Case Competition 2023 Case 1 Left Cheek reconstruction with VY- and transposition flap
Authors: Harald Welling, Resident, Roskilde Hospital, Denmark
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.
Before and after
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.
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.
Step 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.
Step 2: Excision
The lateral tumour was excised first and closed primarily. The medial tumor was excised secondly, resecting deep subdermal structures including parts of the m. zygomaticus as well as nerve branches form n. infraorbicularis.
Step 3: Flap design
Flap design demarcated. First, the V-to-Y-flap was raised and sutured before the transposition flap was performed.
Step 4: Reconstruction
The predominant part of large medial defect was closed with an advancement V-to-Y-flap from the inferolateral portion of the cheek. Secondly, a transposition flap fromt the lateral zygomatic region of the cheek was raised to fully cover the superior part of the defect. The infraorbital dog ear that occured after flap inset was not corrected intraoperative so as not to compromise blood supply to the flap tip in a critical location where several flap tips met in the most medial portion of the cheek reconstruction.
Step 5: Stitch removal
Patient seen at suture removal 9 days postoperatively. Final suture removal was pushed back three days due to early signs of postoperative infection.
Step 6: Follow-up
Patient seen at 3 months postoperatively. The aesthetic result is pleasing to the patient, and ectropion did not occur. Another follow-up and 6 months postoperatively was planned to assess whether the infraorbital swelling from the non-resected dog-ear would diminish or if cosmetic correction will be warranted.
Frozen sections did not show any carcinoma in the intraoperativ frozen sections, and this was confirmed by final histopathology which revealed nodular and micronodular BCC with free resection margins.
- 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.
- 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.