Reconstruction of a Large Nasal Cutaneous Defect Using Nasolabial and Rhomboid Flaps

CHAPTER 1

This is a case presentation of an 82-year-old female who presented to my office with several months history of a non-healing lesion of the left nasal Ala. She had noticed a progressive increase in size, and the lesion had become more pigmented and raised. There was no discharge associated with it. She does have a past medical history consistent with basal cell cancer, but no family history of skin cancer. She has had moderate exposure to the sun in the past and does not use sunblock or sunscreen regularly. Her past medical history is consistent with hypertension, kidney disease, and atrial fibrillation. Her past surgical history is consistent with prior pacemaker placement. She is not a smoker, and current medications include Xarelto, Flecainide, and Diltiazem. On physical examination, this is an elderly female, who is not in any acute distress. Her weight is 140 pounds. She is five foot, three inches tall, and her body mass index is 24.8 kilograms per meter squared. Her skin exam shows that she has a Fitzpatrick type two skin, it's warm and dry, specifically, examination of the left nasal ala skin revealed approximately 2-cm by 1.5-cm diameter, diffusely pigmented, scaly lesion, which looks very suspicious. It was nontender to palpation and with no evidence of any infection. Given the clinical findings, I went ahead and performed a punch biopsy. The results of the punch biopsy revealed a basal cell cancer. Given the clinical findings, location, and the size of this tissue, the decision was made to refer her to Mohs extraoperative surgery for excision. She underwent two stages of Mohs extraoperative surgery to achieve complete tumor-free margins. The size of the final defect was 3 cm by 2 cm along the left nasal ala and the inferior portion of the left nasal sidewall. The external valve was collapsed, but the mucosa was intact. I recommended a combination of nasolabial flap from the superior portion of the left nasal sidewall and the glabella and a rhomboid flap from the left medial cheek and the nasolabial fold. I also prepped the left ear for cartilage graft donor site.

CHAPTER 2

So there is a defect here. We'll try to close that up. Let me see a 5-0 chromic, please. And this defect is about 3 cm by about 2 cm. It's full-thickness, skin is gone, cartilage is gone, and there's a little defect within the mucosa as well. So we'll start by approximating the mucosa. I'm just going to use chromic 5-0 and two absorbable sutures. There's a portion of the cartilage that you still see there. Do you see that? Do you want a little film? Yes, please. So two simple, interrupted sutures. And I'm going to put this suture so that the tails are actually not on the mucosa side, but on the external side.

Next, what I'm going to try to do is see where the edges of the cartilage are. Just gentle dissection to identify where was the cartilage cut? And we are talking about the lower lateral cartilage here. Still trying to dissect the cartilage to see where the cut edge is. Just going to get some hemostasis. I think it's right underneath where my - do you want me to take it out? No, let's try here. So actually, the cartilage seems to be intact. So this is where we are seeing the lower lateral cartilage, and it does seem to be intact. So, I don't think we would need to use the cartilage graft in this location.

So, what it comes down to is a cutaneous defect, and the size of this defect is fairly large, considering the location. So we'll split it up into two, and I'm going to use a bilobed flap for the medial portion and a rhomboid flap for the lateral portion. I'll just take some lidocaine with epinephrine.

So just using some local anesthesia here, and the bilobed flap is going to be based superiorly. And it's going to be a transposition flap, and it's going to be based on the blood supply from here. I'll take a 15 blade.

CHAPTER 3

So raising the bilobed flap. I'll take a double hook for that.

Trying to get - getting some hemostasis here and raising the flap. This patient is on Xarelto at home, has stopped for a few days now. That might account for some of the bleeding that we are seeing. Okay I'm just trying to get hemostasis. Remind me what this flap is? Bilobed. Bilobed? Bilobed meaning that it has two lobes. I'll take another 4 by 4, please. So some of that is just from the skin too. I need to fix that up. Yeah, well it's right where we put this thing, it's almost like… [Indistinct]. Do you want me to take it out? Sure. Yeah, I feel like it's making… I get good control and then I move it, and… What's the cautery on Amber? It's got to be… It's on 15/15. We can go to maybe 30/30. I think there are some… And I'll take a double hook again. And a lot of times the dissection which I do is just with a cautery. I'll take another 4 by 4, please. I have it right here. So still trying to raise this flap up. Into the nasolabial branches. So the plan is to kind of rotate this flap down to see if that can help close the defect. At least a portion of it. And do you have a Biosyn, please? How about a 4-0 Biosyn? I'm going to mobilize it a little bit more.

