Nasolabial Flap: Versatile Flap for Basal Cell Carcinoma Nose

Abstract

Nasolabial flap is very versatile flap for the lesion of basal cell carcinoma of nose. It is preferred choice for the closure of surgical defect of nose after removing the lesion of basal cell carcinoma. This flap has very good vascularity and scar is almost invisible. The objective of this study to evaluate the suitability of nasolabial flap for the basal cell carcinoma, the survival of the flap, cosmetic appearance of the patient after the surgery and patient satisfaction. This is the case study of ten cases of basal cell carcinoma of the nose. The skin lesion was at the nasal tip, dorsum and the side of the dorsum. All the surgeries were performed by the same and first author of the article at the department of Otorhinolaryngology Sir T General Hospital Bhavnagar Gujarat. The patient age ranged from 5th to 6th decades of life. All the patients were from the coastal region of Saurashtra Gujarat. All the surgery was performed as single stage surgery. The defatting of the flap was done in all cases to match with the texture of skin of nose. The biopsy was performed in all the cases before the surgery to confirm our clinical diagnosis. The underlying cartilage was removed in all the cases to prevent the recurrence and was sent separately for the frozen and histopathology examination. The nasolabial flap survived in all the ten cases. The color and the texture of the flap matched perfectly with the adjoining skin color of nose. The scar mark of the cheek side malar flap was almost invisible. There was no trap-door deformity observed and there was good aesthetic outcome. The nasolabial flap is very reliable and versatile flap for the basal cell carcinoma sugary of nose. It can reach to almost to the all area of nose including tip of the nose. Its single stage surgery with very good aesthetic results.

Introduction

The nasolabial flap is very versatile flap and one-stage flap for the basal cell carcinoma of nose and it is a very versatile flap for reconstructing moderate facial defect [1, 2]. This flap can be used to reconstruct many areas of the nose [3]. The flap is based on the angular branch of facial artery, the infraorbital artery and the transverse facial artery [4]. The flap can be superiorly based to reconstruct defects on the cheek, sidewall or dorsum of the nose, alae, columella and the lower eyelid. Inferiorly based flaps can be used to reconstruct defects in the upper lip, anterior floor of the mouth and the lower lip [5]. The nasolabial flaps are easy to dissect, elevate, position at the appropriate place and is a single stage procedure. Its proximity to the nose provides good color and texture match. Additional advantages are the robust vascularity of the flap, simplicity of the flap and the satisfactory contour created from the relatively hairless skin utilized from the nasolabial fold. In fact this flap withstands radiotherapy due to its excellent vascularity.

The advantage of the flap-The advantages of this flap is the close proximity of the flap to the nose. It is a single stage procedure. There is perfect matching of the skin. It is very to harvest with very satisfactory outcome results.

Materials and Methods

This is the case study of ten cases of basal cell carcinoma of nose in which nasolabial flap was performed. All the patients were in fifth or sixth decades of life. They all were from the coastal region of Saurashtra Gujarat. None of the patient had any history of trauma. Biopsy was done in all the cases which confirmed our clinical diagnosis of basal cell carcinoma. The two cases had lesion at tip and rest of the eight cases had lesion at dorsum or side of the dorsum. We conducted a retrospective review of all patients who had undergone lesion excision with nasolabial flap reconstruction. All the surgeries were done by the first author of this article at the Department of Otorhinolaryngology, Sir T General Hospital Government Medical College Bhavnagar Gujarat. Outcome measures included the ability to close the defect with minimal tension, cosmetic appearance, any complications, and any need for further repair.

Flap Design

A circular area of lesion was marked leaving clear skin margin of 0.5 cm safety skin margin. And the malar area flap was designed immediately lateral to the nasolabial fold, such that the medial edge of the flap laid within the fold. The flap was tapered inferiorly for good closure of the donor defect (Fig. 1).

