Bilobed Flap Research Articles

Surgical Reconstruction of the Congenital Absent Earlobe

Introduction: A simple technique for earlobe reconstruction in a single stage, with satisfactory esthetic results and minimal morbidity. Cases: Two patients with congenital absent earlobe are presented. In both cases, a bilobed flap comprising skin, subcutaneous tissue, and fat was used to reconstruct the lower border of the earlobe. Discussion: Different techniques for earlobe reconstruction are discussed, including flap overlap, the use of skin and cartilage grafts, and double-bilobed flaps. Conclusion: The procedure described in this article is based on a modification of Gavello’s surgical technique, supplying a simple and effective approach for earlobe reconstruction in a single procedure.

Head and Neck Airbag Penetrating Injuries.

Airbags have significantly decreased fatalities in frontal vehicle accidents, but their deployment can lead to more severe injuries and rarely death. The authors present a case of a penetrating injury causing tissue loss in the left cheek, an "explosion" of the zygomatic arch, and facial nerve damage, discussing the management in the contest of literature examining similar injuries in the head and neck region. Reviewing English literature from 1995 to 2023, 9 patients experienced severe airbag-related penetrating head and neck injuries, in 3 cases resulting in death. In addition, we describe the case of a young male reporting a deep cheek laceration with facial nerve damage, tissue loss, and comminuted maxilla-zygomatic fracture; 48 hours after trauma, he underwent surgical reconstruction using a bilobed flap, direct suture of the resected masseter muscle, closed reduction of the comminuted zygomatic arch fracture, and direct neurorrhaphy of the lacerated facial nerve. Five months after surgery, facial nerve function recovery was observed. Mouth opening was restored, but a mixed low-medium hearing loss persisted for high frequencies. In another case marginal nerve damage was reported, but management is not described. The use of seat belts and airbags has led to a significant reduction in the incidence of facial fractures and fatalities after motor vehicle accidents, but at the same time, in some cases, complex facial trauma and/or penetrating injury can be observed. In case of suspected or certain facial nerve damage, it is mandatory to perform exploration and eventual reconstruction within 72 hours.

A Comprehensive Review of Bilobed Flaps in Nasal Reconstruction: Technique, Outcomes, and Considerations.

Reconstruction of nasal defects, particularly in the lower third of the nose, presents significant challenges due to the area's complex 3-dimensional structure and thicker, more sebaceous skin. The bilobed flap, a double transposition flap, has been a popular method for addressing these nasal defects. This retrospective review examines a single surgeon's experience with bilobed flaps for nasal reconstruction over the last 15 years. Demographics, defect characteristics, intraoperative details, postoperative complications, and revisionary procedures were documented, and univariate and multivariate logistic regression analyses were used to assess complication rate associations. In all, 148 bilobed reconstructions were analyzed, with a mean patient age of 62.6 years and 46.0% male prevalence. The most common indication for the procedure was basal cell carcinoma following Mohs surgery, with the majority of the defects located on the lower third of the nose. The average defect size was 1.11cm². Complications occurred in 52.0% of cases, including pincushioning, scar thickening, asymmetry, alar stenosis, and wound dehiscence. Reoperations and additional treatments such as dermabrasion, steroid injections, and laser therapy were frequently necessary to address these issues. Logistic regression analysis demonstrated significantly more postoperative complications when the defect was located on the lower third of the nose when compared with the upper two-thirds. While the bilobed flap can provide adequate skin coverage with perfect color match, it is associated with notable complications that impact esthetic outcomes. Proper patient selection and surgical technique are crucial for optimizing results.

