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- Presentation
Bilobed Flaps: Design, Indications, and Common Pitfalls
Description
The talk reviews bilobed flaps, explaining their evolution from the original Esser flap with 90-degree angles to the Zatelli-modified bilobed flap with 45-degree angles. Bilobed flaps are favored because they are single-stage, use nearby skin with good color and texture match, provide greater movement than a simple transposition flap, and are reliable for the nose and other body sites. The speaker emphasizes careful design and orientation, especially keeping the second lobe perpendicular to free margins to avoid traction on the alar rim, and notes that a trilobed design may sometimes better achieve this. Precise measurements are key: on the nose, arc placement, dog-ear sizing, pivot point, and lobe heights must be carefully planned, with 360-degree undermining over cartilage or bone and attention to the nasal valve. Classic indications include lower-third nasal defects under 1.5 cm and about 1 cm from the alar rim, though select defects up to 2 cm can be repaired successfully; the flap can also be used on the medial cheek, lips, chin, dorsal hand, ear helix, and distal fingers. Common pitfalls include alar retraction, which may result from undersized lobes, older 90-degree designs, or poor perpendicular alignment; this can sometimes be corrected with a Z-plasty or added lobes. Other issues are bulldozing in thick sebaceous skin and pincushioning, which can be reduced by precise sizing, 360-degree undermining, tacking the flap base, and anti-beveling the primary lobe.
View moreConclusions
- Bilobed flaps are presented as a reliable, versatile single-stage reconstruction option that provides good color and texture match while allowing greater tissue movement than a standard transposition flap.
- The modern Zitelli modification with roughly 45-degree lobe angles is favored over the original Esser design because it improves flap mechanics and usability.
- Successful outcomes depend heavily on precise flap design, especially making the second lobe perpendicular to nearby free margins when possible and matching lobe dimensions to defect geometry.
- The classic best indication is a small lower-third nasal defect, but the talk suggests bilobed flaps can also work well for select defects on the cheek, lip, chin, ear, hand, and fingers.
- For nasal defects, good results are typically seen in lesions under about 1.5 cm, though carefully planned cases up to around 2 cm may still be suitable.
- The most important complications to avoid are alar retraction, bulldozing, and pincushioning, with alar retraction highlighted as the most reported complication.
- Alar retraction is usually linked to poor sizing or tension vectors that are not perpendicular to the free margin, and can often be prevented by better design or corrected later with a Z-plasty.
- Thicker, sebaceous noses are especially prone to bulldozing, so exact flap sizing and resizing are critical in these cases.
- Pincushioning can be minimized by meticulous measurement, 360-degree undermining, bevel control, and tacking the flap base.
- Overall, the presentation concludes that bilobed flaps are highly effective when carefully planned and executed, and that most common problems are preventable with attention to orientation, sizing, and tension management.
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