INTRODUCTION
Skin cancer is commonly located on the face, especially in the nasal region1. About 75% of nonmelanoma skin tumors occur in the head and neck, 30% are located
in the nose2. Basal cell carcinoma and squamous cell carcinoma are major clinical-surgical indications
of oral reconstructions3.
The skin flaps used for nasal reconstruction have great versatility in their application4. The reconstruction’s success will depend on the location, size and depth of the
defect, the availability of the donor area and, more importantly, the surgeon’s options
in terms of material, method and approach5.
Burget and Menick, in 19856, revolutionized nasal reconstruction surgery with the introduction of the concept
of aesthetic subunits of the nose based on differences in elasticity, color, contour
and skin texture, which contributes to the refinement of nasal surgery.
Due to nasal architecture’s location and complexity, a reconstruction of the nose
represents a challenge to the plastic surgeon. The particular characteristics of the
skin that lines the area and the multiple concavities and convexities existing on
its surface must be respected to restore the normality of form and function 7,8. A minimal subtle change in structure can have a profound impact on appearance and
architecture. Thus, the treatment involves restorative and aesthetic issues, aiming
to cure and the lowest possible deformity1,9.
OBJECTIVES
According to the affected nasal anatomical subunit, to analyze the efficacy of the
reconstructive technique used to cover the defect after tumor exeresis.
METHODS
It consists of a retrospective study of the medical records of 118 patients who, from
August 2012 to March 2017, were submitted to resection the nasal tumors at the Mário
Penna Institute in Belo Horizonte/MG. The research was submitted to the institution’s
ethics and research committee (CEP), where the study was conducted, being approved
with CAAE 33431020.8.0000.5121 and opinion number 4.182.872.
There were included in the study Patients with primary nasal tumor with no history
of previous resection, whose anatomopathological diagnosed nonmelanoma tumor (basal
cell carcinoma or squamous cell carcinoma). Patients who did not fit these criteria
were excluded from the study. Regarding oncologic follow-up, patients who did not
have a postoperative follow-up for more than 12 months were also excluded. As substance
losses secondary to oncologic surgery were mapped according to the anatomical subunits3,9 described by Burget and Menick (1985)6.
RESULTS
Epidemiological profile of patients
Of the 119 patients studied, the mean age was 71.3 years, ranging from 41 to 93 years.
A majority of the sample consisted of whites (54.3%) with females’ predominance (56%).
Only 17.8% of the patients were from the capital, the majority of whom were from cities
in the interior of Minas Gerais.
Epidemiological profile of tumors
In total, 125 tumors were resected, with 53.6% already presenting ulceration at the
initial clinical examination. One main clinical-surgical indication for nasal reconstruction
was basal cell carcinoma, responsible for 90.4% of cases, with the nodular solid histological
subtype (33.6%) the most frequent (Table 1).
Table 1 - Percentage of histological subtype.
| Histology |
n=125(%) |
| BCC |
113 (90.4%) |
| SCC |
12 (9.6%) |
| Histological subtype |
n=125 (%) |
| BCC nodular solid |
42 (33.6%) |
| Sclerodermiform BCC |
22 (17.6%) |
| BCC nodular adenoid |
20 (16%) |
| Multicenter superficial BCC |
8 (6.4%) |
| BCC micronodular |
6 (4.8%) |
| PIGMENTED BCC |
5 (4%) |
| Metatypical BCC |
5 (4%) |
| Basosquamous BCC |
3 (2.4%) |
| Keratotic BCC |
2 (1.6%) |
| Well differentiated CCE |
8 (6.4%) |
| Moderately differentiated CCE |
4 (3.2%) |
Table 1 - Percentage of histological subtype.
Regarding the degree of tumor invasion, skin involvement alone was predominant, affecting
81.6% of the cases. The sclerodermiform subtype (23%) and ulcerated solid (23%) prevailed
in tumors with deep invasion at the subcutaneous, muscular or cartilage layer level.
In total, 17 (17%) cases had compromised microscopic surgical margins, with 6 (35.3%)
surgical reapproaches to enlarge the margins, with no residual tumor in the anatomopathological
area after enlargement.
The nasal ala (36.7%) was the most involved subunit, followed by the nasal tip (28.6%).
