Cheek, Temple, Forehead & Scalp Reconstruction

The cheek is one of the most favorable regions for reconstruction after Mohs surgery because of its generous tissue laxity, excellent blood supply, and relatively uniform skin characteristics. The cheek can be conceptualized as three zones: the medial cheek (infraorbital and malar region), the lateral cheek (preauricular region), and the buccal cheek (over the buccinator muscle). Tissue laxity is greatest in the lateral and inferior cheek and least in the medial cheek near the lower eyelid and nose. The relaxed skin tension lines (RSTLs) on the cheek run in a predominantly oblique direction from superolateral to inferomedial, and primary closures oriented along these lines produce the least conspicuous scars. Key anatomic structures to protect during cheek reconstruction include the parotid duct (Stensen duct), the facial nerve branches, and the infraorbital nerve. The parotid duct exits the parotid gland and crosses the masseter muscle on a line drawn from the tragus to the midpoint of the upper lip. Injuries to the duct can produce sialoceles or fistulae. The facial nerve branches (particularly the buccal and marginal mandibular) traverse the cheek in a deeper plane, generally protected by the SMAS layer, but can be injured during deep undermining.

The temple is a critical danger zone for reconstruction because of the superficial course of the temporal (frontal) branch of the facial nerve (CN VII). This nerve exits the parotid gland and crosses the zygomatic arch in the superficial temporal fascia (temporoparietal fascia), running within or just deep to this layer toward the frontalis muscle. Injury to the temporal branch causes ipsilateral frontalis paralysis, resulting in brow ptosis and asymmetric forehead animation. A conspicuous and often permanent deformity. The critical zone for nerve injury lies within a triangle bounded inferiorly by the zygomatic arch, anteriorly by a line from the tragus to the lateral brow, and superiorly by a line from the tragus to the highest forehead crease. Within this triangle, all undermining must be performed SUPERFICIALLY. Above the superficial temporal fascia (temporoparietal fascia) and within the subcutaneous fat layer. Deep undermining in this region risks transecting the temporal branch. Above the level of the superior temporal line, the nerve has already entered the frontalis muscle, and undermining in the subgaleal plane is safe. Reconstructive options for the temple include primary closure (which is often achievable due to the moderate laxity of temporal skin), rotation flaps from the forehead or scalp, transposition flaps, and full-thickness skin grafts from the preauricular region. The superficial temporal artery provides strong blood supply to the temporal region, supporting reliable flap perfusion.

The forehead is a broad, convex surface with horizontally oriented RSTLs that correspond to the frontalis muscle action lines (forehead rhytids). Primary closure oriented horizontally along these RSTLs is the simplest and most cosmetically favorable option for forehead defects up to approximately 3 cm, particularly in patients with pre-existing forehead rhytids that camouflage the scar. For circular or oval defects that do not lend themselves to simple elliptical closure, the A-T plasty (for triangular or angled defects) or O-T plasty (for circular defects) converts the wound into a T-shaped closure that distributes tension bilaterally and places the primary scar along a horizontal RSTL. Larger defects require rotation flaps, which recruit tissue from the adjacent forehead and temporal regions. Undermining on the forehead follows a depth-dependent strategy: for small defects, undermining is performed in the deep subcutaneous plane (above the frontalis muscle); for larger defects requiring more extensive mobilization, undermining is performed in the subgaleal plane (between the galea aponeurotica and the pericranium), which is a nearly avascular plane that allows rapid, wide undermining with minimal bleeding. The subgaleal plane provides greater tissue mobility but carries a risk of undermining the supraorbital and supratrochlear neurovascular bundles, which exit the orbit and pierce the frontalis muscle. Preserving these structures during undermining is important for forehead sensation.

