Reconstruction with Dorsal Nasal Flap after Excision of Basal Cell Carcinoma of the Nose

Sir,

Reconstruction of nasal defect after excision of a neoplasm is a surgical challenge due to the complex three-dimensional structure involving different components of the nose. Repair of the resultant defect is difficult and should be aesthetically acceptable.[1] The method of repair is based on the defect's size, location and structural involvement (i.e., skin, cartilage, bone, mucosa).[2] Local flaps are preferable as they provide better match for color and texture.[3]

Basal cell carcinoma (BCC) of the nose is common with a high recurrence rate. A wide variety of surgical techniques are available which assure complete tumour removal with good aesthetic and functional outcome.[4]

A 72-year-old male presented with a 2 cm × 2 cm ulcer over the dorsum of nose for the last 6 months. Another small, pigmented ulcerated lesion of size 4 mm × 4 mm was present below the right medial canthus [Figure 1]. Dorsal nasal flap was used to reconstruct the resultant defect.

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Figure 1

Ulcer over the dorsum of nose

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Incision site was marked to include the lesion over the nose. The donor site flap was also designed and marked [Figure 2a]. Wide excision of the nasal skin lesion was done taking 3 mm margin all around. The flap was raised in subcutaneous layer extending to glabella based on the right-sided vascular pedicle [Figure 2b]. The flap was rotated to cover the defect and sutured. The lesion below the right medial canthus was also excised and primary suturing was done [Figure 2c].

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Figure 2

(a) lesion over the dorsum of nose and donor flap site marked. (b) defect after excision of lesion and raised dorsal nasal flap. (c) flap was rotated to cover the defect and sutured

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All the sutures were removed on the 7^th post-operative day [Figure 3a]. Histopathology was reported as BCC. After 2-month follow-up, the patient was asymptomatic with good aesthetic appearance [Figure 3b].

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Figure 3

(a) Seventh post-operative day picture after suture removal. (b) Picture after 2 months

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BCC is the most common non-melanoma skin cancer. It accounts for up to 25%–30% of tumours of the face. The nose has a 2.5 times higher risk of recurrence of BCC after surgical excision due to its anatomical peculiarities and problems in pre-surgical identification of tumour margins. Despite this, surgery is the mainstay of treatment of BCC of the nose.[4]

Cover of nasal defects after cancer-ablative surgeries include numerous reconstructive modalities such as free skin grafting and local flaps.[5]

Dorsal nasal flap (Rieger) is time tested and provides good aesthetic result and is a single-staged procedure. This modified rotation flap recruits redundant skin from the glabella. It can be used to repair skin defects of the nasal tip, dorsum and sidewall. It utilises the entire dorsal nasal skin to facilitate repair. It can repair relatively large lower and mid-nasal defects, measuring 2.5 cm or less with matching adjacent tissue with an exact colour, thickness and contour. It is a safe flap, and the donor site morbidity is minimal. Although originally described to repair the defects of lower third of nose, a little modification can repair the defects of the dorsum of the nose with good outcome.[5] The disadvantage of the flap is limitation regarding size of the defect and the need to elevate an extensive area of nasal tissue.

Our patient had an uneventful post-operative recovery with acceptable cosmetic appearances. Currently, he is doing well.