Introduction

Basal cell carcinoma (BCC) is the most common neoplasm in humans. In approximately 80% of cases, the primary location is the head and neck region, and about one-quarter of cases involve the nose [1–3]. Apart from the aesthetic aspect related to its facial location, reconstruction must also address functional aspects – such as ensuring proper nasal cavity structure and unobstructed airflow through the upper airways, particularly at the level of the nasal valve [4].

The first-line treatment is surgical excision. In selected cases, radiotherapy may be an option – for example, in cases of large tumours or when general anaesthesia is contraindicated due to comorbidities. Topical chemotherapy is also used in some cases, such as 0.5% fluorouracil ointment or 5% imiquimod cream [3].

Possible complications include: positive surgical margins on histopathological examination, graft necrosis, improper wound healing, infection, and airway obstruction [4].

Case report

On 23 March 2024, a 65-year-old male patient presented to the Laryngology Department (OL) for further evaluation of a tumour located on the right floor of the nasal vestibule.

Initially, the lesion presented as a poorly healing wound that did not respond to conservative treatment – including local antibiotic therapy – administered in the primary care setting. This treatment continued for approximately six months. During that time, the ulceration progressively enlarged. After consultation with a general surgeon in the patient’s hometown, he was referred to the otolaryngology centre.

At the first visit to the OL, examination revealed an ulcerated, mobile tumour located on the right floor of the nasal vestibule, measuring approximately 20 × 10 mm. It was connected to the right ala of the nose. There were no signs of columellar or maxillary bone invasion (Figure 1). The only reported comorbidity was hypertension. Based on the biopsy and histopathological examination (No. GH 0025XX/24), invasion of BCC was confirmed. Following a literature review, a two-stage surgical treatment using a melolabial flap was proposed.

On 28 April 2024, under general anaesthesia, resection with macroscopic margins (en bloc) was performed. The margins from all sides – right, left, proximal, distal, and deep (floor) – were then excised separately for histopathological evaluation (Figure 2).

In the next stage, a right-sided melolabial flap was created. After flap elevation, the subcutaneous adipose tissue was partially reduced. An incision was made along the nasolabial fold, and the flap was connected to the nasal cavity. The flap was then passed through the created tunnel. Wound closure was performed at both the donor site and within the nasal vestibule (Figure 3). At the end of the procedure, after local wound cleansing, a hydrogel dressing was applied to the external wound, and nasal tamponade was placed inside the nasal cavity.

On the first day after surgery, a wound healing assessment was performed. The graft appeared pink and demonstrated proper vascularization, and the wound healing was progressing well. On the second day, the patient was discharged and continued treatment in the outpatient department. The sutures were removed in two stages: on the 8^th and 10th days after the procedure.

Final histopathological examination (No. GH 035XX/24) confirmed complete resection of BCC with negative margins (R0).

After a 5-weeks, under general anaesthesia, the vascular pedicle was removed. The channel for the melolabial flap was reconstructed, and the connection between the nasal mucosa and the proximal part of the graft was repaired. After local wound cleansing, a nasal dressing was applied, and the patient was discharged on the following day. The sutures were removed on the 7^th day after surgery (Figure 4).

The patient reported satisfaction with the breathing effect on both sides, so rhinomanometry was not performed. The patient is currently under follow-up care at an outpatient clinic in Gorzów Wielkopolski. At the time of publication, no recurrence of the cancer was noted.

Discussion

The most challenging aspect of the presented case was selecting the appropriate reconstruction approach. All of the following surgical goals were focused on: 1) achieving negative margins (R0) – the most important objective, 2) preserving proper airway flow, 3) ensuring a satisfactory aesthetic outcome, and 4. minimizing postoperative complications.

Achieving clear surgical margins – at least a few millimetres – was essential and non-negotiable. As a result, the resection was relatively extensive and penetrated into the nasal cavity. A strategy involving primary closure without a flap could have led to nostril obstruction and significantly reduced quality of life [4].

The literature review led the authors to a similar case described by Krogerus et al.: a 66-year-old male patient with squamous cell carcinoma (SCC) of the right nasal vestibule. Due to the different histological type of cancer, the resection in that case also involved the columella. As a result, the authors used bilateral melolabial flaps to reconstruct the membranous (skin-covered) part of the nasal septum (columella) [5]. Based on Krogerus
et al., the authors prepared a schematic representation of the reconstruction (Table 1).

The literature also describes other techniques for reconstruction of the nasal vestibule floor.

In cases of small tumours (a few millimetres in diameter), primary closure may be a viable option. For larger tumours, a buccal flap from the region near the nasal ala can be used. In this approach, tissue loss and scarring at the donor site are significantly smaller compared to the melolabial flap. Additionally, the scar can be easily concealed within the natural curvature of the nasal ala [6, 7]. Due to the extensive resection, this type of flap was not preferred in our case.

Another option was to use a flap from the upper lip, but the authors decided against this approach for the following reasons: 1) aesthetic concerns related to the appearance of the lip, 2) hair growth in the area (moustache region), which may hinder proper skin care.

In this case, free flap techniques were not considered due to the following reasons: 1) increased risk of flap necrosis, and 2) potential for nostril adhesion and airway obstruction as a consequence. However, in selected cases, free flap reconstruction may still be a suitable option [6].

Although Mohs micrographic surgery allows for minimal tissue resection, it also has some drawbacks – most notably, a significantly longer procedure time, often requiring extended general anaesthesia [8].

In conclusion, the use of a unilateral melolabial flap is a favourable option for the reconstruction of large (> 1.5 cm), unilateral defects of the nasal vestibule floor.

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.

References