Three-Stage Paramedian Forehead Flap Reconstruction of the Nose Using the Combination of Composite Septal Pivot Flap with The Turbinate Flap and L-Septal Cartilaginous Graft – a Case Report

Introduction

Basal cell carcinoma is the most common malignant skin tumor of the face. Basal cell carcinomas can grow locally infiltratively and destructively, usually without metastasizing. Due to the stochastic effect of sunlight, the predilection site for these tumors is all the sunlit areas, which include the face (forehead, nose, cheeks), both forearms and often the skin of the chest, lower legs and back [1,2].

The prevalence of basal cell carcinoma is increasing; the incidence increases with age, the most at risk group are patients after the 6th decade of life. The growth rate of basal cell carcinoma is individual for each patient. The removal of large tumors in the face results in large, complex defects that affect the eyelids, nose and adjacent areas. Nasal basal cell carcinomas can be treacherous in that they lead to the destruction of soft tissues to varying depths and, in the case of the nose, they can cause complex defects in all layers of the nose and often the loss of the soft nose. Repeated re-excision is often required to achieve histologically clear margins and to safely begin reconstruction of the nose or other parts of the face [1–4].

The nose has a pyramidal shape, the nasal cartilage and bones lie between the mucous lining and the skin cover. During the reconstruction of the nose, the procedure is carried out in individual layers up to the outer skin cover. The basis of nasal reconstruction is to create a well-vascularized inner lining of the nose, on which the construction of the nasal skeleton can be performed by implantation of a bone and cartilages, and the last step is to cover a large skin defect with a well-vascularized pedicled forehead flap. The advantage is that the forehead flap has the same color and texture as the skin of the nose, but is inadequately thick. Therefore, after the forehead flap has adhered, its re-elevation, thinning and shaping is recommended with an interval of 1 month, and the flap pedicle can be removed in the next month [5–7]. In order for the above to be done, the entire reconstructed nose must be built on a well-vascularized inner lining. Many methods of its reconstruction are described, but the most advantageous methods are those in which the original mucosa of the nasal cavity is used, because it is thin, well vascularized and does not obstruct the airways. A good source is the septal mucosa, which is supplied by the septal branch of the superior labial artery and other multiple arteries, and therefore the septum is used as the most common source of material, although it is of limited size. An alternative source of lining may be the turbinate flap on its ventral pedicle. The following case describes the unique use of a combination of composite septal pivotal flap and turbinate flap, which allows completely replacing the inner lining of one nostril without having to use both forehead flaps or free flap due to the size of the defect.

Description of the case

In a 73-year-old female patient who had her basal cell carcinoma of the left nasal wing removed by excision in 2014, extensive tumor recurrences of approximately 1.5 cm in diameter were found during the outpatient examination, causing L deformation of the nasal wing. The patient had been prescribed anticoagulant therapy for cardiac arrhythmia; otherwise she had not been treated for any other serious illness. The patient’s pre-tumor status is shown in Figure 1.

Tumor excision was primarily planned with delayed reconstruction due to unclear clinical margins of the tumor. Histologically, it was a basal cell carcinoma with a positive resection margin, therefore subsequent re-excisions were indicated. Radical resection of the tumor was achieved only after the fourth re-excision, resulting in the loss of half of the soft nose to the right in the tip area, complete loss of the left half of the soft nose and loss of soft tissues of the upper lip and left cheek of 9 × 5 cm. The gradually expanding defect was covered by COM 30 (VUP Brno, Czech Republic) between the individual phases of resection (Figure 2a,b).

Immediately after the radical excision of the basal cell carcinoma, a multi-stage reconstruction of the nose and left facial defect was planned.

The first step in facial reconstruction was to create a stable platform on which nose reconstruction could take place [8]. First, the left face defect was covered in the mean of reverse face-lift advancement, the so-called French plasty [9]. A shift of the skin cover of the face medially with the majority coverage of the defect was achieved, the remaining two small defects were closed by a full-thickness skin graft taken from the preauricular area on the right. Thus, skin grafts were implanted into the dorsal defect of the nose with a size of about 3 × 2 cm and on the upper lip on the left with a size of 2 × 1 cm (Figure 3a,b).

