Overview of Bilobed Flaps
The bilobed flap is a specific type of skin graft that doctors mainly use to repair small to medium-sized skin defects in the nose, although it can be used on other parts of the body too. The technique of this graft was first introduced in 1918 by a doctor named Esser for procedures involving the reconstruction of the nose tip. The initial design for the flap involved a 180-degree rotation and a second part of the flap located towards the region between the eyebrows.
In 1953, another doctor named Zimany discovered that the second and third parts of the flap could be smaller than the first. He also found that this type of graft could be used for repair work in more specific areas of the body. In the 1980s, two doctors named McGregor and Soutar suggested that reducing the angle at which the flap is twisted would result in smaller and less visible skin irregularities, also reducing a side effect called ‘pincushioning’, where the skin appears dimpled or uneven.
Later on, a doctor named Zitelli further improved the technique by suggesting that the total rotation angle be limited to between 90 and 110 degrees. This modified technique is the most commonly used version of the bilobed flap today. This easy-to-understand explanation will focus on the most recent version of the bilobed flap procedure, including the important parts of the anatomy involved, when it is most effective, and how to plan and carry out this flexible procedure.
Anatomy and Physiology of Bilobed Flaps
The bilobed flap is a surgical technique used to heal wounds on the skin. Imagine, it’s like a two-step dance. The first step or “lobe” fills in the primary, or initial, wound. The second step uses another part of the skin to fill in the space that the first lobe used to occupy, this is what we call the “secondary defect”. The idea behind this is to spread the tension or pull on the skin over a larger area, reducing the stress on any one part. The downside is it requires more cuts and can leave more visible scarring.
The skin used (the ‘flap’) gets its blood from the subdermal plexus, which is a web of blood vessels underneath the skin surface. Blood supply is vital for the flap as it brings essential nutrients to heal. However, the supply from the subdermal plexus is ‘random’, meaning it doesn’t always come from a particular or named vessel.
Because of this, surgeons need to operate very carefully to keep this blood supply intact. In some cases, such as in nose surgeries, surgeons might include some muscle tissue in the flap to ensure better blood supply.
Drainage of fluid from the flap can be a bit tricky. The veins, which are responsible for returning the blood, sometimes don’t work as effectively. This can cause the flap area to swell in the first week after the surgery. This is often temporary and is commonly referred to as the “trapdoor deformity”. Lymphatic drainage, the system that removes excess fluid and waste products, can also face issues, leading to swelling.
Why do People Need Bilobed Flaps
The bilobed flap is a surgical method typically used for repairing the side area of the nose. It was originally designed for the reconstruction of the nasal tip, involving a 180-degree arc that uses a secondary tissue donor site from the region between the eyebrows, known as the glabellar region. However, this technique is not preferable anymore because it makes large flaps that demand significant adjustments during surgery.
Now, the bilobed flap technique uses mobile skin from the upper part of the nose to replace the less mobile skin in the lower part of the nose. The second tissue donor site should stay located towards the glabella allowing at least one portion of the surgical scar to be hidden in the nasofacial junction, that’s the spot where your nose meets your face (as shown in the image).
It’s important to note that while the bilobed flap is often used in nasal reconstruction, it’s not just limited to that area. It can be used in many different areas of the body. Tissiani and his colleagues documented the diverse use of the bilobed flap method in a study involving 42 patients. The technique was successfully used in different sites like the cheek, upper lip, the zygoma (part of your cheekbone), as well as the upper and lower limbs.
When a Person Should Avoid Bilobed Flaps
A type of skin graft surgery called bilobed flap transposition may not be suitable for some people due to certain health conditions. Those conditions could be anything that might cause the area of skin involved in the surgery to lose its healthiness and strength.
People with a particular type of heart and blood vessel condition close to the surgical area, known as peripheral vascular disease, may not be good candidates for this type of skin graft surgery. Similarly, people who smoke might also not suit this procedure.
