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Saturday, August 15, 2015

Medical History: Replacing a Lost Cheek with a Shoulder Flap

Dr. Edmund Andrews
In 1882, Dr. Edmund Andrews (a surgeon from Chicago) had a serious problem to deal with. One of his patients, a young woman of about 22 years of age, had been shot in the face at close range with a shot gun one year prior. The bullet entered from front to back on a diagonal angle, tearing away her right cheek and stripping the skin off her jaws. The woman was horribly scarred and the deformity from the injury caused the opening of her mouth to appear triangular in shape. Without a cheek, one could see the woman’s molars through the side of her face.

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Dr. Andrews tried to figure out if there was a way to remove skin from one part of her body and transplant it to the cheek area. He looked at her forearm and neck for spare tissue but this was to no avail because she was too thin. What he needed was not only skin but fat in order to provide a thick cushion in the cheek area.  He found that her deltoid muscle (shoulder muscle) served this need quite well.  He therefore anesthetized the patient and cut an oval flap of tissue from the front of the deltoid (2 inches wide by 2.5 inches long) and left it attached to her collar bone. He then washed the flap and wrapped it in the tissue of the gutta-percha tree for about a week. This tree tissue was used by surgeons at the time for the repair and preservation of body tissue. In this case, it helped the body tissue recover its circulation.

The surgeon’s next step was to anesthetize the patient again and use a scalpel on the scarred area of the cheek to make the hole match the size of the should tissue flap. The patient bent her neck towards the flap and raised her shoulder to meet it. The flap was then stitched into the open cheek area.  The head and shoulder area were then plastered together with adhesive straps and bandages. The patient had to stay like this for a week. This must have been quite uncomfortable but it was needed at the time to allow the shoulder tissue to form a viable union in the cheek area.  After a week, when the union was established, Dr. Andrews separated the tissue flap from the shoulder and the patient’s head was released from confinement.

Over time, most of the transplanted tissue remained but one part near the mouth sloughed off.  Three weeks after the shoulder flap was separated, Dr. Andrews filled in the gap with other tissue. Due to this pioneering procedure at the time, the patient developed a reasonably full and rounded cheek. The full reference for more detailed documentation of this historical surgical procedure is:  Andrews, E. (1883). Restoration of a lost cheek by a flap from the shoulder. Journal of the American Medical Association, 1, 20-21.

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