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\begin{document}

\title{Reconstruction of nasal and upper lip defect using bilateral inferiorly
based malar transposition flaps: a case report}



\author[1]{Mahboobe Asadi}%
\author[1]{Zahra Rutivand}%
\author[1]{Hossein Molai}%
\author[1]{Arvin Shahzamani}%
\affil[1]{Shahid Beheshti University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\textbf{Introduction}

However, nasal reconstruction has always been challenging to the
otolaryngologists, various nasal reconstruction methods have been
introduced.These reconstruction techniques depend on various factors
including defect etiology, size, location, and
depth.\textsuperscript{1}Recently, the forehead flap and the radial
forearm free flap are recommended in nasal complex
defects.\textsuperscript{2}

Our patient had a complex defect involving nasal tip, columella, septum,
and a portion of upper lip after MOHS surgery for squamous cell
carcinoma. Restoration of a nasal and lip function and contour are the
main goals of reconstruction in this case.This report details a two
stage approach to repairing such a defect using bilateral inferiorly
based malar transposition flaps with auricular cartilage graft for more
support and contour.

\textbf{Case presentation}

A 71-year-old male, with a history of 2 month painful erythematous
lesion in the nasal base and columella, referring to our otolaryngology
clinic with the primary impression of nasal abscess. On examination,
there was a destructive lesion involving nasal columella, septum with
erythematous margins extended to upper lip. Nasal squamous cell
carcinoma was confirmed through a biopsy of the nasal lesions. (Figure
1) The patient underwent resection of the lesion until all margins were
free of tumor based on the histopathologic examination. A large defect
created that involved nasal base, columella, septum, upper two thirds of
upper lip, and philtrum. (Figure 2)Then, patient underwent nasal
reconstruction in two stages. In the first stage, bilateral malar
transposition flaps were planned and elevated to cover both the missed
skin of nose and upper lip. For more support and contour the nasal tip
and columella were shaped by an auricular cartilage graft. On both
sides, The incision involved the inferior orbital rims then the flaps
were elevated over the facial musculature from medial to lateral.
Moreover, further undermined was done laterally to facilitate
advancement. After transposition of both flaps, they were divided to two
portions to cover the columella and nasal tip in superior and the upper
lip in inferior. The superior division of flap made the columella
lateral surface in one side and medial surface in the other side, while,
columella was more supported in middle layer by cartilage graft. The
donor sites were closed directly. (Figure 3) In the second stage, six
weeks later, pedicle release and nasal base restoration was performed.
In the second surgery, pedicle was released on both sides ,then it was
rotated to restore nasal base. After that, the remaining tissue from the
pedicle was excised. (Figure 4, 5)

Also,at the supra tip, a small site of tissue necrosis was detected that
was excised with fusiform incision. Since the histopathology analysis
confirmed there was no tumor recurrence on biopsied tissue, it was
closed primary while supporting with an on lay cartilage graft. All
steps were performed under general anesthesia.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1. Pre-operative view of the patient's nose, displaying the
biopsy-confirmed squamous cell carcinoma.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 2. Post-surgical defect, illustrating the extent of the neoplasm,
and nasal and lip structures involved prior to histological clearance.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

Figure 3. One day following surgery, displaying an excellent color
matches with minimal tissue distortion.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

Figure 4.a, b.lateral and basal view after 6 weeks of malar
transposition flaps .Of note, at the supra tip, a small site of
resolving tissue necrosis can be seen.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image7/image7}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image8/image8}

\end{center}
\end{figure}

Figure 5.a, b.lateral and basal view after second stage surgical
reconstruction. Pedicle release and nasal base restoration can be seen.

