The nasolabial flap (NLF) reconstruction technique is the oldest soft tissue flap technique since 700 BC. Started from there, the NLF technique has been used for reconstruction of the facial skin in skin dome replacement, nasal reconstruction, alar reconstruction and internal lining of the nose. Furthermore, the NLF technique is useful to resurface anterior floor of the mouth defects, replacement of buccal mucosa, oronasal fistula closure in palate and reconstruction of tongue [1]. Basal Cell Carcinoma (BCC), previously known as basal cell epithelioma, is the most common cancer in Humans. BCC mostly arises on sun-damaged skin and rarely develops on the mucous membranes or palms and soles. Basal cell carcinoma is usually a slow-growing tumor for which metastases are rare [2]. Although rarely fatal, BCC can be highly destructive and disfigure local tissues when treatment is inadequate or delayed. On clinical examination, BCC usually appears as flesh- or pink-coloured, pearly papules with overlying ulceration or telangiectatic vessels. BCC occurs on the head or neck in most cases but can involve the trunk and extremities [3]. A multitude of reconstructive options are available and with the advent of musculocutaneous flaps and free microvascular tissue transfer, orofacial reconstruction has entered an era of sophistication whereby repair of defects of all types and sizes has become possible. However, these techniques are not suitable for every patient, as at times, either the defect is too small or the patient's age and medical status do not permit a prolonged general anaesthesia and lengthy surgical procedure. The nasolabial flap represents the available local tissue that often avoids these problems for repair of 2-<5 cm extra or intra-oral defects [4]. Currently the proven reliability of the nasolabial flap, with its predictable functional and acceptable aesthetic results, makes it the ideal local flap for reconstruction of oral defects that are too large for primary closure and too small for conventional musculo-cutaneous and micro vascular free flaps. Other major advantages of this flap are its versatility, easy to raise flap, a quick single stage procedure [5]. NLF is a very resourceful flap for the defect of basal cell carcinoma in the maxillofacial region. However, the reconstruction of the lip defect, which is a maxillofacial structure associated with the oral cavity, requires more attention and surgical consideration [1]. Herein, we report a case of nasolabial flap procedure of Basal Cell Carcinoma (BCC) on upper lip.

A 45-year-old female, farmer by occupation for more than 20 years, came to our hospital with an ulcerated nodule lesion on the upper lip for five years. The lesion was located above the left oral commissure. It was approximated one-sixth of entire upper lip size (Figure 1). There were purulent discharge and infrequent bleeding from the ulcerated lip. Meanwhile the ulcer was no associated with pain.

The fine-needle aspiration biopsy revealed BCC. We planned for wide-local excision with clearance borders of 5 mm. The lip reconstructive option was left nasolabial flap for lining and cover. The size of NLF was 8.3 x 2 cm (Figure 2). Then, we continued to perform wide-local ulcerated upper lip excision.

Post-excision defect included upper-left vermilion, orbicularis oris muscle, left oral commissure and buccal mucosa beneath the lesion. It had dimension and full depth loss approximately 2 x 1.5 x 0.7 cm. Further, we began with NLF for lining and covering (Figure 3). Histopathology confirmed the BCC diagnosis without metastases in the ulcerated margin. The patient was discharged from hospital on the seven post-surgical day. There were no further complication such as hematoma and infection. One week follow-up we removed the suture and the patient was satisfy with the cosmetic and oral functional result.

