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Case 4: BCC on nose, graft from upper eyelid (Blepharoplasty)

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

Patient history and examination

A 65-year-old male patient was referred to the out-patient clinic with a nodular basal cell carcinoma, localized in close proximity to the left medial canthus, confirmed by punch biopsy.

Before and after

Pre-Operative Considerations

Excision in 2 mm margin with peri-operative frozen sections performed was chosen, as the BCC is well localized and demarcated.

Due to the lack of excess tissue in the local area, primary closure was assessed not to be possible following excision. Various possibilities for local flaps were considered. Transposition or advancement flaps from the cheeks were considered not optimal due to the difference in skin thickness and texture, compared to the skin surrounding the eye area.

The tumor was considered to be localized too medial in applying the Mustarde cheek rotation flap.

A bilobed glabellar flap was considered to be a potentially suitable option.

However, the patient demonstrated excess skin on both his upper eyelids. For this reason, we agreed on reconstruction using excess skin from the patient’s eyelid as full thickness skin graft, in conjunction with a bilateral upper blepharoplasty.

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Step 1: Pre-operative photo with excision margins

Pre-operative view of patient with basal cell carcinoma of the medial canthus. The tumor was excised with a 2-3 mm margin as it was well localized and demarcarted.

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Step 2: Defect after excision

Intra-operative view of defect following excision. Frozen section evaluation confirmed radical excision of the basal cell carcinoma.

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Step 3: Design of bilateral upper blepharoplasty

Assessment of excess skin on eyelids and design of bilateral blepharoplasty.

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Step 4: Design of upper blepharoplasty

Assessment of excess skin on eyelids and design of bilateral blepharoplasty.

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Step 5: Design of upper blepharoplasty

Assessment of excess skin on eyelids and design of bilateral blepharoplasty.

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Step 6: Skin graft performed

The upper eyelid defects have been closed used running nylon sutures, which should be removed after 5-7 days.
The medial nasal defect is reconstructied using the full thickness skin graft from right eyelid. Sutures for the bolus is shown.

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Step 7: Closure and pressure dressing performed

Pressure dressing covering skin graft on left medial nasal defect. Running nylon sutures used to close donor defect on upper eyelid.

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Step 9: 1 week Follow-up, with eyes open

Post-operative view following suture removal, 1 week post-surgery.
The skin transplant and upper eyelids are healing well.

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Step 10: 1 week follow-up, with eyes closed

Post-operative view following suture removal, 1 week post-surgery.

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Step 11: Follow-up after 10 months

Final results 10 months post-surgery. The patient was sastisfied with the result.
The skin grasft has healed with minor scars and good color match.
The bilateral upper blepharoplasty with a natural look.

Post-Operative Plan

The pressure dressing was kept for 1 week until the removal of sutures from both upper eyelid and skin graft.

Pearls

  • It is important to design the blepharoplasty avoiding excessive tension, while at the same time assuring the excision will provide enough quantity of skin to cover the defect.

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