Bilobed Flaps in Nasal Reconstruction (2023)

The bilobed flap is a local transposition flap useful for the repair of nasal defects commonly seen after Mohs surgery. The bilobed flap has benefits over other nasal transposition or advancement flaps because it distributes wound closure tension over a larger surface area through the use of 2 lobes. This property is especially helpful for defects of the caudal portion of the nose, where the skin is less elastic. This article discusses the bilobed flap for nasal reconstruction along with the appropriate selection, design, and placement of the flap and the potential complications.

(Video) Bilobed flap for nasal reconstruction

Bilobed flaps are local flaps useful for the reconstruction of nasal defects. These flaps are especially useful for defects of the caudal portion of the nose. Defects in this region pose a reconstructive challenge because the skin is thick, sebaceous, and lacks elasticity. Significant advancement, rotation, or transposition in this area can result in distortion of the nasal tip.

The bilobed flap is a double transposition flap whose basic principle relies on transposing mobile skin from the cephalic portion of the nose in order to close defects of the thicker immobile skin of the caudal portion of the nose. This double transposition flap distributes tension over an area greater than a single transposition, allowing for successful closure of defects in the inelastic skin of the nose.

The bilobed flap for nasal reconstruction was first described by the Dutch surgeon Esser in the early twentieth century. He described a total transposition arc of greater than 180°. The large degree of rotation created large lobes that required the flap to extend into the glabella, resulting in significant standing cutaneous deformities. Later in the twentieth century, McGregor and Soutar discussed the use of the bilobed flap with smaller pivotal arcs, which resulted in smaller standing cutaneous deformities and decreased pincushioning. Zitelli’s modification of the bilobed flap emphasized a total pivotal arc no greater than 90° to 110°, with an approximately 45° pivotal arc between each lobe. His results demonstrated the practical utility of this flap in nasal reconstruction.

Flap selection

Bilobed flaps are ideal for defects of the central or lateral nasal tip that range up to 1.5 cm in size. These flaps are best suited in the distal third of the nose, where most other skin flaps would cause significant distortion of the nasal tip. Defects that extend onto the nasal ala are generally not favorable for this type of repair because of a high likelihood for alar retraction. The defect should be at least 0.5 cm away from the nostril-free margin in order to reduce the risk of notching.

Bilobed flaps may also be used to repair more cephalically positioned nasal defects; however, size limitations exist as the donor site of the second lobe moves cephalad. In these cases, the second lobe donor site would be located at the medial canthus or glabella and donor site closure may lead to distortion of these structures, compromising the overall aesthetic and functional reconstructive outcomes. In these locations, alternative flap selection may lead to a more desirable outcome.

Bilobed flaps are especially advantageous for defects whose depth extends into and past the level of the subcutaneous fat, which is the main benefit of the bilobed flap over skin grafts whenconsidering reconstruction of the nasal tip. Skin grafts placed over deeper defects often results in visible depressions over the nose and a less-than desirable aesthetic result. The depth of the nasal defect often dictates the use of a bilobed flap over a skin graft in this area.


Flap design

Bilobed flaps are classified as random flaps whose blood supply originates at the base of the flap. The flap is most commonly based laterally, on thenasal sidewall, where there is a robust arterial supply to the nose. However, medially based flaps can also be placed successfully, if necessary, with little risk of flap necrosis. The high vascularity of this region makes the blood supply to the bilobed flap robust and provides for a high success rate of flap viability.

The design of the bilobed flap is based on a geometrically configured pattern that spans a 90° pivotal arc. The first step in the proper design of this flap is to mark the 2 arcsthat will define the boundaries of the flap and its proper angulations. In order to do so, the radius and diameter of the nasal defect are measured with calipers. A pivot point is selected 1 radius from the free edge of the defect and is placed in the region from where the standing cutaneous cone has to be removed. This pivot point is most commonly placed within the alar groove. A marking pen is used to mark the pivot point over which the arcs are based.

A suture is then passed full thickness through the nose at the pivot point, and a knot is placed within the suture itself to anchor it into position at the nasal vestibule ( Fig.1 A). Next, the suture is marked at the center of the defect with a hemostat. The hemostat is then pivoted cephalad in a 120° rotation, using a marking pen at the level of the hemostat to draw the first arc (see Fig.1 B). The second arc is then configured by repositioning the hemostat at the center of the defect’s distal edge (see Fig.1 C) and marking out the resultant arc using a similar 120° rotation (see Fig.1 D). Alternatively, a standard geometry compass can be used to perform these markings.

