Case 13 (2023): Axial frontonasal flap for nasal tip reconstruction after BCC excision

Linn Anna Fiehn; Anna Louise Norling

Journal of Plastic, Breast & Reconstructive Surgery·Rapports de cas chirurgicaux en libre accès, évalués par les pairsÉvalué par les pairs · Libre accès

Case 13 (2023): Axial frontonasal flap for nasal tip reconstruction after BCC excision · JPBRS

Rapport de cas

Case 13 (2023): Axial frontonasal flap for nasal tip reconstruction after BCC excision

Linn Anna Fiehn, Anna Louise Norling

Publié 29 avril 2023123 vues6 min de lecture

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Résumé

73-year-old male was referred to the dept. of Plastic Surgery by his local dermatologist with a recurrence of basal cell carcinoma (BCC) of the nodular/micronodular type after 2x curettage on the apex nasi. Medical preconditions: Arterial hypertension, mild COPD, sciatic pain, previously operated for umbilical and inguinal hernia.

Points clés à retenir

Conseils pratiques

The frontonasal flap is a one-stage procedure and allows defect coverage with directly adjacent skin, which often provides the best aesthetic results in color and texture [1].
The incision pattern follows the subunit principle [3], also leading to good cosmetic results.
By bringing the thick skin of the ala to the thick skin of the tip, visible scarring is prevented as it most often occurs in areas with a thickness discrepancy between the flap and the skin [1, 2, 4].

Écueils

To prevent damage to the dorsal nasal artery, it is important for the surgeon to maintain a 12 mm margin above and below the choroid fissure while raising the axial frontonasal flap [5].
To prevent traction of the nose towards the cheek or alar uplifting, always remeber to undermine the surrounding tissue before flap inset [6].
The pivot point of the flap determines wether the elevated flap can reach all defect borders without tension. Careful planning can therefore prevent alar uplifting due to tethering at the pivot point [6].
The flaps’ cutback at the glabella should be long enough and lie medially to the medial canthus. Otherwise, mobility of the flap is lost which can result in asymmetry.

Patient history

Examination

The patient appears awake, alert, cooperative, and oriented in time, place, and personal data. Skin: At the apex nasi, a localized, circular curettage scar with two nodular lesions at 4 and 6 o’clock are visible. The curettage scar measures approx. 13 x 15 mm and is freely displaceable in relation to the underlying tissue. It appears pale in color and has uneven borders, as well as a non-ulcerous central depression. Tumor thickness is estimated at 3 mm. Overall, the clinical findings are consistent with the diagnosis of BCC. Lymph nodes: Regionally, no pathologic lymph nodes were palpable.

Pre-operative considerations

The patient is presented with the treatment options for his condition in the form of surgery with an excision margin of 3 mm or radiotherapy and the associated advantages and disadvantages. The patient prefers surgery. When removed, the tumor will leave a defect that cannot be closed directly. It is a rather large defect in a very visible area and leaving the defect for secondary healing will result in a long process with frequent dressing changes and the scarring might be prominent. Closing the defect with a skin graft would possibly leave a dent and different coloring than the rest of the nose which also would be very visible at the tip of the nose. The best option, in this case, would be reconstruction with a local flap. When doing a local flap the excision margin needs to be cleared with frozen sections. This kind of defect is big for a bilobe flap and a bit small for a forehead flap. To reconstruct this defect a nasofrontal flap seems the best option. Using directly adjacent skin, aesthetic outcomes of the nasofrontal flap are usually excellent and blood supply is ensured by axial vascularization by branches of the angular and dorsal nasal artery.

Plan: This one-step procedure can be performed at the outpatient clinic under local anesthesia. The tumor is excised at a 3 mm margin and specimens are sent for rapid histological analysis. The flap design follows the adaptions made by de Fontaine [1] to Marchac [2]. The incision lines follow the subunit principle from the defect to the line between the cheek and nose up to the V-incision on the glabella, directly adjacent skin is used to cover the defect, and the excess skin is removed – all to ensure the best possible functional and cosmetic outcome.
Patient information: Excision of the BCC on the apex nasi and closure with a local frontonasal flap in local anesthesia at the outpatient clinic is planned. The patient was given oral and written information about the surgical procedure and risks, especially about the risk of bleeding, infection, disfiguring scars, sensitivity disorders, lack of radical excision leading to further treatment and expected postoperative course. Sutures can be removed after 10 days and a 3-month follow-up is scheduled.

Références

de Fontaine, S., M. Klaassen, and D.S. Soutar, Refinements in the axial frontonasal flap. Br J Plast Surg, 1993. 46(5): p. 371-4.
Marchac, D. and B. Toth, The axial frontonasal flap revisited. Plast Reconstr Surg, 1985. 76(5): p. 686-94.
Burget, G.C. and F.J. Menick, The subunit principle in nasal reconstruction. Plast Reconstr Surg, 1985. 76(2): p. 239-47.
Marchac, D., Les résultats à distance du lambeau fronto-nasal. 1974.
Aoi, J., et al., Simple and effective modification of the axial frontonasal flap to prevent flap distortion. The Journal of Dermatology, 2019. 46(1): p. e46-e47.
Baker, S.R., et al., Local flaps in facial reconstruction. First Edition. Mosby. St. Louis, Missouri.1995. p:232.

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Case 13 (2023): Axial frontonasal flap for nasal tip reconstruction after BCC excision

Résumé

Points clés à retenir

Patient history

Examination

Pre-operative considerations

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Étape 1 — BCC excision

Étape 2 — Flap elevation

Étape 3 — Flap inset

Étape 4 — Results at 3-month follow-up

Étape 5 — Follow-up

Post-operative plan

Pearls

Pitfalls