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and no patients complained of ventilation barriers. Three cover the primary tissue defect. The second lobe also
patients presented with an obscure alar crease and did transposes 90°, to cover the surgical defect produced by
not require further repair. There was incision infection the displacement of the primary lobe. The primary lobe
in one patient 3 days after the operation owing to the is located on the nasal dorsum adjacent to the primary
exudation of a sebaceous gland. The wound healed defect. The second lobe is located on the more proximal
well 10 days later [Figure 1]. There was mild trapdoor nasal dorsum. Due to the large transposition arc, the
deformity in one patient 1 month after the operation; flap rotation has to be accomplished with significant
however, the deformity disappeared after two steroid surgical effort and high wound-closure tension. It is
injections. All of the flaps survived completely with ideal inevitable that numerous significant standing deformities
color and texture matching. All of the scars healed well are produced after this operation, including “dog ear”,
and were inconspicuous. All 34 patients were satisfied alar displacement, and alar asymmetry. A second repair
with the results. procedure is necessary for some patients.

DISCUSSION In 1989, Zitelli modified the bilobed flap to include a
[5]
total transposition arc of 90°-110° and an approximately
Before the techniques for nasal reconstruction being 45° pivotal arc between each lobe. Zitelli’s bilobed
discussed, some general comments regarding the nature flap uses skin from the mid dorsum and the sidewall.
of nasal skin are warranted. The nasal skin is typically Smaller angles of flap transposition produce less severe
divided into three zones. Zone I, the upper half of the “dog ear” deformities along the border of the flap.
[3]
nose, is the thin, loose, compliant, and non-sebaceous Furthermore, smaller angles of flap transposition allow
skin of the dorsum and sidewalls. In contrast, Zone II the surgeon to transfer the flap more easily. The flap can
includes the thick, taut, non-compliant, and sebaceous be rotated with lower wound tension, which produces
skin of the nasal supratip, tip, and alae. It readily reforms less alar displacement. This design clearly decreases the
to its previous shape, and thus it is difficult to contour likelihood of complications. It is especially suitable for
and reconstruct. Due the thickness and stiffness of the the reconstruction of defects of the lower third of the
sebaceous skin, even small defects cannot be closed in a nose.
linear manner, as the surgical tension might cause obvious
nasal deformation. Zone III encompasses the areas of However, vertical scarring on the mid dorsum and
the triangles, columella, and nasal infratip lobule, where interrupted scarring on the tip occurs after using
the skin again becomes thin, loose, and nonsebaceous. Zitelli’s bilobed flap. The wound might heal well and be
Consideration of such categories is critical in the nasal inconspicuous in older patients or patients with compliant
reconstruction of small- to medium-sized defects as the nasal skin. However, the scar can be conspicuous in
type, color, and texture of the skin surrounding the nasal younger patients, particularly in individuals with darker
defect play a critical role in ultimately determining the skin tones. Most of the patients in our study could not
optimal method for reconstruction. accept the predicted outcomes of using Zitelli’s bilobed
flap. A modified bilobed flap utilizing skin from the lower
In conventional algorithms for nasal reconstruction, dorsum and cheek was therefore recommended to these
classic options for the repair of defects in Zone II include patients, and they agreed with the plan.
the bilobed flap, nasolabial flap, dorsal nasal flap, forehead
flap, and full-thickness skin graft. These reconstruction This technique combines the advantages of the nasolabial
options are time-tested and reliable, although none is flap and Zitelli’s bilobed flap, and thus offers more
without disadvantages. advantages. First, it is a single-stage procedure and
is less technically complex. The two flaps (the primary
The nasolabial flap is a good reconstructive option for and secondary lobes) are transposed with a total arc
lateral nasal defects such as defects in the sidewall and no more than 90°-100°. The flaps can be rotated easily
alae. The transposition design can be performed as a due to the smaller angles. Although the skin beside the
single-stage procedure, and can provide excellent color defect is thick and noncompliant, the primary lobe can
and texture matching. However, for central defects in the be transposed to the correct location with small closure
nasal supratip and tip, an interpolated design should be tension. The surgeon can repair the second defect easily
performed. The pedicle has to be divided 3 weeks later, with a nasolabial flap (the second lobe).
and the flap has to be reshaped 2-3 months later.
Second, this technique has lower morbidity. Any degree
The bilobed flap is also known as the “workhorse flap” of alar asymmetry can be quite noticeable since the
for the reconstruction of defects of the lower third of the nose is the most prominent part of the center of the
nose. It was first described by the Dutch surgeon Esser face. Accordingly, one of the most important principles
[1]
in 1918. Esser’s initial flap design described two equally of nasal reconstruction is that asymmetry deformity
[4]
sized transposition flaps transferred to cover defects of should be avoided. As described above, the skin on the
the distal nasal tip. The primary lobe transposes 90° to nasal dorsum and sidewall is thin, loose, compliant, and
18 Plast Aesthet Res || Vol 1 || Issue 1 || Jun 2014