About 24 (20.3%) patients had complex tumors that affected more than one aesthetic
subunit, with the dorsal association with the nasal tip (33.3%) being the most affected
concomitant subunits. Only one patient had three affected nasal aesthetic subunits
located in the distal third of the nose (Table 2).
Table 2 - Reconstruction of simple nose defects.
| subunit nasal |
n=98 (%) |
Type of reconstruction |
n=98 (%) |
| Wing |
36 (36.7%) |
Nasogenic |
22(61.1%) |
| Bilobed |
5(13.8%) |
| Frontal |
3 (8.3%) |
| Primary synthesis |
2 (5.6%) |
| Total graft |
2 (5.6%) |
| Rhomboid |
1 (2.8%) |
| Esser |
1 (2.8%) |
| Tip |
28 (28.6%) |
Bilobed |
14 (50%) |
| Primary synthesis |
8 (28.5%) |
| Frontal |
2 (7.1%) |
| Nasogenic |
1 (3.6%) |
| Glabellar |
1 (3.6%) |
| Retail advancement |
1 (3.6%) |
| Total graft |
1 (3.6%) |
| Dorsum |
26 (26.6%) |
Primary synthesis |
7 (26.9%) |
| Bilobed |
5 (19.3%) |
| Glabellar |
4 (15.4%) |
| Total graft |
4 (15.4%) |
| Retail advancement |
3 (11.5%) |
| Rhomboid |
2 (7.7%) |
| frontal |
1 (3.8%) |
| Lateral |
7 (7.1%) |
Bilobed |
2 (28.55%) |
| Retail advancement |
2 (28.55%) |
| Primary synthesis |
1 (14.3%) |
| Rhomboid |
1 (14.3%) |
| Glabellar |
1 (14.3%) |
| Columella |
1 (1%) |
frontal |
1 (100%) |
Table 2 - Reconstruction of simple nose defects.
Reconstruction of nasal defects after tumor resection
After surgical resection, the average size of the defects to be reconstructed was
2.5x1.8cm and were operated with surgical margins ranging from 2mm to 1cm. The presence
of ulcers increased the planning of surgical margins by 2 mm. In general, the techniques
for reconstructing defects that affected only one nasal subunit were mostly using
the bilobed flap (26 cases, 26.5%), followed by the nasogenian flap (23 cases, 23.4%).
The flaps used specifically for each nasal subunit will be described in more detail
below (Table 2).
Nasal ala reconstruction
For the specific reconstruction of the nasal ala, the most used flap was the nasogenian
flap in 22 (61.1%) cases, followed by bilobed (13.8%) and frontal flap (8.3%). Primary
synthesis (5.6%) and total skin graft (5.6%) were performed in 2 patients each. The
Esser flap (2.8%) and rhomboid (2.8%) were used in only one patient. Two patients
received a conchal cartilage graft to repair the nasal ala after tumor resection.
Reconstructions of the nasal tip
At the nasal tip, the most used reconstruction was with a bilobed myocutaneous flap
(50%) encompassing the proximal, corrugator and nasal muscles, followed by the primary
closure technique after spindle resection (28.5%)
Dorsal nasal reconstructions
For dorsal nasal tumors, seven primary closures were performed, corresponding to 26.9%
of cases. Then, the bilobed flap appears as the second most frequent flap, and it
was performed in 19.3% of cases.
Reconstruction of the lateral wall
The bilobed flap (28.5%) and V-Y advancement flap (28.5%) were the most used in reconstructing
defects in the lateral wall. Primary synthesis (14.3%) was also an option used, as
were rhomboid (14.3%) and glabellar (14.3%) flaps.
Columella reconstruction
In our study, only one patient presented isolated tumor involvement in the columella
region, and its reconstruction was performed with a myocutaneous flap of the frontal
muscle and septal cartilage graft.
Complex nose reconstructions
In the case of complex nose reconstructions (involvement of more than one aesthetic
subunit), the bilobed myocutaneous flap (45.8%) with extension to a glabella region
(encompassing the procerus, corrugator and nasal muscles) was the most used in the
complex defects of the lower third of the nose (Figure 1).
