The bilobed flap is a local transposition flap useful for the repair of nasal defects commonly seen after Mohs surgery. The bilobed flap has benefits over other nasal transposition or advancement flaps because it distributes wound closure tension over a larger surface area through the use of 2 lobes. This property is especially helpful for defects of the caudal portion of the nose, where the skin is less elastic. This article discusses the bilobed flap for nasal reconstruction along with the appropriate selection, design, and placement of the flap and the potential complications.
Bilobed flaps are local flaps useful for the reconstruction of nasal defects. These flaps are especially useful for defects of the caudal portion of the nose. Defects in this region pose a reconstructive challenge because the skin is thick, sebaceous, and lacks elasticity. Significant advancement, rotation, or transposition in this area can result in distortion of the nasal tip.
The bilobed flap is a double transposition flap whose basic principle relies on transposing mobile skin from the cephalic portion of the nose in order to close defects of the thicker immobile skin of the caudal portion of the nose. This double transposition flap distributes tension over an area greater than a single transposition, allowing for successful closure of defects in the inelastic skin of the nose.
The bilobed flap for nasal reconstruction was first described by the Dutch surgeon Esser in the early twentieth century. He described a total transposition arc of greater than 180°. The large degree of rotation created large lobes that required the flap to extend into the glabella, resulting in significant standing cutaneous deformities. Later in the twentieth century, McGregor and Soutar discussed the use of the bilobed flap with smaller pivotal arcs, which resulted in smaller standing cutaneous deformities and decreased pincushioning. Zitelli’s modification of the bilobed flap emphasized a total pivotal arc no greater than 90° to 110°, with an approximately 45° pivotal arc between each lobe. His results demonstrated the practical utility of this flap in nasal reconstruction.
Flap selection
Bilobed flaps are ideal for defects of the central or lateral nasal tip that range up to 1.5 cm in size. These flaps are best suited in the distal third of the nose, where most other skin flaps would cause significant distortion of the nasal tip. Defects that extend onto the nasal ala are generally not favorable for this type of repair because of a high likelihood for alar retraction. The defect should be at least 0.5 cm away from the nostril-free margin in order to reduce the risk of notching.
Bilobed flaps may also be used to repair more cephalically positioned nasal defects; however, size limitations exist as the donor site of the second lobe moves cephalad. In these cases, the second lobe donor site would be located at the medial canthus or glabella and donor site closure may lead to distortion of these structures, compromising the overall aesthetic and functional reconstructive outcomes. In these locations, alternative flap selection may lead to a more desirable outcome.
Bilobed flaps are especially advantageous for defects whose depth extends into and past the level of the subcutaneous fat, which is the main benefit of the bilobed flap over skin grafts when considering reconstruction of the nasal tip. Skin grafts placed over deeper defects often results in visible depressions over the nose and a less-than desirable aesthetic result. The depth of the nasal defect often dictates the use of a bilobed flap over a skin graft in this area.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