So this is the bilobed flap. This is the top part. This is the bottom part. So we're going to try to sort of like move it this way. And this is a 4-0 Biosyn. So this would be the primary defect, secondary defect, and tertiary defect. So in this case, the tertiary defect is going to be closed with advancement. So this tissue, which used to be here, is going to come and reconstruct this, and this tissue, which used to be here, is going to take care of part of this. And then we'll use the rhomboid flap for this part here. So are you going to have to use cartilage to support the...? No because the cartilage was intact, and when I actually mobilized it, it was okay. Okay. Knife, please. And so there is some redundancy of the tissue that you need here. So I'm just going to trim some of the flap that you do not need anymore. And I'm going to thin this up too because you don't want it to be too thick. And then take the nylon please, the 4-0. So in a bilobed flap, what you do is take these two flaps, and kind of rotate them both down, and you use it in instances when we are talking of like a really big defect there, like this was. Can I get another 4-0 nylon, please? C13. I'll take another one. So this is the bilobed flap, but as we can see, that's not going to be enough. And then the other one's rhom- Rhomboid flap is what I'm gonna have to do. So what does that mean, like why? It's just shaped like a rhombus. Okay. Yeah, that's what I figured, but I just… I need to go back to geometry. I hear that. Yeah. But the advantage of using this over a skin graft type of that, that would have been like a postage stamp forever. And it would be like a depressed, sort of an area. If that - if it healed well too, right? Could it have healed well technically with a flap? Or not a flap, a? t may or may not have, or… I don't know. Depending on her skin condition… So how do you take it from here without it distorting like the lip? You'll see. I'll take the lidocaine again, please. Or, actually, let's put one more right here.

CHAPTER 4

So this flap, I'm going to raise it as a rhomboid flap, and it's going to rotate like this, into the defect.

So this is going to rotate like that.

So in this flap, this is going to rotate superiorly and medially to kind of obliterate that, and then this will advance together to close. So I'll take the Biosyn again. We're closing the secondary defect of this rhombus flap. And this is going to come in this way to close it. And I probably will just pin this flap a little bit also. Just conservatively. I'll take the Biosyn again. With this stitch I'm actually going to go down and try to get some deeper tissue as well. And the purpose is to kind of like help create a little bit of a depression here. And I'll take the nylon again, please. What kind of dressing do you want? Just, I think antibiotic cream and maybe a gauze and some paper tape. She's allergic. Oh, yeah. She's allergic. To? Triple A. And tape, actually. Bacitracin cream? How about Bactroban - mupirocin? Yeah, we should have that one. So this is approximating one flap to the other to close this defect completely. So sometimes you need more than one local flap to kind of like completely obliterate the defect. I'll take the knife, please, Carter. Again, a little bit of a redundancy there, which I'm going to conservatively remove. A little bit of a dog ear here. I'm going to excise as well. No tension at all on any of these lines that I'm closing. Do you think you're going to need the nasal trumpet to start working? I don't think so. I think it looks open to me. I'll take a wet sponge, please. So there were two different flaps. There was a bilobed flap, which was taken from here, and moved down to close this part, and rhomboid flap taken from down here to close this part of it. She has that thing in her eye. Yeah, we need BSS. Hey Jess, could we get some BSS, please? Yes. Can you give me another 4-0 Monosof? Some bruising around the periorbital area here, that's to be expected. You could use ice on this area? Yeah. So it doesn't swell up too much. I'll take that ointment, please. But first actually, if you can give me BSS. BSS.

CHAPTER 5

For postoperative course, at 1-week post-op visit, the incisions were clean, dry, and intact, both flaps were viable, and there was no evidence of any seroma, infection, or cellulitis. The sutures were intact, and the contour of the nose was good. All sutures were removed at this visit. At 4-weeks post-op, the incisions were all healed, both flaps were viable, there was no evidence of dehiscence, infection, or cellulitis, the contour of the nose was very good, and the patient was very pleased with the outcome.