Bilobed Flaps in Nasal Reconstruction (1)

( A ) The central arc is drawn by marking the center of the defect with a hemostat. ( B ) The central arc is marked while rotating the hemostat 120° from the center point ( C ) The central arc has been drawn, and the distal point of the defect is marked with a hemostat. ( D ) The hemostat is once again rotated 120° and the distal arc is drawn. ( E ) The first lobe of the flap is drawn at 45° away from the defect and with a diameter equal to that of the defect. ( F ) The second lobe is designed at 45° away from the first lobe, with a diameter slightly smaller than that of the defect. The lobe is extended to remove a standing cutaneous cone to allow for primary closure of the donor site. ( G ) A bilobed double transposition flap marking is complete using a pivotal arc totaling 90°.

(Video) Nasal Reconstruction: Bilobed Flap after Mohs resection of Nasal Tip cancer

Once the 2 arcs are properly drawn, the 2 lobes of the flap are configured. The thick skin of the nasal tip has minimal elasticity and does not allow for significant advancement without distortion. Unlike bilobed flaps in the rest of the face and body, the first lobe of a nasal bilobed flap should have the same diameter as the defect itself (see Fig.1 E). The first side of the first lobe is drawn as a perpendicular line between the 2 arcs, 45° away from the defect. The second side of the first lobe is then drawn parallel to this line, 1 diameter away from the first side. The first side of the second lobe is then marked, 45° away from theadjacent lobe. A line marking this side of the second lobe is then drawn. The second lobe is then marked out to be similar or slightly smaller then the nasal defect (see Fig.1 F), which will depend on the elasticity of the skin in this region and can be judged by pinching the skin of the lateral nasal wall. Once again, the final side of the second lobe is marked, extending the planned incision past the arcs in order to allow for the excision of an additional triangle of skin for adequate donor site closure (see Fig.1 G).

When designing a bilobed flap, the standing cutaneous cone excision, at the base of the defect, is taken into consideration and preferably placed within the alar crease. The apex of the cone is positioned at the pivot point that was previously marked. However, one should not be too conservative as to the amount of skin to remove because small dog-ears in this area do not settle out well. A disadvantage of the bilobed flap is theamount of incision necessary, which cannot be placed within the relaxed skin tension lines. Despite this, incisions of the nose heal well when meticulously closed in layers.

(Video) (21) Bilobed flaps in Facial surgery

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(Video) Bilobed flap repair if the nose. #103

Tags: Facial Plastic Surgery Clinics of North America Volume 19 Issue 1

Feb 8, 2017 | Posted by drzezo in General Surgery | Comments Off on Bilobed Flaps in Nasal Reconstruction


What is the Bilobed flap for nasal reconstruction? ›

The bilobed flap is a local transposition flap used primarily for the reconstruction of small to moderate-sized cutaneous nasal defects, although it can be applied to other areas of the body. It was first described in 1918 by Esser for use in nasal tip reconstruction.

What are the principles of Bilobed flap? ›

Definition of Bilobed Flap

The key principles to this repair are5,6,7: First lobe fills the primary defect, second lobe fills the secondary defect. Double transposition will distribute tension to wider area of skin. No specific blood supply (random pattern).

What is Bilobed flap closure? ›

Closure of the bilobed flap can occur with suturing of the primary lobe to the first frenulum and suturing the secondary lobe to the second frenulum with circumferential sutures in the periphery of each lobe. One would suture these lobes with 4.0 nylon in a simple interrupted suture mattress.

How long does it take for a nose flap to heal? ›

The flap remains attached until the nose is fully healed. This is usually around 4 weeks. Once the nose has healed, the flap will be separated from the forehead.

What is the blood supply of the Bilobed flap? ›

The bilobed flap is a random transposition flap because its blood supply does not arise from a segmental artery and no defined pedicle is present. Blood is supplied to the skin via musculocutaneous and cutaneous arteries that perforate subcutaneous tissue.

What is Bilobed structure? ›

The male reproductive part of the flowering plant has stamens. These stamens are filamentous structures that support the anther that produces the pollen grains. These anthers have two lobes and are termed bilobed anthers. The transverse section of the anther helps to distinguish this bilobed structure.

