Management of a Locally Advanced Central Face Basal Cell Carcinoma: From Micrographic Excision to Multi-segment Reconstruction

Abstract

Introduction: Basal cell carcinoma (BCC) is the most frequent cutaneous malignancy and may cause substantial local tissue destruction when diagnosis and treatment are delayed. Tumours of the central face are particularly challenging because oncological clearance must be balanced with preservation of the nasal, cheek, and upper lip aesthetic subunits. Case Presentation: A 65-year-old farmer presented with a 20-year history of an extensive lesion involving the left alar rim, cheek, and upper lip. Initial excision with a 5 mm margin and histopathological assessment by the Slow Mohs technique identified an infiltrative BCC measuring 3.5 × 2 cm, with involvement of the underlying muscle plane and positive superior, inferior, and deep margins. A further Slow   Mohs-guided excision of the positive margins was performed and achieved negative margins. The final full-thickness defect involved three major facial units, including transfixing involvement of the alar rim and extension to the upper white lip. Reconstruction was planned after confirmation of oncological clearance. A paramedian forehead flap was used for the nasal component, a Mustardé cervicofacial rotation-advancement flap for the cheek, and a Gillies perioral rotation flap for the upper lip. This multi-segment approach aimed to restore contour, cutaneous continuity, and oral sphincter function while respecting facial aesthetic units. At 18 months post-operatively, the clinical result documented restoration of facial contour and continuity. Conclusion: This case demonstrates that staged margin-controlled excision with Slow Mohs, followed by tailored multi-segment flap reconstruction, can address locally advanced central facial BCC while supporting oncological safety, tissue preservation, and functional-aesthetic reconstruction.