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Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 217-219

An interesting case of synchronous basal cell carcinoma of face successfully treated by surgery

1 Dermatologist, Zonal Hospital Dharamshala, H.P, India
2 Department of Burns and Plastic surgery, AIIMS Bilaspur, H.P, India
3 Department of Pathology, Dr RPGMC Tanda, H.P, India

Date of Submission18-Jun-2020
Date of Decision11-Sep-2020
Date of Acceptance23-Nov-2020
Date of Web Publication26-Aug-2021

Correspondence Address:
Navneet Sharma
Assistant Professor, Department of Burns and Plastic Surgery, AIIMS Bilaspur, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CDR.CDR_96_20

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Basal cell carcinoma (BCC) is the most common type of nonmelanocytic tumor. Multiple BCCs are generally associated with heredo-familial conditions or syndromes, but in sporadic cases, multiple BCCs are relatively rare. They tend to occur in synchronous or metachronous manner, but in our setup, synchronicity is uncommon and metachronous BCCs are attributed mainly to reoccurrence. We present a case of dual BCC of face with synchronicity and different histopathology, treated with wide local excision using full-thickness grafting and V-Y advancement flap.

Keywords: Basal cell carcinoma, flap, synchronous

How to cite this article:
Pathania S, Sharma N, Bodh TD. An interesting case of synchronous basal cell carcinoma of face successfully treated by surgery. Clin Dermatol Rev 2021;5:217-9

How to cite this URL:
Pathania S, Sharma N, Bodh TD. An interesting case of synchronous basal cell carcinoma of face successfully treated by surgery. Clin Dermatol Rev [serial online] 2021 [cited 2021 Dec 1];5:217-9. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/2/217/324585

  Introduction Top

Basal cell carcinoma (BCC) was first described by Jacob in 1827. It arises from the basal cell layer of the epidermis. Being locally invasive and infiltrative in nature, it is also known as rodent ulcer. Its etiology is multifactorial including ultraviolet (UV) radiation exposure and genetic predisposition. Its incidence is less in the Asian population as compared to that of Caucasian, and multiple BCCs are still a rarer entity.

  Case Report Top

A 78-year-old female (Fitzpatrick skin type III) presented with a reddish lesion over the glabellar region for the last 1 year, which was of size 1 cm × 1 cm initially but gradually progressed to the size of ~6 cm × 4 cm. There was a history of occasional bleeding from the lesion. After 4 months, the patient developed another pigmented lesion over the right lower eyelid which was initially about 0.5 cm × 0.5 cm in size, but over a period of 6 months, it encroached 2/3rd of the lower eyelid. There was no history of similar lesions in the family. Examination revealed a 6.5 cm × 4.5-cm, single, hyperpigmented plaque with well-defined margins over the glabellar region extending up to the forehead. Areas of crusting were present in between. The lesion was freely mobile and was not fixed to the underlying structures [Figure 1]. Another dark pigmented lesion was present over the right lower eyelid encroaching the middle 2/3rd of the lid of size approximately 3 cm × 1 cm [Figure 1]. Palpebral conjunctiva was involved near the lid margin. There was no evidence of lymphadenopathy. Systemic examination was normal. Punch biopsy from both the lesions was suggestive of BCC. The patient was thus planned for wide local excision (WLE) of both lesions with simultaneous reconstruction.
Figure 1: A well-defined erythematous plaque with areas of crusting at places present on the forehead, another pigmented lesion on the right lower eyelid

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WLE of the forehead growth was done with 0.5 cm of normal tissue and the defect was covered with a full-thickness graft harvested from the groin region. The pigmented lesion of the right lower eyelid was excised with 0.3 mm of margins with full-thickness loss of approximately 60% of the lower eyelid [Figure 2]a. Closure of the palpebral conjunctiva and tarsal plate was done primarily, and V-Y skin advancement flap was raised from the infraorbital region for the outer covering of the lower lid [Figure 2]b. The entire surgery was performed under local anesthesia. The postoperative course was uneventful. Histopathology of the skin lesions revealed superficial spreading type of BCC over the forehead and pigmented BCC over the eyelid [Figure 3].
Figure 2: (a) Intraoperative picture showing defect of the right lower eyelid and forehead. (b) Immediate postoperative reconstruction of the eyelid with V-Y advancement flap and full-thickness graft over the forehead

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Figure 3: (a) Islands and nest of basaloid cells arising from the epidermis. Cells are uniform with hyperchromatic nuclei. At places, pigment deposits can be seen (H and E, ×10). (b) Small cords and nests of basaloid cells scattered in the dermis separated by collagenous stroma (H and E, ×10)