What are the basic principles of flap surgery? ›

A flap is transferred with its blood supply intact, and a graft is a transfer of tissue without its own blood supply. Therefore, survival of the graft depends entirely on the blood supply from the recipient site. Flap surgery is a subspecialty of plastic and reconstructive surgery.

What is the primary objective of flap surgery? ›

One major objective of flap surgery is to eliminate or reduce the pocket itself. To access it, a flap-like incision is made in the gum tissue.

What are the ideal properties of flap? ›

A well-designed flap should use the minimal amount of tissue required, cause the least amount of donor site morbidity, and maximize the return of form and function to the tissue defect, while simultaneously optimizing the survivability of the flap to obviate the need for revision surgery in the future.

Is flap surgery risky? ›

Blood vessels supplying the flap may kink or get clots, leading to bleeding and a loss of circulation. This may cause the tissue to die, leading to a partial or complete loss of the flap. This is more common in women who smoke or have recently quit. Quitting before surgery will help you to decrease the risk.

What is flap healing complication? ›

Following surgery, flap complications include:
  1. Dislocation – a movement of the flap from its intended place.
  2. Folds or wrinkles – flap is not smooth.
  3. Epithelial ingrowth – epithelial cells from the outer cornea migrate under the flap.
  4. Diffuse Lamellar Keratitis – inflammation under the flap.
May 20, 2022

What are flaps for reconstructive surgery? ›

Flap surgery is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. This is distinct from a graft, which does not have an intact blood supply and therefore relies on growth of new blood vessels.

Does your nose go back to normal after surgery? ›

You should notice a difference in the appearance of your nose about a week after rhinoplasty surgery when your splint comes off. It can take up to a year for your nose to fully settle into its new shape.

How long does it take to look normal after nose surgery? ›

Every patient is different, so recovery times vary, but generally speaking, most patients can expect to look “normal” after about three to four weeks, with a small amount of residual swelling and tenderness lasting about three months — though it is usually only noticeable to the patient themselves.

Does nose tissue grow back? ›

Cartilage, which covers and cushions the surface of joints, generally does not regenerate once damaged, but "cartilage cells from the nasal septum (the part of the nose that separates the nostrils) are known to have a great capacity to grow and form new cartilage."

Are flaps of tissue that control blood flow? ›

Valves are actually flaps (leaflets) that act as one-way inlets for blood coming into a ventricle and one-way outlets for blood leaving a ventricle.

What is a nasolabial flap? ›

Nasolabial Flaps are frequently used to repair defects of the nostril and nasal tip. In this procedure, skin is transplanted from the cheek to the nose in two outpatient procedures. Cheek skin has a similar color and texture to nasal skin, and the donor site scar can be hidden in a naturally occurring cheek fold.

What are the types of flap blood supply? ›

Multiple classifications have been described, but, in general, flaps for reconstruction are classified based upon the type of blood supply (ie, random, axial), proximity of the donor tissue to the recipient (ie, local, regional, distant), and tissue composition (eg, musculocutaneous, fasciocutaneous) [1].

What does bilobed mean medically? ›

Medical Definition

bilobed. adjective. bi·​lobed (ˈ)bī-ˈlōbd. : divided into two lobes.

What do we mean by Bilobed? ›

Definitions of bilobed. adjective. having two lobes. synonyms: bilobate, bilobated compound. composed of more than one part.

What does it mean when the nucleus is bilobed? ›

A lobed quality inhering in a nucleus by virtue of the nucleus being divided into or having two lobes.

What is the most common flap surgery? ›

TRAM (transverse rectus abdominis muscle) flap is one of the most common types of flap surgery. The surgeon takes muscle and tissue from the lower belly and moves it to the chest area.

What are the advantages and disadvantages of flap surgery? ›

advantages • Provides excellent access. allows surgery to be performed on more than one or two teeth. produces no tension in the tissues, allows easy reapproximation of the flap to its original position and hastens the healing process. Disadvantages • Produces a defect in the attached gingiva (recession of gingiva).

What is a contraindication for flap surgery? ›

Relative contraindications to rotational flap transfer include an increased risk of hemorrhage and active smoking. Smokers, in general, have a higher risk of developing complications following surgery. Specifically, they are at increased risk of flap necrosis, which means that other closure options may be preferable.

