Objective: A case of big and multiple BCC is presented. It turned out to be life threatening because of various failed reconstruction attempts, dural exposure and CSF fistula, added to nosocomial colonization. Free, local and regional flaps and radiotherapy were used in order to obtain local control, which was finally achieved.

Patient: 69-years old patient was refered to our office because of two huge BCC in both auricular regions. These were 12 and 20 cm ulcerated lesions. The left one had dural infiltration and auricular and externar canal ear destruction. He also presented another two 1 cm-BCC in free margin of upper rigth eyelid and in right internal cantal region. Surgical excision was decided for both auricular BCC, with petrosectomy and dural excision in the left side. Bilateral reconstruction was performed with anterolateral tight free flaps. Left ALT was partially lost, so a rescue surgery was performed: a pedicled latissimus dorsi miocutaneous flap. Partial detachment of the LD produced dural exposure and CSF fistula. During postoperative period, the patient suffered Acinetobacter Baumanii colonization that forced contact and respiratory isolation. Finally the defect could be reconstructed by an occipital scalp rotational flap based on right occipital artery. The eyelid BCC was treated with brachytherapy. The internal cantal BCC was excised and reconstructed with a glabelar flap.

Result: Admisible esthetic result was achieve despite the loss of one of the free flaps. CSF fistula was solved. The patient recovered his former life status.

Conclusion: BCC can be very aggressive, especially in long-time evolution, like the reported case. Reconstructive options were limited because of huge size. Nosocomial colonization added difficulty and risks specifically due to dural exposure.