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Case 2: Limberg flap reconstruction of tragus

Authors: Mari Irgens Bøkset, M.D., Magnus Balslev Avnstorp, M.D.

A 65-year-old male patient with basal cell carcinoma localized anterior to the tragus of his left ear/cheek, confirmed by punch biopsy.

Before and after

Pre-Operative Considerations

Since the lesion only measured approximately 7 x 5 mm in size, surgical excision with a margin of 5 mm, followed by primary closure, was initially considered. However, the close proximity to the ear was assessed to cause considerable tension, increasing the risk of postoperative wound dehiscence and a wide open meatus.

We decided to excise the tumor with a 5 mm’s margin, followed by local flap closure. When designing the flap, areas of excess skin were assessed. The most suitable donor site was inferior to the defect on the cheek, in accordance with the vertical line seen in the pre-operative photo.

A few design options were considered, including a transposition or a rhomboid flap anterior to the defect, and a rhomboid (Limberg) flap harvested inferiorly as demonstrated in the intra-operative photo.

We chose the latter option using a limberg flap, as we considered the excess skin to be localized in this area. Moreover, the method allowed for the donor site scar to be hidden in the pre-existing relaxing skin tension line, as well as to be placed as laterally on the cheek as possible.

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Step 1: Pre-operative marking of tumor

Pre-operative view of pre-auricular basal cell carcinoma on the left cheek.
The carcinoma is outlined by dots and excision margin marked by continous pen. Margin 4-5 mm.

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Step 2: Excision of tumor and design of flap

Tumor excised to the SMAS plane.
Design and elevation of Limberg flap (transposition flap), using excessive skin on the lower cheek.

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Step 3: Elevation of flap

Intra-operative view and elevation of flap. Flap has been dissected in the subdermal fat layer – SMAS (Superficial Musculo-Aponeuretic System) plane before the flap is transposed into the defect. The distal edge of the flap is slightly trimmed by scalpel to fit the defect.

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Step 4: After reconstruction with transposition flap

The flap has been transposed into the defect.
Closure performed using absorbale vicryls 4-0 in the depth and single nylon sutures in the skin.

Pitfalls

  • The size of the flap should be measured to fit the defect. This can be ensured by using a folded gauze, measuring the distance between the pivot point to the tip of the flap, and from the pivot point to the most distal part of the defect. After the flap is harvested, the surrounding skin can be further undermined, in order allow tension-free closure.

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