Bilobed Flaps


Article Author:
Rosalind Mole


Article Editor:
Talel Badri


Editors In Chief:
Brian Downs
Ziad Katrib


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Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/1/2019 5:05:45 PM

Introduction

The bilobed flap is a local flap used primarily for the reconstruction of small to moderate cutaneous nasal defects. It was first described in 1918 by Esser for use in nasal tip reconstruction. The original flap used a rotational arc of 180 degrees and based the second lobe superiorly towards the glabellar region. In 1953 Zimany demonstrated that the second and third lobes could be smaller than the first and that the flap could be utilized for reconstruction in more anatomical areas. In the 1980s McGregor and Soutar introduced the concept that a reduced pivotal angle would result in smaller standing cutaneous deformities and decreased pin-cushioning. Zitelli went onto to describe limiting the total rotational arc to between 90 to 110 degrees. This is the most common modification in use today. This overview of the bilobed flap will focus on the most recent modification. It will describe the relevant anatomy, the situations in which you might choose to use the bilobed flap, and describe in detail how to plan and execute this valuable flap.[1][2][3]

Anatomy

The bilobed flap is a double transposition flap where the first flap (or lobe) is utilized to fill the primary defect, and a further flap (or lobe) is used to fill a secondary defect. This seeks to distribute the tension across a wider area. It is a random pattern flap. The random pattern nature of the flap means that the flap has no specified blood supply. The flap is supplied by musculocutaneous and cutaneous arteries which perforate through the subcutaneous tissue.[4][5][6]

Indications

The bilobed flap was first described for it use in reconstruction of the nasal tip using a rotational arc of 180 degrees and having the second donor site in the glabellar region. This technique has fallen out of favor as the large arc created large flaps which require significant undermining. It is now more commonly used for reconstruction of the lateral portion of the nose. It utilizes the mobile skin of the cephalic part of the nose to reconstruct the more immobile skin in the caudal part of the nose. The second donor site should remain in the superior plane towards the glabella (see image). 

The bilobed flap is very versatile, and although frequently associated with nasal reconstruction, it is in fact very useful in many anatomical locations. Tissiani et al. describe the versatility of the bilobed flap in a case series of 42 patients who had bilobed flaps undertaken in a wide range of anatomical sites including, but not limited to, cheek, upper lip, zygoma, upper limb, and lower limb. [7][8][9]

Contraindications

Cutaneous scars in the flap donor area is a contraindication.

Equipment

This procedure can be undertaken with a standard, minor operations surgical set.

Personnel

This local flap is most commonly undertaken by plastic surgeons and dermatologists. As it is performed in a sterile field, a scrub nurse and a theatre runner are important members of the team.

Preparation

Patients should be educated about what to expect from the surgery. This includes counseling the patient about the theatre setting, explanation of the procedure and possible complications, and what to expect in the post-operative period. The patient is then asked to sign a consent form. 

Technique

The vast majority of these flaps will be undertaken under local anesthetic. The infiltration of the local anesthetic often results in distortion of lines of contour. Therefore, the flap should be planned and drawn prior to the infiltration of local anesthetic. 

We shall use the example of the side wall of the nose to illustrate planning the bilobed flap. When planning local flaps on the nose, it is advisable to try and avoid crossing the delineation of the nose and the cheek. The second lobe of the flap should be positioned superiorly, pointing towards the glabellar region.

Firstly, the lesion due to be removed should be marked with an appropriate margin circumferentially. The pivot point should be marked across the dorsum of the nose 0.75-1 x the wound diameter. The first transposition flap (lobe) should be the length of the defect with a narrower base. The second transposition flap (lobe) should be slightly longer, have a narrower base than the first lobe, and be excised with a triangular tip. This triangular excision will produce a linear scar and decrease the chance of having a dog ear. The pivot point is the right angle produced by the horizontal axis through the midpoint of the defect and the vertical axis through the midpoint of the second lobe. This produces a total transposition arc of 90 degrees, with each transposition flap having an arc of 45 degrees. The triangle of skin which traverses the area between the defect and the pivot point is excised as excess. The local flap should then be raised as per the pre-operative markings. Ensure the thickness of the flap is uniform and appropriate to fill the defect. The first step of insetting the flap is a deep suture with an absorbable stitch at the angle created by the separation of the lobes (see figure, x to x). The remainder of the flap is then secured in place. The tip of the second lobe requires trimming to fit nicely into the secondary defect created by the first lobe.

