Case 1 (2023): Left Cheek Reconstruction with Combined VY- and Transposition Flap

Harald Welling; Michael Rose

Journal of Plastic, Breast & Reconstructive Surgery·Relatos de casos cirúrgicos revistos por pares, de acesso abertoRevisto por pares · Acesso aberto

Case 1 (2023): Left Cheek Reconstruction with Combined VY- and Transposition Flap · JPBRS

Relato de caso

Case 1 (2023): Left Cheek Reconstruction with Combined VY- and Transposition Flap

Harald Welling, Michael Rose

Publicado 2 de abril de 2023234 visualizações3 min de leitura

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Resumo

50-year old male presented to the dept. of Plastic Surgery in 2022 with a larger eroding tumour on the left cheek. The tumour had been present for several years. Recently, a new tumour had also started to form on the lateral portion of the left cheek. Biopsi revealed basal cell carcinoma, nodular subtype for both carcinomas.

Pontos-chave de aprendizagem

Dicas

When the ideal “textbook example” flap for the defect is not available, sometimes, two smaller local flaps can present a valid alternative one-stage reconstruction option.

Armadilhas

When there is clinical suspicion of deep infiltration, preoperative MRI-scans may be warranted to ensure adequate surgical planning of the excision as well and the reconstruction demands.

Patient history

Examination

On the medial part of the left cheek was a sclerotic, eroding tumor that permeated into the deeper subcutaneous and muscular layers of the cheek. The tumour measured approx. 33×47 mm and appeared to infiltrate the deeper structures on palpation. The tumour had visibly contracted the surrounding tissues that over exaggerated the natural infraorbital tear trough line and partially eradicated the left nasolabial fold. On the more lateral portion of the same cheek was a more superificial tumor measuring approx. 11×8 mm with out any clinical signs of any involvement of the deeper facial structures. On clinical examination of the lymph nodes of the face and neck there was no suspicion of pathology.

Pre-operative considerations

Basal cell carcinoma is a slow-growing tumor that rarely metastasizes, but can become locally invasive and permeate deep into several tissue types. In this case, the challenge was to achieve radical excision with free margins and to reconstruct both a larger and small defect on the same cheek in a one-stage manner. PLAN: To excise the larger tumour with frozen section biopsies – four from the superficial skin and three from the wound bed after resection – followed by reconstruction of the large medial defect with one or two local flaps so as to avoid a cheek rotation flap due to the placement of the smaller carcinoma. Both carcinomas were to be resected with a 5 mm margin. PATIENT INFORMATION: Bleeding, infection, flap necrosis, infraorbital nerve damage, ipsilateral ectropion and changes of facial expression and sensation.

Passo 1 — Pre-operative evaluation

Large BCC on the medial left cheek and a smaller BCC on the lateral portion of the cheek. Tumour demarcation and resection margins are marked.

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Case 1 (2023): Left Cheek Reconstruction with Combined VY- and Transposition Flap

Resumo

Pontos-chave de aprendizagem

Patient history

Examination

Pre-operative considerations

Passo 1 — Pre-operative evaluation

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Passo 2 — Excision

Passo 3 — Flap design

Passo 4 — Reconstruction

Passo 5 — Stitch removal

Passo 6 — Follow-up

Passo 7 — Follow-up

Post-operative plan

Pearls

Pitfalls