Keywords: Casal cell carcinoma, non melanoma skin cancer, Limberg flap, facial reconstruction
Authors: Ema Sutakova, MD, Dominika Miklisova, med. student, Miroslava Verbat, med. student, Jana Bartoskova, MD, Iva Tresnerova, MD, Julia Bartkova, MD, MBA
A 73-year old man with suspected basal cell carcinoma of the right lower eyelid area was admitted to the Department of Burns and Plastic surgery, University Hospital Brno for excision and further reconstruction. The patient was referred from his dermatologist and complained about a skin erosion under the medial canthus of the right eye, that appeared 6 months ago and requested a surgical resolution.
Regarding anamnesis, the patient has hypertension and hyperlipidemia on medication (bisoprolol, perindopril, rosuvastatin), benign prostate hypertrophy and hepatopathy.
In 1999 he contracted hepatitis C and was hospitalized in the infectious diseases department. He has a history of depressive disorder.
He had undergone several surgeries, two times inguinal hernia repair and arthroscopy of the left knee. The patient is a non-smoker, denies alcohol and drug abuse. No allergies are reported. In terms of family history, he acknowledges the occurrence of stroke and asthma. (1)
Before and after
Patient examination
An ulcerated tumor, measuring 15×7 mm, located to the right lower eyelid area, under the medial canthus. There were no signs of reddening or swelling in the proximity of the lesion.
Pre-Operative Considerations
The procedure was performed with local anesthesia, using 1% Mesocain with adrenaline. In terms of reconstructing the defect, a modified Limberg flap (Rhomboid flap) was chosen as the patient had excessive skin on the central right cheek.
Other solutions were considered, both a standard transposition flap, a VY-flap and a cheek rotation flap.
The modified Rhomboid flap was chosen as the flap would end up with a more diguised scar in the nasolabial fold, and no traction on the lower right eyelid.
Step 1: Pre-operative drawing
Pre-operative marking of the lesion with safety borders was performed.
- The tumor was marked with a 5mm excision margin. Notice the margin getting close to the medial canthus, but not involving it.
Step 2: After excision of the tumor
After a proper preparation of the sterile field, the excision of the lesion with safe borders was performed. The patient requested a single phase procedure, therefore we chose a wide safe margin to decrease the risk of another re-excision. The orbital septum of the right lower eyelid is safely sutured to the orbicullaris occuli muscle with safyl sutures. Proper hemostasis was maintained. The defect after excision is estimated to measure 3×4 cm.
- The defect following tumor excision and hemostasis.
- The tumor has been excised including the subdermal fat layer, and to the orbicularis oculi muscle to obtain free margins.
Step 3: Limberg flap design (modified rhomboid flap design)
According to the size and the location, a limberg flap from the patient’s right cheek is chosen for closure of the primary defect. The anatomical position of key structures, the laxity of the surrounding skin and the direction of Relaxed Skin Tension Lines (RSTL) are all assessed, respected to avoid distortion and achieve optimal aesthetic results.
- A modified Limberg flap was drawn for reconstruction of the medial right lower cheek and eyelid.
- Notice the border follows the nasolabial fold laterally, and is twice as long as normal. Thereby a modified flap.
Step 4: Scheme I – Drawing
The cutaneous primary defect is drawn in the form of a rhombus with four equal sides, with two angles of 60° and two angles of 120°(2).
- A simplyfied drawing of the modified Limberg flap, following the nasolabial fold
- As seen the drawing does not obtain the vertical green line as the standard drawing
Step 5: Scheme II – Drawing
The first incision is made directly as an extension of the small diagonal and creates a 120° angle. The second incision is made at a 60° angle of the first incision. The decision for the final flap position is made based upon skin laxity (3).
- Notice the lenght of the flap, which is nearly double the length of the other side in the rhomboid defect.
Step 6: Transposition of the flap into the defect
To avoid distal pain by stretching, it may be sometimes useful to oversize the flap. Therefore, the designed, raised flap rotates to reconstruct the primary defect, whereas the secondary defect is enveloped by stretching parallely along RSTL.
- Notice there is no downward drag into the right lower eyelid.
Step 7: Closure with sutures
After accurate orientation and positioning, the deep dermis and dermis are sutured.
- The flap was sutured with nylon 5-0 single sutures
Post-Operative Plan
One day after the surgery, swelling was present in the wound area; therefore, the patient was prescribed escin for its anti-inflammatory and antiedematous effects.
In the first follow-up, four days after the surgery, the patient complained about the strong swelling of the both eyelids of the right eye with a slight secretion. Redness was present in the wound but the stitches appeared to be holding strong. Antibacterial ointment (Framykoin) was prescribed and the treatment with escin was resumed. The wound was covered using ointment gauze and a sterile dressing.
Nine days after the surgery, the swelling decreased, the secretion cleared off. The stitches were removed and the wound closure strips were applied. The patient was advised to use artificial tears to prevent the dryness of the eye.
Two weeks after the surgery the patient came for the final check-up. The wound was clean and firm, without swelling or dehiscence. The histological examination confirmed the diagnosis of nodular basal cell carcinoma with squamous carcinoma signs, excision was done completely in sano. Regarding the diagnosis, further controls by the dermatologist was recommended (3).
- Well-performed and healed rhomboid flap presents a successful functional and aesthetic outcome. The design of the flap is very versatile and can be used almost anywhere on the body. Skin texture and color remains the same as the surrounding skin, making the local flap reconstruction favored contrary to grafts. Skin grafts also require more dressing changes, greater personal hygiene, reduced physical activities and delay patient functionality. The overall recovery is much shorter for patients with local flaps (4).
- The standard design of rhomboid flap can be modified individually in each case based on a surgeon’s experience. Together with the simplicity of the technique and rapid healing, it makes this a preferred technique especially for reconstructions after skin cancer of head and neck (2).
- The major limitation in use of rhomboid flap can be lack of skin. This condition can derive from reduced skin elasticity or lower body mass index. When the defect size is too large, other flap might be considered or a combination of multiple flaps.
- Nicotine abuse as well as diabetes are relative contraindications for rhomboid flap reconstruction (2).
References
- BARTKOVÁ, Júlia; MIKLIŠOVÁ, Dominika; VERBAT, Miroslava; ŠUTAKOVÁ, Ema; BARTOŠKOVÁ, Jana et al. Limberg flap reconstruction after basal cell carcinoma excision. Online. Onkologie. 2024, roč. 18, č. 1, s. 78-82. ISSN 18024475. Dostupné z: https://doi.org/10.36290/xon.2024.016. [cit. 2024-04-21].
- Aydin, O. E., Tan, O., Algan, S., Kuduban, S. D., Cinal, H., & Barin, E. Z. (2011). Versatile use of rhomboid flaps for closure of skin defects. The Eurasian journal of medicine, 43(1), 1–8. https://doi.org/10.5152/eajm.2011.01
- Nemet, A. Y., Deckel, Y., Martin, P. A., Kourt, G., Chilov, M., Sharma, V., & Benger, R. (2006). Management of periocular basal and squamous cell carcinoma: a series of 485 cases. American journal of ophthalmology, 142(2), 293–297. https://doi.org/10.1016/j.ajo.2006.03.055
- Kang, A. S., & Kang, K. S. (2021). Rhomboid flap: Indications, applications, techniques and results. A comprehensive review. Annals of medicine and surgery (2012), 68, 102544. https://doi.org/10.1016/j.amsu.2021.102544
