Bilobed Flap Research Articles

Large bilobed flap in the repair of face and neck defects

While the bilobed flap is an extremely useful flap and its usefulness in coverage of the small facial defects has been well described, there is no report related to its usage as an alternative to regional flaps, tissue expansion technique and free tissue transfers in the face and neck reconstruction. This report presents our experience with nine patients who had skin defects of their face and neck areas reconstructed with large bilobed flaps from adjacent areas. The results of the repair were satisfactory with respect to colour match, texture and functional properties. The purpose of this paper is simply to emphasize that this old and well-known technique for small-sized defects can also be suitable for reconstruction of large defects in the face and neck in selected cases.

Bilobed flaps for nonhealing ulcer treatment.

Healing of round ulcers may be difficult particularly in the plantar area. Rigidity and thickness of the plantar skin do not allow fusiform excision and primary suturing. The bilobed flap is a simple reconstructive technique principally used to repair substantial defects in the facial region. The authors' experience with this local flap in the foot is presented with good short-term results. Between 1995 and 1998, five female and seven male neuropathic foot patients with round plantar ulcers were treated with bilobed flaps. The average age of the patients was 50 (range, 15-76). The average size of the ulcers was 1.6 cm (1-3.2 cm). Debridement and orthotic insoles were used at least for 3 months before considering bilobed flaps. Seven patients were diagnosed as type II diabetes mellitus, four patients had cerebral palsy, and another patient had meningomyelocele. The minimal follow-up period was 1 year (average, 19.5 months). The only complication was wound dehiscence at the lateral side of the heel in a type II diabetic. Subsequently, this complicated ulcer was managed with a sliding flap and skin graft without further problem. The study concluded that nonhealing foot ulcers can be effectively treated with a bilobed skin flap of healthy tissues rotated from nonweightbearing parts of the sole.

Earlobe reconstruction using a Limberg flap in six ears

Many methods of earlobe reconstruction using one or two stages have been described. These have used (i) the superimposition of two flaps, (ii) a single flap lined with a skin graft or (iii) doubled-over single or bilobed flaps. We present a new method of earlobe reconstruction using a doubled-over Limberg flap, which we have used in six ears. This produces a good-looking earlobe, which needs defatting after 3–4 months and suffered minimal necrosis at the tip of the folded flap in three cases. There was no earlobe shrinkage on long-term follow-up.

Meningomyelocele reconstruction with bilobed flaps

A new method for the repair of meningomyeloceles is described. After neurosurgical repair and closure of the placode, the soft-tissue deficit is closed using a bilobed flap. The flap is based superiorly and laterally to the area to be covered. The first lobe crosses the midline above the defect, and the second lobe goes up the midline perpendicular to the first lobe. Once in place, the flap provides a tension-free repair; no suture lines overlie the cord closure.

The rhombic bilobed flap for nasal reconstruction.

The bilobed flap is a useful tool for reconstruction of the nose but is occasionally complicated by pincushioning or trapdoor deformity. To describe the use of a rhombic bilobed flap for use in reconstructing defects on the lower third of the nose. Reconstruction of skin cancer defects following Mohs surgery was performed using a bilobed rhombic flap design in 10 patients. Good to excellent results were seen in 9 of 10 patients. Significant pincushioning was not present postoperatively in any patient. Despite some disadvantages, the rhombic bilobed flap is useful in reconstructing nasal defects on the lower third of the nose.

The contralateral bilobed trapezius myocutaneous flap for closure of large defects of the dorsal neck permitting primary donor site closure

The contralateral bilobed trapezius myocutaneous flap for closure of large defects of the dorsal neck permitting primary donor site closure

The axial bilobed flap for burn contractures of the axilla

The axial bilobed flap, based on the transverse and descending branches of the circumflex scapular artery, was used to successfully reconstruct burn contractures of the axilla. The main advantages of this flap are that the donor site is closed primarily, it provides an adequate amount of healthy and pliable skin with an excellent blood supply and no chance of contraction, and it is an easy technique. In this paper, two cases are presented.

