Elevation of the skin flap can vary according to the needs of the area. Patients who have had multiple facial injections including fat, Restylane, Perlane and so on may have a scarred cheek area between the skin and the superficial musculo-aponeurotic system (SMAS), leading to potential problems.
The decision of undermining thickness can trigger problems. Undermining of a skin flap could end up with devascularization of the cheek, leading to skin necrosis. Do not undermine superficially close. If the surgeon decides to make the flap thicker, he/she could inadvertently end up elevating the SMAS with the skin flap, resulting in multiple problems.
Beware of motor nerve injuries in elevating a secondary skin flap, especially when dissecting anterior
to the parotid since it could lead to nerve injury and localized paresis. Deep secondary elevation of the skin flap can enter the superficial parotid, resulting in a parotid cyst or fistula (Fig. 65.8).
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