Figure 1 - A. Lesion on the tip and nasal dorsum with marking of the bilobed myocutaneous flap.
B. Immediate postoperative outcome after rotation and fixation of the flap. C. Result after 6 months postoperatively.
Figure 1 - A. Lesion on the tip and nasal dorsum with marking of the bilobed myocutaneous flap.
B. Immediate postoperative outcome after rotation and fixation of the flap. C. Result after 6 months postoperatively.
One patient with tip involvement and nasal ala required a septal cartilage graft associated
with a bilobed flap for nasal ala repair after tumor resection.
The nasogenic myocutaneous flap (16.6%) covering the superficial musculoaponeurotic
system of the superficial face (SMAS) and major and minor zygomatic muscles was the
second most used, is intended mainly for reconstructions that covered the lateral
wall with the nasal alas (Figure 2). The frontal myocutaneous flap (16.6%) was used in complex reconstructions that
covered the distal nasal tip/columella and in a case of compromised three nasal aesthetic
subunits of the distal portion of the nose (Table 3).
Figure 2 - A. Ala lesion and lateral nasal wall with marking of the area that will be respected
and drawing of the nasogenian flap. B. Postoperative result.
Figure 2 - A. Ala lesion and lateral nasal wall with marking of the area that will be respected
and drawing of the nasogenian flap. B. Postoperative result.
Table 3 - Reconstruction of complex nose defects.
| >01 Nasal subunit |
n=24 (%) |
Type of
reconstruction
|
n=24(%) |
| Dorsum + Tip |
8 (33.3%) |
Bilobado |
4 (50.0%) |
| Frontal |
1 (12.5%) |
| Romboide |
1 (12.5%) |
| Rintala |
1 (12.5%) |
| Enxerto total |
1( 12.5%) |
| Lateral + Wings |
7 (29.1%) |
Bilobado |
3 (42.9%) |
| Nasogeniano |
3 (42.9%) |
| Enxerto total |
1 (14.2%) |
| Tip + Wing |
6 (25%) |
Bilobado |
3 (49.9%) |
| Frontal |
1 (16.7%) |
| Nasogeniano |
1 (16.7%) |
| Enxerto total |
1 (16.7%) |
| Columella + Tip |
2 (8.4%) |
Frontal |
1 (50%) |
| Bilobado |
1 (50%) |
| Tip + Right nasal wing + Left nasal wing |
1(4.2%) |
Frontal |
1 (100%) |
Table 3 - Reconstruction of complex nose defects.
Alternatively, in a single case with columella involvement associated with the tip,
the myocutaneous bilobed flap was used for tip reconstruction and associated with
an advanced flap with the columella’s primary synthesis after partial exeresis of
the alar cartilage. The flap provided adequate volume without the need for cartilaginous
grafts (Figure 3).
Figure 3 - A. Nasal tip and columella injury. B. Defect after tumor resection and flap in advance for reconstruction in the columellar
region. C. Immediate postoperative outcome after rotation and fixation of the flap. D. Result after 6 months postoperatively with good aesthetic and functional satisfaction
by the patient.
Figure 3 - A. Nasal tip and columella injury. B. Defect after tumor resection and flap in advance for reconstruction in the columellar
region. C. Immediate postoperative outcome after rotation and fixation of the flap. D. Result after 6 months postoperatively with good aesthetic and functional satisfaction
by the patient.
Only three cases were submitted to total skin grafts, with a supraclavicular region
as a donor area (Figure 4).
Figure 4 - A. Lesion on the tip and nasal dorsum with marking of the area that is resected. B. Defect after resection. C. Postoperative result.
Figure 4 - A. Lesion on the tip and nasal dorsum with marking of the area that is resected. B. Defect after resection. C. Postoperative result.
Postoperative complications
In the 122 reconstructive procedures performed, there were only five surgical complications
(4%). One principal was mild epidermolysis after bilobed flap but without partial
or total loss of the flap. There was only partial frontal flap necrosis in the columella
region. Regarding skin grafts, one case evolved with necrosis and partial loss of
the partial graft in the nasal tip. Only one patient presented infection and small
surgical wound dehiscence after primary synthesis in the nasal tip.
