What is the optimal approach to nasal reconstruction after excision of a basal cell carcinoma, taking into account defect size, depth, anatomic subunit involvement, and patient comorbidities?

Nasal Reconstruction After Basal Cell Carcinoma Excision

Direct Recommendation

For nasal defects after BCC excision, reconstruct the defect itself rather than the entire aesthetic subunit, using local flaps for small-to-medium defects (<4 cm²) and forehead flaps for larger or full-thickness defects, with primary dermabrasion to optimize aesthetic outcomes. 1

Reconstructive Algorithm Based on Defect Characteristics

Small Defects (<1 cm²)

• Primary closure or healing by secondary intention is appropriate for superficial defects on the nasal dorsum or sidewall 1
• Local advancement flaps (V-Y advancement, S-shaped rotation flaps) provide excellent results for alar and tip defects up to 0.5 cm² 2
• These techniques require minimal dissection compared to bilobed flaps and offer superior cosmetic outcomes 2

Medium Defects (1-4 cm²)

• Bilobed flaps are the workhorse for alar and tip defects in this size range 3, 2
• Nasolabial flaps work well for lateral nasal wall and alar defects 3
• Local rotation flaps with S-shaped design can cover defects up to 3.5 cm² on the alar and tip with minimal complications 2
• Complication rates are low (1.2% revision rate) when proper technique is employed 1

Large Defects (>4 cm²)

• Paramedian forehead flap is the gold standard for extensive nasal defects 1, 3, 4
• This is typically a two-stage procedure with flap division at 3 weeks 1
• In Asian patients, consider that thicker skin and pigmentation require careful flap thinning to optimize outcomes 5

Full-Thickness Defects

• Three-layer reconstruction is mandatory: internal lining, structural support, and external coverage 4
• Internal lining: Use inverted skin flap or intranasal mucosal advancement 4
• Structural support: Conchal cartilage graft to replace missing alar cartilage 4
• External coverage: Forehead flap provides the best color and texture match 4

Critical Technical Principles

Tissue Conservation Strategy

• Reconstruct the defect, not the entire aesthetic subunit - this preserves native tissue and reduces unnecessary resection of healthy skin 1
• The traditional subunit principle (replacing entire subunits) leads to excessive tissue removal and increased morbidity 1
• 81% of reconstructions can be completed in three or fewer stages using this conservative approach 1

Complementary Procedures

• Primary dermabrasion or CO₂/erbium laser resurfacing should be performed at the time of reconstruction in nearly every case 1
• This technique blends flap edges, improves color match, and significantly reduces the need for revision procedures 1
• Primary flap defatting also decreases revision rates by improving contour 1

Flap Selection Hierarchy

• Axial pattern flaps are preferred when possible due to superior blood supply and reliability 1
• Local random pattern flaps are acceptable for smaller defects where axial flaps are impractical 2
• The aesthetic endpoint is good contour, not perfect subunit replacement 1

Patient-Specific Considerations

Age and Comorbidities

• Elderly patients (mean age 71 years in reconstruction series) tolerate local and regional flaps well 2
• For patients who cannot undergo surgery, radiation therapy is appropriate, though generally reserved for those over 60 years due to long-term sequelae concerns 6

Skin Characteristics

• Asian patients require special consideration: thicker skin necessitates more aggressive flap thinning to prevent bulky appearance 5
• Pigmentation differences between donor and recipient sites must be anticipated and addressed with dermabrasion 5

Tumor Characteristics

• High-risk features (nasal location, aggressive histology, positive margins) mandate Mohs surgery before reconstruction 7
• The nose is classified as Area H (high-risk) regardless of tumor size 8
• Do not perform complex tissue rearrangement (flaps/grafts) until clear margins are confirmed, as residual tumor can be spread 7, 6

Common Pitfalls and How to Avoid Them

Timing of Reconstruction

• Never close with flaps or grafts before confirming negative margins - this is an absolute indication for re-treatment if margins are later found positive 7
• If margins are positive after flap reconstruction, re-excision or Mohs surgery is mandatory regardless of the complexity of the prior repair 7

Inadequate Margin Control

• The nose is a high-risk location with 1.9% recurrence rate even after Mohs surgery 1
• Average time to recurrence is 39 months, necessitating long-term surveillance 1
• For aggressive histologic subtypes (infiltrative, morpheaform, micronodular), consider Mohs surgery even if initial margins appear negative 7

Flap Complications

• Partial flap necrosis occurs in approximately 1% of cases and typically requires revision 1, 3
• Forehead flap donor site dehiscence can occur; meticulous closure technique is essential 1
• Minimal rim necrosis in bilobed flaps may result in irregular scarring requiring revision 3

Functional Considerations

• Avoid techniques that cause nasal valve collapse or airway obstruction 3
• Maintain distinct nasal contour - avoid creating a flat or tented appearance 3
• Preserve nasal symmetry and natural expressions 3

Expected Outcomes

Aesthetic Results

• Color and texture match is excellent with properly selected local flaps 3
• Scars should be inconspicuous and placed in natural skin creases when possible 3
• Patient and surgeon satisfaction rates are high when principles of defect-based reconstruction are followed 1, 3

Functional Results

• All patients should maintain patent airways without valve collapse 3
• Nasal contour should remain distinct without flattening or distortion 3

Revision Rates

• Overall revision rate of 1.2% is achievable with proper technique and primary dermabrasion 1
• 75% of reconstructions are completed in two stages, 81% in three or fewer stages 1