Figure1: Phisical Examination

Figure 2: Durante Operation

Figure 3: Post op

Basal cell carcinoma is one of the malignancies of tumor on the skin. It approximately 20% of all new diagnoses of cancer and 90% of all cutaneous malignancies recorded [6,7]. The most common craniofacial sites were the nose, cheek, forehead and temple [8]. Increase with age, ranged 36-103 years old, ratio male to female 1:1.38 and more frequent in geographic locations with greater UV exposure [9]. In this case, a 45-year-old female, farmer by occupation for more than 20 years, had an ulcerated nodule lesion on the upper lip for five years. There were purulent discharge and infrequent bleeding from the ulcerated lip. Meanwhile the ulcer was no associated with pain. In BCC, patients have an history of crusting and recurrent bleeding. Treatment of BCC is usually surgical which are the main goals of treatment are to completely remove the tumour to prevent recurrency, to give the best cosmetic, to correct any functional impairment resulting from the tumour. In this case, the patient was planned for wide-local excision with clearance borders of 5 mm. The lip reconstructive option was left nasolabial flap for lining and cover. The nasolabial flap size was 8,3 x 2 cm. The purpose was to lining and covering. Then, continued to perform wide-local ulcerated upper lip excision. In general, the reconstructive procedure depends on the size and location of the defect [8]. Some NLFs can be designed to have an axial pattern blood supply which include the inferiorly based axial nasolabial flap that is nourished by facial artery and the superiorly based reverse flow NLF containing angular artery [10,11]. The nasolabial flap is a local arterialized flap with an axial blood supply provided either by the facial artery (inferiorly based flap) or by the superficial temporal artery through its transverse facial branch and the infraorbital artery (superiorly based flap). 1 1-13 It is a reliable, versatile and easy to raise flap for a variety of small to medium sized defects in the orofacial region [7]. The first nasolabial flap for intraoral reconstruction was reported toward the end of the 19th century [4]. In the postoperative results we find that there is no retraction on the left cheek because NLF follows RSTL, the shape of the right cheek and the left cheek is relatively the same although there is a slight asymmetry in the edge of the left lip. The NLF technique that we are doing is a combination of flap interpolation with v-y flap. After follow up, no inflammation, pus or fistula was found. The patient is able to speak well, move his cheeks freely and most importantly is able to chew food well.

The NLF is the best choice technique for BCC. It is a very useful and reliable flap for the lip defect coverage. It gives better color and contour match with surrounding soft tissue of the lip. Despite some cases reported that majority of lip reconstruction required prolonged post-operative time and sometimes need a second surgical intervention. NLF still represents as a good option for achieving good oral opening for speech, chewing and dental hygiene.

1. Rahpeyma, A. and S.Khajehahmadi. “Unilateral One Stage Nasolabial Flap for Reconstruction of the Lips.” Journal of Maxillofacial and Oral Surgery, vol. 14, no. 2, 2015, pp. 234-239.

2. Walocko, F. et al. “Basal Cell Carcinoma Histopathologic Upgrading and Mohs Micrographic Surgery: A Single Institution, Retrospective Review.” Archives of Dermatological Research, vol. 314, no. 7, 2022, pp. 705-707.

3. Wollina, U. et al. “Basal Cell Carcinoma of the Outer Nose: Overview on Surgical Techniques and Analysis of 312 Patients.” Journal of Cutaneous and Aesthetic Surgery, vol. 7, no. 3, 2014, p. 143.

4. Singh, S. et al. “Nasolabial Flap Reconstruction in Oral Cancer.” World Journal of Surgical Oncology, vol. 10, no. 1, 2012, p. 1.

5. Chandraiah, R.B. et al. “Versatility of the Inferiorly Based Nasolabial Flap for Reconstruction in Early Oral Cancer Patients: Our Experience in a Tertiary Cancer Centre.” International Journal of Otorhinolaryngology and Head and Neck Surgery, vol. 6, no. 12, 2020, p. 2207.

6. Kondo, R.N. et al. “Recurrence Rate of Basal Cell Carcinoma in Patients Submitted to Skin Flaps or Grafts.” Anais Brasileiros de Dermatologia, vol. 94, no. 4, 2019, pp. 442-445.

7. Sinha, V. et al. “Nasolabial Flap: Versatile Flap for Basal Cell Carcinoma Nose.” Indian Journal of Otolaryngology and Head and Neck Surgery, 2020, pp. 1-5.

8. Devine, C. et al. “Epidemiology of Basal Cell Carcinoma: A 10-Year Comparative Study.” British Journal of Oral and Maxillofacial Surgery, vol. 56, no. 2, 2018, pp. 101-106.

9. Choi, J.H. et al. “Distribution of Basal Cell Carcinoma and Squamous Cell Carcinoma by Facial Esthetic Unit.” Archives of Plastic Surgery, vol. 40, no. 4, 2013, pp. 387-391.

10. Dika, E. et al. “Basal Cell Carcinoma: A Comprehensive Review.” International Journal of Molecular Sciences, vol. 21, no. 15, 2020, pp. 1-11. https://doi.org/

11. Mahipathy, S.R.R.V. et al. “Nasolabial Flap Cover for a Defect Following Excision of Basal Cell Carcinoma Nose.” Scholars Journal of Applied Medical Sciences, vol. 9, no. 6, 2021, pp. 1053-1055.