What happens after flap surgery? ›

You will be sore in the breast and in the area where the flap was taken. You may have a pulling or stretching feeling in those areas. You can expect to feel better and stronger each day, although you may need pain medicine for a week or two. You may get tired easily or have less energy than usual.

How long does flap surgery last? ›

DIEP flap or tissue flap breast reconstruction can be performed immediately following a mastectomy or as delayed reconstruction. Patients will be given general anesthesia before surgery. The surgery takes four to six hours, but it can take longer if performed along with a mastectomy.

What are the advantages of free flap reconstruction? ›

The advantages of Free Flap Procedure are: The coverage achieved by free flap surgery is very stable, and there are very few chances of breakage or damage to the flap. The chances of the donor site developing an infection or a disease are also minimal since both sites are less exposed to threats.

What are the risk factors of flap failure? ›

Conclusions: BMI, smoking, and operative time were identified as independent risk factors for free flap failure among all flaps or within flap subsets.

What is the disadvantage of flap? ›

Disadvantages of the flap include the longer operative time and the more difficult dissection.

What are the limitations of flap? ›

The main limitations of invasive flap monitoring technologies include the need for complex operative technique, unsuitable equipment design and malfunction, and high cost. The limitation of unsuitable equipment design and malfunction is common to all invasive monitoring techniques.

What is the success rate of flap reconstruction? ›

Results. Overall flap success rate was 90%, with the radial forearm flap occurring to be most reliable (93%) in head and neck reconstruction.

Can flap surgery fail? ›

This is known as a “complete flap failure.” If you originally had a delayed reconstruction (when the reconstruction surgery takes place some period of time after the mastectomy), you'll lose some breast skin that was part of the transplanted flap when the flap is removed.

What is the most common cause of flap failure? ›

Vascular occlusion (thrombosis) remains the primary reason for flap loss, with venous thrombosis being more common than arterial occlusion. The majority of flap failures occur within the first 48 hours.

Is flap reconstruction safe? ›

As with any major surgery, DIEP flap surgery also has risks. Common risks from major surgeries can include excessive bleeding, infection, the wound opening, asymmetry, and deep vein thrombosis.

How long does it take for a flap graft to heal? ›

You will probably see your provider to have your dressing changed in 4 to 7 days. You may need to have the dressing to your flap or graft site changed by your provider a couple times over 2 to 3 weeks. As the site heals, you may be able to care for it at home.

How do you prevent flap necrosis? ›

Flap Necrosis

Proper flap design and plane of elevation, careful handling of the flap, and the avoidance of flap desiccation intraoperatively are all important factors for the prevention of this complication.

Which is better flap or graft? ›

Skin flaps are thought to provide better cosmetic results than skin grafting (Fig. 5), as the skin tone and texture are usually better matched. Additionally, they have a reduced chance of failure in comparison to skin grafts.

Is flap surgery painful? ›

Most patients experience some discomfort after a flap procedure. Depending on your needs, we may prescribe pain medication or recommend over-the-counter medicine. It is important to relax after surgery, as strenuous activity may cause the treated area to bleed.

How long does it take for nerves to heal after nose surgery? ›

The tip of your nose will feel numb as nerves to sensation have to be cut. The sensation to this area usually returns after about 3 months as the nerves regrow but some people may still have an area of numbness over the nasal tip.

Can nose surgery go wrong? ›

Plastic surgeries, especially rhinoplasty treatments, have been known to go wrong for many reasons. Sometimes it can be because of mistakes made by the surgeon. It can also be because the patients do not do their research properly before going through the procedure and so, are unsatisfied with the results.

Should I massage my nose after surgery? ›

Since the nose retains fluid (for up to a year) following surgery, the massaging motions and compression help push the edema or tissue fluid out of the skin and subcutaneous tissues. This can help mold the nose into a more refined, narrow shape as well as straighten the nose.

How long is bed rest after nose surgery? ›

It is amazing how quickly the body heals after cosmetic surgery. The first week is the most critical period for rhinoplasty healing. After 7-10 days, patients can begin to use other sleeping positions.

Can I bend down after nose surgery? ›

Bending over is not recommended for at least three weeks, as this can increase swelling and aching. Avoid exercise for the allotted timeline of four to six weeks, and avoid activities that will be likely to injure or damage your nose.

