Case 7 (2024): Closure of larger tip defect by a modified Peng-Flap with extended Nasofrontal dissection

Lukas Kure-Rosenberg; Magnus Balslev Avnstorp

Journal of Plastic, Breast & Reconstructive Surgery·Peer-reviewed, open-access surgical case reportsPeer-reviewed · Open access

Case 7 (2024): Closure of larger tip defect by a modified Peng-Flap with extended Nasofrontal dissection · JPBRS

Case report

Case 7 (2024): Closure of larger tip defect by a modified Peng-Flap with extended Nasofrontal dissection

Lukas Kure-Rosenberg¹, Magnus Balslev Avnstorp¹

¹Roskilde, SUH, Denmark

Published March 31, 2024389 views7 min read

Peng-FlapSupratipPollybeak ConfigurationModified FlapBCCNasal Skin cancer.

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Abstract

79-year-old woman with nodular basal cell carcinoma (nBCC) located at the apex of the nose, otherwise healthy. Biopsy and referral were made at least 3 months prior admission in 2023, but the patient reports a nodule on the site present for longer. Since development into a non-healing wound, the patient sought medical care.

Key learning points

Pearls

Vertical excision of skin in the adaptation of flaps in this design can, in patients with a bulbous nose resembling a pollybeak configuration, give a more defined supratip⁶. Furthermore, centripetal contraction of flaps tends to produce convex concurs ideal on nasal tip reconstruction^7
We found that the vertical incision lines can be used as a contra-vector to reduce pull when closed in a staggered suture pattern to shifting tip projection central, when flap design is lateralized and of different lengths.
In this design, the vertical incision is the only crossing of anatomical transition zones making the overall healing aesthetically pleasing with only minimal visible scarring^8

Pitfalls

In theory, bilateral incisions on the nose could give rise to shortening of the nose or an overprojected tip due to flap shrinkage as seen in the Rintala flap⁹, although we have not seen this and it is not described in the literature for used flaps.
Be aware of the blood supply to the flaps and not to advance the incision line too far superior on the lateral side of the nose, cutting the blood supply^3

Patient history

Examination

At the apex of the nose, a localized 8x8mm clinically morpheaic tumor with a central ulcerous depression, uneven borders, and no apparent nodular elements was seen. Tumor thickness was estimated to be 3 mm. Overall, clinical findings are consistent with the diagnosis of BCC. Regionally, no pathologic lymph nodes were palpable

Pre-operative considerations

The patient was presented with the treatment options for her condition in the form of surgery with an excision margin of 3 mm, with per operative freezing histology assessment or radiotherapy, with the associated advantages and disadvantages of both. The patient preferred surgery. When removed, the tumor will leave a defect that cannot be closed directly. It is a moderate defect in a very visible area with several anatomical landmarks and subunits. Leaving the defect for secondary healing will result in a long healing process of at least one month with frequent dressing changes, and the scarring might be prominent. By closing the defect with a full thickness skin graft, it would possibly leave a dent and different skin coloring than the surrounding skin of the tip, which would also be very visible. The best option, in this case, would be a reconstruction using a local flap. When doing a local flap, the excision needs to be radical, requiring rapid histological analysis using frozen sections. This defect was assessed to be too big for a bilobe flap and too small for a forehead flap. To reconstruct this defect, surgery was planned using a modified Peng-Flap. This procedure can be performed as a one-step procedure at the outpatient clinic under local anesthesia. The tumor is planned for excision by a 3mm margin, and frozen sections sent for rapid histological analysis. The flap design follows the idea made by Peng et al¹, but with a modified incision pattern suggested by Ahlers et al², thus hiding scars in anatomical junctions and offering wider flap pedicles. The incision lines give rise to blood supply through the angular-, lateral-, and dorsal nasal artery³. Directly remaining adjacent skin of the tip is used to cover the defect, but due to a lateralization to the right side of the nose of the defect, a modified, more extensive cranial pedicle dissection is utilized on one side, comparable to the principles used in a frontonasal flap (Gillies/Rieger)⁴, thus ensuring sufficient length and advancement besides the main goal of distal rotation. Excess skin on the dorsum, central to the bilateral flaps, is excised to remove “dog ear” formation and drape the skin smoothly over the perichondrium⁵. All to ensure the best possible functional and cosmetic outcome.

Patient information: The patient was given oral and written information about the surgical procedure and the risks, hereunder bleeding, infection, disfiguring scars, lack of radical excision leading to further treatment, flap necrosis, and expected postoperative course. Suture removal after 7 days and 3-month follow-up.

References

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Romaní, J., and M. Yébenes. “Repair of Surgical Defects of the Nasal Pyramid.” Actas Dermo-Sifiliográficas (English Edition), vol. 98, no. 5, 2007, pp. 302–311, https://doi.org/10.1016/s1578-2190(07)70453-5. Accessed 24 Nov. 2021.