Reconstruction of scalp defects using simple designed bilobed flap.

We have devised a novel rational method to design a bilobed flap. In our method, two triangle flaps are designed; the angle of the first flap is three-fourths the angle of a rhombus at the defect site, and the angle of the second flap is also three-fourths that of the first flap. We have successfully performed reconstruction of scalp defects as large as 50 x 45 mm using simple designed bilobed flaps. The location of the defect was the parietal region in 10 cases, the frontal region in 6 cases, the temporal region in 3 cases, and the occipital region in one case. The advantages of this method for use in reconstruction of scalp defects are as follows: (1) the dispersion tension on the flap provides stable circulation and prevents expansion of scar formation; (2) since the suture line is zigzag, alopecia at the suture line can be hidden under the hair; (3) since this flap is a random pattern flap using galea aponeurotica with blood flow to the skin, flap design is possible for any part of the scalp; and (4) design and elevation of this flap are easy and do not take much time.

THE BILOBED FLAP: A NEW APPLICATION IN THE RECONSTRUCTION OF CONGENITAL THUMB DEVIATION

Congenital radial angulation deformity of the thumb in Rubinstein-Taybi syndrome is generally corrected by a wedge osteotomy of the delta phalanx and a redistribution of the overlying skin using a Z-plasty or, rarely, skin grafting. We describe a new application of the bilobed flap in the reconstruction of the thumb and discuss its advantages over traditional methods in providing tension-free skin cover, excellent access to the delta phalanx and aesthetically acceptable scars.

Simple Method of Designing a Bilobed Flap

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A review of the bilobed flap's design with particular emphasis on the minimization of alar displacement.

The bilobed flap excels in the surgical reconstruction of the distal nose. Unfortunately the aesthetic success of the flap is occasionally limited by the production of distracting alar displacement. To review elements of the bilobed flap's design with a particular emphasis on understanding techniques to minimize distortion of the alar margins. With a proper understanding of the bilobed flap's intricate design, the surgeon can anticipate those factors that are most likely to produce temporary or permanent alar asymmetry. Appropriate prospective flap design and meticulous surgical technique can significantly minimize the risk of a poor surgical outcome.

The bilobed island flap in nasal ala reconstruction

The bilobed island flap in nasal ala reconstruction

Evaluation of five different incisions for correction of radial dysplasia

The complications of the five different incisions used for centralization from 1970 to 1996 were evaluated. In five cases access was by an S- shaped incision, in one with a transposition flap. Sixteen centralizations were done using a radial Z-plasty in combination with an ulnar excision and four by using two opposite Z- plasties, preserving wrist mobility as much as possible. In 1995 and 1996 a bilobed flap was used in seven cases. No complications occurred with the primary procedures prior to 1995. In all seven cases where the bilobed flap was used venous congestion was seen. In four out of these seven superficial necrosis of parts of the flaps occurred. In all cases though wound healing occurred spontaneously by delayed primary healing after the standard 8 weeks of cast immobilization.

The use of a bilobed flap in the correction of radial club hand

A new incision is described for the correction of radial club hand. By the use of a bilobed flap, redundant skin is transferred from the ulnar side of the wrist to the radial side, where there is tension as the wrist becomes straight. The flap has been shown to be safe and effective in six consecutive cases, and access to the wrist and surrounding soft tissue structures is excellent.

Reconstruction of the nose utilizing a bilobed flap.

Defects of the distal nose are particularly challenging to reconstruct because of this area's unique texture, lack of elasticity, and possible distortion of the alar rim. The bilobed flap has been criticized for having a high incidence of "trapdooring," flap necrosis, dog ears, and prominent suture lines. Patients who underwent bilobed flap repairs of the distal nose (n = 171) were reviewed for complications and cosmetic results. The modifications from the traditional design include minimizing the angle of transposition between lobes, thinning of the flap, basing the pedicle on the lateral aspect of the nose, and creating the lobes of the flap to be of equal diameter to the defect. There was a 3% incidence of infection, 7% incidence of partial flap necrosis, and 5% incidence of "trapdooring" and contour distortion. Color match and contour were excellent for all other patients. The modified bilobed flap is an excellent choice for reconstruction of defects of the lower nose because of the good skin match and low incidence of complications.