After reaching a stable platform [10] a month later, the first stage of reconstruction of the nose itself was performed, when the re-elevated facial flap was rotated into the originally grafted areas of the upper lip and face. At the same time, the inner lining of the nose was reconstructed using a combination of a septal composite pivotal flap [11] and a left ventrally pedicled turbinate flap from the lower turbinate [12] (see Figures 3a,b and 4). Only with the combination of both flaps was it possible to achieve a sufficient size of the inner lining determined according to the contralateral pattern.

The nasal skeleton was subsequently reconstructed by implanting a cartilaginous L-graft harvested from the cartilage of the left sixth rib to form a central frame (Figure 5a). The cartilaginous framework was anchored after cutting the lateral cartilage at the root of the nose with a non-absorbable monofilament suture, caudally anchored to the spina nasalis anterior area. Rotated septal cartilage was fixed to this framework by many non-absorbable sutures, so that a sufficiently stable central nasal support layer was created (Figure 5b,c). The remaining side walls were then reconstructed with septal cartilage and the remaining cartilage of the 6^th rib. The nasal wing support layer was reconstructed by implanting conchal cartilages taken from the dorsal approach from both auricles (Figure 5d), which were extraanatomically implanted into both edges of the nasal wings [8,13,14]. In the final phase, the nasal skeleton was covered with a left paramedian forehead flap elevated with the frontal muscle, the donor area was almost closed by forehead advancement, only a small 3 × 1 cm defect was left for secondary healing under Granuflex Thin (ConvaTec, UK) (Figure 6a–c). A month later, the second stage of nose reconstruction took place, during which the forehead flap was thinned by removing the frontalis muscle and the flap was re-fixed to the base using transmural stitches to eliminate dead space under the flap [13]. Simultaneously, a facial advancement was performed in the mean of rotation to widen the bottom of the left nostril and to insert a wedge of the forehead flap into the area of the soft triangle on the left to widen the circumference of the nostril. In the following month, the reconstruction was completed by removing the nutrient pedicle and reducing the soft tissues on the glabella (Figure 7a,b). Follow up is now 5 months after tumor resection and nose reconstruction, with no signs of recurrence. The patient is now satisfied with the functional and aesthetic result, the current state is presented in Figure 8.

Discussion

The etiology of basal cell carcinoma is not entirely clear; the main risk factor is chronic, long-term exposure of the skin to ultraviolet radiation, which correlates with a more frequent occurrence in old age in sunny areas. Usually, the first physician to diagnose basal cell carcinoma is a dermatologist who, after examination with a dermatoscope for superficial lesions, can perform cryotherapy with liquid nitrogen or other conservative therapy, but this solution is not sufficient for deeper forms of basal cell carcinoma. For this reason, radical surgical resection with a safety margin of 3–15 mm depending on the size of the tumor and subsequent biopsy verification of the completeness of the excision remains the dominant treatment for deep forms of basal cell carcinoma. If the resection margins are not free with a sufficient safety margin, then the tumor very often recurs. Therefore, it is important to perform re-excision until the entire tumor site is safely removed. Basal cell carcinoma usually does not metastasize, its malignancy is mainly manifested locally by its growth and destruction of surrounding structures. The best solution for invading tumors is early surgical removal before the tumor can form large deposits and destroy surrounding structures, such as growth into the orbit, spread through nasal structures, etc. [1,4].

Modern principles of nasal reconstruction are based on five basic rules [10,14,15]:

1.The most suitable flap for the reconstruction of the skin cover is the forehead flap due to its texture and skin color [14].

2.For large complex defects of the nose, when nasal resurfacing is performed, it is more appropriate to use the three-stage technique of reconstruction of the skin cover by the forehead flap, in which the flap thinning phase is inserted (after a 1-month delay) between the flap harvesting and transfer to the recipient area phase and the flap pedicle removing phase [16,17]. This makes it possible to form a corresponding physiological thin layer of soft tissues on the nasal skeleton.

3.If more than 50% of the subunit is missing, it is more appropriate to remove the remaining tissue of the nasal subunit and replace the entire area of the subunit [18].

