Case Competition 2024 – All submitted cases Case 7 Closure of larger tip defect by a modified Peng-Flap with extended Nasofrontal dissection
Keywords: Peng-Flap, Supratip, Pollybeak Configuration, Modified Flap, BCC, Nasal Skin cancer, .
Authors: Lukas Kure-Rosenberg (MD) and Magnus Balslev Avnstorp (MD). Roskilde, SUH, Denmark
79-year-old woman with nodular basal cell carcinoma (nBCC) located at the apex of the nose, otherwise healthy. Biopsy and referral were made at least 3 months prior admission in 2023, but the patient reports a nodule on the site present for longer. Since development into a non-healing wound, the patient sought medical care.
Before and after
Patient examination
At the apex of the nose, a localized 8x8mm clinically morpheaic tumor with a central ulcerous depression, uneven borders, and no apparent nodular elements was seen. Tumor thickness was estimated to be 3 mm. Overall, clinical findings are consistent with the diagnosis of BCC. Regionally, no pathologic lymph nodes were palpable
Pre-Operative Considerations
The patient was presented with the treatment options for her condition in the form of surgery with an excision margin of 3 mm, with per operative freezing histology assessment or radiotherapy, with the associated advantages and disadvantages of both. The patient preferred surgery. When removed, the tumor will leave a defect that cannot be closed directly. It is a moderate defect in a very visible area with several anatomical landmarks and subunits. Leaving the defect for secondary healing will result in a long healing process of at least one month with frequent dressing changes, and the scarring might be prominent. By closing the defect with a full thickness skin graft, it would possibly leave a dent and different skin coloring than the surrounding skin of the tip, which would also be very visible. The best option, in this case, would be a reconstruction using a local flap. When doing a local flap, the excision needs to be radical, requiring rapid histological analysis using frozen sections. This defect was assessed to be too big for a bilobe flap and too small for a forehead flap. To reconstruct this defect, surgery was planned using a modified Peng-Flap. This procedure can be performed as a one-step procedure at the outpatient clinic under local anesthesia. The tumor is planned for excision by a 3mm margin, and frozen sections sent for rapid histological analysis. The flap design follows the idea made by Peng et al¹, but with a modified incision pattern suggested by Ahlers et al², thus hiding scars in anatomical junctions and offering wider flap pedicles. The incision lines give rise to blood supply through the angular-, lateral-, and dorsal nasal artery³. Directly remaining adjacent skin of the tip is used to cover the defect, but due to a lateralization to the right side of the nose of the defect, a modified, more extensive cranial pedicle dissection is utilized on one side, comparable to the principles used in a frontonasal flap (Gillies/Rieger)⁴, thus ensuring sufficient length and advancement besides the main goal of distal rotation. Excess skin on the dorsum, central to the bilateral flaps, is excised to remove “dog ear” formation and drape the skin smoothly over the perichondrium⁵. All to ensure the best possible functional and cosmetic outcome.
- Patient information: The patient was given oral and written information about the surgical procedure and the risks, hereunder bleeding, infection, disfiguring scars, lack of radical excision leading to further treatment, flap necrosis, and expected postoperative course. Suture removal after 7 days and 3-month follow-up.
Step 1: BCC Marking
The patient was preoperatively seen for surgical planning in the outpatient clinic, where the baseline photos were obtained. Reconstruction of the defect was initially planned using an nasofrontal-flap. The specialist surgeons changed the tentative plan to a Peng-flap based on the available baseline photos (left), and intraoperative tumor markings (right) extending unilateral to the right side of the tip, made it necessary to do a minor modification of the surgical Peng flap design.
Step 2: BCC Excision and margins
After identifying the excision site and application of local anesthesia (1% lidocaine + adrenalin), the tumor is excised with a 3 mm safety margin at an appropriate depth to the pericondral layer, resulting in a 14×19 mm nasal tip defect (left). Hemostasis is performed and frozen sections was obtained from the borders of the defect at 12, 3, 6, and 9 o’clock and base, and sent for rapid histological examination. The modified flap design in then drawn on the skin. Notice the bulbous tip almost resembling a pollybeak configuration (right)
Step 3: Flap elevation
Frozen sections showed no malignancy at the margins: 3, 6 og 9 o’clock or base, but was seen at 12 o’clock. The incision lines (left picture) begins distal at the defect, follows the alar curves, preserving the alar subunit and camuflaging scars in nasal creases. Due to the design of the flaps, the area still containing nBCC at 12 o’clock was already planned for excision. (middle-left picture). The incision line then proceeds along the intersections of the nose and cheek, with the furthest incision and pedicle undermining on the left side (middle-right picture), until flap lengthening and rotation was achieved sufficiently enough mobilize the remaining skin of the apex over the defect (Right picture).
