Abstract
Wide resection of recurrent basal cell carcinoma (BCC) in the peri-orbital–infraorbital–nasal area may include periosteum resection with maxillary or nasal bone exposure. The absence of vascularized periosteum makes the defect ungraftable and local flaps are often required. As an alternative to a large single flap or a combination of flaps, it is possible to turn the ungraftable portion of the defect into a graftable one. The suborbicularis oculi fat (SOOF) flap is an advancement flap that is used in aesthetic surgery for midface rejuvenation. The use of the SOOF flap along with a full-thickness skin graft, as an alternative to the use of other standardized flaps to cover defects in the peri-orbital–infraorbital–nasal area with avascularized tissue or noble structure exposure, is reported herein. As an immediate single-stage reconstruction, this procedure leaves other flap options intact in the event of re-operation for a recurrent tumour.
Wide resection of malignant skin tumours in the peri-orbital–infraorbital–nasal area may include periosteal resection and can result in soft tissue defects with maxillary or nasal bone exposure (dual tissue defect). Maxillary or nasal bone exposure without periosteal cover represents an avascularized site. The absence of vascularization makes it ungraftable and local flaps are often required. If a large dual tissue defect is present, one alternative to the use of a large single flap or a combination of flaps is to turn the ungraftable portion of the defect into a graftable one.
As described for aesthetic surgery techniques in midface rejuvenation, where central and medial compartments of the suborbicularis oculi fat (SOOF) have been used to resurface the orbital crease, these fat compartments have been used at the authors’ institution as an advancement flap to cover the exposed bone portion of the defect, making it readily graftable.
The cases of two patients with basal cell carcinoma (BCC) of the peri-orbital–infraorbital–nasal region infiltrating the underlying periosteum, treated with a SOOF flap and full-thickness skin graft following tumour resection, are presented herein.
Case reports
Case 1
A 71-year-old female patient was admitted to the clinic with an extensive recurrent BCC of the right peri-orbital–infraorbital–nasal area. After complete ophthalmological examination to exclude ocular involvement, wide resection of the lesion with a 1-cm tumour-free margin was performed under local anaesthesia. The resection, in its central portion, included the underlying periosteum of the maxillary bone. Bipolar haemostasis was achieved. The result was a defect measuring 3.7 cm × 2.1 cm with a portion of exposed maxillary bone measuring 1.5 cm × 1.6 cm ( Fig. 1 ). Intraoperative histology identified an aggressive BCC with tumour-free margins.
Beneath the pretarsal segment of the orbicularis oculi muscle, the orbital septum was released at the arcus marginalis. The medial and central fat compartments were mobilized inferiorly as a sliding pad (SOOF flap) to cover the exposed bone. This was secured to the superficial musculoaponeurotic system at the zygomatic arch below the exposed bone area with a few 5–0 Vicryl sutures ( Fig. 2 ).
A full-thickness skin graft, harvested from the pre-auricular region, was positioned over the vascularized fat flap for wound closure. Quilting sutures and a tie-over dressing were used to guarantee adherence of the skin graft to the defect bed. Graft take was optimal on day 6 postoperative ( Fig. 3 ).
Definitive histology confirmed an aggressive BCC, which had been completely excised. At the 18-month follow-up there was no sign of local recurrence and the patient was satisfied with the result, despite the presence of a mild medial scleral show ( Fig. 4 ).
Case 2
A 68-year-old male patient was admitted to the clinic with a skin lesion located in the nasal–peri-orbital area. He reported that the lesion had first appeared 7 years earlier as a nodule and had progressively enlarged. On examination the lesion extended from the right nasal dorsum to the right internal canthus, without ocular involvement, and inferiorly towards the upper lip along the nasolabial crease. An excisional biopsy was performed.
Histology showed an aggressive micronodular BCC extensively infiltrating the underlying dermis. A larger and deeper excision of the primary tumour site was performed, including the nasal bone periosteum. This resulted in a 5.5 cm × 3 cm defect in the nasal–peri-orbital area with a portion of exposed nasal bone measuring 1.9 cm × 1.1 cm ( Fig. 5 ). Intraoperative histology identified a BCC with tumour-free margins. Thereafter, reconstruction was performed at the same stage: a SOOF flap was harvested and advanced medially and inferiorly to cover the nasal bone exposure ( Fig. 6 ). A full-thickness skin graft was harvested from the left supraclavicular region and was placed on top of the vascularized fat for wound closure. A tie-over dressing was added.
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