Case Competition 2023 Case 13 Axial frontonasal flap for nasal tip reconstruction after BCC excision
Authors: Linn Anna Fiehn (stud. med.), Anna Louise Norling (MD)
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.
Before and after
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.
- Plan: This one-step procedure can be performed at the outpatient clinic under local anesthesia. The tumor is excised at a 3 mm margin and specimens are sent for rapid histological analysis. The flap design follows the adaptions made by de Fontaine  to Marchac . The incision lines follow the subunit principle from the defect to the line between the cheek and nose up to the V-incision on the glabella, directly adjacent skin is used to cover the defect, and the excess skin is removed – all to ensure the best possible functional and cosmetic outcome.
- Patient information: Excision of the BCC on the apex nasi and closure with a local frontonasal flap in local anesthesia at the outpatient clinic is planned. The patient was given oral and written information about the surgical procedure and risks, especially about the risk of bleeding, infection, disfiguring scars, sensitivity disorders, lack of radical excision leading to further treatment and expected postoperative course. Sutures can be removed after 10 days and a 3-month follow-up is scheduled.
Step 1: BCC excision
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.
Step 2: Flap elevation
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.
Step 3: Flap inset
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.
Step 4: Results at 3-month follow-up
The 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.
- The frontonasal flap is a one-stage procedure and allows defect coverage with directly adjacent skin, which often provides the best aesthetic results in color and texture .
- The incision pattern follows the subunit principle , also leading to good cosmetic results.
- By bringing the thick skin of the ala to the thick skin of the tip, visible scarring is prevented as it most often occurs in areas with a thickness discrepancy between the flap and the skin [1, 2, 4].
- To prevent damage to the dorsal nasal artery, it is important for the surgeon to maintain a 12 mm margin above and below the choroid fissure while raising the axial frontonasal flap .
- To prevent traction of the nose towards the cheek or alar uplifting, always remeber to undermine the surrounding tissue before flap inset .
- The pivot point of the flap determines wether the elevated flap can reach all defect borders without tension. Careful planning can therefore prevent alar uplifting due to tethering at the pivot point .
- The flaps’ cutback at the glabella should be long enough and lie medially to the medial canthus. Otherwise, mobility of the flap is lost which can result in asymmetry.
- de Fontaine, S., M. Klaassen, and D.S. Soutar, Refinements in the axial frontonasal flap. Br J Plast Surg, 1993. 46(5): p. 371-4.
- Marchac, D. and B. Toth, The axial frontonasal flap revisited. Plast Reconstr Surg, 1985. 76(5): p. 686-94.
- Burget, G.C. and F.J. Menick, The subunit principle in nasal reconstruction. Plast Reconstr Surg, 1985. 76(2): p. 239-47.
- Marchac, D., Les résultats à distance du lambeau fronto-nasal. 1974.
- Aoi, J., et al., Simple and effective modification of the axial frontonasal flap to prevent flap distortion. The Journal of Dermatology, 2019. 46(1): p. e46-e47.
- Baker, S.R., et al., Local flaps in facial reconstruction. First Edition. Mosby. St. Louis, Missouri.1995. p:232.