An unusual complication of nasolabial flap reconstruction

Abstract

Squamous cell carcinoma is the most common carcinoma in the oral cavity. Resection of these cancers often requires reconstruction. Nasolabial flaps are a robust and reliable local flap that provide a satisfactory outcome. We report two cases where an epidermoid cyst developed within the scar of the nasolabial flap and review the literature. KEYWORDSNasolabial flap -Epidermoid cyst -Inclusion cyst Case 1An 81-year-old woman presented to our head and neck clinic with a firm and enlarging mass in the soft tissues of her left cheek, which had developed rapidly. She had a recent history of a T2 moderately differentiated SCC, which had been excised completely from the left floor of her mouth. The defect had been reconstructed with a two-stage, inferiorly-based, left-sided nasolabial flap. The new mass measured 4cm in diameter and was fixed to the overlying skin at the inferior limit of the nasolabial flap donor site scar (Fig 1). Swelling in the buccal vestibule produced a homogenous hyperkeratotic appearance of the mucosa abutting the teeth. There was no other evidence of local or regional recurrence.Fine needle aspiration produced a small amount of necrotic material containing scanty atypical squamous cells, which were suspicious for metastatic SCC. Magnetic resonance imaging (MRI) was also suggestive of local recurrence but showed no other nodal disease. Recurrent metastatic SCC in the facial lymph node group was strongly suspected.Follow-up review proved unusual as the mass had drained spontaneously and disappeared following the MRI. There was still overlying firmness in the left nasolabial area and histology from a biopsy revealed an inflammatory picture. Multinucleate giant cells were present around hair follicle material with surrounding fibrosis, in keeping with an inclusion cyst. To date, there remains no evidence of recurrent disease. Case 2A 76-year-old presented to our head and neck clinic with a sudden onset swelling in the right cheek of 1 week's duration. She had a history of a T2 N0 M0 SCC of the right mandibular alveolus, which was excised completely seven years previously. Furthermore, 18 months previously, she was diagnosed with a new T1 N0 M0 SCC of the right cheek mucosa. This was treated with wide local excision and a two-stage nasolabial flap repair. The new lesion was firm and measured 2cm in diameter with surrounding erythema (Fig 2). A recurrence was suspected. Open biopsy revealed an epidermoid cyst and imaging did not indicate metastatic disease. The patient underwent a further excision of the cyst, which showed dermal scarring only, and made a good recovery.