Fig. 1.

a Flap design and b flap design

Surgical steps-The lesion was marked with marker pen leaving clear safety margin of 0.5 cm around the lesion. The nasolabial flap was marked at the cheek. The width of the flap was equal to the width of the lesion so that it covers adequately the surgical defect of the lesion. The 2% xylocaine with adrenaline was infiltrated at around and underneath the lesion and at the dorsal skin to create the hydro edema for the dissection. Similar infiltration was also given at flap marking at the malar region. With sharp skin blade the lesion including safety skin margin of 0.5 cm was removed. All the bleeding points were cauterized. The cartilage underneath the lesion was also removed and was sent separately for the frozen section and histopathological examination. The removal of underneath cartilage is important to prevent its recurrence. The resultant gap was filled up with the harvested fat readily available from the cheek, while elevating the cheek flap. The dorsal upward skin flap was elevated as per earlier marked with marker pen till reaches almost to nasion. The cheek flap was dissected, elevated and rotated to fit in at the resultant gap. The defatting of the cheek flap was done with sharp curved scissor to match with the dorsal part of the nose. The extra redundant length and width of the flap was excised, and flap was sutured with three zero non absorbable suture material. Some coetaneous elevated skin crease appeared while rotating the flap at the nasion area which was cut and sutured to camouflage with normal skin (Fig. 2).

Fig. 2.

a Basal cell carcinoma of tip of nose, b flap marking, c defect after wide local excision, d immediate postoperative result and e post operative result after 3 weeks

Results

All the cases had excellent take-up of the flap and all flaps survived completely. As the cheek flap contained the muscle and the blood supply was from the forehead, there was no necrosis of flap noted in any of the flap. None of the cases had recurrence. The skin color match was excellent without any color defect. The underneath removed cartilage did not have any evidence of basal cell carcinoma at the histopathology examination. The tip retained the normal contour after filling with the fat.

All the surgical defects of the lesion were closed successfully without any difficulty using this technique. The defects were repaired under minimal closure tension as a single-stage procedure. The patients were then followed up for 3 months and 12 months. There were no dissymmetry, deformity or retraction deformities of the flap in any of the cases.

The wound healed satisfactorily. There was no any trapdoor deformity found after the operation. Post op period of all the patients were uneventful. All the flaps survived completely with ideal color and texture matching. All the scars healed well and were inconspicuous. All 10 patients were entirely satisfied with the results.

Discussion

The nasolabial flap has been used for nasal reconstruction since the mid-nineteenth century. Since then, numerous modifications to this flap have been described for reconstruction of a variety of nasal defects. These include nasal tip, ala and columellar defects, with or without the requirement of nasal lining. Recent modifications have attempted to prevent the cosmetic deformities including pin cushioning and loss of the nasofacial groove that have been reported using this technique. This has resulted in renewed interest in including the nasolabial flap in the armamentarium of nasal tip reconstruction.

The superiorly based nasolabial flap is a random skin flap, with branches from the angular, infraorbital, transverse facial and infra trochlear arteries contributing to the subdermal plexus. The flap is rotated on a pivot point just superior to the lateral incision. The size of the flap is usually limited by the ability to close the donor site primarily. In patients with redundant tissue near the nasolabial fold, a flap width of up to 5.0 cm has been described, although the width should usually be kept to less than 3.0 cm. A flap length of up to 10–12 cm can be taken safely. If the flap length required is greater than 12 cm, a delay procedure should be seriously considered.

The nasolabial flap has several advantages over other techniques used for closure of dorsal, side or nasal tip defects. The donor site morbidity is fairly minimal, because the incision is made in the nasolabial fold, and the surrounding nasal skin is not violated as part of the flap. The length of the flap available is usually sufficient to reach the defect on the nasal tip, including those that cross the midline. A nasolabial flap can also be used for the reconstruction of full thickness defects, in which both skin coverage and nasal lining are required. If the full thickness defect of the nasal tip extends to include the alar rim, the nasolabial flap can be folded on itself to provide nasal lining and reconstruct the alar rim. A modification of folding the nasolabial flap on itself has been described for full thickness defects of the tip and ala with an intact alar rim. This provides both lining and skin coverage without sacrificing the patient’s own alar rim in an ala and alar rim cosmetic subunit reconstruction. Another option for full thickness defects involves using the nasolabial flap in conjunction with a skin or mucosal graft.