\textbf{Discussion}

Given the tri-dimensional shape of nose, reconstruction of large nasal
defects especially in the complex cases with defect involving peripheral
tissue such as lip, can be a challenging task. Various cutaneous flaps
are chosen based upon defect size and location to restore nasal function
with minimal scar.\textsuperscript{3}

A variety of local flaps have been reported in the literatures that are
named based on their donor site. Choosing the best technique with
satisfactory result in nasal reconstruction requires the surgeons
experience and knowledge, as well as the patient's tolerance. Nowadays,
the forehead flap is considered the procedure of choice for
reconstructing extensive nasal defects.The mentioned flap can be carried
out in single or multiple stages.\textsuperscript{4}

In this patient, the involvement of upper lip along with a columella
defect limits the various different methods. Hence, we selected
bilateral inferiorly based malar transposition flaps that inspired its
shape by nasofacial sulcus flaps. Historically, nasofacial sulcus flaps
have been used for upper lip defects
reconstruction.\textsuperscript{5}However, nasal reconstruction using
bilateral nasofacial flap was reported in two case
reports.\textsuperscript{6, 7}

In our report, bilateral malar transposition flap covered nasal and
upper lip defect while providing an excellent tissue match. However, the
second step was done; there was no need for skin graft. This flap could
not be considered for the patient as the defect was too large and
involved multiple nasal subunits. In addition, placing the flap
incisions at the junction of aesthetic subunits lead to excellent
cosmetic outcomes. This point is important in nasal ala and tip that are
more susceptible to distortion.\textsuperscript{8}

On the other hand, dividing the flap into two parts could increase the
risk of flap ischemia and necrosis especially in columella. However,
there are some techniques to avoid flap ischemia, like placing the
lateral border of incision more laterally to make a larger pedicle
base.\textsuperscript{9}

Although, bilateral malar transposition flap covered a large nasal
defect extending from the nasal base,columella, and portions of the
upper lip, further revision will be needed in order to achieve a better
functional and cosmetic outcome.

\textbf{Conclusion}

Malar transposition flap may be an adequate alternative for nasal and
upper lip reconstruction after skin cancer resection.

\textbf{Refrences:}

1. Alp E, Leman D, Demiroz A (2020) Nasolabial Perforator Flap: A
Multi-Tool for Reconstruction of Facial Units. J CraniofacSurg 31:
1042-1045.

2. Chioaru B, Dragu E, Lascar I. Nose defects reconstruction with
forehead flap: case report. Maedica (Bucur) 2014; 9:76-8.

3. Austin G, Shockley W. Reconstruction of nasal defects: contemporary
approaches. CurrOpinOtolaryngol Head Neck Surg 2016; 24(5): 453--460.
Crossref. PubMed.

4. Fudem GM, Montilla RD, Vaughn CJ. Single-stage forehead flap in nasal
reconstruction. Ann Plast Surg. 2010;64:645-8.

5. Nowicki J, Abbas JR, Sudbury D, Anari S. Nasal columella
reconstruction - A comprehensive review of the current techniques. J
Plast Reconstr Aesthet Surg. 2020 May;73(5):815-827. doi:
10.1016/j.bjps.2020.01.016. Epub 2020 Jan 21. PMID: 32146115.

6.Jayarajan R. Total columella reconstruction using nasocheek flap and
septal cartilage graft. Plastic and Reconstructive Surgery Global Open.
2015 Nov;3(11).

7.Akba\selectlanguage{polish}ş \selectlanguage{english}H, Keskin M, G\selectlanguage{ngerman}üneren E, Ero\selectlanguage{polish}ğ\selectlanguage{english}lu L, Demir A. Reconstruction of
columella, membranous septum, and upper lip in a single stage operation.
British journal of plastic surgery. 2003 Apr 1;56(3):291-2.

8. Cesar A, Barros A, Santos P, et al. Surgical pearl on reconstructing
surgical defects of the nasal tip. Dermatol Report 2016; 8(1): 6828.

9. Rowe D, Warshawski L, Carruthers A. The Peng flap. the flap of choice
for the complex curve of the central nasal tip. Dermatol Surg 1995; 21:
149--152.

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