Case 12 (2023): Bilobe flap for mandibular border reconstruction after BCC excision

Anna Louise Norling; Linn Anna Fiehn

Journal of Plastic, Breast & Reconstructive Surgery·Informes quirúrgicos de acceso abierto revisados por paresRevisado por pares · Acceso abierto

Case 12 (2023): Bilobe flap for mandibular border reconstruction after BCC excision · JPBRS

Informe de caso

Case 12 (2023): Bilobe flap for mandibular border reconstruction after BCC excision

Anna Louise Norling, Linn Anna Fiehn

Publicado 29 de abril de 2023137 vistas4 min de lectura

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Resumen

86-year-old well-preserved and active male with a medical history of AFib, hypertension, and hypercholesterolemia and medicated with acetylsalicylate. He was referred to the dep. of plastic surgery at SUH, Roskilde by his local dermatologist with a biopsy verified nodular and infiltrating basal cell carcinoma (BCC) on the jaw.

Puntos clave de aprendizaje

Pearls

A well-designed bilobe flap is a great way to use skin from local areas with excess skin.
By using directly adjacent skin, the outcome appears more natural when the defect is closed with a local flap from a hair-bearing area.

Pitfalls

The tumor could infiltrate deeper structures and excision might lead to nerve and vessel damage
It’s a quite large random flap, which relies on the blood flow from the subdermal plexuses. This potentially leads to necrosis of part of the reconstruction. And with a defect the risk of infection increases.
Although there is a good amount of excess skin on the neck, if the flap is too big, the skin at the neck will be tight and could affect the movement and the posture of head and neck.

Patient history

Examination

Highly active male with a good general health condition. At the right side of the jaw, crossing the inferior border of the mandibular, a 25 x 25 mm elevated and mobile tumor presents itself with an irregular border and a central ulceration. No lymphadenopathy at the head, neck or peri clavicular.

Pre-operative considerations

It’s a quite large tumor placed at the jawline with no clear border and a biopsy, which shows an invasive component of basal cell carcinoma. The tumor seems mobile and therefore not thought to be invasive to the deeper structures. Because of the invasive component, the excision margin needs to be 5 mm [1], leaving a defect of approx. 35×35 mm in an area with hair growth. A skin graft would be quite obvious in the middle of the beard. Therefore, a local flap involving hair-bearing skin to cover the defect would be preferable. A big bilobe flap from the neck seemed to be the best option in this case [2]. Before a reconstruction with a flap, the border and bottom of the defect must be cleared. To do the procedure with excision and reconstruction in one step, an intraoperative histopathological examination must be planned. In the area of this tumor, there are some precious structures that, if possible, need to be spared. The marginal branch of the facial nerve lies under the deep facial fascia together with the facial artery and vein, whereas the cervical branch of the facial nerve lies on the deep surface of the platysma. The cervical branch is more likely to be damaged due to its more superficial position. Damage to either nerve will lead to some asymmetric mimics of the mouth, but damage to the marginal branch will also lead to difficulty in controlling the lower ipsilateral part of the lip and may lead to difficulty in chewing and swelling food, and drooling. At the neck, even more valuable structures are placed but these structures lie under the platysma and are therefore not directly at risk. Excision to deeper than the platysma must be performed with great caution and raising the flap should be superficial of the platysma.

Paso 1 — BCC excision and flap definition

Referencias

Krammer, C.W., et al., Treatment algorithm for non-melanoma skin cancer. Ugeskr Læger, 2018. 180:V01180044
Salgarelli AC, Cangiano A, Sartorelli F, Bellini P, Collini M. The bilobed flap in skin cancer of the face: our experience on 285 cases. J Craniomaxillofac Surg. 2010 Sep;38(6):460-4. doi: 10.1016/j.jcms.2009.10.022. Epub 2009 Nov 24. PMID: 19939690.

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Case 12 (2023): Bilobe flap for mandibular border reconstruction after BCC excision

Resumen

Puntos clave de aprendizaje

Patient history

Examination

Pre-operative considerations

Paso 1 — BCC excision and flap definition

Referencias

Case 20 2026: Staged Excision and Delayed Primary Closure of a large Nodular Basal Cell Carcinoma of the Anterior Scalp

Case 22 2026: Superior Gluteal vessel: A rarely used recipient for free flap reconstruction of lumbosacral defects: a case report.

Case 23 2026: “Minimally Invasive Finger Amputation Using a Volar ‘Toilet seat’ Flap for Invasive Squamous Cell Carcinoma”

Paso 2 — Flap elevation and inset

Paso 3 — Follow-up 8 days postoperative

Paso 4 — Follow-up

Post-operative plan

Pearls

Pitfalls