Immediate reconstruction of nasal alar defects after malignant skin tumor excision without mohs surgery

Abstract

Objectives: The National Comprehensive Cancer Network guidelines state that any nasal region with squamous or basal cell skin cancer is at high risk. Although Mohs surgery is the gold-standard procedure for many types of skin cancer, it is not applicable worldwide. A mean of 1.7 Mohs surgery stage is performed in cases of tumors. Nasal obstruction is a problem with Mohs surgery. In this study, we aimed to investigate nasal alar region nonmelanoma malignant skin tumor excision using immediate reconstruction without Mohs surgery.

Methods: Ten patients underwent reconstruction surgery between 2018 and 2022. The inclusion criterion were ulcerated lesions in the nasal alar region measuring less than 1 cm in diameter, the lesions which were suspected either as basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) on dermatoscopic examination, the patients who had intact nasal mucosa during anterior rhinoscopy.

Results: The mean follow-up duration was 26 months. No patient required re-operation because of an excisional biopsy result that involved border proximity. We observed no serious complications or long-term recurrences.

Conclusion: We recommend our algorithm for patients for whom Mohs surgery is not applicable.

Keywords

• Malignant skin tumor
• Mohs surgery
• nasal alar defects
• reconstruction

References

1. 1. Wong E, Axibal E, Brown M. Mohs micrographic surgery. Facial Plast Surg Clin North Am 2019;27:15-34.
2. 2. Mehta D, Jacobsen R, Godsey T, Adams B, Gloster H Jr. Effectiveness of the "Mohs and close technique" in increasing the efficiency of a Mohs micrographic surgery. J Drugs Dermatol 2016;15:1481-3.
3. 3. Moran B, Wynne B, Thomas S, Griffin M, McMenamin M, Ormond P. Malignant cytology in washings of Mohs micrographic surgery instruments. Dermatol Surg 2013;39:133-5.
4. 4. Kok K, Moncrieff M, Garioch J, Ramaiya A. The inking brush in Mohs micrographic surgery: a potential source of malignant cell contamination. Clin Exp Dermatol 2014;39:650-1.
5. 5. Alam M, Berg D, Bhatia A, Cohen JL, Hale EK, Herman AR, et al. Association between number of stages in Mohs micrographic surgery and surgeon-, patient-, and tumor-specific features: a cross-sectional study of practice patterns of 20 early- and mid-career Mohs surgeons. Dermatol Surg 2010;36:1915-20.
6. 6. Berens AM, Akkina SR, Patel SA. Complications in facial Mohs defect reconstruction. Curr Opin Otolaryngol Head Neck Surg 2017;25:258-64.
7. 7. Rudy SF, Moyer JS. Nasal obstruction after Mohs surgery: prevention and correction. Facial Plast Surg 2020;36:84-90.
8. 8. National Comprehensive Cancer Network. Squamous Cell Skin Cancer (Version 2.2022). Available at: https://www.nccn.org/professionals/physician_gls/pdf/squamous.pdf. Accessed January 30,2023.

9. 9. National Comprehensive Cancer Network. Basal Cell Skin Carcinoma (Version 2.2022). Available at: https://www.nccn.org/professionals/physician_gls/pdf/nmsc.pdf. Accessed January 30,2023.
10. 10. Jomah J, Elsafi RA, Ali KSAE, Abdullah R, Gelidan AG. Nasal Skin Thickness measurements using computed tomography in an adult Saudi population. Plast Reconstr Surg Glob Open 2019;7:e2450.
11. 11. Drew BA, Karia PS, Mora AN, Liang CA, Schmults CD. Treatment patterns, outcomes, and patient satisfaction of primary epidermally limited nonmelanoma skin cancer. Dermatol Surg 2017;43:1423-30.
12. 12. Krishnan A, Xu T, Hutfless S, Park A, Stasko T, Vidimos AT, et al. the American College of Mohs Surgery Improving Wisely Study Group. Outlier Practice Patterns in Mohs Micrographic Surgery: Defining the problem and a proposed solution. JAMA Dermatol 2017;153:565-70.
13. 13.Singh DJ, Bartlett SP. Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits. Plast Reconstr Surg 2003;111:639-48.
14. 14. RohrichRJ, Griffin JR, Ansari M, Beran SJ, Potter JK. Nasal reconstruction-beyond aesthetic subunits: a 15-year review of 1334 cases. Plast Reconstr Surg 2004;11:1405-16.
15. 15. Cherpelis BS, Carls JL. One-stage reconstruction of a full-thickness nasal defect involving the alar rim. Dermatol Surg 2007;33:1361-4.
16. 16. Coban YK, Geyik Y. An ideal composite graft donor site for postburn alar rim deficiencies: root of helix. J Craniofac Surg 2010;21:1246.
17. 17. Neltner SA, Papa CA, Ramsey ML, Marks VJ. Alar rotation flap for small defects of the ala. Dermatol Surg 2000;26:543-6.
18. 18. Fujiwara M. One-stage reconstruction of an alar defect using a bilobed nasolabial-nasal tip flap based on the aesthetic subunits in Orientals: case report. Aesthetic Plast Surg 2004;28:13-6.
19. 19. Asgari M, Odland P. Nasalis island pedicle flap in nasal ala reconstruction. Dermatol Surg 2005;31:448-52.
20. 20. Ünlü RE, Orbay H, Ylmaz AD, Aksoy E, Uraloğlu M, Sensöz O. A new approach to alar rim defects: mucocartilaginous turnover flap. J Craniofac Surg 2007;18:661-4.
21. 21. Ying Z, Jianlin F, Guoxian Z, Min W, Wei W, Zuoliang Q. Ultralong pedicled superficial temporal fascia island flaps for lower nasal defect. J Craniofac Surg 2009;20:864-7.
22. 22. Kakinuma H, Iwasawa U, Honjoh M, Koura T. A composite nasolabial flap for an entire ala reconstruction. Dermatol Surg 2002;28:237-40.
23. 23. Selçuk CT, Ozalp B, Durgun M, Bozkurt M, Baykan H. Reconstruction of full-thickness nasal alar defects using cartilage-supported nonfolded nasolabial flaps. J Craniofac Surg 2012;23:1624-6.
24. 24. Alagoz MS, Işken T, Sen C, Onyedi M, Izmirli H, Yücel E. Three-dimensional nasal reconstruction using a prefabricated forehead flap: case report. Aesthetic Plast Surg 2008;32:166-71.
25. 25. Li S, Cao W, Cheng K, Yin C, Qian Y, Cao Y, et al. Microvascular reconstruction of nasal ala using a reversed superficial temporal artery auricular flap. J Plast Reconstr Aesthet Surg 2006;59:1300-4.
26. 26. Otley SC, Sherris DA. Spectrum of cartilage grafting in cutaneous reconstructive surgery. J Am Acad Dermatol 1998;38:982-92.
27. 27. Quatela VC, JAcono AA. Structural grafting in rhinoplasty. Facial Plast Surg 2002;18:223-32.
28. 28. Becker DG, Becker SS, Saad AA. Auricular cartilage in revision rhinoplasty. Facial Plast Surg 2003;19:41-51.