A Surgical Conundrum: Addressing a Large Nasal Defect Following Mohs Micrographic Surgery

Abstract

Managing large nasal defects following Mohs surgery presents complex reconstructive challenges due to the nose's prominent and visible nature. These cases require a careful balance of preserving structural integrity, optimizing cosmetic outcomes, and maintaining vascular health. In situations where primary closure is impractical due to defect size and location, innovative techniques like the double rhomboid transposition flap offer versatile solutions, addressing both aesthetic concerns and functional requirements. The double rhomboid flap allows surgeons to achieve continuity of surrounding tissue, ensuring aesthetically pleasing texture, color, and thickness while minimizing complications like skin tension and potential airway issues. This case highlights the reconstructive challenges faced in managing large nasal defects following Mohs micrographic surgery for basal cell carcinoma. An 84-year-old male presented with a significant nasal defect following Mohs surgery that involved the dorsum, sidewall, tip, and ala, complicating primary closure due to skin tension and cosmetic concerns. Utilizing a double rhomboid transposition flap technique allowed for effective aesthetic and structural reconstruction, addressing skin tension and preserving nasal symmetry. This case emphasizes the importance of tailored reconstructive strategies to achieve optimal cosmetic and functional outcomes in complex nasal Mohs defects.

Keywords: basal cell carcinoma; dermatology; facial plastic surgery; mohs micrographic surgery; nasal defect.

Figure 1. Pearly telangiectatic papule on the dorsal nose, confirmed as nodular basal cell carcinoma on histology

Figure 2. The 6 cm x 4 cm defect after six stages of Mohs micrographic surgery involving the nasal sidewall, dorsum, and tip

Figure 3. The post-reconstruction defect with a W-shaped scar, aligned with natural crease lines for improved concealment