The Zitelli bilobed flap for soft tissue coverage after mucoid cyst resection: a retrospective cohort study

Purpose: Digital mucoid cysts are frequently found at the distal interphalangeal (DIP) joint in patients with degenerative osteoarthritis. In complicated cases, surgical treatment with mucoid cyst resection is considered, and soft tissue is covered with one of various local flap techniques. Among these, bilobed flaps are reliable and aesthetically favorable, with primary healing of the donor site. In this study, we investigated a case series of bilobed flaps for digital mucoid cysts.Methods: We retrospectively reviewed our electronic medical records and found 26 digital mucoid cysts treated with bilobed flaps at our facility between July 2022 and February 2024. We extracted data from the records of these patients on sex; age; time to surgery; clinical findings including nail ridging, the presence of osteophytes, cyst size and location, and additional procedures (arthrodesis); and follow-up data including the occurrence of complications, such as delayed wound healing, infection, stiffness, and recurrence.Results: Among the 26 patients in our sample, 19 were female and seven were male. The average age was 62.2 years, and the average time to surgery was 10.8 months. Preoperatively, the average cyst measured 6.9×8.3 mm. Nail ridging was found in 19 patients (73.1%) and osteophytes in 22 patients (84.6%). The most commonly affected digit was the middle finger, which accounted for 10 cases (38.5%). All the flaps totally survived, without major complications.Conclusion: Based on our series, a bilobed flap for soft tissue coverage after mucoid cyst excision can achieve high-quality surgical results.

Combined with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold for the repair of a mid-distal adjacent finger defect: a retrospective study

PurposeAssessing the clinical effectiveness of combining with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold to repair mid-distal defects in adjacent fingers.MethodsFrom September 2012 to April 2022, 21 patients with 42 mid-distal defects of adjacent fingers underwent treatment using combined with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold. The flaps size ranged from 2.1 cm * 1.6 to 4.9 cm * 3.2 cm. Follow-up evaluations included assessing function, sensation, and appearance, etc. of the injured fingers and donor areas.ResultsAll 42 flaps survived in 21 patients without any vascular crises, and the wounds healed in phase I. The mean follow-up time was 12.2 months (range 7–22 months). During follow-up, in injured fingers, according to the Michigan Hand Outcomes Questionnaire (MHOQ), the functional recovery and appearance were satisfactory; in Dargan Function Evaluation (DFE), the results were both “excellent” in fourteen patients, “excellent” and “good” in five patients, both “good” in one patient, “good” and “general” in one. In static two-point discrimination (2PD), the variation ranges from 4 to 9 mm in injured fingers and 6—10 mm in donor toes. Cold Intolerance Severity Score (CISS) is mild in all patients. The visual analogue score (VAS) showed no pain in the injured fingers and donor toes. No deformities or other complications were noted at the donor toes. According to Chinese Manchester Foot Pain and Disability Index (C-MFPDI), there was no morbidity on foot function in all donor areas.ConclusionThe surgical procedure of combined with the first dorsal (plantar) metatarsal artery pedicle free bilobed flap with a cell scaffold for the repair of mid-distal adjacent fingers defect is highly satisfactory. This approach helps the injured fingers to achieve good function, sensibility and appearance, while also achieving satisfactory results in the donor toes.

Zitelli´S Bilobed Flap for a Nasal Tip Skin Defect: A Case Report

Zitelli´S Bilobed Flap for a Nasal Tip Skin Defect: A Case Report

The Tree Flap: A Novel Modification of the Hatchet Flap for Lower One-third Nasal Reconstruction.

Nasal reconstruction after skin cancer excision has routinely been challenging without any aesthetic sequelae, and any defects on the nose are readily noticeable. To circumvent this problem, surgeons have developed different flap techniques to mobilize adjacent tissue to repair aesthetically sensitive defects. We describe our experience, outcomes, and valuable tips for using the "tree flap," a novel modification of the hatchet flap that extends the back cut to significantly increase mobility, leaving only a small skin paddle to maintain perfusion to the flap. The combination of undermining, a rotatory component, and minimal skin attachment allows radical mobility without compromising blood supply. Thus, the tree flap allows for reconstruction of defects of the dorsum of the nose and defects near the nasal tip with ease, given both advancement and rotational movements. Compared with other local flaps such as the shark pedicle flap or bilobed flap, the tree flap has a similar learning curve, minimal donor site morbidity, and equivalent aesthetic outcome. It may be used to repair larger defects that may not be amenable to the bilobed flap as an alternative to a full-thickness skin graft. In our experience, the tree flap also has the advantage of a lower rate of pin cushioning when compared with other options such as the bilobed flap. The tree flap has great mobility and is a reliable option for reconstruction of the lower one-third of the nose with excellent aesthetic results and minimal complications.

