Porocarcinoma of the nose- reconstructed with seagull flap Authors:Balasubramaniam, Ramanandham, Pradeep, Sivakumar, Kalpa Pandya Int J Biol Med Res. 2024; 15(1): 7760-7763 https://www.biomedscidirect.com/2847/porocarcinoma-of-the-nose-reconstructed-with-seagull-flap Abstract: Of all the cutaneous tumours, the reported incidence of porocarcinoma is as low as 0.005-0.01%. Very few cases of porocarcinoma of the nose have been described in English literature. Median forehead flap, also known as seagull flap is an excellent reconstruction modality for the nasal defect. We describe here an interesting case of porocarcinoma of the dorsum of the nose which was reconstructed in the first stage using a seagull flap providing the patient with a pleasing nasal profile.

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International Journal of Biological & Medical Research
Int J Biol Med Res. 2024; 15(1): 7760-7763
Porocarcinoma of the nose- reconstructed with seagull flap
a b c d e
Balasubramaniam, Ramanandham, Pradeep, Sivakumar, Kalpa Pandya
A R T I C L E I N F O A B S T R A C T
Keywords:
Case Report
Of all the cutaneous tumours, the reported incidence of porocarcinoma is as low as 0.005-0.01%.
Very few cases of porocarcinoma of the nose have been described in English literature. Median
forehead flap, also known as seagull flap is an excellent reconstruction modality for the nasal defect.
We describe here an interesting case of porocarcinoma of the dorsum of the nose which was
reconstructedinthefirststageusingaseagullflapprovidingthepatientwithapleasingnasalprofile.
Neoplasmsof skin appendages are extremely rare. Porocarcinoma are rare malignancies of the
eccrine glands of the skin.1 Of all the cutaneous tumours, the reported incidence of
porocarcinoma is as low as 0.005-0.01%.2 3 Pink and Mehregan are credited for first
describing this rare clinical entity in 1963 which they termed epidermotropic eccrine
carcinoma.4 Mishima and Morioka described the tumour as porocarcinoma.5 They are most
commonlyfoundintheextremitiesandoccurmoreintheelderly.Theymaypresentasanodule
that may be ulcerated or with a discharging sinus.6 Very few cases of porocarcinoma of the
nose have been described in the English literature. Seagull flap is a midline forehead
musculocutaneous flap supplied by the supratrochlear artery and a random blood supply at its
distal end. This flap delivers excellent aesthetic and functional outcomes for nasal tip loss and
total nasal defect.7 We report a case of porocarcinoma of the nose reconstructed with seagull
flapwithareviewoftherelevantliterature.
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CASE PRESENTATION DIFFERENTIAL DIAGNOSIS
TREATMENT
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A72yearoldfemalereportedtotheoutpatientdepartmentwitha
history of cauliflower like growth approximately 2.5X2 cm in size on
the dorsum of the nose for 2 months. (figure 1A and 1B) The patient
reportedasteadyincreaseinthesizeofthegrowthbutwasotherwise
asymptomatic. The growth was centered over the tip of the nose and
was extending over alae bilaterally. An incisional biopsy suggested a
skin adnexal tumour further suggesting a confirmation with an
excisional biopsy. Computed Tomography (CT) showed the lesion
was involving the septum. There were no clinical or radiologically
suspiciousnecknodes.Thepatientdidnothaveanyco-morbidities.
Porocarcinoma can often be confused with poroma which is a
benign adnexal tumour and often occurring as a precursor of
porocarcinoma. Considering the proliferative nature of the lesion
coupledwithill-definedmargins,wesuspectedittobeamalignant
lesion. With a differential diagnosis of Squamous cell carcinoma
andskinadnexaltumour,thepatientwasplannedfortreatment.
The patient was taken up for wide local excision. (figure 2) The
defect was reconstructed with a median forehead flap (Seagull
flap). The incision was planned with the body of the seagull in the
middle of the forehead with the wings across the transverse brow
lines. (figure 3) The flap was raised as a musculocutaneous flap
with the left supratrochlear vessels at the base. (figure 4) After
achieving adequate mobilization, it was inset on the defect to
reconstruct the alae, dorsum, and columella.(figure 5) Nasal
packing was done to maintain the patency of the nasal aperture.
Thedefectwasclosedprimarily.(figure6).Sincethepatientwas
* Corresponding Author : Dr. Kalpa Pandya
Oral and Maxillofacial Surgery Sri Ramachandra Institute of Higher
Education and Research
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Madurai Medical College, Surgical Oncology
Consultant, Apollo Hospitals, Greams Road, Chennai
Oral and Maxillofacial Surgery Sri Ramachandra Institute of Higher Education and Research -

