Reconstruction of the nasal defects following surgical excision of basal cell carcinoma

This clinical study included (23) patients with basal cell carcinoma (BCC) of the nose who attended the Specialized Surgical Center in Medical City in Baghdad in 2005. These patients have been studied regarding the sociodemographic characteristics, clinical characters, and anatomical distribution of the BCC on the nose.
Flaps were used for (13) patients with lesions reaching and/or involving the underlying bone and cartilage. Grafts were used for (5) patients. Direct suturing was done for (3) patients with small lesions less than 1cm in diameter, and mixed graft - flap was used for full thickness lesions involving the lining of the nose in (2) patients. Primary reconstruction of any modality was carried out for lesions less than or equal to 2cm in diameter while secondary reconstruction was attempted for lesions more than 2cm in diameter with indefinite margin in the absence of frozen section. Flaps were associated with fewer complications compare to grafts. Secondary reconstruction was associated with a lower incidence of complications compared to primary reconstruction. The only recurrence was recorded following a primary reconstruction, so that the recurrence is less dependent to the size of the tumor and making the secondary reconstruction a more superior choice. IntroductionThe nose is the most prominent part of the face. It's a sandwich of delicate cartilage pieces kept alive by a thin vascular skin surface and a thinner more vascular lining.(3)BCC of the nose comprises (25.5%) of the total body incidence as primary lesion and about (38%) of total body incidence of recurrent BCC (8). Despite occasional case reports, metastases from BCC are exceedingly rare. BCC may kill by extension.(11)Careful planning is especially important when operating in nasal region. The treatment must completely eradicate the neogenesis, yet spare the surrounding healthy tissue as much as possible. Therefore particularly on the nose surgery is superior to radiation due to anatomic structure here. The danger of causing radiation injuries to the skin and cartilage lying directly beneath it, is especially grate.(9)Surgical reconstructions include usage of graft or flap or both accordingly. Patients and methodsA total of (23) patients who were admitted to the Specialized Surgical Center in Medical City in Baghdad with BCC of the nose for excision of these lesions and reconstruction of the nasal defect. BCC of the nose was diagnosed by the typical slow growing lesions of various macroscopic appearance, confirmed later by histopathological examination.These patients were examined fully; information regarding type, number, the site, size and shape of the lesion were recorded. Preoperative photographs were taken too. The patients were grouped according to the site, size , and number of the lesions.Methods of reconstruction:Reconstruction of the nose was carried out for all patients using direct suture, grafts or flaps under local or general anesthesia. Skin graft were mainly used when the tumor were superficial and did not involve underlying bone or cartilage.Grafts used in reconstruction were the split thickness skin grafts (STSG.s), full thickness skin grafts (Wolfe graft) and composite graft.Skin grafts were used in 5 patients. Flaps were carried out in 13 patients that were used mainly for reconstruction of lesions involving the bone and cartilage.The flaps were used in our study included: 1- V-Y advancement flaps (2 patients)2- Forehead flaps (2 patients)3- Cheek advancement flaps (1 patient)4- Nasolabial flaps (3 patients)5- Bilobed flaps (3 patients)6- Dorsal nasal flaps (1 patient)7- Caudal advancement flaps (1 patient). For full thickness lesion, both flaps and grafts (mixed type) were used for reconstruction, we use scalping forehead flap with composite graft (skin and cartilage) for reconstruction of these lesion (2 patients).A silicon implant was used for reconstruction of nasal skeleton defect in 1 patient but extruded later on. Direct suture were used in reconstruction of small lesions less than 1 cm in diameter (3 patients).The primary reconstructions of nasal defects were carried out for lesions 2cm or less in diameter; the tumor is excised with 5 mm safe margin and reconstructed immediately after excision of the lesion.Secondary reconstructions were carried out for lesions more than 2 cm in diameter, the tumor is excised with 5mm safe margin and reconstructed later on, until the result of histopathology confirmed the clearance of the defect from malignant cells (during this period the patient was daily dressed with povidone iodine 10%).All patients were followed up weekly for the first month, then monthly for the first year, this included local examination, and photographs were carried out.The following complications were noted and recorded: Infection, Hematoma, Partial skin loss, Wound dehiscence, Local recurrence, and incomplete excision. Complications were treated accordingly. We were using Prolene (5-0) cutting needles for skin suturing while chromic Catgut (3-0) cutting needles were used to suture the subcutaneous tissue. Stitches were removed within 5 - 7 days.Regarding the dressing of the wound, tie over dressing were used when we reconstruct the lesions with skin grafts, otherwise we used the usual dressing (Sofra-tulles, guaze, Povidone Iodine 10%) in layers in other types of reconstructions.ResultsRegarding the sex , (56.5%) of patients were female, (43.5%) of patients were males as shown in figure (1).Figure (2) shows the percentage distribution of employment status of the study group. Most of the patients were housewives (47.8%).Figure (3) shows the anatomical distribution of the lesions on the nose, and the majority of the lesions appeared on the middle third of the nose (52.2%).Figure (4) shows the percentage distribution of patients in relation to the size of the lesion. The size of the lesion in (34%) of patients was more than 2 cm in diameter, were as (65.2%) of patients have lesions which are 2 cm or less in diameter.Figure (5) shows the multiplicities of lesions among the study group. Most of patients were with single lesion (73.9%) . Figure (6) shows that (69.65%) of the patients were with nodular lesion, (17.3%) with ulcerative lesion, only (4.4%) were with pigmented lesion, and (8.61%) were sclerosing.Figure (7) shows the percentage distribution of presenting symptoms among the study group. Most of the patients presented either with itching alone (43.5%) or with a symptomatic lesion (34.8%), where as only few patients presented with bleeding (13.04%), and bleeding with itching (5.2%).Three of the patients had associated with xeroderma pigmentosa. Table (1) shows the duration of the disease (in years) among the study group. Most of the patients have lesions for 1 - 5 years (65.22%).Table (2) shows the complications according to the methods of reconstruction. Generally complication occurred; 2 patients developed postoperative infection, 1 patient developed hematoma, 1 with partial skin loss, 1 with wound dehiscence, 2 patients had incomplete tumor excision, and 1 had recurrence.Table (3) shows the average days of stay in hospital in relation to the type of reconstruction. The mixed graft - flap procedures were associated with longest stay in hospital (17 .5 ± 4.949 days).