Patients who take blood-thinning medications could face problems during and after surgery. The risks include higher chances of bleeding and the formation of a blood-filled swelling called a hematoma. A hematoma could potentially lead to the failure of the skin graft.
Also, people with damaged or infected skin in the area where the skin would be moved, like from scarring, a history of radiation therapy, or an active infection or inflammation, should consider different ways of repairing their skin.
Finally, any other medical conditions that make the risks of anesthesia too high are reasons to consider a different procedure. These could include severe heart and lung diseases, a history of a severe reaction to anesthesia called malignant hyperthermia, and a history of allergic reactions to local anesthesia. It’s important for people with these conditions to discuss surgical options with their primary healthcare provider.
Equipment used for Bilobed Flaps
Before Surgery:
A skin marker is used to pinpoint areas on your body where the surgery will take place. Lidocaine mixed with a bit of epinephrine is prepared in a small syringe with a thin, short needle. This mixture helps numb your skin and reduce bleeding during your operation. The doctor will clean your skin with isopropanol, chlorhexidine gluconate, or povidone iodine – all of which are substances known to kill harmful germs.
During Surgery:
The surgeon uses a #15 blade, #15C blade, or a #6700 beaver blade to make precise cuts. Techniques to gently hold or move your tissues are applied by using the Adson-Brown forceps or the smaller 0.5 mm Castroviejo forceps. Kaye blepharoplasty scissors are used for cutting tissues while suture scissors help in trimming or removing sutures. A special device known as bipolar electrocautery is used to control bleeding by using small electrical currents. Guthrie skin hooks assist in holding your skin apart during the surgery to keep the surgical site visible. A Castroviejo needle driver helps in positioning and driving sutures – these sutures could either be absorbable (poligelcaprone or polyglactin), which naturally dissolve over time, or non-absorbable (nylon or polypropylene), which may need to be removed later.
After Surgery:
Post operation, the doctor may apply bacitracin antibiotic ointment to prevent infection. Alternatively, skin glue or adhesive and sterile tape strips could be used to close and protect the wound. These options enhance the healing process and minimize the risk of infection.
Who is needed to perform Bilobed Flaps?
These procedures usually don’t need a lot of medical staff. If local anesthesia is used, you won’t need to be fully asleep during the procedure. This means the procedure can be done in an outpatient clinic where you can go home the same day. Here, it would just be the surgeon and a nurse or a medical assistant.
However, if the treatment involves a larger reconstruction, especially if there’s a large cancerous growth that has to be removed in the same session, we’ll need to use the main operating room. This room is better equipped and designed to handle these bigger procedures.
Here, more medical staff would be involved. Besides the surgeon, there’d be an anesthesia provider (a doctor or nurse who would administer the medicine to put you to sleep during the surgery), a circulating nurse (who helps to coordinate the procedure in the operating room), a scrub tech (a professional who assists during surgery, including passing instruments to the surgeon), and a surgical first assist (someone with advanced training who directly assists the surgeon during the procedure).
Preparing for Bilobed Flaps
Before going into surgery, your doctor will discuss with you what to expect, both before and during the operation. They will also explain the care you’ll need to take of the surgical wound once you get home. You’ll be informed about things like what medications you’ll need to take, how to manage any pain, and how to take proper care of the treated area to promote healing.
Written instructions will be given to you to ensure you know exactly how to care for yourself post-surgery. Your doctor will also explain the possible outcomes of the operation, why it is necessary, and what the possible alternatives might be. This is a routine process known as giving ‘informed consent,’ which means you fully understand the procedure and its potential risks and benefits. You’ll usually sign this form in the waiting area before going into the operation room.
Your doctor will share some potential risks and side effects of this procedure, which could include experiencing pain or bleeding, risk of an infection, scarring that you’re not happy with, changes in the appearance of nearby areas on your body, or the surgical wound not healing as expected, which may require further treatment. They will also discuss the risks of the cancer returning if you’re having an operation to treat a malignant tumor, and any risks linked to the use of general anesthesia, if it’s going to be used during your surgery.