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  Discussion Top

BCC is a skin cancer with low mortality owing to its nature of being locally invasive and rarely metastatic. The reported incidence of BCC in the Asian population is relatively low, 16–20/100,000 (same ratio of sex) as compared to that of Caucasians with an incidence of 400/100,000 in males and 200/100,000 in females.[1],[2] Multiple BCCs are still rarer, however the true incidence is unknown. Western literature have demonstrated the incidence of multiple BCC as approximately 30% as compared to single BCC that can occur either in synchronous or metachronous manner.[2],[3] The main risk factors for the development of multiple BCCs are male sex, UV exposure, red hair, Fitzpatrick skin Types I–III (high tendency to develop sunburn), and higher educational levels.[4] Nodular BCC is the most common variant seen in both solitary and multiple BCCs. In the case of multiple BCC, the second most common variant is superficial spreading type in >50% of cases.[2] Early age of presentation of primary BCC and superficial spreading type variant are significantly associated with increased risk of developing a second BCC.[5] A location other than the head or neck is a risk factor for developing multiple lesions, especially the ones located on the upper extremities.[6] However, in our case, both the lesions were present on the face and were of pigmented and superficial spreading type, which makes our case unique from that of previous studies. Treatment modalities include conventional surgical excision, Mohs micrographic surgery, and nonexcisional ablative techniques. Surgical excision is the most commonly practiced and most effective treatment. However, in an area like face where vital structure preservation and anatomy restoration is important, surgical modality becomes challenging. In our case, WLE of both lesions was done, and reconstruction of the forehead was done with full-thickness grafting and lower lid anterior lamella reconstruction was done with V-Y advancement flap.

The challenge in the reconstruction of eyelid is to replace each layer, that is, both anterior and posterior lamella with intervening cartilage support. In our case, the defect was approximately 80% of the anterior lamella and 60% of the posterior lamella. Hence, the conjunctiva and tarsal plate were repaired primarily and the remaining anterior defect was closed with V-Y advancement flap.

Full-thickness defects up to 50% of tissue loss in young patients and up to 60% in older people can be repaired primarily. As the wound defect approaches 50%, closure with local tissue advancement is required and in many cases, a lateral canthotomy is required. These local flaps include Tenzel semicircular flap, unipedicled Fricke flap, Hughes transconjunctival flap, and Mustarde flap.[7] However, all these procedures are more complex. Because our patient was an elderly with two large lesions, we planned simpler single-stage surgery under local anesthesia as a day-care procedure. The V-Y advancement flap is a simple and easy flap which is very useful to reconstruct small defects of face, as there is ample and mobile adjacent tissue. It provides similar color and texture to the area being reconstructed.[8]

Advanced age, female gender, and synchronous BCC of two different histopathological types were the highlights of our case. In addition, BCC was managed with simple surgical intervention, resulting in acceptable cosmetic outcome [Figure 4].
Figure 4: Follow-up picture showing no evidence of ectropion and 100% graft uptake with acceptable cosmetic appearance after 3 months

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Li CL, Chen YC, Yang KC, Chen LW. Different histopathologic profiles and outcomes between sun-exposed BCC and non-sun-exposed BCC. Sci Rep 2020;10:1-8.  Back to cited text no. 1
Adachi K, Yoshida Y, Noma H, Goto H, Yamamoto O. Characteristics of multiple basal cell carcinomas: The first study on Japanese patients. J Dermatol 2018;45:1187-90.  Back to cited text no. 2
Richmond-Sinclair NM, Pandeya N, Ware RS, Neale RE, Williams GM, van der Pols JC, et al. Incidence of basal cell carcinoma multiplicity and detailed anatomic distribution: Longitudinal study of an Australian population. J Invest Dermatol 2009;129:323-8.  Back to cited text no. 3
Kiiski V, de Vries E, Flohil SC, Bijl MJ, Hofman A, Stricker BH, et al. Risk factors for single and multiple basal cell carcinomas. Arch Dermatol 2010;146:848-55.  Back to cited text no. 4
Verkouteren JAC, Smedinga H, Steyerberg EW, Hofman A, Nijsten T. Predicting the risk of a second basal cell carcinoma. J Invest Dermatol 2015;135:2649-56.  Back to cited text no. 5
Ramachandran S, Fryer AA, Smith A, Lear J, Bowers B, Jones PW, et al. Cutaneous basal cell carcinomas: Distinct host factors are associated with the development of tumors on the trunk and on the head and neck. Cancer 2001;92:354-8.  Back to cited text no. 6
Thorne C, Chung KC, Gosain A, Guntner GC, Mehrara BJ. Grabb and Smith's plastic surgery: Editor-in-chief, Charles H. Thorne ; editors, Kevin C. Chung, Arun Gosain, Geoffrey C. Gurtner, Babak Joseph Mehrara, J. Peter Rubin, Scott L. Spear (Seventh edition.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health. (2014).  Back to cited text no. 7
Fukudome EY, Bharadia DR, Helm DL, Sinha I. Extended VY Advancement Flap Reconstruction of a Large Posterior Upper Midline Trunk Defect. Plastic and Reconstructive Surgery Global Open. 2016;4(5):e713.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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