Classification and reconstructive algorithm for nasal alar defect in Asians

BackgroundThe nasal alar defect in Asians remains a challenging issue, as do clear classification and algorithm guidance, despite numerous previously described surgical techniques. The aim of this study is to propose a surgical algorithm that addresses the appropriate surgical procedures for different types of nasal alar defects in Asian patients. MethodsA retrospective case note review was conducted on 32 patients with nasal alar defect who underwent reconstruction between 2008 and 2022. Based on careful analysis and our clinical experience, we proposed a classification system for nasal alar defects and presented a reconstructive algorithm. Patient data, including age, sex, diagnosis, surgical options, and complications, were assessed. The extent of surgical scar formation was evaluated using standard photography based on a 4-grade scar scale. ResultsAmong the 32 patients, there were 20 males and 12 females with nasal alar defects. The predominant cause of trauma in China was industrial factors. The majority of alar defects were classified as type I C (n=8, 25%), comprising 18 cases (56.2%); there were 5 cases (15.6%) of type II defect, 7 (21.9%) of type III defect, and 2 (6.3%) of type IV defect. The most common surgical option was auricular composite graft (n=8, 25%), followed by bilobed flap (n=6, 18.8%), free auricular composite flap (n=4, 12.5%), and primary closure (n=3, 9.4%). Satisfactory improvements were observed postoperatively. ConclusionFactors contributing to classifications were analyzed and defined, providing a framework for the proposed classification system. The reconstructive algorithm offers surgeons appropriate procedures for treating nasal alar defect in Asians.

The Versatility of Keystone Flaps for Skin Cancer Reconstruction of the Nose.

Nasal reconstruction has been a challenging problem for even the most experienced surgeon to provide excellent esthetic and functional outcomes. Although the bilobed flap offers distinct advantages for reconstructing these defects using an adjacent tissue with similar esthetic qualities, this flap has several potential limitations. The authors hypothesized that the conventional keystone flap and its variants provide a versatile and easily reproducible reconstructive option for nasal reconstruction after wide skin cancer excision. The authors retrospectively reviewed 12 consecutive soft tissue reconstruction data using 3 types of keystone flaps between May 2021 and July 2023. The authors reviewed all patients who underwent reconstruction with the keystone flap or its modification to repair cutaneous nasal defects following wide skin cancer excision. The authors reconstructed small- to medium-sized nasal defects ranging from 1×1 to 2.5×2.5cm2 with a mean size of 1.2×1.1cm2 using either a conventional keystone flap or its modification, including the Omega variant and rotation Hemi-keystone flap. All patients were satisfied with the esthetic outcomes. Keystone flaps are a versatile option for reconstructing the nose after cancer surgery. This strategy obviates the need for a bilobed flap after cancer removal in the nose.

Comparing Feedback Techniques in Bilobe Flap Simulation Using 3D-Printed Facial Models.

To compare live versus delayed feedback on trainee performance of bilobe flaps using 3-dimensional (3D)-printed facial simulators and determine whether these effects are sustained on repeat performance. Cohort study. University of Arkansas for Medical Sciences. 3D-printed facial models with a nasal ala defect were provided to 18 subjects. Subjects were stratified and randomized based on their training level into 1 of 3 groups corresponding to live feedback (Group 1), delayed feedback (Group 2), and no feedback (Group 3). Subjects performed a bilobe flap following a structured lecture. Four weeks later, subjects independently repeated the exercise on the contralateral ala. Likert surveys were used to assess subjective parameters. Objective grading was performed by a plastic surgeon, which included a point system and score for the overall appearance. Following exercise 1, Group 1 reported a significant improvement in knowledge (P < .001), which was sustained after exercise 2 (P < .001); Group 2 reported a significant improvement after exercise 1 (P = .03) but was not sustained (P = .435). After the second exercise, Group 1 and Group 2 improved their confidence in bilobed repair (P = .001 and P = .003, respectively), but this was greater for Group 1. Group 1 showed a significant improvement in their design time following exercise 2 (P = .007). There were no significant differences between groups on total time for repair, total score, and appearance. 3D-printed models are valuable in teaching the bilobe flap for nasal defects, with live feedback providing the greatest level of improvement in self-reported knowledge and confidence.

