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Case 3: Transposition flap to left temporal region

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

Patient examination

81-year-old male patient, previously known with multiple basal cell carcinomas in the head and neck region, admitted with a keratotic skin lesion in his left temporal region. The tumor, measuring approximately 15 mm in diameter, had developed through 3-4 months.

The patient was initially treated using topic Aldara cream by the dept of dermatology. Due to lack of treatment response, the patient was referred to the Dept of Plastic Surgery for surgical excision. Punch biopsy from the lesion confirmed the diagnosis squamous cell carcinoma, and the patient was booked for surgery.

Before and after

Pre-Operative Considerations

Pre-operative evaluation considered excision with primary closure not to be possible, due to the large size of the resulting defect. The possibility of a local transposition flap was considered a good alternative, as the skin in the regional area was similar in structure, color and thickness relating to the area of defect, resulting in a better cosmetic outcome compared to skin grafting. By pinching the skin we determined excess skin localized inferior to the defect. The flap was designed as a transposition flap, according to the skin tension lines.

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Step 1: Pre-operative photo

The tumor located to the left temporal region. Size 15×11 mm. Margin marked by dots.

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Step 2: Design of excision margin and transposition flap

Excision margin was designed to be 4-5 mm.
The local transposition flap was designed by pinching.

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Step 3: After closure

The flap was raised in the subdermal plane, with cautioness to the frontal branch of the facial nerve.
The flap was transposed into the defect and closed with running nylon sutures without tension.

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Step 4: Follow-up 3 months

The patients own photo from home.
Sufficiently healed local flap.
The tumor was excised with free margins.

Pitfalls

  • The patient was pre-operatively informed of the risk of post-operative complications, including the risk of injury to the frontal branch of the facial nerve. The tumor was excised with sufficient subcutaneous tissue underneath, however with caution to the facial nerve branch.
  • The flap should be elevated with thickness similar to that of the defect, in order to match the defect.

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