Reconstruction of the nasal pharangeal defects following

surgical excision of nasopharangeal cancer (basal cell

carcinoma) in child hood with zeroderma pigmentosa

Dr. Kamal H. Saleh (F.I.C.M.S. M.B.CH.B.)

Specialist plastic surgeon in al emadi hospital-doh
Key word:nasopharangeal carcinoma,.zerodermapigmentosa
Basal cell carcinoma
Abstract:
This clinical study included (23) patients with basal cell
carcinoma (BCC) of the nose of chidren with zeroderma
pigmentosa who attended the Specialized Surgical Center in
Medical City in Baghdad in 2005.these patients have been
studied regarding the sociodemographic characteristics,
clinical characters, & anatomical distribution of the BCC on
the nose.
Flaps were used for (13) patients with lesions reaching
and/or involving the underlying bone and cartilage. Grafts
were used for (5) patients. Direct suturing was done for (3)
patients with small lesions less than 1cm in diameter,& mixed
graft – flap was used for full thickness lesions involving the
lining of the nose in (2) patients.
Primary reconstruction of any modality was carried out
for lesions less than or equal to 2cm in diameter while
secondary reconstruction was attempted for lesions more than
2cm in diameter with indefinite margin in the absence of
frozen section. Flaps were associated with fewer complications
compare to grafts.
Secondary reconstruction was associated with a lower
incidence of complications compared to primary
reconstruction. The only recurrence was recorded following a
primary reconstruction, so that the recurrence is less
dependent to the size of the tumor & making the secondary
reconstruction a more superior choice.

1
 Introduction:
The nose is the most prominent part of the face. It’s a
sandwich of delicate cartilage pieces kept alive by a thin
vascular skin surface & a thinner more vascular lining.(3)
Bcc of the nose comprises (25.5%) of the total body
incidence as primary lesion & about (38%) of total body
incidence of recurrent BCC (8). Despite occasional case
reports, metastases from BCC are exceedingly rare. BCC may
kill by extension.(11)
Careful planning is especially important when operating
in nasal region. The treatment must completely eradicate the
neogenesis, yet spare the surrounding healthy tissue as much
as possible. Therefore particularly on the nose surgery is
superior to radiation due to anatomic structure here. The
danger of causing radiation injuries to the skin & cartilage
lying directly beneath it, is especially grate.(9)
Surgical reconstructions include usage of graft or flap or
both accordingly.

Patients & methods:

A total of (23) patients who were admitted to the

Specialized Surgical Center in Medical City in Baghdad with
BCC of the nose for excision of these lesions & reconstruction
of the nasal defect. BCC of the nose was diagnosed by the
typical slow growing lesions of various macroscopic
appearance, confirmed later by histopathological examination.
These patients were examined fully; information
regarding type, number, the site, size &shape of the lesion
were recorded. Preoperative photographs were taken too. The
patients were grouped according to the site, size , &number of
the lesions.

Methods of reconstruction:
Reconstruction of the nose was carried out for all
patients using direct suture, grafts or flaps under local or

2
general anesthesia. Skin graft were mainly used when the
tumor were superficial & did not involve underlying bone or
cartilage.
Grafts used in reconstruction were the split thickness
skin grafts (STSG.s), full thickness skin grafts (Wolfe graft) &
composite graft.
Skin grafts were used in 5 patients. Flaps were carried
out in 13 patients that were used mainly for reconstruction of
lesions involving the bone & cartilage.
The flaps were used in our study included:
1- V-Y advancement flaps (2 patients)
2- Forehead flaps (2 patients)
3- Cheek advancement flaps (1 patient)
4- Nasolabial flaps (3 patients)
5- Bilobed flaps (3 patients)
6- Dorsal nasal flaps (1 patient)
7- Caudal advancement flaps (1 patient).

For full thickness lesion, both flaps & grafts (mixed type)
were used for reconstruction, we use scalping forehead flap
with composite graft (skin & cartilage) for reconstruction of
these lesion (2 patients).
A silicon implant was used for reconstruction of nasal
skeleton defect in 1 patient but extruded later on.

Direct suture: were used in reconstruction of small lesions

less than 1 cm in diameter (3 patients).

Types of reconstruction of nasal defects:

The primary reconstructions were carried out for
lesions 2cm or less in diameter; the tumor is excised with 5
mm safe margin & reconstructed immediately after excision
of the lesion.
Secondary reconstructions were carried out for
lesions more than 2 cm in diameter, the tumor is excised
with 5mm safe margin & reconstructed later on, until the
result of histopathology confirmed the clearance of the

3
defect from malignant cells (during this period the patient
was daily dressed with povidone iodine 10%).
Follow up: All patients were followed up weekly for the first
month, then monthly for the first year, this included local
examination, & photographs were carried out.