Reconstruction methods for and cosmetic evaluation of external nasal tumour resections: flap versus graft.

Nose reconstruction is challenging given the three-dimensional structure and free edge, and various methods have been reported. In general, local flaps provide cosmetic outcomes that are better than those following skin grafts, but there are no published comparative studies on Asians. To determine whether local flaps or skin grafts may optimally be used to reconstruct external nasal defects among Asians. We retrospectively collected data on patients who underwent external nasal tumour resection and reconstruction by 14 plastic surgeons in eight Japanese institutes from 2009 to 2021. The cosmetic results were scored by 14 surgeons using anonymized preoperative and six-month postoperative photographs. Scores for each reconstruction method were statistically evaluated. In total, 86 cases were enrolled; 57 received local flaps and 29 received skin grafts. Most local flaps showed better outcomes compared to skin grafts, but this was not the case for nasolabial and forehead flaps. Notably, local flaps placed in the nasal ala tended to be less successful than flaps placed elsewhere; only the bilobed flap scored better than skin grafts. The defect site did not affect the results of skin grafts. For Asians requiring nasal reconstruction, local flaps provide better cosmetic outcomes than skin grafts, except for those in the nasal ala. Skin grafts may be a good alternative when the bilobed flap is unavailable for the nasal ala.

A Cost-Effective, Three-Dimensionally Printed Simulation Model Facilitates Learning of Bilobed and Banner Flaps for Mohs Nasal Reconstruction: A Pilot Study.

Flap design for Mohs reconstruction is a complex 3-dimensional process. Simulation offers trainees the chance to practice techniques safely before performing them in the operating room. To aid in teaching, the authors developed a high-fidelity, cost-effective model of the face using three-dimensional printing to simulate flap reconstruction after Mohs surgery. A model face was sculpted digitally to include skin, bone, and cartilage. Negative molds were printed and used to cast silicone, representing external skin. The cartilage and bone models were combined to create a single three-dimensionally printed base. Surgical residents practiced performing banner and bilobed flaps on the simulation model, and improvement was assessed using boards-style pretests and posttests assessing flap design on clinical photographs. Medical students were randomized to complete a similar practice session with the model or a reading on the topic, after which they completed the same assessment. Participants also completed a questionnaire about the model's didactic and monetary value. Residents showed significant improvement after use of the model (banner flap: P = 0.002, bilobed flap: P = 0.04). Medical students who used the model scored significantly higher than those assigned to train by reading ( P = 0.001). Subjective comfort with flap design and execution increased after practice with the model ( P = 0.001). The cost of materials for each model was $2.50; participants reported willingness to pay $24.36 (mean) for this tool. This accessible model was superior to traditional teaching materials for Mohs reconstruction, and aided the comfort and proficiency of trainees.

Bilobed Flaps: An Esthetic Method of Reconstructing Circular Defects.

Local flap reconstruction is an important skill used to excise and repair many cutaneous defects in various anatomical regions of body. In this article, the authors have described the bilobed flap reconstruction technique useful in the resection of various circular and semicircular defects, especially over nose tip and lateral wall of the nose. The authors have highlighted various indications, procedural techniques, and complications related to the surgery which will help in better esthetic outcome.

Locoregional Flaps for the Reconstruction of Midface Skin Defects: A Collection of Key Surgical Techniques.

The reconstruction of midface skin defects represents a challenge for the head and neck surgeon due to the midface's significant role in defining important facial traits. Due to the high complexity of the midface region, there is no possibility to use one definitive flap for all purposes. For moderate defects, the most common reconstructive techniques are represented by regional flaps. These flaps can be defined as donor tissue with a pedunculated axial blood supply not necessarily adjacent to the defect. The aim of this study is to highlight the more common surgical techniques adopted for midface reconstruction, providing a focus on each technique with its description and indications. A literature review was conducted using PubMed, an international database. The target of the research was to collect at least 10 different surgical techniques. Twelve different techniques were selected and cataloged. The flaps included were the bilobed flap, rhomboid flap, facial-artery-based flaps (nasolabial flap, island composite nasal flap, retroangular flap), cervicofacial flap, paramedian forehead flap, frontal hairline island flap, keystone flap, Karapandzic flap, Abbè flap, and Mustardè flap. The study of the facial subunits, the location and size of the defect, the choice of the appropriate flap, and respect for the vascular pedicles are the key elements for optimal outcomes.

