The patient presented with a lesion on the right cheek that had progressively enlarged over the past month. Initially, the lesion appeared as a black spot resembling a mole, which first developed five years ago. Over time, it became pruritic, fragile, and prone to bleeding. The patient had previously undergone a surgical procedure; however, the pigmented lesion reappeared and continued to expand, eventually leading to ulceration.
Currently, the patient reports minimal pain but denies pruritus or fever. The patient has a history of prolonged sun exposure due to her occupation as a farmer during her younger years. On physical examination: A well-demarcated, pigmented nodular lesion measuring approximately 3cm x 4cm was observed on the right cheek, with areas of central ulceration and peripheral pearly borders. The lesion exhibited telangiectatic vessels on its surface and an indurated, slightly elevated margin. No signs of regional lymphadenopathy were noted, and no other suspicious lesions were identified on the face or body.

Although basal cell carcinoma (BCC) has a low risk of distant metastasis, it can exhibit locally invasive behavior, necessitating complete excision with histologically confirmed clear margins. A 5 mm clinical safety margin is generally recommended for well-defined BCCs, but larger margins may be required for more aggressive subtypes or ill-defined lesions. Given the tumor’s location on the cheek, careful reconstructive planning was essential to restore both function and aesthetics while minimizing donor site morbidity.

The cervicofacial flap was selected as the optimal reconstructive approach due to its ability to provide well-matched tissue with minimal tension. This flap offers a reliable blood supply primarily from perforators of the facial and transverse cervical arteries, ensuring robust vascularization. Unlike local advancement flaps, which may cause distortion of surrounding structures, the cervicofacial flap allows for a tension-free closure with excellent contour restoration.

Surgical Plan: The cervicofacial flap was designed as a rotation-advancement flap, elevated in a subcutaneous and sub-SMAS plane to maximize vascularity while preserving the integrity of the underlying facial nerve. Adequate undermining in the preauricular and cervical regions ensured sufficient mobilization and reduced tension at the closure site. To prevent standing cutaneous deformities, lateral undermining was performed, allowing the flap to drape naturally over the defect. Donor site closure was achieved with minimal scarring along relaxed skin tension lines, optimizing aesthetic outcomes.

Patient Information: The procedure was planned under general anesthesia due to the extent of the flap elevation and the need for meticulous dissection. A single-stage reconstruction was favored to minimize patient morbidity and recovery time. The patient was counseled on potential complications, including hematoma, infection, and partial flap necrosis, though the cervicofacial flap’s robust vascularity significantly reduces these risks. Given the literature and clinical experience, an excellent functional and aesthetic outcome was anticipated.

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.

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.

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.

The patient at follow up after 3 years. Minimal scars visible. No signs of ectropion. No signs of recurrency.

Minimal scar visible.

Flap Design & Planning:

Design the flap along relaxed skin tension lines to optimize scar camouflage and minimize distortion.

Ensure the flap has an adequate arc of rotation and sufficient length to cover the defect without excessive tension.

Flap Elevation & Vascular Considerations:

Elevate the flap in the subcutaneous and sub-SMAS plane to preserve vascular supply from the facial artery perforators and transverse cervical artery.

Gentle handling of tissues prevents compromising flap perfusion and reduces the risk of venous congestion.

Mobilization & Inset:

Adequate undermining in the cervical and preauricular region is essential for tension-free closure.

Lateral advancement techniques help redistribute tension and avoid excessive pulling on the medial cheek.

Burrow’s triangles or back-cuts can be used strategically to improve flap contour and prevent dog-ear deformities.

Inadequate Undermining

Insufficient mobilization can lead to tension at the closure site, risking partial flap necrosis and wound dehiscence.

Overly Tight Closure

Excessive tension on the flap can cause distortion of surrounding structures (e.g., lower eyelid retraction, alar distortion).

Neglecting Vascular Integrity

Too deep dissection in the preauricular area risks injuring facial nerve branches.

Over-thinning the flap may compromise vascularity, especially in smokers or patients with vascular comorbidities.

Poorly Planned Scar Placement

A poorly positioned scar may result in visible contour irregularities, particularly if it crosses cosmetic subunits.

Older patients or those with sun-damaged skin may have reduced skin elasticity, requiring a more conservative undermining approach.

Patients with a history of smoking or diabetes may have a higher risk of flap necrosis and should be counseled accordingly.

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.

• Søreide K, Guest K, Reineke R, Helvig E, Milathianakis C, Gladhaug IP. Surgical excision margins in primary cutaneous basal cell carcinoma: A systematic review. Br J Dermatol. 2021;185(5):954–964. doi:10.1111/bjd.19867
• Matsui T, Hinni ML. Cervicofacial flap: Technical pearls and pitfalls in reconstruction of complex facial defects. Facial Plast Surg Aesthet Med. 2020;22(4):267–274. doi:10.1089/fpsam.2020.0067
• Taghinia AH, Lee BT. The cervicofacial flap: A versatile option for cheek reconstruction. Facial Plast Surg Clin North Am. 2019;27(2):193–204. doi:10.1016/j.fsc.2019.01.005
• Venegas MV, Mazzaferro DM, Papay FA, Zins JE. Local flaps for facial reconstruction: Principles and applications. Plast Reconstr Surg. 2020;145(5):1040e–1053e. doi:10.1097/PRS.0000000000006692
• Kaufman AJ, Patel UA, Carlson ER. Regional and free flap reconstruction of facial defects. Oral Maxillofac Surg Clin North Am. 2018;30(4):507–526. doi:10.1016/j.coms.2018.06.003