Complications: the following complications were noted and

recorded:
1- Infection.
2- Hematoma.
3- Partial skin loss.
4- Wound dehiscence.
5- Local recurrence.
6- Incomplete excision.
Complications were treated accordingly.

Skin sutures: we were using Prolene (5-0) cutting needles

for skin suturing while chromic Catgut (3-0) cutting
needles were used to suture the subcutaneous tissue.
Stitches were removed within 5 – 7 days.

Dressing: regarding the dressing of the wound, tie over

dressing were used when we reconstruct the lesions with
skin grafts, otherwise we used the usual dressing (Sofra-
tulles, guaze, Povidone Iodine 10%) in layers in other types
of reconstructions.

4
 Results:
Regarding the sex , it can seen that (56.5%) of

Fig (1): show the incidence of BCC in rekation to sex.

43%

57%

Female Male

patients were female, (43.5%) of patients were males as

shown in fig
Fig (3) shows the anatomical distribution of the lesions on the
nose. It can be seen that the majority of the lesions appeared
on the middle third of the nose (52.2%).

Fig ( 3 ): show the anatomical distirbution of the lesion

on the nose

13% 17%

17%

53%

Upper 1/3 Middle 1/3 Tip Ala

5
Fig (4) shows the percentage distribution of patients in
relation to the size of the lesion. It can be seen that the size
of the lesion in (34%) of patients was more than 2 cm in
diameter, were as (65.2%) of patients have lesions which
are 2 cm or less in diameter.

Fig ( 4 ): show the percentage distribution of

patients according to the size of lesion

65.20 %
80.00%
60.00% 34.80 %
percentage

40.00%
20.00%
0.00%
< or equal than > 2cm
2cm
size of lesion

< or equal than 2cm > 2cm

Fig (5) shows the multiplicities of lesions among the study

group. Most of patients were with single lesion (73.9%)

Fig ( 5 ): show the multiplicity of lesions among the study group

26%

74%

Single lesion multiple lesion

Fig (6) shows that (69.65%) of the patients were with

nodular lesion, (17.3%) with ulcerative lesion, only

6
 (4.4%)were with pigmented lesion, & (8.61%) were
sclerosing.

FIg ( 6 ): show the type of the lesions among the study group
.

69.65
70

60

50
Pe rce ntage

40
30
17.39
8.61
20
4.4
10

0
Nodular Ulce rativ e Pigmne te d Scle rosing
Type of le sion
Nodular Ulcerative Pigmneted Sclerosing

Fig (7) shows the percentage distribution of presenting

symptoms among the study group. Most of the patients
presented either with itching alone (43.5%) or with a
symptomatic lesion (34.8%), where as only few patients
presented with bleeding (13.04%), & bleeding with itching
(5.2%).

7
 Three of the patients had associated with xeroderma
pigmentosa.

Fig ( 7 ): show the percentage distribution of the prsenting symptoms among the
study group

43.5

45 34.8
40
35
30
Perenctage

25 13.04
20 8.2
15
10
5
0 1

Type of presenting symptom

Itching only Bleeding only Itching + Bleeding Asymptomatic lesion

Table (1) shows the duration of the disease (in years)

among the study group. It can be seen that most of the
patients have lesions for 1 – 5 years (65.22%).

Table (2) shows the complications according to the

methods of reconstruction. Generally complication
occurred; 2 patients developed postoperative infection, 1
patient developed hematoma, 1 with partial skin loss, 1 with
wound dehiscence, 2 patients had incomplete tumor
excision, & 1 had recurrence.

Duration in No. of patients %

years
< 1 year 3 13.04
1 – 5 years 15 65.22
>5 years 5 21.74
8
 Table (3) shows the average days of stay in hospital in
relation to the type of reconstruction. It can be seen that
mixed graft - flap procedures were associated with longest
stay in hospital (17 .5 +_ 4.949 days).
Type of Tota No. of patients with complication %
opertio l no. Infectio Hematom Partia Wound Incomplet Recurrenc
n n a l skin dehiscenc e excision e
loss e
Graft 5 1 - 1 - - 1 60
Flap 13 1 1 - 1 1 - 3
0.8
Mixed 2 - - - - 1 -
Direct 3 - - - - - -
suture

Type of the No. of the Sty inhospital (in

reconstruction patients days)
Mean +- S.D.
Graft 5 7+- 3.937
Flap 13 7.15+- 4.239
Mixed 2 17.5 +- 4.949
Direct suture 3 0

Discussion:
Most of our patients were middle aged & elderly theis is
comparable to other studies (6), (4). Five patients were less
than 40 years of age, 3 of them had xeroderma pigmentosa, &