Cosmetic outcome of nasal tip reconstruction with the frontonasal flap and other locoregional flaps - Cosmetic Outcome of Nasal Tip Reconstruction

This study investigates the results of nasal tip reconstruction with the frontonasal flap compared with other locoregional flaps. All nasal tip reconstructions with locoregional flaps performed during a 10-year period were included. Defect size, flap type, risk factors, comorbidities, complications, revisions, and secondary operations were retrospectively assessed. Clinical follow-up examinations were performed after 12 months. Digital photographs were taken in standard projections preoperatively and at the time of the last follow-up examination, and the aesthetic results were assessed by three independent examiners, with nasal contour, symmetry, scarring, and match of skin colour between flap and nasal skin rated on a 4-point scale. Finally, patient satisfaction was obtained. A total of 112 nasal tip reconstructions were performed in 68 women and 44 men with a mean age of 71,4±10,2 years. Taking into account defect size, individual factors and patient preference, reconstruction was performed with 58 frontonasal flaps, 23 Rintala flaps, 20 paramedian forehead flaps and 11 bilobed flaps. Mean age and comorbidities of patients were comparable between flap types, except for a higher incidence of arterial hypertension and a lower incidence of diabetes mellitus in patients treated with frontonasal flaps. Defect size was the same in reconstructions with frontonasal flaps and Rintala flaps, smaller in bilobed flaps, and more extensive in paramedian forehead flaps. There were no differences in complication rates between the different flap techniques. Taking into account the planned second interventions (flap pedicle separations) in the paramedian forehead flaps, the frequency of unplanned corrections was comparable for all flap techniques. Aesthetic results and patient satisfaction were rated as very good or good in more than 90% with all techniques. Compared with the paramedian forehead flap, the frontonasal flap avoids a planned secondary procedure and an extensive donor defect. It allows for the coverage of defects at least the size of the Rintala flap and larger defects than the bilobed flap.

A Novel Utility of Bilobed Flap for Amputation Stump Coverage

Preparing a good amputation stump with a well-padded, stable, sensate, and painless soft tissue coverage is of utmost importance to achieve early ambulation and return the patient to the daily activity level. When the primary closure is impossible or fails to achieve a good closure, secondary closure must be considered. To date, no literature reported the use of bilobed flaps for stump defect closure. We aimed to utilize this technically easy procedure for better management of defect closure on amputated limb stumps that often cause complex clinical problems. This is a retrospective observational study in limb amputation patients with various etiologies: crush injury, chronic limb necrosis, and amniotic band syndrome. All patients had stump defect closure with bilobed flap and were observed with a minimum of 6-months follow-up to evaluate the wound healing, the use of prosthesis, and the complications. A bilobed flap was performed in 11 amputation cases as the final closure (64% trans-femoral, 18% trans-tibial, 9% trans-humeral, and 9% trans-radial). The mean follow-up time was 8.5 ± 2.21 months. Most of the patients healed uneventfully with the optimal use of prosthesis in a mean healing time of 29.64 ± 7.49 days. The bilobed flap potentially provides a good amputation stump coverage that is ideal for prosthesis fitting. This simple procedure can be done without the necessity of special microsurgery settings. Thus, when the neighboring tissue is available and mobile enough to be transposed to the stump defect, a bilobed flap can be considered.

Repair of multiple hand defects with superficial circumflex iliac artery perforator flap.

