Case Competition 2024 – All submitted cases Case 8 Right ala nasi reconstruction with a superior based nasolabial flap
Keywords: Nasal reconstruction, ala nasi reconstruction, nasolabial transposition flap, skin cancer.
Authors: David Salim (MD), Roskilde, SUH, Denmark
58-year-old female, otherwise healthy, presented to the Department of Plastic Surgery in March of 2024 with a 2 mm punch biopsy verified case of infiltrative basocellular carcinoma. The lesion was located to the right ala nasi subunit of the nose. In December 2023 a primary 2 mm punch biopsy was performed on the same lesion showing basophil degeneration. Due to progression in size in the meantime, a new punch biopsy was taken by a private practicing dermatologist, revealing the before mentioned infiltrative basocellular carcinoma.
Before and after
Patient examination
Well preserved 58-year-old female in a generally good health condition, no noteworthy comorbidities. At the right ala subunit, a 13 x 9 mm macular and mobile tumor was observed, no ulceration, borders fairly regular, no lymphadenopathy of the head, neck or peri-clavicular lymph nodes. The underlying mucosal membrane was palpated and inspected, revealing no mucosal involvement.
Pre-Operative Considerations
Surgery and radiation were discussed with the patient, the first mentioned solution was preferred by the patient under local anesthesia. The plan for surgery involved a resection margin of 3 mm and frozen section biopsies – four from the superficial skin and one from the wound bed after excision. Due to the localization of the defect, it was ideal for a superior based nasolabial flap, which would contribute to a fine reconstruction of the ala nasi crease as well. This can be done as a one-stage procedure in an out-patient setting under local anesthesia. The patient was given oral and written information about the surgical procedure. A Shark flap was also considered as an alternative, but this was not chosen as the mode of reconstruction, since the defect would be a tad too large for this method. Full thickness skin graft was deemed too inappropriate for this defect, mainly because it would render too visible of a color discrepancy and ala nasi depression, but also because the defect was quite obviously suitable for a nasolabial flap.
Step 1: Excision of the basocellular carcinoma.
After applying local anesthesia (1% lidocaine + adrenaline), the tumor was excised with a 3 mm safety margin with an appropriate depth in the underlying soft tissue. Hemostasis was performed. Frozen sections were taken from the borders of the defect at 12, 3, 6, and 9 o’clock and the base of the defect – the sections were sent to fast-track histological examination. Answer was obtained approximately one hour later.
Step 2: The excised specimen.
Picture of the bottom of the specimen marked superiorly with a safety needle pointing towards the medial canthus of the right eye (pencil marking can be seen on the photo before surgery). Notice the level of excision including the skin, subdermal fatty tissue and not deeper. There is no cartilage in the ala nasi.
Step 3: Frozen sections.
In this picture, the 12 o’clock frozen section is displayed. When taking the sections, it is imperative to take a suitable amount of tissue for analysis. It is a fine balance between not too large of a section and at the same time not too small preventing proper analysis.
Step 4: Flap design.
A superior based nasolabial flap was drawn on the right side – the drawing was based on the dimensions of the defect so it would fit appropriately herein. The width of the flap corresponded the width of the defect. The flap was drawn 2-3 mm longer to avoid traction on the ala nasi. The flap was designed in the nasolabial crease with correction of skin excess in the flap apex.
Step 5: Flap elevation and closure of donor site
Frozen sections showed no malignancy and the appropriate flap was elevated, prior to this local anesthesia (1% lidocaine + adrenaline) was administered. The flap was dissected at the subcutaneous level and transposed into the defect on the ala nasi – suitable debulking and thinning of the flap was conducted bearing the aesthetic shape of the ala nasi subunit in mind.
Step 6: Flap inset
Donor-site was sutured with 5-0 monofilament and nylon 5-0. Defect-site with nylon 5-0. The ala nasi crease can be seen fairly appropriately reconstructed, mimicking the contralateral side.
Step 7: Anterior view
Anterior view after suturing
Step 8: Ala nasi crease
Here the reconstructed ala nasi crease can be seen and compared to the contralateral side.
- Thinning of the flap: The flap can be thinned to avoid a too voluminous flap on the ala nasi.
- Vascular supply: understanding the vascular anatomy of the nasolabial flap is imperative. The superior pedicle relies on branches from the facial artery, ensuring proper blood supply to the flap and avoiding necrosis – careful planning might help mitigate this issue, especially the flap pedicle should be thought of.
- Preservation of aesthetic subunits: it is important to pay attention to preserving the aesthetic appearance of the nasal subunit that is to be reconstructed in order to maintain a natural appearance – in the case of the ala nasi subunit, particularly the ala crease and bulkiness of the flap should be considered.
- Excessive traction: it is worth considering adding some extra millimeters of length to the flap in order to avoid excessive traction to the ala nasi.
- Too deep of an excision in the ala nasi: this should be avoided unless tumor has grown too deep in the underlying tissue. If excision is made too deep, soft tissue deficiency might occur, leading to potential visible depression on the subunit – this kind of defect would be cosmetically undesirable and might require additional procedures to correct.
