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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00980-5
10.1016/j.ijscr.2024.110199
110199
Case Report
Reconstruction of nasal and upper lip defect using bilateral inferiorly based malar transposition flaps: A case report
Asadi Mahboobe mahboobeh_farvardin@yahoo.com
a⁎
Rootivand Zahra a
Jahanshahi Fatemeh ab
Molai Hossein a
Shahzamani Arvin a
a Otolaryngology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
b Research Committee Member, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
⁎ Corresponding author at: Taleghani Educational Hospital, Tabnak St. Velenjak Region, Chamran High Way, Tehran, Iran. mahboobeh_farvardin@yahoo.com
20 8 2024
10 2024
20 8 2024
123 11019929 6 2024
15 8 2024
17 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Surgical flaps are accepted as the best option for nasal reconstructions depending on various factors, including defect etiology, size, location, and depth.

Case presentation

A 71-year-old man presented with a squamous cell carcinoma of the columella extended to the nasal tip and upper lip. He underwent Mohs resection followed by staged reconstruction with bilateral inferiorly-based malar transposition flaps. Then, the patient was scheduled for radiation therapy for four weeks. The patient had been free of recurrence after a two-year follow-up.

Clinical discussion

In this case, the inclusion of the upper lip and columella defect restricted our choices. However, the bilateral malar transposition flap effectively covered both nasal and upper lip defects, providing an excellent tissue match without the need for a skin graft. This method is particularly suited for extensive multiple nasal subunits and upper lip defects.

Conclusion

A malar transposition flap may be an adequate alternative for columella and upper lip reconstruction after skin cancer resection.

Highlights

• Mohs surgery may cause large, complex defects that need advanced reconstruction techniques.

• Reconstruction options are limited for multi-unit defects in lower nose and upper lip.

• Bilateral malar transposition flap can effectively cover both nasal and upper lip defects post-cancer resection.

Keywords

Nasal reconstruction
Surgical flaps
Cutaneous squamous cell carcinoma
Mohs surgery
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pmc1 Introduction

Various nasal reconstruction methods have been introduced in the literature. These reconstruction techniques depend on various factors, including defect etiology, size, location, and depth [1]. So, each reconstruction requires an individualized approach. Recently, the forehead and radial forearm free flap have been recommended for nasal complex defects. [2,3]

Our patient had a complex defect involving the nasal tip, columella, septum, and a portion of the upper lip after Mohs surgery for squamous cell carcinoma. Restoration of nasal and lip function and contour were the main goals of reconstruction in this case. This report details a two-stage approach to reconstructing such a defect using bilateral inferiorly-based malar transposition flaps with an auricular cartilage graft for more support and contour. This report adheres to the SCARE 2023 criteria. [4]

2 Case presentation

A 71-year-old male with a 2-month history of a painful, erythematous lesion in the nasal base and columella was referred to the otolaryngology clinic with the primary impression of nasal abscess. He had a history of lifetime sun exposure without sun protection. His medical history revealed no previous cancer, no family history of skin cancer, and no use of immunosuppressive medications or radiotherapy. On examination, there was a destructive lesion involving nasal columella, septum with erythematous margins extending to the upper lip. A biopsy of the nasal lesion confirmed nasal squamous cell carcinoma (Fig. 1). An endoscopic examination revealed a destructive tumor involving columella and nasal base with no extension to other adjacent structures.Fig. 1 Preoperative basal view of the patient's nose, displaying the biopsy-confirmed squamous cell carcinoma.

Fig. 1

Moreover, a computed tomography scan with intravenous contrast revealed a 3 × 2.5 cm size, mildly enhancing soft tissue attenuation lesion noticed along the anterior nasal septum. Paranasal sinuses and surrounding structures were normal. Metastatic workup with CT scan of the neck, thorax, abdomen, and pelvis were negative for local or distant metastasis. The patient was presented to the multi-disciplinary team, and Mohs surgery and postoperative radiotherapy were agreed upon.

