Bishop's Miter Flap Reconstruction Case 1
Basal Cell Cancer of Nose
Bishop Miter Flap Case 1
Skin Cancer
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After Surgery |
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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
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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
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After surgery |
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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
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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
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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
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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
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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. I try 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
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My 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.
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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, I would also improve the
right lower lateral nose (which I 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.
Nasal Reconstruction (rebuilding
the nose after skin cancer)
Hand 
