Use of a Double-Opposing Advancement Flap for closure of a Basosquamous Carcinoma on the Forehead: A Technique Designed to Optimize the Esthetic Outcome in a Young Patient
Introduction:
One variant of basal cell carcinoma (BCC), termed “basosquamous” carcinoma (BSC), displays the unique characteristic of differentiating into squamous cell carcinoma (SCC). BSC presents with a more insidious course than BCC, as it is more invasive locally and possesses a higher metastatic rate. Additionally, the recurrence rate tends to be significantly higher than BCC, necessitating appropriate removal of the initial lesion, with monitored follow-ups thereafter. While the lesion can appear in nearly every location of the body, most occur on the head and neck.
The standard treatment for BSC is excision, obtaining adequate margins to ensure a low rate of metastases. The average age of patients diagnosed is approximately 68, ranging from 51 to 89. In our case, however, the patient was in his mid 20s, which was unusual for this type of pathology. Taking the patient’s age and esthetics into consideration, we elected to use a double-opposing advancement flap (or H-flap). While there were other options regarding potential flaps, we felt that this flap, if placed within the forehead’s resting skin tension lines, would provide the best esthetic outcome given the patient’s age and social status.
Patient and Methods:
The patient is a 25-year old male who initially complained about a lesion on his left forehead, which had recurred after laser treatment. The lesion was approximately 1 cm in diameter, with a differential diagnosis of the following: BCC, SCC, and keratoacanthoma. Based on the patient’s age and associated social factors, it was determined that the most esthetically pleasing outcome would be achieved with a double-opposing advancement flap. The lesion was excised in the standard fashion, and then the flaps were developed, advanced, and closed to cover the defect area. Care was taken to ensure the transverse incisions were made in the patient’s natural creases to facilitate blending of the scar. The area was then sutured and the patient returned for follow-up.
Results and Conclusions
Final histopathologic diagnosis was consistent with well-differentiated invasive basosquamous carcinoma with margins free of tumor. The transverse incisions of the advancement flaps were made in approximation of the resting skin tension lines of the forehead, resulting in decreased scar visibility, improved scar appearance, and favorable patient acceptance.
References:
1. Bowman PH, Ratz JL, Knoeff TG, et al. Basosquamous Carcinoma. Dermatol Surg 2003;29:830-833.
2. Ransom ER, Jacono AA. Double-Opposing rotation-advancement flaps for closure of forehead defects. Arch Facial Plast Surg 14(4), Sept. 2012