The patient underwent Mohs resection of the lesion until all margins were free of tumor based on the histopathologic examination. A large defect involved the nasal base, columella, septum, and upper two-thirds of the upper lip (Fig. 2). Then, the patient underwent nasal reconstruction in two stages. The first stage of reconstruction immediately followed resection: bilateral malar transposition flaps were planned and elevated to cover both the missed skin of the nose and upper lip (Fig. 3). For more support and contour, the nasal tip and columella were shaped by an auricular cartilage graft. On both sides, the incision involved the inferior orbital rims, and then the flaps were elevated over the facial musculature from medial to lateral.Fig. 2 Intraoperative photograph of the defect, illustrating the extent of the neoplasm, and nasal and lip structures involved prior to histological clearance.

Fig. 2

Fig. 3 Design of the bilateral inferior base malar transposition flaps. (B) After setting the flaps in place. Lateral sides of the flaps (a–b and c –d) form the columella and medial sides (b-c and c-f) forms the upper lip.

Fig. 3

Moreover, further undermining was done laterally to facilitate advancement. After the transposition of both flaps, they were divided into two portions to cover the columella and nasal tip superiorly and the upper lip inferiorly. The superior flap division made the columella lateral surface on one side and the medial surface on the other. In contrast, the cartilage graft supported the columella in a middle layer. The donor sites were closed directly (Fig. 4). In the second surgery, four weeks later, the pedicle was released on both sides, and then it was rotated to restore the nasal base. After that, the remaining tissue from the pedicle was excised (Fig. 5). Also, at the supra tip, a small site of tissue necrosis was detected, and it was excised with a fusiform incision. Since the histopathology analysis confirmed there was no tumor recurrence on biopsied tissue, it was primarily closed and supported with an on-lay cartilage graft. All steps were performed under general anesthesia.Fig. 4 Photograph of the early postoperative anteroposterior (A) and basal (B) appearance with malar transposition flap, conchal cartilage graft. The images showed an excellent color matches with minimal tissue distortion.

Fig. 4

Fig. 5 Photograph of four postoperative weeks lateral (A) and basal (B) appearance. Of note, at the supra tip, a small site of resolving tissue necrosis can be seen. Photograph of intraoperative lateral (C) and basal (D) appearance after second stage surgical reconstruction. Pedicle release and nasal base restoration can be seen.

Fig. 5

The postoperative course was smooth, and the skin flap was warm with normal color without any sign of infection, necrosis, severe inflammation, redness, or unusual discharge. The wound had healed perfectly after four weeks. The patient was scheduled for radiation therapy for four weeks. After a six-month follow-up, the patient was free of recurrence. Besides, regular 6-monthly follow-up was recommended without any need for adjuvant treatment. Upon follow-up after two years, no signs of cancer recurrence were observed. The patient was highly satisfied with the outcome of the reconstruction and expressed no desire for additional reconstructive surgery (Fig. 6).Fig. 6 Photograph of two years postoperative anteroposterior (A) and basal (B) appearance with malar transposition flap, conchal cartilage graft.

Fig. 6

3 Discussion

Cutaneous squamous cell carcinoma (SCC) is a malignant skin tumor with a risk of rapid growth, local invasion, and metastasis. It is the second most common cancer in the U.S. after basal cell carcinoma. Factors influencing recurrence include tumor depth, cellular differentiation, and location, with deeper and poorly differentiated SCCs having higher recurrence and metastasis rates.

SCC in situ, linked to actinic keratosis, has minimal metastasis risk, but invasive SCCs, which can develop from untreated in situ lesions, have a 3 % to 5 % metastasis rate, rising to 10 %–30 % for lesions on mucosal surfaces or previous injury sites.

Research highlights that larger tumors and those over 4 mm in depth are more likely to recur and metastasize. Poorly differentiated SCCs and those with perineural invasion also show higher rates of metastasis. Immunosuppressed patients face significantly increased SCC risks and earlier onset.

Treatment options, including Mohs micrographic surgery, are selected based on tumor characteristics and prior treatments [5,6].

Mohs micrographic surgery (MMS) is a highly effective method for treating nonmelanoma skin cancers. It carefully removes cancerous tissue and cells while preserving healthy tissue. This approach reduces errors and improves treatment accuracy. It is particularly effective for recurrent and primary SCCs on high-risk sites where tissue conservation is crucial. Recent US guidelines recommend MMS for high-risk BCCs and SCCs on the face because it maximizes skin preservation and reduces tumor recurrence [6,7].