Bilobed flap variations

Bilobed flaps are useful to reconstruct defects in the lower half of the nose. Using this three-circle technique, one is sure to a create flap which is appropriate in size and rotation for the given defect because its design is dictated by the location of donor tissue. The overall configuration of the three-circle bilobed flap is similar to previous descriptions. However, the design is conceptually different because one is able to choose from a variety of flaps with a gradation of rotation or advancement characteristics. Bilobed flaps are useful to reconstruct defects in the lower half of the nose. Using this three-circle technique, one is sure to a create flap which is appropriate in size and rotation for the given defect because its design is dictated by the location of donor tissue. The overall configuration of the three-circle bilobed flap is similar to previous descriptions. However, the design is conceptually different because one is able to choose from a variety of flaps with a gradation of rotation or advancement characteristics.

Use of the bilobed flap for coverage of exposed structures on the fingers

An original surgical procedure for the repair of soft tissue defects localized on the dorsal aspect of the proximal phalanx of the fingers is described. A patient was seen with a posttraumatic soft tissue loss corresponding to the dorsal aspect of the second metacarpophalangeal joint and the adjacent proximal half of the proximal phalanx of the index finger with extensor tendon exposure. The repair of the defect using a local flap taken from the second web space and the dorsum of the proximal phalanx of the long finger provided excellent coverage with early movement and a good functional result.

Clinical Applications of the Subgaleal Fascia

The anatomic boundaries and vascular supply of the subgaleal fascia have been described previously. The thin and malleable subgaleal fascia was selected for difficult reconstructive problems in seven patients. This flap has been based on either the supraorbital or the superficial temporal vascular leash. The subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and a skin-graftable calvarium. The flap conforms to a cartilage framework for ear reconstruction. It takes a skin graft well. The subgaleal fascia can patch dural defects and fill sinus dead space. It has been used to augment facial contour. Free vascularized transfer of the subgaleal fascia has included the temporoparietal fascia, which was partially split from the subgaleal fascia for bilobed flap resurfacing of the hand. The subgaleal fascial flap should be considered when ultrathin, vascularized coverage is needed.

Vascularised reconstruction of the clavicle

A rare malignant tumour presented as a pathological fracture in the clavicle of an 11-year-old girl. This was resected and the defect reconstructed using a pedicled bilobed flap based on the thoracodorsal system with latissimus dorsi and serratus anterior with a rib to replace the clavicle. The innervation of both donor muscles was preserved. The reconstruction was cosmetically acceptable and maintained the function of the thoracohumeral articulation. Although the use of vascularised rib grafts in composite flaps is well documented, this is the first report of clavicular reconstruction using the technique.

Controversies

The consultants agreed that dermatofibrosarcoma protuberans is characterized by its persistent growth and locally aggressive behavior. However, they did not all agree on the mode of treatment. Drs. Schuller and Snyderman favored surgical resection of the involved areas including the right cheek, lower eyelid, and any necessary portions of the nasal ala and upper lip. They encouraged the use of Moh's chemosurgery to detect microscopic disease. They were also in agreement regarding reconstruction, suggesting a cervical-facial or bi-lobed flap for the cheek. A full-thickness skin graft was recommended for the lower eyelid with primary closure planned for the lip defect. They disagreed on the use of postoperative radiation therapy. Dr. Schuller elected not to irradiate; Dr. Snyderman favored 60 to 65 Gy post-operatively. Dr. Quivey expressed concern regarding the morbidity from such a large resection and extensive reconstruction and suggested primary radiation therapy with external beam. All three consultants felt that good follow-up would include thorough head and neck examinations with MRI and/or CT scans if there were any concern about tumor recurrence.