How is Bilobed Flaps performed
Most of these medical procedures will be performed using local anesthesia, which means you’ll be awake but won’t feel any pain in the area being treated. Because injecting local anesthesia can often change the look of the skin’s surface, the doctor will plan and draw the outline of the surgery area before numbing you.
Let’s use the example of a surgery on the side of your nose to understand how the doctor plans the use of a special technique called a bilobed flap. When designing local skin flaps on the nose, the doctor always tries to ensure the surgery does not noticeably affect the natural line between the nose and the cheek. The procedure involves creating two rounded pieces of skin (called “lobes”) that are repositioned to cover the area where the lesion was removed. The second lobe is planned to be above the first so the surgical scar will be hidden in the natural line where your nose meets your face.
First, the doctor will mark the skin around the lesion that needs to be removed. Lesions on the tip of the nose which are about 10-15 mm in size can usually be well reconstructed with a bilobed flap. Once the lesion is cut out, the doctor will remove the skin and underlying tissues right down to the layer above the cartilage. This is done not for cancer-related reasons, but to make the moving of the skin flaps easier and to ensure good blood flow to the new flap. The first lobe of the flap is planned to be just above the spot where the lesion was, and almost the same size as the wound. The second lobe of the flap is marked just next to the first, in a position slightly diagonal to it, and is designed with a small triangular extension to facilitate closure.
Once the skin incisions are made, the doctor will gently separate the skin and the underlying tissues. This is extremely important in almost all flap reconstructions because it allows better movement of the skin flap. After controlling any bleeding, the closure process begins. The doctor will stitch up the wound made to elevate the triangular extension of the second flap first. Then the wound from the second lobe of the flap is closed, usually requiring the removal of some or all of the triangular extension. Finally, the original wound from the lesion removal is closed. Any extra tissues, if not removed before, will be resected at this step. The final step is to close the remaining outer layer of skin, which will be secured with a special type of suture that can be removed after a week. The doctor might also apply adhesive strips and a nose cast that can help reduce swelling and protect the surgical area, just like after a nose reshaping surgery.
Possible Complications of Bilobed Flaps
The specific complications that might happen after this type of surgery include swelling, scarring, flap necrosis (where part of the skin used in the procedure dies), infection, and bleeding. Since the flap of skin used is shaped like a crescent, it could form a bump (a pincushion deformity), a result of tissue under the skin shrinking. The bump is less likely to show up if there’s less tension when the skin is attached to the new site. This can be achieved by reducing the rotation of the skin flap or loosening up the skin below. It’s also possible for irregularities to appear on the skin’s surface, which can be mitigated by a smaller rotation arc.
In the original two-lobed flap method, as described by Dr. Esser, these irregularities were almost guaranteed, but they’re less frequent with the Zitelli modification of the method. If the skin flap is too tightly closed, blood flow could suffer, especially the flow of blood back to the heart. This could lead to the loss of the flap. Infections can occur anywhere on the wound but are more likely to appear where there is necrosis i.e. where the cells in the tissue have died. After the surgery, if there is bleeding it can lead to a hematoma (blood clot) forming under the flap. This clot can interfere with blood flow and potentially result in loss of the flap.
What Else Should I Know About Bilobed Flaps?
A bilobed flap is a type of skin graft, which is a surgical procedure where skin from one area of your body is moved to another area of your body. This technique is especially useful because it helps to evenly distribute the tension that occurs from the movement of the skin and covers a bigger area than traditional skin grafts that simply rotate the skin.
However, it’s important to know that this method can result in longer scars that may be more visible. Through continuous improvements in surgical techniques over the years, the procedure has improved a lot.
This procedure is most often used for surgeries in the head and neck area. The nose, in particular the very tip of it, is the most common spot for this procedure. But, the technique can also be used in other parts of the body if needed.
