Reconstruction with Rotation Flap of Infraorbital Dextra Basal Cell

Carcinoma

Fitriah, Yulia Farida Yahya, Hartika Ketty Marpaung, Theresia L. Toruan.

Department of Dermatology and Venereology Faculty of Medicine Sriwijaya University/Dr. Moh. Hoesin General Hospital

Palembang, Indonesia

Keywords: Basal cell carcinoma, dermoscopy, histopathology, rotational flap

Abstract: Basal cell carcinoma (BCC) is the most common cancer with an incidence rate approximately 70-80% among

all skin malignancies. BCC in the head and neck usually presents as slow growing, well-defined, papule or

nodul. It is locally destructive lesion and could cause serious disfigurement. However, the case of metastasise

rarely occured. Nevertheless, various treatments are available, in which the surgical excision is found to be

the most effective one. Unfortunately, in facial area, any tumor excision may be aesthetically detrimental,

therefore difficult to restore. In such case, the use of local flap such as rotational flap, is the standard option

for reconstuction. This paper is to report a case of infraorbital dextra basal cell carcinoma with rotational flap

as the reconstruction method. Reconstruction with rotational flap technique on infraorbital region give a good

outcome and easy to learn with a minimal time and give an aesthetically good result.

1 INTRODUCTION

Basal cell carcinoma (BCC) is derived from the non-

keratinizing cells originating from the basal layer of

the epidermis. BCC generally characterized by slow

growth, minimal soft tissue invasiveness and a high

cure rate. However, in certain occasion it could derive

an agressive form causing deep tissue invasion with

regional or distant metastasis and potentially

recurrence. It commonly located in the facial region,

whilsy seldom occured in the area of limbs and trunk.

Correspondingly, the management of BCC is guided

by the anatomic location and the histological features.

As for the treatment, it consists of the surgical and the

non-surgical procedure. The surgical therapy includes

standard excision, Mohs micrographic surgery, and

cryosurgery (Carucci, 2012), (Madan, 2016).

Surgical excision of tumors from the face may create

a defect that is difficult to restore. Sometimes

excision of all tumors requires closure of wounds

caused by an excision known as a flap. Flaps are

commonly classified according to their primary

movement as advancement, rotation transposition, or

interpolation. The use of regional flaps like rotational

flap are very useful and versatile local flaps (Seehan,

2012), (Cook, 2005).

2 CASE

A 43-year-old woman presented with

hyperpigmented nodule on infraorbital dextra since

two years ago. The nodule gradually became enlarged

and itchy. Approximately 1 year ago,

hyperpigmentation nodule got bigger, and easily

bleed even with a gently touch. From the edge of the

nodule, few ulcers also arised. During physical

examination, the generalized status was within

normal range. The findings in Dermatologicus status

from infraorbital dextra region: hyperpigmentation

nodule, size 1.8 x 0.9cm, solitary, irregular, ulcerated

plaque and rolled out edges. The multiple blue gray

globules and ulceration were found in the two images

obtained by the Dermoscopy examination. While as

for laboratory examination yielded normal.

Histopathological examination was found nodulo

infiltrative based on growth pattern including

aggressive BCC. The incision in the margin area was

not free from tumor. The patient treated with in toto

excision followed by rotational flap reconstruction.

Patients were given systemic drugs, cephadroxil dose

of 500mg every 12 hours for 7 days and mefenamic

acid dose of 500mg every 8 hours after surgery.

Fitriah, ., Yahya, Y., Marpaung, H. and Toruan, T.

Reconstruction with Rotation Flap of Infraorbital Dextra Basal Cell Carcinoma.

DOI: 10.5220/0008161105190522

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 519-522

ISBN: 978-989-758-494-7

519



Figure 1: a,b) Location of the tumor c,d) histopathological examination.



Figure 2: a) Sketch of rotation flap pattern. b) In toto excision c) Post wound suture excision with rotation flap. d,e,f) Rotation

flap with simple curved design from the primary defect. The rotating end portion is located shorter than the primary defect

that flap will cover the furthest edge of wound if the flap edge is expanded with secondary defects.

3 DISCUSSION

Basal cell carcinoma includes non-melanoma skin

cancer which is a malignant skin tumor originating

from stem cells in the basal layer of the epidermis and

a small part originates from the outer layer of unit

pilosebasea root sheath.

