatment, but reconstruction of facial defects requires careful planning to optimize both function and aesthetics. Case Presentation: We report a case of a 59-year-old female with a pigmented solid BCC of the right cheek. Wide local excision was performed, achieving histopathologically confirmed clear margins. The resultant defect, extending from the midface toward the nasolabial fold, was reconstructed using a cervicofacial advancement-rotation flap. Novelty and Rationale: The cervicofacial flap was selected due to its robust vascularity, excellent tissue match, and ability to provide a tension-free closure with minimal donor site morbidity. The flap was elevated in a subcutaneous and sub-SMAS plane to preserve vascularity, primarily based on the perforators from the facial and transverse cervical arteries. Meticulous dissection in the preauricular and cervical regions allowed for optimal mobilization without compromising facial nerve integrity. A lateral undermining technique enhanced flap rotation and reduced standing cutaneous deformities, ensuring a natural contour. Outcome: The patient’s postoperative course was uneventful, with complete flap survival and no complications. At the 6-month follow-up, there was no evidence of tumor recurrence, and the patient expressed high satisfaction with the functional and aesthetic results. Conclusion: This case highlights the cervicofacial flap as a versatile and reliable option for large cheek defects following on
BeforeAfterThe patient had no significant underlying medical conditions. Three years prior to presentation, she underwent a biopsy of a pigmented lesion on her right cheek, which was not followed by definitive treatment. Over time, the lesion progressively enlarged, prompting further evaluation and eventual surgical management.
Outline the tumor with a 5 mm clinical safety margin for wide local excision.
Mark the cervicofacial flap extending from the preauricular region down to the lateral neck, ensuring adequate length for rotation and advancement.
Design the flap with a gentle curve along relaxed skin tension lines to optimize closure.
Plan for undermining in the subcutaneous and sub-SMAS plane to improve mobility.
Wide local excision of the tumor with full-thickness skin removal, extending into subcutaneous fat.
Ensure histopathological confirmation of clear margins via frozen section if available.
Assess the size and depth of the defect to determine the required flap mobilization.
2
Incise along the marked flap outline.
Elevate the flap in a subcutaneous and sub-SMAS plane, preserving vascularity from the facial artery perforators and transverse cervical artery contributions.
Proceed with careful dissection around the preauricular region and along the lateral neck, ensuring preservation of the facial nerve branches.
3
Gradual advancement and rotation of the flap toward the defect.
Perform lateral undermining to enhance flap mobility and reduce tension.
Tension-free closure of the defect with layered suturing:
Deep dermal sutures (e.g., absorbable 5-0 Vicryl) to reduce tension.
Skin closure with fine interrupted sutures (e.g., 6-0 nylon) along natural skin creases.
Donor site closure with primary approximation, ensuring minimal distortion of surrounding structures.
Place a closed-suction drain.
4
5
The patient at follow up after 3 years. Minimal scars visible. No signs of ectropion. No signs of recurrency.
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Minimal scar visible.
7
Flap Monitoring:
Regular assessment of flap color, temperature, capillary refill, and turgor to ensure adequate perfusion.
Watch for signs of venous congestion (bluish discoloration, edema) or arterial insufficiency (pale, cool skin), especially in the first 48 hours.
Wound Care & Dressing:
Apply a light pressure dressing to minimize hematoma formation while avoiding excessive compression that may compromise flap circulation.
Consider placing a closed-suction drain in the undermined cervical region if significant dead space is present.
Instruct the patient to keep the surgical area clean and dry, with dressing changes as needed.
Patient had the suture removal at 7 days postop, and patient showed excellent outcomes.
How to cite this article
Bertha Kawilarang, Agus Roy Rusly Hariantana Hamid, I Gusti Putu Hendra Sanjaya. Case 7: Cervicofacial Flap for Cheek Reconstruction Post Excision of Pigmented Solid Basal Cell Carcinoma. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
Open access. © 2025 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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