Re: superficial large Basal cell carcinoma over the face, reconstructed by v-y plasty.

Dear Editor,

Deshmukh et al. published a case of “Superficial large basal cell carcinoma over face, reconstructed by V-Y plasty”.[1]

As the authors suggest, the VY flap is a very versatile option and is an excellent form of reconstruction on the face.[2]

This however is a complex case for both oncological excision and reconstruction, and clearly documents the difficulties encountered in surgical excision and reconstruction in this area.

The options for oncological excision include Mohs micrographic surgery (MMS), surgical excision with a margin and the use of intra-operative frozen sectioning. The reconstructive options include skin grafting and local flap reconstruction as a one-stage or two-stage procedure.

For a large Basal cell carcinoma (BCC), oncological clearance is imperative prior to any reconstruction. MMS is the best method of establishing oncological clearance while minimising the subsequent defect required for reconstruction.[3] Where MMS is not available, suitable surgical oncological clearance must be confirmed prior to definitive local flap reconstruction. In the absence of MMS. this is most commonly performed using frozen sectioning examination intra-operatively.

Where surgical excision with a margin and reconstruction is required where oncological excision has not been confirmed intra-operatively. a skin graft - either split thickness or full thickness-is the best method of initial reconstruction from an oncological standpoint. This allows routine haemotoxylin and eosin assessment as used by the authors[1] to confirm oncological clearance. If oncological clearance is not achieved, a further excision can be performed easily subsequently. This is not the case when a re-excision is required with a local flap reconstruction where theoretically all the local flaps should be removed in the re-excision specimen. A local flap for a defect of this extent would not therefore be recommended as a one-stage reconstructive option without clarification of oncological clearance.

As the authors suggest, a skin graft can lead to a contour defect and is not the ideal aesthetic result. A skin graft however can be removed at a later stage using serial excision, tissue expansion or removal and replacement with a local flap, and clinicians need to be aware of all the oncological and reconstructive options available and the pros and cons of each option.