If there is a need to provide support to the hyoid area or maximum support to submaxillary glands, an occipital transposed cheek SMAS flap may be useful . A flap as wide as possible is made from the posterior margin of the SMAS flap by closure of the donor site before cutting the flap. The donor site closure is made from the posterior margin of the SMAS flap anterior to the tragus of the ear and below the mandibular angle (Fig. 38.12). This SMAS flap is rotated to the mastoid area and sutured in place with the chin-neck angle at 90° so that when the patient looks upward there is no increased tension along the direction of the SMAS flap. When looking downward, there is submental support across to the opposite SMAS flap. The support produced by submental pla-tysmal invagination completes the hammocklike support to the upper part of the neck and submental area. The SMAS flap rotated to the occipital area completes a three-direction support which has increased SMAS tension directed toward the temporal area, toward the occipital area and toward the midline muscle approximation in the submental area. This rotated mastoid SMAS flap produces a wide choice of direction and precision support individualized to each patient's need and avoids shifting of the sternocleidomastoid muscles (Fig. 38.12d).
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