Bcc Of The Nose Dr Kamal Hussein Saleh Consultant Cosmetic &plastic Surgery,al Emadi Hospital-qatar-doha

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.

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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

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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

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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 (Sofratulles, guaze, Povidone Iodine 10%) in layers in other types of reconstructions.

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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

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Tip

Ala

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.

percentage

Fig ( 4 ): show the percentage distribution of patients according to the size of lesion 80.00% 60.00% 40.00% 20.00% 0.00%

65.20 % 34.80 %

< 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

Pe rce ntage

60 50 40 30

17.39

8.61

20

4.4

10 0

Nodular Nodular

Ulce rativ e Pigmne te d Type of le sion Ulcerative

Pigmneted

Scle rosing

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%).

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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

34.8

Perenctage

45 40 35 30 25 20 15 10 5 0

13.04 8.2

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 years < 1 year 1 – 5 years >5 years

No. of patients

%

3 15 5

13.04 65.22 21.74

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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 opertio n

Tota l no.

Graft Flap

5 13

1 1

Mixed Direct suture

2 3

-

Infectio n

No. of patients with complication Hematom Partia Wound Incomplet a l skin dehiscenc e excision loss e 1 1 1 1 -

-

-

Type of the reconstruction

No. of the patients

Graft Flap Mixed Direct suture

5 13 2 3

1 -

% Recurrenc e 1 -

Sty inhospital (in days) Mean +- S.D. 7+- 3.937 7.15+- 4.239 17.5 +- 4.949 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, &

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60 3 0.8

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.

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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

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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

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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. Pg141158:1992. 11-Epstein E. skin cancer. Technique in skin surgery. Chapter23:p117-183: 1979.

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