Case 2: Glabella flap
Authors: Hasan Gökcer Tekin, MD and Magnus Balslev Avnstorp, MD
Patient History
A 70 years old man presented with a wound on his dorsal nose following an excisional biopsy of squamous cell carcinoma (SCC). The patient was a wheelchair user and had a history of chronic obstructive pulmonary disease, hypertension and diabetes mellitus. He quit smoking several years ago.
Analyzing the case
Surgical margins were not clear, as the tumor reached close to the edge of the primary excisional biopsy. Indication for re-excision in 3-4 mm and reconstruction using a glabella flap was found.
Before and after
Preoperative considerations:
The reconstructive ladder should be in mind when reconstructing the defect:
Healing by secondary intention was not advised, due to the size and depth of the tumor. Furthermore, the patient had a history of diabetes mellitus and at risk of prolonged healing and infection.
The patient had a fair skin type and a full-thickness skin graft could result in an acceptable cosmetic result. Optimal conditions are needed for survival of a full-thickness skin graft, because of the greater amount of tissue requiring revascularization. Re-excision down to the periosteum lowers the chance of survival.
A Limberg flap from the glabella region was preferred in this case to provide color-matched skin for reconstruction and a higher chance of survival compared with a full-thickness skin graft.
Step 1: Excision
The defect was 15mm in diameter and located in the proximal half of the nasal dorsum including both nasal sidewalls (crossing over 3 aesthetic subunits). Surgical margins for re-excision were 5 mm.
The flap was vertically oriented into the RSTL of the glabella to hide the following scar of the secondary defect. The cranial border of the defect did not cross into the glabella staying inside the aesthetic subunits of the nose.
The flap had to rotate about 90 degrees to close the primary defect around the pivot point (white dot).
Step 2: Flap design
The width (X) of the flap is identical to the width of the defect. The length (Y) of the flap is slightly longer (around 20%) than the length of the primary defect. A slight loss of distance occurs during rotation of the flap depending on the rotation angle.
- The flap was thinned of subcutaneous tissue in the distal half to match the surrounding skin on the nose. The proximal half of the flap is not thinned due to maintaining a steady blood supply, which makes the flap appear bulky at the basis.
Step 3: Post-operative photo
The scars of the Limberg flap stay within the horizontal RSTL of the nasal bridge. The flap crosses 3 subunits of the nose (both nasal sidewalls and the nasal dorsum) due to the size of the defect. Note the slight nose deviation of the lower two-thirds of the nose, which was seen preoperative also
Step 4: 1-week follow-up
The flap is slightly hyperemic 1 week postoperative but is expected with time to color-match the surrounding skin. Pincushioning at the wound edges is seen due to lymphedema in the early postoperative stages, which is expected to regress after a few of weeks. The basis of the flap is bulky at the nasal sidewall towards the left medial canthus and may require a second-stage debulking procedure.
Post-operative care
- Stiches removed after 7 days
- Surgery was done in a clean-contaminated operative field
- As the patient had a history with diabetes mellitus. Prophylactic antibiotics were giving for 7 days