2. Balasubramaniam et al. Int J Biol Med Res. 2024; 15(1): 7760-7763
7761
not willing for a microvascular free flap, it was decided to
perform nasal lining reconstruction as a second stage procedure.
Thefinalhistopathologywasreportedasporocarcinoma.
Sutures were removed after 10 days. (figure 7) The patient
recovered well and is on regular follow-up. The nasal profile was
found to be pleasing with high patient satisfaction. Patient is being
counseled for a second surgery for reconstruction of the lining and
the cartilage. DISCUSSION Eccrine glands found abundantly on the
palms and soles followed by head and trunk, consist of a spiral
intraepidermal duct (acrosyringium), straight intraepidermal duct
and a secretory coil. Porocarcinoma arises from the above-
mentioned acrosyringium either de novo or as a malignant
transformation of its benign counterpart, poroma. The possible
factors implicated in the malignant transformation of poroma are
chroniclightexposureandimmunosuppression.8Robsonetalhave
published a series of 69 cases of eccrine porocarcinoma in which
the mean age of occurrence was 73 years with a slight predilection
for females. 44% of the porocarcinoma were found in the lower
limbs, 24% in the trunk while those found in the head consisted of
18%.9 In our case, the patient reported with a fungating growth on
the dorsum of the nose. Porocarcinomas typically present as
polypoid nodules which may show ulcerations or even plaque-like
lesions with erosion or infiltration.9 10 Lymph node metastasis
may be seen in 19% of the cases.9 In a systematic review by Nazemi
et al, of the 66 cases of porocarcinoma affecting the head and neck
region, 6% of the patients had lymph nodal involvement.11
Presence of lymph node involvement has shown a high mortality
rate of about 67%.12 Histopathologically, porocarcinoma
demonstrates irregularly dispersed or epithelial cells arranged in
cords or nests. Few duct-like structures may be seen surrounded by
cuticular cells. Cells may demonstrate prominent nucleoli and a
pagetoid distribution (proliferating from bottom to top). Areas of
atypia, mitosis, necrosis and squamous metaplasia are common.13
Lymphovascular invasion may be seen in 15% of the tumours and
about 1% may show perineural invasion.9 Due to the rarity of the
tumour, there are no standard guidelines for the workup and
treatment.11 Radiology has been used at the time of diagnosis in
about 43% of the cases of which computed tomography was the
most commonly employed imaging modality followed by magnetic
resonance imaging. It was seen that clinical palpation could detect
only 6.3% of the lymphadenopathy. Occult lymph node metastasis
was detected in 60% of the cases in which a CT scan was
performed.11 These statistics emphasize the need of performing a
CT scan at the time of diagnosis. Routine metastatic workup must
also be done considering the distant metastatic potential. The most
commonly advocated treatment is wide local excision.6 Neck
dissection is indicated in case of regional lymphadenopathy,
recurrent or poorly differentiated tumours with intra-lymphatic
permeation however role of elective lymphadenectomy is
debatable. Mohs micrographic surgery has also gained interest in
recent times as an alternative to wide local excision.10 So far, there
is no evidence for the administration of adjuvant therapy.14
However it may be considered in cases of adverse pathological
features and lymph node involvement.11 Porocarcinoma is
considered an aggressive entity. The local recurrence rate for
OUTCOME AND FOLLOW-UP
porocarcinoma is about 17%.9 Robson et al have reported a distant
metastatic rate of about 11%.9 In a systematic review by Nazemi et
al, 6.1% of the head and neck porocarcinoma showed lymph nodal
metastasis, stating that of all the sites porocarcinoma of the head
and neck, has the least propensity to metastasize.11 The prognosis
is poor in cases with lymph node metastasis, more than 14 mitoses
anddepthofinvasionmorethan7mm.9Guoetalhavedevelopedan
algorithm for nasal reconstruction after evaluating 300 patients
with nasal defects, where the nose was divided into three subunits:
proximal, middle and distal third. Forehead flap was believed to be
the mainstay for reconstruction of nasal defects spanning across
three zones.15 Since ancient times, forehead flaps have been used
for nasal reconstruction. However, the seagull flap is unique
amongst all as it can reconstruct the nasal bridge, columella and
alae,allatonceprovidingapleasingnasalprofile.7
Figure 1A: Worm's eye view of the proliferative growth on the
nose Figure 1B: Lateral view of the growth on the nose
179x65mm(300x300DPI)
Figure 2: Frontal view of the primary site after resection of the
tumour341x256mm(300x300DPI
Figure 3: Skin marking of the incision for the seagull flap
341x256mm(300x300DPI)

3. 7762
Figure 4: Musculocutaneous seagull flap raised
341x256mm(300x300DPI)
Figure 6: Intra-operative view after flap in-setting
230x409mm(72x72DPI)
FIGURELEGENDS
Fig1A:Lateralviewoftheproliferativegrowthonthedorsumof
thenose
Fig1B:Worm'seyeviewoftheproliferativegrowthonthenose
Fig 2: Frontal view of the primary site after resection of the
tumour
Fig3:Skinmarkingoftheincisionfortheseagullflap
Fig4:Musculocutaneousseagullflapraised
Fig5:Seagullflapmobilizedtocoverthedefect
Fig6:Intra-operativeviewafterflapin-setting
Figure 7: Nasal profile of the patient after 10 days post-
operatively
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Balasubramaniam et al. Int J Biol Med Res. 2024; 15(1): 7760-7763