Case 7: Closure of larger tip defect by a modified Peng-Flap with extended Nasofrontal dissection

The patient was preoperatively seen for surgical planning in the outpatient clinic, where the baseline photos were obtained. Reconstruction of the defect was initially planned using an nasofrontal-flap. The specialist surgeons changed the tentative plan to a Peng-flap based on the available baseline photos (left), and intraoperative tumor markings (right) extending unilateral to the right side of the tip, made it necessary to do a minor modification of the surgical Peng flap design.

After identifying the excision site and application of local anesthesia (1% lidocaine + adrenalin), the tumor is excised with a 3 mm safety margin at an appropriate depth to the pericondral layer, resulting in a 14×19 mm nasal tip defect (left). Hemostasis is performed and frozen sections was obtained from the borders of the defect at 12, 3, 6, and 9 o’clock and base, and sent for rapid histological examination. The modified flap design in then drawn on the skin. Notice the bulbous tip almost resembling a pollybeak configuration (right)

Frozen sections showed no malignancy at the margins: 3, 6 og 9 o’clock or base, but was seen at 12 o’clock. The incision lines (left picture) begins distal at the defect, follows the alar curves, preserving the alar subunit and camuflaging scars in nasal creases. Due to the design of the flaps, the area still containing nBCC at 12 o’clock was already planned for excision. (middle-left picture). The incision line then proceeds along the intersections of the nose and cheek, with the furthest incision and pedicle undermining on the left side (middle-right picture), until flap lengthening and rotation was achieved sufficiently enough mobilize the remaining skin of the apex over the defect (Right picture).

The flap inset is performed along the lateral edges starting superiority using subdermal inverted single sutures 5-0 absorbable uncolored polyfilament, followed by cutaneous single sutures using 5-0 non-absorbable monofilament, while continuously adapting the position of the “neo”apex. No subdermal anchor sutures was used under flaps to minimize potential flap-perfusion issues. The central triangular spare skin, was excised to eliminate “dog ear” formation and to draped the skin flat on the nose over underlying structures. Closure here was in a staggered fashion to contra-vector lateral pull from the short, right flap thereby centralizing the tip. Notice maintained tip projection (left) with a reduced bulbous tip (right). The operation site is dressed with micropore-tape.

The patient was seen 7 days after surgery for suture removal, with no reported complications and a good postoperative satisfactionary result, experiencing no functional or cosmetic discomfort. The scar showed no sign of infection or irritation. Early postoperative picture was taken by the patient 12 days after surgery. Early, but excellent functional and aesthetic outcome was noticed. The patient is planned for a 3 month follow-up.

The patient was very satisfied with the result. There was found no traction on the tip of the nose and the scar was relatively hard to see. There was found no asymmetry between the two sides of the nose.