Nasal Reconstruction (rebuilding the nose after skin cancer)

Explore nasal reconstruction after basal cell skin cancer, nasal surgery, & sculpture of the nose by Dr. Michael Bermant, MD plastic & cosmetic surgery. A bishop miter's flap was used for the reconstruction.

Michael Bermant, MD
Board Certified by the American Board of Plastic Surgery

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Bishop's Miter Flap Reconstruction Case 1

 

Basal Cell Cancer of Nose
Bishop Miter Flap Case 1

Skin Cancer

 After Surgery

basal cell cancer Bermant plastic cosmetic and reconstructive surgery

after bishop miter flap basal cell cancer Bermant plastic cosmetic and reconstructive surgery

Basal cell cancer of nose with wide area of involvement. The tumor extended to the cartilage of the nose but not into the mucosal inner lining.

 

Basal Cell Cancer of Nose
Bishop Miter Flap Case 1

Skin Cancer Defect After Excision

surgical defect basal cell cancer Bermant plastic cosmetic and reconstructive surgery

By using modified Mohs' surgical control of the margins, the full extent of the tumor was found.

 

Basal Cell Cancer of Nose
Bishop Miter Flap Case 1

Flap design 

 After surgery

flap design basal cell cancer Bermant plastic cosmetic and reconstructive surgery

  result after basal cell cancer Bermant plastic cosmetic and reconstructive surgery

The defect was closed with a Bishop's Miter flap reconstruction. The skin of the nose, region between the eyes, and forehead are used to rebuild the defect. Since the facial aesthetic units are left unharmed, results have a natural appearance.

 

 

Bishop's Miter Flap Reconstruction Case 2

Basal Cell Cancer of Nose
Bishop Miter's Flap Case 2

Recurrent tumor

recurrant basal cell cancer Bermant plastic cosmetic and reconstructive surgery

This patient had a nasal basal cell cancer resected and reconstructed by another doctor. A large nasal labial flap was used to rebuild the defect. The pathologist reported positive margins. There was no intraoperative control of negative margins and the flap was placed on tumor.

 

Basal Cell Cancer of Nose
Bishop Miter's Flap Case 2

 The tumor

recurrant basal cell cancer Bermant plastic cosmetic and reconstructive surgery recurrant basal cell cancer Bermant plastic cosmetic and reconstructive surgery

Notice how the edge of the flap is marked by obvious tumor growth. This tumor was probably not visible to the doctors eyes during that surgery. The pathologist uses a special freezing and slicing tool, special stains, and a microscope to see the tumor during Modified Mohs' analysis of the margins. If this method had been used, further resections would have been necessary.

 

Basal Cell Cancer of Nose
Bishop Miter's Flap Case 2

Preliminary Surgical Defect

surgical defect recurrant basal cell cancer Bermant plastic cosmetic and reconstructive surgery surgical defect recurrant basal cell cancer Bermant plastic cosmetic and reconstructive surgery

Look at the extent of the defect using Modified Mohs' control of the margins. The tumor extended deep to the flap, and down beyond the tip of the nose. Several specimens were sent to the pathologist until the margins were free of tumor. These pictures are not of the final defect. The lower margins were still positive requiring further resection.

 

Basal Cell Cancer of Nose
Bishop Miter's Flap Case 2

Final Surgical Defect

surgical defect recurrant basal cell cancer Bermant plastic cosmetic and reconstructive surgery surgical defect recurrant basal cell cancer Bermant plastic cosmetic and reconstructive surgery

The tip of the nose is supported by flexible cartilage. The cartilage is usually a reasonable barrier to tumor. In this case the tumor had penetrated through the cartilage and into the nasal lining. Notice faint lines on the forehead for a smaller Bishop's miter flap reconstruction. Dr. Bermant tries to use the time the pathologist takes checking for margin invasion by the tumor (frozen section analysis). Since a prior positive margin required me to take more tissue, the flap used to rebuild this defect was larger. This is a large defect to cover with a Bishop's Miter flap.

 

Basal Cell Cancer of Nose
Bishop Miter's Flap Case 2

Reconstructed Nose

result after flap recurrant basal cell cancer Bermant plastic cosmetic and reconstructive surgery result after flap recurrant basal cell cancer Bermant plastic cosmetic and reconstructive surgery

Dr. Bermant's plan was to do a composite graft (skin and cartilage) from the ear as a second stage to rebuild the right alar unit. A graft would need to get its blood supply from surrounding tissue. In this case that would mean from the edge of the new flap. As the flap heals the blood supply will usually improve. Doing the graft at the same time as the flap means that there is a higher chance of the graft failing.

The patient however said she was not bothered by the result and did not want the second stage reconstruction. Notice how the flap was folded to form the inside lining of the nose. The nose looks abnormal from the missing alar unit.

 

Basal Cell Cancer of Nose
Bishop Miter's Flap Case 2

Computer simulation of what an alar composite graft might look like.

computer simulation plastic surgery alar composite graft from ear

This computer simulation of an alar graft is an attempt to show what replacing the alar unit with a graft from the ear might look like. In such a revision, Dr. Bermant would also improve the right lower lateral nose (which Dr. Bermant did not change on the computer drawing). The simulation was designed to show the effect of restoring the alar component alone. Color and symmetry are harder to recreate in real life.


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