According to Moore GM

(2012) retrospective study, the incidence of BCC is

more frequent among Caucasian race. The trend of

skin cancer in Asia shows that BCC increase most

often at the age of more than 60 years of old (Moore,

2012).

Diagnosis of this case based on clinical features,

dermoscopy and histopathology examination. In the

clinical features corresponded to the nodular type

BCC. Nodular type cell BCC is the most commonly

found variant with clinical features of dome shaped,

translucent, and pearly edges spread to the periphery.

Nodular type basal cell carcinoma is common in the

head and neck. Histopathologic examination shows

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nodulo infiltrative based on growth pattern including

aggressive BCC.

BCC on the facial region may yield higher degree

of subclinical spread compare to tumor’s arising

elsewhere. Generally, the cosmetic outcome for the

standard surgical excision is quite satisfying.

Howbeit the lesion removal procedure in which a

significant excision on the margins area needed,

could caused an alarming tissue losses. Special

attention therefore needed to avoid further damages,

for fuctional and cosmetic importance, to certain

locations in the facial region such as the periocular,

perioral and perinasal areas (Jadotte, 2010). In the

current presented case, the location of the tumor was

in the infraorbital dextra, which is considerably a

difficult area. Therefore, the flap selection after

surgery should be adjusted to avoid the lid retraction

as the aftermath.

Additionally, there are several schematic

classifications for flap surgery. The Flap is

categorized based on the blood vessels supply

(random or axial), primary motion (advancement,

rotation, transpotation), configuration (rhomboid or

bilobed) and location (local or distant) (Cook, 2005).

Rotational flap include rotation movement flap.

Rotational flap is flap tissue that transferred over an

area of unaffected skin to reach defect (Chen, 2009).

The procedure of surgery include preoperative,

operative and pascaoperative. The preoperative

planning include examine the patient in the upright

position in both static and dynamic situation. Flap

design with consideration of aesthetic boundaries,

relaxed tension line and decision margin excision. in

this case wound closure using rotational flap. Flap

design was done as preoperative procedure.

There are several principles in the Flap, namely,

1) primary defect; is the post tumor removal wound

which intended to be closed while also acted as the

recipient from the subsequent skin-flap. 2) Secondary

defect; is the Flaps’ procreated wound. It derived

from the incision and removal of the surrounding skin

layer and the subcutaneous tissue, to overlay the

primary defect (thus called the donor) 3) the primary

flap motion is the displacement movement that will

be placed above to cover the primary defect. 4)

Secondary movement is the displacement movement

that is placed into around tissue of primary defect

using flap (Cook, 2005).

The surgical field should include the contralateral

aspect of the surgical wound (i.e. the entire face

should be prepped in the usual sterile fashion). This

will allow the intraoperative assesment of flap

movement on tissue symetry and free margins. BCC

with diameter less than 2 cm, approximately 85%

successful removal of all tumors with margin excision

3 mm while 95% with margin excision 4-5 mm

(Madan, 2016), (Abullarade, 2013).

Undermining

should be perfomed to release vertical and pivotal

tissue restraint and elasticity and the plane of flap

elevation and undermining should match the wound

depth closely.

In this case wide local excision with 3mm margin

was carried out to prevent recurrences. Rotational

flap was done to maintain function and physical

aesthetic post operative. The rotating end portion is

located shorter than the primary defect that flap will

cover the furthest edge of wound if the flap edge is

expanded with secondary defects. After the incision,

the undermining was done with blunt scissors that

made the flap easily rotated towards the wound.

Triangular sutures are done on the end flap and the

donor tissue. Finally, the lateral initiation line is

sutured in interupted while the cranial side lines are

sutured with the continuous suture.

Post operative care after flap reconstruction is

similar for other wound. A pressure dressing, include

ointment shoud be applied over the flap. The initial

dressing should be removed after 24-48 h, the area

cleaned and a dressing of ointment and tape reapplied

(Chen, 2009). In this case

dressing include ointment

applied over the flap.

4 CONCLUSION

We reported BCC cases with nodular infiltrates type

in 43 years old woman. The BCC is treated with the

toto surgical excision with the rotational flaps. The

rotational flap technique can close the primary defect

seemlessly while at the same time causing less lesion’

tension. In the histopathologic examination, the

nodulo infiltrative BCC is found, with the none-free

margin therefore required more observation.

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