Despite the advantages, the nasolabial flap does have some drawbacks in men is that the distal cheek skin is hair bearing and may bring hair bearing tissue onto the nose with the reconstruction. Careful planning and surgical technique, including insetting and meticulous defatting of the flap, can prevent poor cosmetic outcomes.

A transposition flap can also be employed in the patients. The flap thickness is to be decided according to the needs of the defect. The flap can be as thin as just deep to the sub dermal plexus, and as thick as superficial to the facial musculature. Although the extent of the flap is limited by the available redundant tissue, primary closure of the donor site up to 5 cm is possible with wide undermining of the surrounding cheek tissue. Some authors have used the flap as pedicled flap where they needed to divide the pedicle after 2–3 weeks’ time [6]. In the current study all the surgeries were performed as single stage procedure.

In this study we performed superiorly based nasolabial flap in all the patients. This type of flap has shown good results particularly for the basal cell carcinoma. The nasolabial flap has been extensively utilized for nasal reconstruction in many ways. It has also been used as an island flap based on the lateral nasal artery for nasal reconstruction. The flap has also been based on the infraorbital arteries to cover the nasal defects. In nasal reconstruction one of the goals is to give good lining and nasolabial flap is also used for this purpose with other flaps.

Rohrich et al. [7] in their study made use of nonanatomic alar strut grafts to prevent notching and cicatricial distortion of the nose after the reconstruction of the defect with nasolabial flap.

El-Marakby [5] reported that mean operative time for nasolabial flap was 35 ± 10.5 min and performed revision surgery in 20% of patients for correction and adjustment of the flap. We took 40 min time on average for nasolabial flap surgery and performed debulking of the flap in all the patients.

Javaid et al. [8] and his colleagues reported the outcome of nasolabial flap in reconstruction of nasal alar defects. Although they achieved good results with the flap, alar retrusion occurred in 5.71% of patients and flap tip necrosis in 2.86% patients. In the present study these complications were not observed.

The turnover nasolabial flap has been described for reconstruction of full thickness alar defects. Massaoud [9] described the use of turnover nasolabial flap for reconstruction of full thickness alar defects and reported that temporary flap congestion and bulkiness as the common complications. Sohn et al. [10] made use of the nasolabial perforator for full thickness alar defects and they also reported the temporary congestion as common complication. In contrary in this study, no congestion was noticed in any of the flaps because of limited dissection and preservation of ample tissue around the feeding vessel.

The reconstruction of the nasal ala needs to be performed with a thin pliable flap which possesses a good texture and color match. The skin of the nasolabial area suits the texture and color and hence considered as an ideal donor site [7]. A modified application of the flap is described by Spear et al. [11] and Kroll [12] for total full-thickness defects of the alar margin. Moreover this area is in proximity and easily accessible with least donor site morbidity. Defects up to 4 × 2 cm in size were restored due to the laxity of the donor cheek. Aksam et al. [13] observed Trap-door deformity in subcutaneous pedicled nasolabial flap however it was not observed in our study.

We achieved a good contour and color match in our patients without any major complications like flap necrosis. Long term functional and aesthetic results could not be evaluated because of poor fallow up of the patients mainly as all our patients were very satisfied after the surgery.

Conclusions

Nasolabial flap is a very reliable flap for the soft tissue coverage of nasal defects. It is single stage surgery and can be done in same sitting. The flap can be manipulated according to the depth of defect and it possesses an excellent texture and color. This flap can reach up to all region of the nose. There is very reliable vascularity and offers ideal donor tissue with good color match and texture. The flap donor site lies in the same operating field and can be closed primarily. The least donor site morbidity and a lesser conspicuous scar have made it the preferred choice for the basal cell carcinoma of the nose.

Funding

None.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.