Case 8: Perialar Crescentic Advancement Flap for Nasal Reconstruction

Lukas Kure-Rosenberg

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

Case 8: Perialar Crescentic Advancement Flap for Nasal Reconstruction · JPBRS

Rapport de cas

Case 8: Perialar Crescentic Advancement Flap for Nasal Reconstruction

Lukas Kure-Rosenberg¹

¹Department of Plastic Surgery, Zealand University Hospital, Denmark

Publié 2 avril 2025213 vues5 min de lecture

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Résumé

We present the case of a 68-year-old woman with a residual PCC in situ on the nasal dorsum following initial excision and open defect by colleague. The initial pathology revealed incompletely excised changes cranial to the primary defect (12 o’clock position). The patient was booked for re-excision and closure, originally planned with a full-thickness skin graft (FTSG). However, the patient expressed high cosmetic expectations, prompting a change in plan to a local flap-based reconstruction. A perialar crescentic advancement flap was chosen, utilizing the planned re-excision site, which anatomically corresponded to a burrow triangle in the flap design. This case illustrates how integrating oncologic and reconstructive planning can optimize both margin control and aesthetic outcomes. Patient medical history A 68-year-old woman was referred for further management of an ulcerating lesion, consistent with biopsy-confirmed squamous cell carcinoma (SCC/PCC) in situ on the nasal dorsum. The patient was routinely seen at dermatological checkups due to being kidney transplanted, and was therefore also recommended surgical management of the lesion. The lesion was initially excised by a colleague and left as an open wound for secondary intention until the final pathological analysis. Pathology demonstrated no invasive tumor, but histopathological evaluation revealed residual SCC in situ/atypical changes at the superior (12 o'clock) margin of the excised area, necessitating re-excision. Before and After Patient examination Upon reexamination, the surgical defect was located centrally on the nasal dorsum, cranial to the supratip area, measuring 12 mm in diameter. The previously excised region had demarcated edges and healthy granulation tissu

Points clés à retenir

Conseils pratiques

Accurate Flap Design: Careful planning and design of the perialar crescentic advancement flap, considering anatomical landmarks such as the burrow triangle, ensures optimal tissue alignment and aesthetic outcomes.

Local Anesthesia Efficiency: The combination of nerve blocks and infiltration anesthesia allows for adequate pain control in outpatient settings, facilitating a smoother surgical experience.

Early Detection of Infection: Prompt recognition of early signs of infection and initiation of antibiotic treatment can prevent complications and ensure good flap healing.

Écueils

Inadequate Margin Control: Failure to ensure adequate margins during re-excision can lead to incomplete tumor removal, necessitating further interventions and compromising oncologic safety.

Tension on Flap Closure: Excessive tension during flap closure can compromise vascular perfusion, leading to flap necrosis or poor cosmetic results. Adequate undermining and advancement of the flap are crucial to avoid this.

Failure to Consider Patient Expectations: In cases with high cosmetic demands, failing to assess and address patient expectations can result in dissatisfaction, even when the technical outcome is successful.

Baker SR. Local Flaps in Facial Reconstruction. 3rd ed. Elsevier; 2014.Zitelli JA. The crescentic advancement flap. Arch Dermatol. 1989;125(7):957–959.Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. Mosby; 1994.Park SS. Local flaps: cheek and perinasal reconstruction. Facial Plast Surg Clin North Am. 2011;19(1):107–120.Rohrich RJ, Muzaffar AR, Janis JE. The Anatomy and Applications of the Nasolabial Flap. Plast Reconstr Surg. 2003;111(2):811–822.

Patient history

A 68-year-old woman was referred for further management of an ulcerating lesion, consistent with biopsy-confirmed squamous cell carcinoma (SCC/PCC) in situ on the nasal dorsum. The patient was routinely seen at dermatological checkups due to being kidney transplanted, and was therefore also recommended surgical management of the lesion. The lesion was initially excised by a colleague and left as an open wound for secondary intention until the final pathological analysis. Pathology demonstrated no invasive tumor, but histopathological evaluation revealed residual SCC in situ/atypical changes at the superior (12 o'clock) margin of the excised area, necessitating re-excision.

Examination

Upon reexamination, the surgical defect was located centrally on the nasal dorsum, cranial to the supratip area, measuring 12 mm in diameter. The previously excised region had demarcated edges and healthy granulation tissue. No signs of infection or tumor invasion were noted. The re-excision area at the 12 o’clock position was carefully evaluated and integrated into the flap planning.

Pre-operative considerations

Several reconstructive options were considered:

FTSG: Technically simple but suboptimal in cosmetic outcome, especially in this central facial location.

Other local flaps (e.g., bilobed, trilobed): These would not have an advantage in excising residual in situ changes.

Paramedian forehead flap: Overly extensive for this case.

Perialar crescentic advancement flap: This flap addressed the area to be excised in its design, while still providing an optimal balance between coverage, aesthetic blending of scars, and the use of local tissue.

Given the location of the residual tumor area, which matched the position of the superior burrow triangle in the flap design, the crescentic advancement flap was deemed the ideal choice.

Étape 1 — Surgical Preparations

Références

Baker SR. Local Flaps in Facial Reconstruction. 3rd ed. Elsevier; 2014.
Zitelli JA. The crescentic advancement flap. Arch Dermatol. 1989;125(7):957–959.
Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. Mosby; 1994.
Park SS. Local flaps: cheek and perinasal reconstruction. Facial Plast Surg Clin North Am. 2011;19(1):107–120.
Rohrich RJ, Muzaffar AR, Janis JE. The Anatomy and Applications of the Nasolabial Flap. Plast Reconstr Surg. 2003;111(2):811–822.

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Case 8: Perialar Crescentic Advancement Flap for Nasal Reconstruction

Résumé

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Patient history

Examination

Pre-operative considerations

Étape 1 — Surgical Preparations

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Étape 2 — Perioperative planning

Étape 3 — Flap inset and suturing

Étape 4 — 7-Day Postoperative Follow-up

Étape 5 — 3-Month Postoperative Follow-up

Post-operative plan

Pearls

Pitfalls