Page 25 - Read Online

nonsebaceous, and the skin on the distal nose is thick, as needed after the two lobes are transposed into their
taut, noncomplaint, and sebaceous. Improper wound desired locations. Neither undersized nor oversized
tension could not only lead to hypertrophic scarring, but flaps are recommended as the former might lead to alar
also alar displacement. Therefore, it is not recommended elevation, while the latter can push the alar rim inferiorly
that defects of distal nose be treated primarily with and result in trapdoor deformation. The ideally sized lobe
adjacent undermining when the defect is small. The of the bilobed flap should neatly cover the defect under
surgeon must be acutely aware of the influence of the minimal closure tension.
size of the lobes when using the bilobed flap, as both
the width and the length of the lobes can affect the final Third, the scars are less obvious. As already noted, the
incomes of reconstruction. nose is the most prominent part of the face; therefore,
interrupted scars on their nose might not be acceptable
[10]
Moy et al. suggested that the diameter of the primary to many younger patients in Asia. Mature scars are more
[6]
lobe should be 90-100% of that of the primary defect and visible in individuals with darker skin tones than in those
that the diameter of the second lobe should be 80-85% with lighter skin tones. Surgeons should therefore aim to
of that of the primary lobe. In our study, the diameter of decrease the number of scars and control hypertrophic
the primary lobe was equal to that of the primary defect, scars on the nose. In contrast to previous designs, there
which can ensure lower closure tension for repair of were no noticeable scars on the mid-dorsum in patients
the primary defect. Alar displacement may result if the in our study. Most incisions were placed in the natural
diameter of the primary lobe is even slightly smaller. In lines such as the alar crease and the nasolabial groove. As
contrast to techniques described in previous reports, in described above, all defects were closed under minimal
our study, the second lobe was taken from the cheek and tension; therefore, less hypertrophic scarring occurred.
had a diameter of 90-100% of that of the primary lobe. In
fact, the second lobe is a nasolabial flap. The size of the Lastly, this technique can provide better texture matching
second lobe is chosen on a case-by-case basis. The cheek than is available through the conventional bilobed flap.
has more abundant and lax skin than the nasal sidewall; The skin of the distal nose is thick and dense with
therefore, the cheek can provide a larger flap than can the sebaceous glands, similar to the skin of the nasolabial
nasal sidewall. Tertiary defects on the cheek can also be region. In contrast, the skin of the nasal dorsum and
more easily closed in a linear manner. sidewall is thin and non-sebaceous. Particular attention
should be paid to ensuring that the exudation of the
In 1987, Dzubow discussed the effect of pivotal restraint sebaceous glands is removed in time to prevent incision
[7]
on flap rotation and transposition. He stated that the flap infection.
was restrained by the tissue located around the pivotal
point (the base of the flap), when any flap of tissue was The disadvantage of our design is that the primary lobe
either rotated or transposed around a pivotal point. Thus, might destroy the anatomy of the alar crease and result in
the bilobed flap is shortened after it is transposed to a an obscure alar crease-a complication that can be avoided
new site. The greater degree of flap movement around through careful suturing. In addition, the technique is
the pivotal point, the more the flap shortens. only suitable for small- to medium-sized defect repair,
due to the limited size of the primary lobe.
The main reported disadvantage of Zitelli’s bilobed flap is
alar retraction resulted from distal flap tension. Cho and In conclusion, the modified bilobed flap can provide
Kim stated that this distal tissue retraction and distortion satisfying outcomes with lower morbidity and inconspicuous
is a result of pivotal restraint. The rotation of the bilobed scarring. It is simple and suitable for repairing small- to
[8]
flap causes the flap to shorten, thereby creating a gap that medium-sized defects in the particular area of nasal tip.
must be spanned by the distal edge of the defect. Their
study in human cadavers demonstrated that lengthening Financial support and sponsorship
the primary lobe in Zitelli’s design could compensate Nil.
for this expected gap and allow for less tension at the Conficts of interest
distal wound edge. Such a closure would prevent distal None declared.
retraction and reduce anatomic distal distortion.
REFERENCES
Given this concept of pivotal restraint, the loss of flap
length must be accounted for during the bilobed flap 1. Zitelli JA, Baker SR. Bilobe flaps. In: Baker SR, Swanson NA, editors. Local
design. Some researchers proposed to lengthen the Flaps in Facial Reconstruction. St. Louis, MO: Mosby; 1995. p. 165‑80.
flap. [2,7-9] In our study, the length of the primary lobe was 2. Xue CY, Li L, Guo LL, Li JH, Xing X.The bilobed flap for reconstruction
slightly longer than the distance of the distal defect edge of distal nasal defect in Asians. Aesthetic Plast Surg 2009;33:600‑4.
to the pivot point of the flap, and the length of the second 3. Burget GC, Menick FJ. Repair of small surface defects. In: Burget GC,
Menick FJ, editors. Aesthetic Reconstruction of the Nose. St. Louis, MO:
lobe was slightly longer than that of the primary lobe. Mosby; 1994. p. 117‑56.
The redundant distal portions of the flaps are removed 4. Esser JF. Gestielteloakle Nasenplastikmitzweizipfl en Lappen, Deckung
Plast Aesthet Res || Vol 1 || Issue 1 || Jun 2014 19