Step 4: Flap inset
The flap inset is performed along the lateral edges starting superiority using subdermal inverted single sutures 5-0 absorbable uncolored polyfilament, followed by cutaneous single sutures using 5-0 non-absorbable monofilament, while continuously adapting the position of the “neo”apex. No subdermal anchor sutures was used under flaps to minimize potential flap-perfusion issues. The central triangular spare skin, was excised to eliminate “dog ear” formation and to draped the skin flat on the nose over underlying structures. Closure here was in a staggered fashion to contra-vector lateral pull from the short, right flap thereby centralizing the tip. Notice maintained tip projection (left) with a reduced bulbous tip (right). The operation site is dressed with micropore-tape.
Step 5: Results 12-day after surgery
The patient was seen 7 days after surgery for suture removal, with no reported complications and a good postoperative satisfactionary result, experiencing no functional or cosmetic discomfort. The scar showed no sign of infection or irritation. Early postoperative picture was taken by the patient 12 days after surgery. Early, but excellent functional and aesthetic outcome was noticed. The patient is planned for a 3 month follow-up.
Step 6: Follow-up 2 months post-op
Post-Operative Plan
No 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, no engagement in strenuous physical activities, such as sports or housework, until suture removal is advised. Analgesia as OTC by the patient with up to 4×1 g paracetamol a day. Suture removal is planned at 7 days postoperative at the outpatient clinic, followed by expected, final control after 3 months.
- Vertical excision of skin in the adaptation of flaps in this design can, in patients with a bulbous nose resembling a pollybeak configuration, give a more defined supratip⁶. Furthermore, centripetal contraction of flaps tends to produce convex concurs ideal on nasal tip reconstruction^7
- We found that the vertical incision lines can be used as a contra-vector to reduce pull when closed in a staggered suture pattern to shifting tip projection central, when flap design is lateralized and of different lengths.
- In this design, the vertical incision is the only crossing of anatomical transition zones making the overall healing aesthetically pleasing with only minimal visible scarring^8
- In theory, bilateral incisions on the nose could give rise to shortening of the nose or an overprojected tip due to flap shrinkage as seen in the Rintala flap⁹, although we have not seen this and it is not described in the literature for used flaps.
- Be aware of the blood supply to the flaps and not to advance the incision line too far superior on the lateral side of the nose, cutting the blood supply^3
References
- Peng, V T, et al. ““Pinch Modification” of the Linear Advancement Flap.” The Journal of Dermatologic Surgery and Oncology, vol. 13, no. 3, 1 Mar. 1987, pp. 251–253, europepmc.org/article/PMC/3546432, https://doi.org/10.1111/j.1524-4725.1987.tb03946.x. Accessed 23 Nov. 2023.
- AHERN, RYAN W., and NAOMI LAWRENCE. “The Peng Flap: Reviewed and Refined.” Dermatologic Surgery, vol. 34, no. 2, 17 Dec. 2007, pp. 232–237, https://doi.org/10.1111/j.1524-4725.2007.34043.x. Accessed 11 May 2021.
- Dong, Joanna, and C. William Hanke. “Revisiting the Anchor Flap for Nasal Defects: How It Fits in the Current Reconstruction Paradigm.” Journal of Drugs in Dermatology: JDD, vol. 23, no. 1, 1 Jan. 2024, pp. 1271–1273, pubmed.ncbi.nlm.nih.gov/38206140/, https://doi.org/10.36849/JDD.7532. Accessed 29 Mar. 2024.
- Decusati, Filipe Lopes, and Antônio Egidio Rinaldi. “Reconstruction of Nasal Defects Using the Rieger Flap.” Revista Brasileira de Cirurgia Plástica (RBCP) – Brazilian Journal of Plastic Sugery, vol. 35, no. 2, 2020, pp. 149–153, https://doi.org/10.5935/2177-1235.2020rbcp0026. Accessed 5 July 2022.
- César, Artur, et al. “Surgical Pearl on Reconstructing Surgical Defects of the Nasal Tip.” Dermatology Reports, vol. 8, no. 1, 23 Nov. 2016, https://doi.org/10.4081/dr.2016.6828. Accessed 7 Nov. 2019.
- Bhatt, M, et al. “Supratip Excision in Rhinoplasty.” Otolaryngology Case Reports, vol. 5, no. 5, 1 Nov. 2017, pp. 8–12, https://doi.org/10.1016/j.xocr.2017.08.002. Accessed 29 Mar. 2024.
- Vuyk, H, and S Watts. NASAL RECONSTRUCTION.
- Burget, Gary C., and Frederick J. Menick. “The Subunit Principle in Nasal Reconstruction.” Plastic and Reconstructive Surgery, vol. 76, no. 2, Aug. 1985, pp. 239–247, https://doi.org/10.1097/00006534-198508000-00010. Accessed 15 Feb. 2021.
- Romaní, J., and M. Yébenes. “Repair of Surgical Defects of the Nasal Pyramid.” Actas Dermo-Sifiliográficas (English Edition), vol. 98, no. 5, 2007, pp. 302–311, https://doi.org/10.1016/s1578-2190(07)70453-5. Accessed 24 Nov. 2021.