Reconstruction and repair of multiple defects in the hand is a combination of function, sensation and aesthetics. The reconstruction using the superficial circumflex iliac artery perforator flap has become popular, which overcomes the inherent shortcomings of traditional inguinal flaps by preserving the deep fascia. In this report, we present our experience in the design and clinical application of the superficial circumflex iliac artery perforator flap, which we used to repair multiple defects in the hand. From January 2015 to December 2020, 41 patients received free superficial circumflex iliac artery perforator flap to repair multiple hand defects. All flaps were carefully designed according to the hand defect including 21 single and 20 bilobed flaps. The area of ​​the donor area is 2.5cm×3.0cm∼8.0cm×6.5cm. We followed up all patients regularly and completed standardized assessments of outcomes based on post-reconstruction hand function and esthetic scores. 41 cases of flaps survived completely.3 cases of vascular crisis was relieved after surgical exploration, 1 case of mild distal necrosis was healed after dressing change, 1 case of pigmentation happened. There were 41 patients, 27 males and 14 females, with an average age of 40.5 years (4 to 59 years old). The defects included 20 cases opisthenars and 21 cases palms. The wounds were irregular, with exposed or damaged tendons, nerves or bones. All flaps were followed for a mean of 10.5 months (3 to 15 months). The functional and esthetic outcomes were satisfactory for all flaps without complications such as hand spasms, adhesions and scar contractures CONCLUSION: The superficial circumflex iliac artery perforator flap's donor site was concealed, relatively stable perforators, easy dissection. Recipient site condition was good and acceptable for the patients. It is a significant choice for multiple hand defects.

Bilobe Flap for Local Defects Due to Basal Cell Carcinoma of the Facial Region. Case Report

Basal Cell Carcinoma (BCC) is an increasingly frequent pathology in the vast majority hospital of Paraguay. The Nasal region suffers from a disadvantage with respect to its position compared to other parts of the body that are not exposed to ultraviolet radiation, these neoplasms generally have an excellent prognosis, mainly due to their lack of lymphatic spread, distant metastases, self-limitation. Bilobed flaps represent an excellent option for small skin defects, its practical and aesthetic.

Bilobed Flap for Reconstruction of Skin Defects after Excision of Parotid Carcinoma: A Case Report.

Local flaps, pedicled flaps, and free flaps are used to reconstruct medium-sized skin defects after excision of parotid carcinoma. The bilobed flap is a local flap primarily used by plastic surgeons for small defects of nasal skin. We report a case of parotid carcinoma with skin infiltration successfully treated by skin reconstruction with a bilobed flap. An 84-year-old man presented with a parotid mass he had noticed 2 months earlier. Parotid carcinoma with skin infiltration was diagnosed and he underwent radical surgery. The skin defect was round (diameter, 6 cm) and was resected and reconstructed with a bilobed flap designed to be caudal to the defect. Postoperative facial nerve palsy improved within 6 months. The postoperative course was otherwise uneventful, and the patient was discharged on postoperative day 7. Pathological examination revealed a sarcomatoid salivary duct carcinoma. Bilobed flaps are useful for reconstructing skin defects with a diameter of 6 cm or less.

Bilobed flaps for cutaneous nasal defects: a case series

The bilobed flap is a local flap used for the reconstruction of small to moderate cutaneous nasal defects. It was first described by Esser in 1918 for use in nasal tip reconstruction. It is a double transposition flap where the first flap serves to fill the primary defect, and a second smaller fills the secondary defect. This approach seeks to distribute tension across a wider area. It is a random pattern flap with no specified blood supply. This study was done at the department of plastic and reconstructive surgery, Saveetha medical college and hospital, from January 2018 to December 2018. Five patients (four female and one male) underwent bilobed flap to reconstruct the cutaneous nasal defects out of which three patients had naevus while two patients had basal cell carcinoma nose. Their ages ranged from 35-68 years with a mean age of 52 years. The procedures were done under local anaesthesia. Post-operatively, all sutures were removed on the 5th day. This technique was performed in 5 cases with defect size ranging from 0.9×1.1 to 1.3×1.8 cm. All defects were closed under minimal wound tension, all scars were inconspicuous, no obvious complications occurred, and the aesthetic outcomes were considered favorable. The bilobed flap is a versatile, easy to perform and reliable flap for closure of small nasal cutaneous defects with good aesthetic outcomes, reduced morbidity and less scarring.