Case 21 2026: Reconstructing the Challenging Eyelid: Hard Palate Graft and Radial Forearm Free Flap Reconstruction in Gorlin–Goltz Syndrome

Keywords: Gorlin-Goltz Syndrome, Recurrent Basal Cell Carcinoma, Radial Forearm Free Flap, Hard Palate Graft, Oncology, Plastic Surgery, Ophthalmology, Dermatology, Complex Eyelid Reconstruction Authors: Miss Ketki Kaushal, Mr Oliver Bassett Abstract Gorlin-Goltz syndrome, also known as Nevoid Basal Cell Carcinoma Syndrome, is a rare autosomal dominant condition associated with pathogenic variants in the PTCH1 gene and dysregulation of the Hedgehog signaling pathway. A patient with longstanding disease presented with recurrent periocular basal cell carcinoma requiring Mohs excision, resulting in a large full-thickness lower eyelid defect. Reconstruction was performed using a hard palate graft for posterior lamella replacement and a radial forearm free flap with palmaris longus tendon sling for anterior lamella and structural support. Microvascular anastomosis to facial vessels was performed. This case highlights the reconstructive challenges of periocular defects in NBCCS and emphasises multidisciplinary management. Patient medical history A 59-year-old male with a longstanding history of Gorlin–Goltz syndrome (Nevoid Basal Cell Carcinoma Syndrome) diagnosed in 1997 has been under multidisciplinary care involving dermatology, plastic surgery, oncology, and ophthalmology for multiple recurrent basal cell carcinomas. His medical history includes hypertension, iron deficiency anaemia secondary to diverticulosis, chronic gastritis with duodenal ulcer disease, and melanoma in situ of the right knee excised in 2016. He has undergone numerous treatments for cutaneous malignancies including repeated surgical excisions, Mohs micrographic surgery, topical therapies (5-fluorouracil and imiquimod), and reconstructive procedures. In 2012 he underwent Mohs surgery for an infiltrative basal cell carcinoma of the left lower eyelid. Over subsequent years, multiple lesions were treated across the face, temples, ears, forearm, and calf. Since April 2016 he has been managed with the He