Among the 125 resected tumors, about twelve (9.6%) tumors had compromised surgical
margins, evidenced in the anatomopathological exam. Of these, six (50%) tumors underwent
a reapproach to expand the margin, and the remaining patients not approached had narrow
surgical margins.
Postoperative oncological follow-up
In total, 78 patients underwent oncological follow-up for more than 12 months, with
an average outpatient follow-up time of 27.4 months after the surgical procedure,
with a standard deviation of 11.2 months.
Approximately 82 tumors were monitored, six (7.3%) of which had narrow surgical margins
in the anatomopathology.
During the period, eight (9.7%) tumors evolved with recurrence. Among these tumors,
seven (8.5%) presented recurrence even after complete resection, with the average
time for lesions to appear 24 months (standard deviation: 13.4) after initial surgical
procedure.
Only one (1.2%) tumor evolved with recurrence in patients with narrow margins, and
its clinical diagnosis occurred 14 months after initial tumor resection. The other
cases that remained in the follow-up did not present recurrence (Table 4). In recurrent tumors, ulcerated nodular solid BCC was the predominant histological
subtype (42.9%) Squamous cell carcinoma (28.5%).
Table 4 - Postoperative oncological follow-up (>12m).
| |
Tumors n=82 (100%) |
Relapse n=8 (9.7%) |
| Free margins |
76 (92.7%) |
7 (8.5%) |
| Compromised margins (narrow) |
6 (7.3%) |
1 (1.2%) |
Table 4 - Postoperative oncological follow-up (>12m).
DISCUSSION
Due to its central location on the face and functional importance, nasal reconstruction
represents a significant plastic surgeon challenge. Most nasal defects that appear
for reconstruction are secondary to tumor excision10. BCC and SCC represent the first and second types of cancer with the highest incidence
and have cure rates above 90% when treated in the initial phase1,10. In our sample, 90.4% of the nasal tumors were of the CBC type and only 9.6% of the
CCE.
The average age of patients included in this study (71.3 years) follows the literature
since most individuals with skin cancer are older than 60 years, with a higher prevalence
in the 7th decade of life1. Most patients were Caucasian (54.3%) and female (56%). Although it is well known
in the literature that skin tumors tend to occur more frequently in male patients,
especially in the nose4, current studies show a time trend of increasing the proportion of women in relation
to men11.
The histological subtypes most frequently found were solid BCC and sclerodermiform,
and most patients already had ulceration on clinical examination, requiring greater
surgical margins. Also, sclerodermiform BCC is generally a histological subtype present
in cases with local aggressiveness1, which was demonstrated by its greater frequency in an invasion of deep layers (subcutaneous,
cartilage and muscle) together with solid ulcerated and adenoid BCC. Thus, these tumors
need an elaborate reconstruction and should preferably be performed in referral centers.
According to the world literature, the committed margin index was 9.6%, varying from
4% to 18.2% 12.
Among the twelve tumors with compromised margins,6 (50%) surgical approaches for enlargement were performed. All tumors reopened had
free margins in the anatomopathological. Similar data are found in the literature
in which new surgical interventions are performed in 30% to 74.7% of tumors with incomplete
resection9,13-15. The decision to perform a new operation on resected tumors with compromised margins
is not unanimous9,16. A new surgical procedure’s risks and benefits must be assessed individually since
the risk of recurrence after complete tumor resection is also present, reaching up
to 14% 17,18, with a 9.7% recurrence being found in our sample. This fact provides the medical
option’s freedom when choosing conservative treatment for patients with comorbidities
and increased surgical risk9.
The integrity of the aesthetic subunits of the nose is fundamental in maintaining
the harmony of facial features. A nasal ala was the most compromised aesthetic subunit,
followed by the nasal tip. This result is not consistent with the literature’s data,
which show greater appearance in the nasal dorsum3,19.
However, in studies conducted in cancer treatment reference centers, it is possible
to perceive in the sample a higher incidence of lesions in the lower third of the
nose because these require more complex reconstructions19,20.
The choice of the most appropriate flap was based on the affected nasal subunits,
shape and orientation of the defects after tumor surgical resection. The defects of
the upper and middle thirds (dorsal and lateral) were corrected mainly with bilobed,
glabellar flaps and primary synthesis. In dorsal nasal reconstructions, spindle resection
with primary closure was the most used (26.9%), followed by the bilobed flap (19.3%).
