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Linn Anna Fiehn, Anna Louise Norling. Case 13 (2023): Axial frontonasal flap for nasal tip reconstruction after BCC excision. Journal of Plastic, Breast & Reconstructive Surgery. 2023.
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Linn Anna Fiehn, Anna Louise Norling
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.
BeforeAfter73-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.
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.
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.
After identifying the excision site and application of local anesthesia (1% lidocaine + adrenalin), the tumor is excised with a 3 mm safety margin and at an appropriate depth into the subcutaneous tissue, resulting in a 16×18 mm nasal defect. Thorough hemostasis is performed. Frozen sections are obtained from the borders of the defect at 12, 3, 6, and 9 o’clock and base and sent for rapid histological examination.
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Frozen sections showed no malignancy at the margins at 3, 6, 9, 12 o’clock or the base. Therefore, the operation is continued by elevation of a nasofrontal flap. A liberal amount of local anesthesia (1% lidocaine + adrenalin) is administered which also reducing bleeding during the procedure. The incision begins at the defect and follows a curved path along the edge of the nose while preserving the alar subunit. It then proceeds along the intersection of the nose and cheek, finishing with a V-incision at the glabella. The flap is elevated at the subcutaneous level.
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Excess skin, known as the “dog ear,” is removed from both the tip and the alar subunit, allowing the resulting scar to rest in the natural groove. The flap inset is performed with subdermal inverted sutures using 4-0 absorbable uncolored polyfilament, followed by cutaneous single sutures using 5-0 non-absorbable monofilament. The operation site is dressed with micropore and dry gauze.
4The patient presents himself for a 3-month follow-up. He is satisfied with the functional and cosmetic results and reports no discomfort. The scar shows no sign of infection or irritation. The histological analysis of the excised specimen showed the radically removed BCC of nodular/micronodular type without vascular or neural invasion. No clinical suspicion of recurrence. Therefore, the patient is dismissed from our care at subjective and objective well-being, and with an excellent functional and aesthetic outcome.
1,5 g of cefuroxim was applied intraoperatively, and no further antibiotic treatment is planned. The patient is advised to keep the head elevated and avoid hot food and drinks for the first 1-2 days. Furthermore, he should not engage in strenuous physical activities, such as sports or housework, until suture removal. Analgesia can be steered by the patient with up to 4×1 g paracetamol a day. Suture removal is planned at 10 days postoperative at the outpatient clinic, followed by another control after 3 months.