How can I speed up healing after surgery? ›

Ensuring a Fast and Successful Recovery After Surgery
  1. Get Plenty of Rest. The most important thing you can do following a surgical procedure is to get plenty of rest. ...
  2. Move Around Without Overdoing it. ...
  3. Eat a Nutrient-Dense Diet. ...
  4. Rehabilitation Services in Bishop, CA.
Mar 27, 2021

How long does it take damaged nose tissue to heal? ›

You can usually treat a broken nose yourself. It should start getting better within 3 days and be fully healed within 3 weeks.

How long does nose tissue take to heal? ›

3-6 months: The numbness and abnormal sensations in your nose and nasal skin should be resolved. 1 Year: The healing process is complete – swelling should have subsided entirely and the nose's new shape is fully refined.

How long does it take for nose cartilage to grow back? ›

The bone doesn't grow after maturity, but the cartilage continues growing for the rest of your life. As such, over several years and decades, your nose will appear larger than it was during the surgery, and that's inevitable. However, you don't have to worry about this for several decades.

What is the flap in reconstructive surgery? ›

An abdominal flap is tissue that's taken from your abdomen. Abdominal flaps use skin, fat, and sometimes muscle. Surgeons can use an abdominal flap to reconstruct a breast in women who have extra abdominal tissue. Abdominal flaps are often used as a free flap.

What is the purpose of pharyngeal flap surgery? ›

Posterior Pharyngeal Flap (PPF) is a surgery done to help correct velopharyngeal dysfunction, or VPD. VPD occurs when the soft palate cannot properly separate the back of the mouth from the nose during speech.

What is the flap between nostrils called? ›

Septum. This is a thin wall made of cartilage and bone. It divides the inside of the nose into 2 parts. Mucous membrane.

What are the complications of nasal flap surgery? ›

Mean follow-up time was 42 months. There were 50 (25.4%) patients who developed a complication, including impaired nasal function (18.8%), distal flap necrosis (5.1%), infection (2.5%), poor donor site healing (2.5%) wound dehiscence (2.0%), and flap congestion (1.5%).

How long does it take for plastic surgery flaps to heal? ›

You will need to follow the following guidelines until your incisions completely heal. This is usually 6 weeks after your surgery. Your doctor will tell you how long to follow these guidelines for. Keep your surgical sites out of the sun.

What are the risks of pharyngeal flap surgery? ›

The risks associated with Pharyngeal Flap Surgery are: Around 20% cases of successful pharyngeal flap surgery reported the development of hypernasal speech. Apart from this, other surgical risks such as allergic reaction to anaesthesia, and slight bleeding may happen.

How long is recovery from pharyngeal flap surgery? ›

NO straws or sharp utensils for 2 weeks.

No swimming until cleared by your surgeon. Your child may snore after this surgery, which is normal and generally improves as the swelling decreases. Your child's speech may take up to a year to improve following surgery. Speech therapy can begin 4-6 weeks after surgery.

Does cartilage grow back in nose? ›

Cartilage, which covers and cushions the surface of joints, generally does not regenerate once damaged, but "cartilage cells from the nasal septum (the part of the nose that separates the nostrils) are known to have a great capacity to grow and form new cartilage."

Can nasal perforation heal itself? ›

Can A Septal Perforation Heal On Its Own? Sometimes, depending on the size of the septal perforation, it may heal on its own. However, as the size increases, the likelihood of spontaneous resolution decreases. A proper nasal septal perforation repair is important because of the delicate nature of the tissue.

What are 3 major complications in sinus surgery? ›

Orbital involvement in endoscopic sinus surgery occurs in 0.5%64 to 3% of all procedures, and represents 16% to 50% of all complications. Most common risks encountered in endoscopic sinus surgery include bleeding, infection, injury to the eye and its adnexa, cerebrospinal fluid leak, anosmia etc.

Why can't you bend over after sinus surgery? ›

Avoid bending over and lifting heavy objects (over 5 pounds) during the first two to three weeks after surgery. These activities place pressure on the operative site and may cause bleeding.

What are the disadvantages of nose surgery? ›

What are the risks of rhinoplasty?
  • Anesthesia risks.
  • Change in skin sensation (numbness or pain)
  • Difficulty breathing.
  • Infection.
  • Nasal septal perforation (a hole in the nasal septum) is rare. ...
  • Poor wound healing or scarring.
  • Possibility of revisional surgery.
  • Skin discoloration and swelling.


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4. Excision Basal Cell Carcinoma of the Nose and Bilobe Flap Reconstruction - New Jersey
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