Complications

The possible complications specific to this procedure are swelling, scarring, flap necrosis, infection, and bleeding. Due to the crescentic shape of the flap, it is at risk of developing pincushion deformity as a result of tissue contraction beneath the flap. With less tension, this is improved. The small rotation arc helps to reduce tension. Standing cutaneous deformities are also a risk and again can be reduced with a smaller rotation arc. In the original bilobed flap as described by Esser as a 180-degree rotation, standing cutaneous deformities were almost inevitable. If the tension of the flap is too great, it can undergo necrosis. Infection can occur in any area of the wound, but it is most associated with areas of necrosis. Bleeding post-operatively can result in hematoma formation which can go on to compromise the flap.

Clinical Significance

The bilobed flap is a versatile local flap that spreads tension vectors across a wide surface area and recruits skin from areas where there is relative mobility to close defects in areas where the skin is relatively immobile. 

Enhancing Healthcare Team Outcomes

The bilobed flap is versatile and can be used in many parts of the body to revise or reconstruct skin defects. The flap is primarily performed by the plastic surgeon. Wound care nurses and physicians who have patients with facial and extremity defects that need closure should consult with a plastic surgeon.


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    Designed and annotated by Rosalind Mole and Alicja Moore
Attributed To: Designed and annotated by Rosalind Mole and Alicja Moore

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Bilobed Flaps - Questions

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A 66-year-old gentleman presents with an 8-month history of a lesion on the side of his nose. It has an ulcerated center and a rolled pearly edge. On clinical assessment, you diagnose a basal cell carcinoma and plan to excise it and reconstruct the defect using a bilobed flap. When planning the flap, what is the optimum angle of the rotational arc?



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You are seeing a 78-year-old lady in clinic 4 weeks after a bilobed flap reconstruction of a nasal defect from a completely excised squamous cell carcinoma. It has healed very nicely with good contour of the nose. What type of local flap is a bilobed flap?



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An 80-year-old gentleman presents to the plastic surgery clinic with a 10 mm ulcerating lesion over his right zygoma. He is listed to have this removed under local anesthetic with a 4 mm margin. Due to the size of the lesion, the defect is unlikely to close directly and therefore requires a local flap reconstruction. Where is the most common location to undertake a bilobed flap?



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You are undertaking a minor operation using local anesthetic on a 71-year-old gentleman who requires excision of a basal cell carcinoma from the side wall of his nose and reconstruction using a bilobed flap. When planning the flap how should you approximately size the base of each lobe in relation to the diameter of the defect?

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    Designed and annotated by Rosalind Mole and Alicja Moore
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A 79-year-old lady attends the plastic surgery outpatient clinic 6 weeks following a bilobed flap to reconstruct a defect on her nose following excision of a well-defined basal cell carcinoma. She is unhappy as the flap looks “puffy.” On examination, you identify pincushion deformity of the flap. What is the cause of pincushioning?



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Bilobed Flaps - References

References

Maher IA, Extrapolating Straight Lines to Curves: Can the Dynamics of Z-Plasties Be Applied to Bilobed and Trilobed Flaps? Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2019 Mar 28;     [PubMed]
Kim YH,Yoon HW,Chung S,Chung YK, Reconstruction of cutaneous defects of the nasal tip and alar by two different methods. Archives of craniofacial surgery. 2018 Dec;     [PubMed]
Filitis DC,Fisher J,Samie FH, Reconstruction of a surgical defect in the popliteal fossa: A case report. International journal of surgery case reports. 2018;     [PubMed]
Ramanujam CL,Zgonis T, Use of Local Flaps for Soft-Tissue Closure in Diabetic Foot Wounds: A Systematic Review. Foot     [PubMed]
Knackstedt T,Lee K,Jellinek NJ, The Differential Use of Bilobed and Trilobed Transposition Flaps in Cutaneous Nasal Reconstructive Surgery. Plastic and reconstructive surgery. 2018 Aug;     [PubMed]
Grieco MP,Bertozzi N,Grignaffini E,Raposio E, Nose defects reconstruction with the Zitelli bilobed flap. Giornale italiano di dermatologia e venereologia : organo ufficiale, Societa italiana di dermatologia e sifilografia. 2018 Apr;     [PubMed]
Bednarek RS,Ramsey ML, Transposition Flaps 2019 Jan;     [PubMed]
Couceiro J,De la Red-Gallego M,Yeste L,Ayala H,Sanchez-Crespo M,Velez O,Barcenilla R,Del Canto F, The Bilobed Racquet Flap or Extended Seagull Flap for Thumb Reconstruction: A Case Report. The journal of hand surgery Asian-Pacific volume. 2018 Mar;     [PubMed]
Kelly-Sell M,Hollmig ST,Cook J, The superiorly based bilobed flap for nasal reconstruction. Journal of the American Academy of Dermatology. 2018 Feb;     [PubMed]

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