The rhombic bilobed flap for nasal reconstruction

The rhombic bilobed flap, a simple, geometrically designed flap

We describe a combination of the common rhomboid flap and bilobed flap and provide an example of its use. The rhombic bilobed flap is simple to use and is associated with fewer complications, such as pin-cushioning and standing cone deformities, while minimizing the risk of skin necrosis and tension on the flap.

Reconstruction of small soft tissue nasal defects

Nasal defect repair has been one of the more challenging areas of reconstructive surgery due to the lack of uniform nasal skin thickness and complex contours. Currently, algorithms for medium to large nasal soft tissue defects have been well defined by various authors. Small defects, arbitrarily defined as 1 cm or less, still present significant challenges. In this article, the authors examine the options available to repair small soft tissue nasal defects and the appropriate situations in which each method is best suited.

[Early hypertrophic scar after surgery on the nasal region: value of long-acting corticosteroid injections]

BACKGROUND

"Pincushioning" is a complication of post-surgical scarring following use of transposition flaps particularly when surgery is performed on the nasal region. The transposition flap technique is very useful for the repair of certain defects of the tip of the nose, the medial canthus or of the ala nasi. The aim of this study is to define the clinical characteristics of this scarring dystrophy, which we propose to call "early hypertrophy scarring", to clarify the nature thereof and to assess the efficacy of intralesional injection of corticosteroids at the first signs of hypertrophy.

PATIENTS AND METHOD

A prospective, open, non-comparative, single-centre study examined the clinical and histological characteristics of early hypertrophy scarring and the effectiveness of therapy with one or two injections of corticosteroids performed on the 15th day post-operatively and optionally repeated at D45 depending on the outcome. From January 2011 to January 2013, 12 consecutive patients with early hypertrophy scarring were included (ten men and two women - mean age: 64 years). All had undergone surgery for basal cell carcinoma under local anaesthesia with one-stage repair by means of a rhombic flap or a bilobed flap located in the nasal area. Scars were injected strictly intra-lesionally with triamcinolone acetate (40 mg/1 mL) until whitening occurred. A single injection was performed in three cases of rhombic flap while a second injection was given at D45 in the remaining nine cases.

RESULTS

Complete regression of the early hypertrophy scarring was obtained in ten of the 12 patients by D90. Incomplete regression was observed but with a marked improvement in the other two patients.

DISCUSSION

Early hypertrophy scarring is distinguished by its clinical characteristics of hypertrophic or keloid scars. Biopsy performed in two cases showed the fibrous but non-fatty nature of early hypertrophy scarring. Biomechanical factors particular to the nasal region and the transposition flap technique could account for the early and excessive collagen production causing early hypertrophy scarring. Early injection of corticosteroids, which was consistently effective in our study, could represent a simple treatment for early hypertrophy scarring, thus avoiding surgical correction. These preliminary results in a small number of patients require confirmation by a comparative, multicentre, prospective controlled study.

The AIRNS flap: an alternative to the bilobed flap for the repair of defects of the distal nose

BACKGROUND

Defects of the distal nose and nasal tip are inherently challenging to reconstruct. Although the bilobed flap has a pivotal role for the closure of such defects to achieve a satisfactory outcome, it demands meticulous planning and execution.

OBJECTIVE

We sought to present our experience of the advancement and inferior rotation of the nasal sidewall (AIRNS) flap as a possible alternative to the bilobed flap for reconstruction of the distal nose.

METHODS

All patients who underwent AIRNS repair after Mohs tumor extirpation of the nose at 2 regional skin cancer units since April 2011 were reviewed.

RESULTS

In all, 45 patients underwent the AIRNS flap repair. There were 25 men and 20 women, with a mean age of 70 years (range 41-88). The average defect size was 1.2 × 1.2 cm. The majority of cases involved the nasal tip. A single case of postoperative infection occurred in a smoker, which resolved without any long-term sequelae. No cases of flap necrosis or nasal airflow obstruction were seen. All cases produced good or excellent cosmetic results.

LIMITATIONS

Because of blunting of the superior alar crease, which may be avoided in a bilobed repair, the AIRNS flap is best avoided in laterally based defects of the nasal alar.

CONCLUSIONS

The AIRNS flap is a reliable, single-stage closure option that, in our opinion, is simpler in design and execution compared with the bilobed flap and thus adds to the reconstructive surgeon's armamentarium when faced with centrally located defects of the distal nose.

A Simple Method of Designing a Bilobed Flap Using a Triangle Template

BACKGROUND

The bilobed flap is useful for the reconstruction of skin defects in which the primary closure is difficult. Proper design is paramount to achieve excellent cosmetic results, but flap design often appears unnecessarily complex and difficult.

OBJECTIVE

The objective was to discuss the geometry of the bilobed flap and describe a simple and practical method for constructing such flaps using a triangle template with emphasis on the pivot point.

METHODS

A detailed description with diagrams and an illustrative case are presented to demonstrate the technique.

RESULTS

A patient with a scalp defect was reconstructed with a triangle-template-designed bilobed flap with excellent postoperative results.

CONCLUSION

This new method using a triangle template ensures proper placement of the pivot point and will enable practitioners to achieve superior outcomes.

Two-lobed advancement flap for cutaneous helical rim defects

BACKGROUND

Bilobed flaps, transposition repairs used primarily on the nose, recruit tissue from an area of laxity via rotational motion. A variant of the bilobe, the two-lobed flap based on the W-plasty, is a transposition flap that shifts tissue predominantly via advancement.

OBJECTIVE

To apply the two-lobed advancement flap to the problem of reconstructing cutaneous helical rim defects of the ear.

METHODS

Helical two-lobed advancement flaps were designed and implemented to correct small- to medium-sized defects.

RESULTS

The ear helix was successfully repaired with two-lobed advancement flaps. There was minimal distortion of the ear architecture or cartilage, and blood supply was sufficient to ensure flap viability.

CONCLUSIONS

In selected cases, cutaneous helical rim defects of the ear can be aesthetically repaired with a two-lobed advancement flap derived from the posterior auricular surface.

[The bilobed flap: a very efficient method in aesthetic reconstruction of small skin defects at the alar and tip regions of the nose]

From October 1996 to January 2001, 20 patients (14 men and six women) ranging from 36 to 75 years old have been treated for their small skin defects of the nose by using the bilobed flap. These skin defects were located in 15 cases at the alar region and in five cases at the tip region. They were secondary to the resection of basal cell carcinoma in 17 cases and benign tumors in three cases. Their diameter ranged from 8 to 17 mm and in all these cases there was no involvement of the lining or cartilage. The design used for this bilobed flap was the Zitelli one, based on some mathematical principles; its base was medial or lateral depending on the site of the defect. With this method, the skin defects were reconstructed esthetically without any distortion of local anatomy of the nose with skin having the same color, texture and thickness. With an average of 28 month follow-up, all these reconstructions were stable with discreet scars and without the trapdoor phenomenon. No complications were reported. Esthetic reconstruction of such subunit nasal skin defects is easily done by this technique and is better than that obtained by the majority of others methods.