9
1 had multiple nevus basal cell syndrome, both of which
predispose to BCC at young age (1).
In our study, females were affected more than males
(56.5%) which differs from other studies (4). This higher
incidence in females ca be explained partly by increasing sun
exposure & probably by baking at home.
(43.5%) of our patients were from Baghdad & this is
explained by limited number of centers used for patients
collection.
(47.8%) of our patients were housewives, & (26.1%) were
farmers. Both statuses are also related to sun exposure & heat
radiation exposure, baking.
(52.2%) of lesions were seen on middle third of the nose,
which is comparable to other studies (8).
(65.2%) of lesions were 2cm or less in diameter at
presentation, & (73.9%) of patients have a single lesion, which
is comparable to other studies (4).
(69.65%) of lesions were of nodular type, which is
comparable to other studies (4).
(43.5%) of our patients were presented with itching at the
site of lesion, which differ from other studies (4)..
(65.22%) of our patients had the lesion for 1-5 years
before attempting to medical advice, which may reflect some
degree of ignorance on the side of the patients.
Primary reconstruction was attempted for lesion 2cm or
less in diameter & was done in different patients. For lesions
larger than 2cm in diameter with less definite edge & in the
absence of frozen section & with a doubt about the
completeness of excisions secondary reconstruction was
attempted (4). And so 8 patients had secondary reconstruction.
Flaps are preferable as they will match the color &
texture of the area to be reconstructed and so it was attempted
for 10 patients with lesions of 2 cm or less, 3 patients with
lesions more than 2 cm.
Skin graft was attempted for 2 patients with lesions less
than 2 cm, for 3 patients more than 2 cm lesions.

10
 Mixed graft & flap was attempted to 2 lesions with full
thickness defect, which are more than 2 cm in diameter.
Direct suturing was used for 3 patients with lesions less
than 1 cm in diameter (7)).
Generally complications which occurred in our patients
were non serious & flaps were generally associated with fewer
complications compared to graft, & this may be explained by
the fact that flap maintains a better blood supply & may be
used for covering the recipient bed with poor vascularity (5).
The rate of complications associated with primary
reconstruction was higher than that for secondary
reconstruction (40%, 25% respectively), & the only recurrence
occurred following a primary reconstruction by skin grafts, so
that the recurrence is less dependant to the size of the lesion
which differ from other studies (10), so the completeness of
excision is more in secondary reconstrution & the final
reconstructive is well selected (4).
Hospitalization was longest in patients in whom mixed
flap – graft procedure were attempted (17.5 +_ 4.949) days, &
this is explained by the fact that this type of reconstruction is
more extensive & needs closer follow up.

Conclusios:
1- Surgery is one treatment modality for BCC of the nose,
and is associated with few side effect, short
hospitalization, & low recurrence rate.
2- The nose differs from other structures of the body,
because it comprises three components (skin cover,
skeleton, & lining), so the reconstruction of nasal lesions

11
 needs more meticulous planning & careful selection of
surgical procedures. Different surgical procedures can
be used for reconstruction of nasal defects created by
excision of BCC of the nose.
3- Secondary reconstruction of nasal defects appears to be
more preferable, especially for defects with doubtful
margins, with the absence of frozen section (independent
to the size of the lesion) as it is associated with low rate
of complications, & low rate of recurrence.
4- Falps are superior to grafts, because they are associated
with lower incidence of complications, give better
contouring (except few) & are especially useful if there is
bare cartilage & bone. They give better healing with best
color match.
5- The recurrence of BCC of the nose is less dependent to
the size of the tumor.

References:

1- Ahmed L. Al-Kadhi. Office surgery in BCC of head &

neck. A thesis submitted to the Iraqi commission for
medical specialization. Pg: 40. 1993

12
2- Barton F.E. reconstruction of the nose Grabb & smith
plastic surgery. 4th edition, Little & brown company:
pg:491 –503; 1991.
3- Burget G.C., Menick F.J. nasal reconstruction seeking a
fourth dimension. P.R.S; V78: N2; Pg. 145.August 1986.
4- Emmet A.J.J. & Micheal G.E. malignant skin tumor.
Churchill livingstone. Pg. 30-61; 1982
5- Grabb W.C. Cohen I. Basic technique of plastic surgery.
Little & Brown company. Grabb & Smith. 1991.
6- Harris T.J. skin cancer in sunny Queensland. B.J.P.29.
pg.61-67;1976
7- Jackson I.T. local flap in head & neck reconstruction.
The C.V. Mosby company. Pg. 87- 189.1985.
8- Koplin L., Zarem H.A. recurrent BCC. P.R.S: V65,No.5
PG.657-658:May 1980.
9- Petress J. reconstruction of nasal defects. Dermo –
surgery. Springer – Veralg pg. 50-60. 1978.
10-Suzzanne M. & Joel M. Cutaneous carcinoma textbook
of plastic, maxillofacial & reconstructive surgery. Pg141-
158:1992.
11-Epstein E. skin cancer. Technique in skin surgery.
Chapter23:p117-183: 1979.

13