The scalp presents unique reconstructive challenges due to its limited intrinsic elasticity. Unlike the cheek or forehead, scalp skin is tightly bound to the underlying galea aponeurotica with minimal subcutaneous tissue laxity. The scalp layers follow the classic S-C-A-L-P mnemonic: Skin, subCutaneous connective tissue, Aponeurosis (galea aponeurotica), Loose areolar tissue, and Pericranium (periosteum). Scalp reconstruction relies heavily on rotation flaps, which are the dominant technique for all but the smallest defects. Small scalp defects (under 3 cm) may be amenable to primary closure, provided there is adequate laxity, which can be tested by pinch test preoperatively. For moderate defects, a single large rotation flap is designed with a radius 2-3 times the defect diameter, undermined in the subgaleal plane. For larger defects, double rotation flaps (the O-Z plasty) recruit tissue from both sides, with each flap rotating toward the defect from opposite directions. Galeal scoring. Making parallel incisions through the full thickness of the galea aponeurotica perpendicular to the direction of closure. Provides additional tissue mobility by allowing the galea to stretch. Each galeal score provides approximately 1-1.5 cm of additional advancement. For very large defects where flap coverage is not possible, split-thickness skin grafts (STSG) or dermal substitutes can be applied directly to intact pericranium (periosteum). If the pericranium has been removed and bare calvarium is exposed, granulation will not occur and the outer table of the calvarium can be burred with a diamond burr to expose the diploe, which will granulate and accept a skin graft. Alternatively, a dermal substitute (e.g., Integra) can be applied to bare bone and subsequently skin-grafted.

The cervicofacial rotation-advancement flap (also known as the Mustarde flap when used for the cheek) is the workhorse technique for large cheek, preauricular, and lower facial defects. This versatile flap recruits the entire cervicofacial tissue envelope by combining rotation and advancement vectors to mobilize tissue from the neck, preauricular, and lateral cheek regions toward the defect. The incision begins at the inferior border of the defect, extends laterally along the jawline or submental crease, curves superiorly in the preauricular crease, and may extend posteriorly into the postauricular sulcus or hairline if additional advancement is needed. Undermining is performed in the subcutaneous plane superficial to the SMAS on the face and superficial to the platysma on the neck. The flap is then rotated and advanced medially to fill the defect. For very large defects, wide undermining extending to the midline of the neck may be necessary. The key back-cut (at the inferior extent of the incision) provides additional flap mobility but must be limited to avoid compromising the flap blood supply from the subdermal plexus. Standing cones at the base of the rotation are excised or allowed to settle over time. The cervicofacial flap provides excellent color and texture match because it uses adjacent facial and cervical skin, and the incision lines can be camouflaged in the preauricular crease, jawline, and neck creases.

Rhombic (Limberg) flaps and their geometric variants are among the most versatile and commonly used local flaps for cheek reconstruction. The classic Limberg rhombic flap converts a circular or oval defect into a rhombus (parallelogram with 60-degree and 120-degree angles), then transposes a rhombic-shaped flap from one side. Four possible flap orientations exist for any given rhombus, and the surgeon selects the orientation that recruits tissue from the area of greatest laxity, places the final scar along favorable RSTLs, and avoids distortion of adjacent free margins (lower eyelid, nasal alar, oral commissure). The Dufourmentel modification uses angles other than 60/120 degrees, allowing greater flexibility in flap design. The Webster 30-degree angle flap uses a more acute angle to minimize the standing cone and produce a less conspicuous closure. On the cheek, rhombic flaps work exceptionally well because the generous cheek tissue laxity provides a reliable tissue reservoir for transposition, and the multiple possible flap orientations allow the surgeon to optimize scar placement. For medial cheek defects near the nose, the flap should be designed to recruit laterally from the cheek laxity rather than medially toward the nose, which would distort the alar-facial sulcus.

Complications of cheek, temple, forehead, and scalp reconstruction are region-specific. On the cheek, the most significant risks are ectropion (when defects involve the lower eyelid-cheek junction), parotid duct injury (over the masseter), and facial nerve branch injury (marginal mandibular in the lower cheek, buccal branches in the mid-cheek). On the temple, temporal branch of CN VII injury is the predominant concern, producing ipsilateral brow ptosis. On the forehead, supraorbital and supratrochlear nerve injury can cause forehead numbness, and conspicuous scarring results from improperly oriented closures. On the scalp, complications include wound dehiscence (due to the inherent tension of scalp skin), alopecia at suture lines and in areas of undermining, hematoma formation in the subgaleal space, and skin graft failure over exposed calvarium without pericranium. Universal complications across all regions include hematoma, infection, flap necrosis (especially in smokers, diabetics, and irradiated tissue), hypertrophic scarring, and wound dehiscence. Prevention of these complications rests on fundamental surgical principles: meticulous hemostasis, appropriate undermining plane selection, tension-free closure, layered wound closure, avoidance of electrocautery near nerves, and respect for anatomic danger zones.