Cheek trauma

Authors: Christian Kaare Paaskesen, MD, and Magnus Balslev Avnstorp, MD

Introduction

Cheek lacerations are common in facial trauma and frequently encountered in emergency and surgical settings. Although often regarded as straightforward soft-tissue injuries, cheek wounds involve a complex anatomical region comprising skin, subcutaneous tissue, the superficial musculoaponeurotic system (SMAS), mimetic musculature, and critical neurovascular structures. Inadequate assessment or improper closure can result in facial asymmetry, functional impairment, and conspicuous scarring.

A key surgical principle in cheek laceration repair is appropriate suture orientation. Vertically oriented sutures may transmit superior tension through the midfacial soft tissues, resulting in inferior displacement of the lower eyelid (eyelid drag). In addition, lacerations near the perioral region demand careful attention to the oral commissures, where even minor asymmetries can significantly affect facial expression and function.

When feasible, the resulting scar should be placed or guided into natural aesthetic subunits, most notably the nasolabial fold, which provides an effective means of scar camouflage.

Assessment

A thorough and structured assessment is essential:

• Depth and extent: Determine involvement of SMAS, mimetic muscles, or exposure of the buccal fat pad.
• Facial nerve function: Assess active facial movement to evaluate possible injury to the buccal or zygomatic branches of the facial nerve.
• Parotid duct: Suspect injury in wounds anterior to the masseter muscle or along a line drawn from the tragus to the oral commissure.
• Oral commissures: Carefully assess alignment and symmetry, particularly in oblique or lateral cheek lacerations.
• Lower eyelid position: Evaluate eyelid tone and pre-existing laxity, as these factors increase susceptibility to tension-induced displacement.
• Aesthetic landmarks: Identify the nasolabial fold and consider whether the wound can be aligned or partially redirected along this natural crease.

Preparation

Infraorbital nerve block or carefully administered local anesthesia is preferred to minimize tissue distortion.

The wound should be thoroughly irrigated to remove debris. Debridement must be conservative, as the cheek has excellent vascularity and excessive tissue removal risks contour defects. Hemostasis should be achieved gently to preserve the subdermal vascular plexus.

Vascular Supply

The cheek is richly supplied by branches of the facial artery, including the angular, transverse facial, and infraorbital arteries. This robust blood supply supports healing, but optimal cosmetic outcomes still depend on meticulous technique and appropriate tension control.

Layered Closure

1. SMAS and Mimetic Musculature

In deep lacerations, disrupted SMAS and underlying muscles (e.g., zygomaticus major/minor or buccinator) should be re-approximated using fine absorbable sutures. Proper restoration of these layers is essential for facial symmetry and dynamic function.

2. Subcutaneous Tissue / Deep Dermis

Deep dermal sutures should be placed in a horizontal or slightly oblique-horizontal orientation. This reduces vertical tension vectors that might otherwise be transmitted toward the lower eyelid or oral commissures.

3. Skin

Skin closure is performed with fine non-absorbable sutures. Horizontal simple interrupted or horizontal mattress sutures are preferred. When anatomy allows, the incision line can be directed toward or partially aligned with the nasolabial fold to improve scar concealment.

Suture Orientation and Tension Direction

Correct suture orientation is the most critical technical aspect of cheek laceration repair.

Why orientation matters

The midface is interconnected through SMAS and fascial planes that readily transmit tension. Vertically oriented sutures on the cheek may:

• Create superior traction on midfacial tissues
• Cause inferior displacement of the lower eyelid (scleral show)
• Distort the oral commissures
• Produce facial asymmetry during expression

How to prevent these complications

• Orient sutures horizontally whenever possible.
• Avoid vertical closure patterns in the infraorbital and mid-cheek regions.
• Use gentle undermining to allow tension-free horizontal closure.
• Distribute tension symmetrically near the oral commissures.
• When feasible, guide the scar into the nasolabial fold for aesthetic camouflage.
• Observe the lower eyelid during closure; any visible movement suggests unfavorable tension vectors.

Suture Techniques

• Muscle/SMAS: 4-0 or 5-0 absorbable sutures (e.g., Vicryl or Monocryl).
• Deep dermis: 5-0 absorbable sutures, placed horizontally.
• Skin: 5-0 or 6-0 nylon.

Slight eversion of wound edges is recommended to prevent depressed scarring.

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Restoring Function and Aesthetics

Restoring Function and Aesthetics

Successful cheek laceration repair restores normal facial movement, preserves symmetry of the oral commissures, and maintains lower eyelid position. Horizontal suture orientation is central to preventing eyelid drag, while strategic scar placement within the nasolabial fold significantly improves long-term cosmetic outcomes.

Scar optimization (sun protection, early suture removal) further enhances outcomes.