Deep-plane cervicofacial ''hike'': Anatomic basis with dog-ear blepharoplasty

The temporal and cheek areas are particularly vulnerable to sun damage and therefore to skin cancers. Rotation-advancement flaps are used commonly in the reconstruction of these regions following resection of skin cancers. Such flaps usually are modifications of the Mustarde, cervicofacial, and Juri flaps. The drawbacks to these flaps relate to a random, unpredictable perfusion with skin loss at the distal flap tip, a vertically oriented dog-ear that predictably is located on the cheek, and the risk of gravitational and cicatricial forces acting on the lower eyelid causing ectropion. The deep-plane technique for raising cheek flaps, as has been described recently for use in rhytidectomy, allows the plastic surgeon to address both drawbacks of the standard cervicofacial flaps. The vertical ''hike'' deep-plane approach addresses both drawbacks of the rotation-advancement flaps by including better perfusion and superior mobility after release of restraining ligaments. We describe the anatomic rationale for the deep-plane dissection of the cheek in cadaver studies and present our clinical technique with a vertical ''hike'' cheek advancement with removal of the horizontally oriented dog-ear as in a blepharoplasty. This single-stage technique will be called the deep-plane ''hike'' flap. The vertically advanced flap must be slightly overcorrected by anchoring the flap to the periosteum just above the recipient defect. This deep fixation removes all tension from the skin and prevents ectropion. This single-stage reconstruction affords excellent cosmetic results without compromising any future reconstructive efforts.