Case presentation
A 71-year-old male, with a history of 2 month painful erythematous lesion in the nasal base and columella, referring to our otolaryngology clinic with the primary impression of nasal abscess. On examination, there was a destructive lesion involving nasal columella, septum with erythematous margins extended to upper lip. Nasal squamous cell carcinoma was confirmed through a biopsy of the nasal lesions. (Figure 1) The patient underwent resection of the lesion until all margins were free of tumor based on the histopathologic examination. A large defect created that involved nasal base, columella, septum, upper two thirds of upper lip, and philtrum. (Figure 2)Then, patient underwent nasal reconstruction in two stages. In the first stage, bilateral malar transposition flaps were planned and elevated to cover both the missed skin of nose and upper lip. For more support and contour the nasal tip and columella were shaped by an auricular cartilage graft. On both sides, The incision involved the inferior orbital rims then the flaps were elevated over the facial musculature from medial to lateral. Moreover, further undermined was done laterally to facilitate advancement. After transposition of both flaps, they were divided to two portions to cover the columella and nasal tip in superior and the upper lip in inferior. The superior division of flap made the columella lateral surface in one side and medial surface in the other side, while, columella was more supported in middle layer by cartilage graft. The donor sites were closed directly. (Figure 3) In the second stage, six weeks later, pedicle release and nasal base restoration was performed. In the second surgery, pedicle was released on both sides ,then it was rotated to restore nasal base. After that, the remaining tissue from the pedicle was excised. (Figure 4, 5)
Also,at the supra tip, a small site of tissue necrosis was detected that was excised with fusiform incision. Since the histopathology analysis confirmed there was no tumor recurrence on biopsied tissue, it was closed primary while supporting with an on lay cartilage graft. All steps were performed under general anesthesia.