Defects after Mohs micrographic surgery (MMS) can range from small, linear closures to large areas requiring flap coverage. One of the challenges of this technique is achieving optimal cosmetic outcomes when closing large defects [7].

Various techniques are used to repair defects based on their location, size, and depth. Choosing the best method can be complex and challenging, with the ideal closure often debated. In these cases, based on the type of defects (location, size, depth, involved subunits, and etc.), patient's condition, and surgeon's discretion, skin flaps and full sickness skin grafts (FTG) can be used [8].

In this case, we must use a local flap rather than a free tissue graft (FTG) due to the large extent and complexity of the defect. Additionally, a local flap may provide a better match in terms of skin color and texture, reduce the risk of necrosis, and offer superior cosmetic outcomes. [9].

Given the three-dimensional shape of the nose, reconstruction of large nasal defects, especially in complex cases with defects involving peripheral tissue, such as lip, can be a challenging task. Cutaneous flaps are chosen based on defect size and location to restore nasal function with minimal scarring [10].

Various local flaps have been reported in the literature and named based on their donor site. Choosing the best technique with satisfactory results in nasal reconstruction requires the surgeon's experience, knowledge, and the patient's tolerance. The forehead flap is considered the procedure of choice for reconstructing extensive nasal defects. The mentioned flap can be carried out in single or multiple stages. [11] Although the forehead flap is a viable option, we opted against it due to the defect predominantly affecting the lower regions of the nose and upper lip in our patient.

Free flaps are a suitable option for very large complex tissue and bone defects where local flaps are not feasible [12]. However, given the type of the defect and the potential use of local flaps in this case, free flaps may not be ideal, as they would involve a more extensive surgical procedure for the patient.

Therefore, in this patient, the involvement of the upper lip and a columella defect limits the various methods. Hence, we selected bilateral inferiorly based malar transposition flaps that inspired its shape by nasofacial sulcus flaps. Historically, nasofacial sulcus flaps have been used for upper lip defect reconstruction. [13] However, nasal reconstruction using bilateral nasofacial flaps was described in two case reports. [14,15]

In our report, the bilateral malar transposition flap covered nasal and upper lip defects while providing an excellent tissue match. However, the second step was done; there was no need for a skin graft. This flap could be considered for the patient as the defect was too large and involved multiple nasal subunits. In addition, placing the flap incisions at the junction of aesthetic subunits leads to excellent cosmetic outcomes. This point is important in nasal ala and tips that are more susceptible to distortion. [16]

On the other hand, dividing the flap into two parts could increase the risk of flap ischemia and necrosis, especially in columella. However, there are some techniques to avoid flap ischemia, like placing the lateral border of the incision more laterally to make a larger pedicle base. [17]

4 Conclusion

Although the bilateral malar transposition flap covered a large nasal defect extending from the nasal base, columella, and portions of the upper lip, further revision may be needed to achieve a better functional and cosmetic outcome. A malar transposition flap may be an adequate alternative for columella and upper lip reconstruction after skin cancer resection.

Patient's perspective

The diagnosis of cancer initially filled me with apprehension. But now, after two surgeries and one month of radiotherapy, I am grateful to say that I have fully recovered from the surgery. Thankfully, I am now very much back to normal in my day-to-day life, so I can say I have made a full recovery.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal.

Ethical approval

Ethical approval for this study was approved by the Ethical Committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran, in June 2022. The present study complies with ethical and research standards involving humans. This article does not contain any studies involving animals performed by any of the authors.

Funding

This study has no financial source and support.

Author contribution

Study concept and design: MA.

Acquisition of data: FJ, ZR, HM.

Drafting of the manuscript: MA, FJ, ZR, HM, AS.

Critical revision of the manuscript for important intellectual content: MA, FJ.

Study supervision: MA.

All authors read and approved the final manuscript.

Guarantor

Please address all correspondence concerning this manuscript to me at Mahboobeh_farvardin@yahoo.com.

Research registration number

N/A.

Conflict of interest statement

There is no conflict of interest to declare.

Acknowledgment

none

Data availability

Data in the current study are available from the corresponding author upon reasonable request.

Acknowledgments

None.
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