Due to the greater availability of skin, the use of primary closure for small defects
and advancement flaps and transposition for larger defects are quite common in the
dorsal region21,22. The bilobed flap (28.5%) and the V-Y advancement flap (28.5%) were the most used
in the reconstruction of lateral wall defects.
In the lower third (tip and wing), the preference was for single-time reconstruction
with a bilobed myocutaneous flap and nasogenians. For the nasal ala’s specific reconstruction,
the most used flap was the nasogenian flap (61.1%). The nasogenian flap is fast to
execute, and, besides, it has the advantages of having a color and texture similar
to that of the nose, and its location allows a transposition with reduced deformity
of the donor site and a slight scar7,23. They are flaps of extreme versatility, being more used to correct defects between
8-2mm24.
At the nasal tip, the most used reconstruction was with a bilobed myocutaneous flap
(50%). The bilobed flap is often used for nasal reconstructions of the dorsum and
lower third of the nose25. When encompassing the proximal, corrugating and nasal muscles, it was possible to
cover major defects; but, as disadvantages, when involving the glabellar region, they
present a greater scar and a reduction in the distance between the eyebrows.
In complex nasal reconstructions in the lower third, the bilobed myocutaneous flap
(45.8%) was more frequent. This flap is described in the literature and is useful
for defects in the lower part of the nose measuring 0.5-1.5cm5; however, by encompassing
the proximal, corrugator and nasal muscles, it allowed a greater arc of rotation and
flap volume with better filling and covering defects of up to three centimeters. In
addition, the design allows for a greater arc of rotation and a sufficiently large
size, also allowing its use for defects located in the upper region of the columella
simultaneously with defect of the tip. Thus, it was possible to reconstruct in a single
time and with less morbidity when compared to the frontal flap. The frontal myocutaneous
flap was reserved for complex reconstructions that covered the distal nasal tip/distal
columella and in a case of involvement of 3 nasal aesthetic subunits of the distal
portion of the nose.
CONCLUSION
The present study adopted the principles of nasal reconstruction added to aesthetic
subunits’ concepts, aiming to respect the nasal contour and anatomy. The reconstructive
techniques used were effective for treating nasal skin cancer and coverage of defects
after resection, with low rates of complication and recurrence. This study can help
guide surgeons in the face of the wide range of flaps available, assisting in deciding
the most appropriate nasal reconstruction without compromising function and providing
satisfactory aesthetic results in the repair of each nasal subunit and in complex
defects.
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1. Fundação Benjamim Guimarães, Hospital da Baleia, Plastic Surgery Service, Belo
Horizonte, MG, Brazil.
2. Instituto Mário Penna Institute, Plastic Surgery Service, Belo Horizonte, MG, Brazil.
Corresponding author: Camila Carvalho Cavalcante Marinho, Rua dos Timbiras, 1228, Apto 1903, Boa Viagem, Belo Horizonte, MG, Brazil Zip Code:
30140-064 E-mail: camila_ccavalcante@hotmail.com
Article received: August 31, 2020.
Article accepted: January 10, 2021.
Conflicts of interest: none
COLLABORATIONS
CCCM Analysis and/or data interpretation, Conception and design study, Conceptualization,
Final manuscript approval, Formal Analysis, Investigation, Methodology, Visualization,
Writing - Original Draft Preparation, Writing - Review & Editing
MLM Data Curation, Final manuscript approval, Investigation, Methodology, Supervision
RCL Final manuscript approval, Formal Analysis, Investigation
CJR Formal Analysis, Investigation, Writing - Original Draft Preparation
KVTP Formal Analysis, Investigation, Writing - Original Draft Preparation
CFR Final manuscript approval, Investigation
SFG Final manuscript approval, Investigation
HLRR Analysis and/or data interpretation, Conception and design study, Conceptualization,
Final manuscript approval, Formal Analysis, Investigation, Methodology, Project Administration,
Realization of operations and/or trials, Supervision, Validation, Writing - Original
Draft Preparation, Writing - Review & Editing
