Case Competition 2023 Case 6 Nasal reconstruction with bilateral nasolabial flaps
Authors: Julie Husted Andersen, Resident, Roskilde Hospital, Denmark
75 year old woman with a history of basal cell carcinoma (nBCC) located to the apex of the nose. The first biopsy was made in 2014. Since then the patient suffered a relapse and in september 2022 the excision was made with a surgical margin of 5 mm. The defect was left open until final histology. Histology showed that the tumor was radically excised and now ready for planning of a facial flap.
Before and after
Patient examination
The skin examination showed sign of a tumor located to the apex of the nose. The tumor was clinically difficult to define with the naked eye. The measure was 12 x 15 mm and the tumor thickness was estimated to be 2 mm. The was no wound and no signs of infection.
Pre-Operative Considerations
The surgery was originally planned for excision and use of per-operative freezing histology with reconstruction of a random facial flap. Due to the difficulty defining the borders of the tumor it was decided not to use the per-operative freezing histology. Instead it was decided to leave the defect open until final histology. Reconstruction with a random flap were discussed for the 2-step-procedure. It was assessed that a bilateral nasolabial flap could cover the defect on the apex of the nose or alternatively a nasofrontal flap. The patient was included in the decision and did not wish for reconstruction with the nasofrontal flap as she was not happy with her forehead.
Step 1: Drawing
The tumor was marked and a surgical margin of 5 mm was drawn.
Step 2: Excision
The tumor was excised in 5 mm margin including subdermal slim tissues and marked a 12 o clock for the histologic assessment. The defect was left open and histology showed that the tumor was radically excised.
Step 3: Flap drawing
Drawing for the bilateral nasolabial flaps.
Step 4: Closing
Closing of the defect and donor sites.
Post-Operative Plan
The patient was not happy with the cosmetic result of her nose. The flaps are very thick leaving her nose with a wide expression. The profile of the nose was quite good. The patient is now in pre-operative planning for surgical thinning of the flap.
- Useful for covering wide defects of the apex of the nose and an alternative to a nasofrontal approach.
- The end result of a bilateral nasolabial flap is a “bulky” nose.
