Multi-flap Cheek Reconstruction: Merging Triple Advancement, Island Pedicle, and Rotation Flaps for Optimal Aesthetic and Functional Outcomes After Mohs Micrographic Surgery

An 85-year-old white male presented with a basal cell carcinoma on the right cheek, treated with Mohs micrographic surgery, resulting in a 5.8 x 3.2 cm defect across multiple facial subunits. Given the defect's size and patient's age, options such as second-intention healing, primary closure, and skin grafting were deemed suboptimal. The cheek's anatomical complexity requires innovative surgical strategies for large defects. A multi-faceted surgical approach using adjacent tissues was employed: a triple advancement flap, an island pedicle, and a rotation flap to optimize aesthetic and functional outcomes. The defect was primarily closed using a triple advancement technique to minimize the tension and distortion at the lateral canthus and oral commissure. An island pedicle flap was then utilized to close the anterior part of the defect. Finally, a rotation flap and excision of a small standing skin cone allowed repair of the superior defect with minimal distortion of the lateral canthal skin. Key suturing strategies were implemented to maximize skin laxity and minimize aesthetic disruption. By integrating Mohs surgery, multiple flap techniques, and careful tension management, effective closure was achieved with excellent oncologic and aesthetic outcomes. This case underscores the importance of tailored surgical approaches in facial reconstructive surgery, particularly in elderly patients with significant aesthetic and functional considerations.