4.Reconstruction of the nasal support layer from bone and cartilaginous grafts must be an integral part of the primary reconstruction [5], because otherwise collapse and contracture of the displaced soft tissues occurs and the result of nose reconstruction is not permanent [8,11,16,19].

5.Adequate reconstruction of a well-vascularized intranasal lining is the cornerstone of a successful nose reconstruction [14].

Adherence to these five basic rules is a basic prerequisite for successful nose reconstruction, especially the creation of adequate intranasal lining, on which the entire nose is then built. Its failure leads to a failure of nose reconstruction.

Reconstruction of such a large intranasal lining defect under given conditions requires either the use of a bilateral forehead flap (one flap for intranasal lining and the other flap for the skin cover of the nose) or possibly a free flap [20]. In the first case, the morbidity of the donor site on the forehead increases [13], in the second case the surgical burden and complexity for the patient. In both cases, moreover, the flaps are too thick and obstruct the airways, often requiring secondary thinning of the flaps or enlargement of the airways [8,13].

The composite chondromucosal pivotal flap from the septum alone, on the other hand, does not provide enough mucosa to create adequate nostril circumference. However, the unique addition of a turbinate flap, which due to the arc of rotation can only be used to reconstruct the base of the nasal ala, will allow completing the rest of the perimeter of the nostril to achieve a sufficiently spacious nostril. In addition, it is a thin mucosa that does not obstruct the airways. Although in the reported case this combination of flaps was used only unilaterally, it can also be used bilaterally and thus achieve the reconstruction of adequate nasal lining for complex subtotal nasal losses affecting the base of the nasal wings.

Another innovation was the combination of an L-graft with a composite pivot flap. The use of the L-graft eliminated the risk of collapse of the rotated composite septal chondromucosal pivotal flap in the area of the nasal dorsum and thus ensured the robustness of the reconstruction of the nasal skeleton while ensuring an adequate position of the rotated composite septal flap.

This reported case of the patient also verified in practice that it is appropriate to plan the reconstruction of the nose into individual stages and that gradual steps can be used to achieve an adequate reconstruction result, which in no way separates the patient from society. The higher aesthetic result of nasal reconstruction using the three-phase forehead flap technique compared to the already obsolete two-phase technique was confirmed again [5,6,8,17].

Conclusion

In basal cell carcinoma, as in other skin tumors, free resection margins should always be achieved before reconstruction. Reconstruction of large nasal defects should be planned in individual steps, so that first a sufficient platform for reconstruction is created and only then the entire nose, including the intranasal lining and skeleton, is reconstructed. The result of the first stage of reconstruction is then corrected in the following stages in terms of achieving the physiological appearance of the nose.

The use of composite septal pivot flap and turbinate flap is an original method that ensures a sufficient diameter of nostrils for subtotal losses and allows avoiding more demanding reconstruction techniques or higher morbidity of donor sites, as we verified in this case report. In addition, the combination of the use of the L-graft and the pivot septal flap eliminates the shortcomings of both separately used techniques, ensures a sufficient framework for the nasal skeleton, and ensures the durability of the achieved result of reconstruction.

Role of authors: Zdeněk Dvořak – operating surgeon, conceptualization, methodology, supervision, visualization, writing – original draft. Antreas Cheimaris – assisting surgeon, data curation, investigation, writing – original draft, and writing – review & editing, photo documentation, methodology. Martin Knoz – investigation, data curation, writing – original draft. Richard Pink – investigation, data curation, writing – original draft.

Disclosure: Authors have no conflicts of interest to disclose. Authors declare that this study has received no financial support. All procedures performed in this case were in accordance with ethical standards of the institutional and/or national research committee and with the Helsinki declaration and its later amendments or comparable ethical standards.

Antreas Cheimaris, MD

Department of Plastic and Aesthetic Surgery,

St. Anne’s University Hospital

Berkova 34

612 00 Brno, Czech Republic

e-mail: antreas.cheimaris@fnusa.cz

Submitted: 18. 12. 2020

Accepted: 24. 01. 2021