Pre-Operative Defect:  This patient had Mohs Surgery by the dermatologist for basal cell carcinoma.  The cancer had deep roots and the majority of the cancer was beneath the skin.  A large defect was present consisting of loss of 75% of the nasal skin and subcutaneous tissue, a through and through defect of the right naris, and a medial right cheek defect.  Planned reconstruction consisted of two separate surgical stages.  The first stage consisted of three parts.  The pre-operative defect is shown below:  Click on Photos to Enlarge!

             
First Stage, Part I:  Closure of right medial cheek defect.  A cheek advancement flap was created by resecting a triangular shaped piece of tissue inferiorly and undermining and advancing cheek skin.  Click on Photos to Enlarge!

             
First Stage, Part II:  Closure of left nasal defect.  A nasal labial flap, 2.0 cm in width, was elevated and placed into position.  This was a random flap.  Great care was taken not to injure the angular artery, since this artery will be the vascular supply for the forehead flap used in the next stage.  Note the "dog-ear" created with rotation of the nasal labial flap.  This dog-ear will be taken down in the second stage of the operation.  It is left intact to preserve the blood supply to the flap.  Click on Photos to Enlarge!

           
First Stage, Part III:  Closure of right nasal defect.  The remaining defect on the right side was 2.75 cm in width. A forehead flap was elevated and trimmed into position to be placed into the defect.  It was folded onto itself to form the inner lining of the nasal cavity.  The flap was based on the left supraorbital and supratrochlear vessels.  Both of these vessels are supplied by the internal carotid artery system but can receive collateral flow from the dorsal nasal artery which connects with the angular artery.  The right side was not used because the status of the angular artery after Mohs Surgery was not known.  Click on Photos to Enlarge!

  
Within a short period of time the distal portion of the forehead flap became slightly cyanotic, indicating poor venous return.  Most flaps are lost due to venous stasis.  This often occurs two to four days after the operation when the arterials hook up with the surrounding tissue but the venous drainage has yet to increase.   If this happens treatment and "blood letting with leaches" may be of benefit.   Click on Photos to Enlarge!
  

A dental roll and Adaptic was placed under the base of the flap to prevent kinking.  This relieved the venous stasis within twenty minutes.    Click on Photos to Enlarge!

Ten Day Post Operative Result
Click on Photos to Enlarge!

 

Second Stage:  The second stage of the surgery was performed 6 weeks later.  The longer period of time was chosen because the forehead flap must attach to two other flaps, rather than to highly vascular tissue.  During this stage the pedicle of the forehead flap will be divided and the base reinserted into the forehead and the "dog-ear" of the nasal-labial flap will be resected.

Immediate Post Op Appearance.

  
Five Week Post Operative Result:

Six Month Post
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Three Year Post
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Four Year Post
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