SurgDerm Case Study: Pitfalls to Avoid & Nasal Repairs!

 

It's "Surgical Tip Tuesday"!

Where I practice, the nose can often times be one of the most common anatomic locations we treat for skin cancer.  

Once the Mohs surgeon clears the skin cancer, my role as a surgical dermatology nurse practitioner is to reconstruct the nose...and it can be quite challenging.

The nose has a distinct topography filled with a myriad of convexities, concavities, creases, and textures that you have to mindfully respect in order to choose the best repair option.  

Despite its complexity, nose reconstructions have grown to be one of my favorite anatomic locations to reconstruct because every nose is unique like a masterpiece.

So this week, I am going to share with you one of my favorite Mohs repairs to perform for a nasal defect called the: BILOBED FLAP. 

What is the Bilobed Flap?

The BILOBED FLAP is a random-pattern, geometric, transposition flap and can be used for small to medium sized nasal defects that provide superior cosmesis. 

The bilobed flap is a double transposition flap where the first lobe serves to fill the primary defect (area where the original skin cancer is removed), and a second lobe fills the defect created by the first lobe.

This repair helps distribute tension across a wider area of tissue as the blood supply to bilobed flaps arises from the subdermal plexus. 

Because of this, it is labeled as a "random pattern" flap, opposed to an "axial" flap where blood supply typically comes from a named vessel entering the flap. 

Due to venous drainage flow through the subdermal plexus, a phenomenon known as a "trapdoor deformity" (aka "pincushioning") may result. 

This is caused by lymphatic drainage that then causes the dependent part of the flap to rise above the surrounding tissue, resulting in flap congestion. 

This is common over the first weeks postoperatively, and often times resolves over time.

If not, there are other treatment options to help, so be sure you follow how well your patient is healing closely. 

Application

The bilobed flap is more commonly used for reconstruction of the lateral portion of the nose.

It utilizes the mobile skin of the superior part of the nose to repair the more fixed skin located at the inferior part of the nose.

When deciding if this repair is an optimal repair to choose, the goal is to provide the patient with the best functional and aesthetic result.

Ask yourself these 2 questions:

1. Does this flap design preserve and not distort anatomic structures of the nose?

2. Does this flap design preserve function and not occlude the nasal valve?

If you conclude that the answer to those 2 questions above are "Yes!" and it is an optimal repair choice, then when executing this repair, pay attention to:

  • Preserving aesthetic subunits and junction lines
  • Mindfully placing incisions in creases and borders between subunits to leave a less conspicuous scar
  • Understanding facial structures and landmarks to avoid tension that can lead to distortion (e.g. any subtle tension to alar rim can cause asymmetry)  
  • Preserving function of nasal valve when repairing nose 

Watch Video

Now that you learned about the bilobed flap, WATCH THIS QUICK VIDEO reviewing the simple steps on how to perform a similar repair called the RHOMBIC FLAP. 

This flap design is very similar on how you would approach the bilobed flap, and hones down the key points to remember that have been highlighted in this article. 

Take Away Point!

Remember, a beautifully repaired nose will be overshadowed if the patient's breathing is compromised!

Function always takes precedence over aesthetics! 

However, if you can achieve both - functional and aesthetic - optimal results for your patients, then that is a win-win for everybody!

Here is another example of a patient where the bilobed flap was performed, but it was utilized on a Mohs defect on the right side of the nose.

The patient was pleased and healed well!

Empower the Dermatology NP/PA Community

I hope you found this article helpful and would love to hear any feedback from you!

If you know anyone that would want to learn more about these surgical tips to leverage their skills, forward this article to them to help empower our Surgical Dermatology NP/PA Community!

 

P.S. My new online advanced SUTURING WORKSHOP will be opening next month 🎉!!! SIGN UP HERE FOR THE WAITLIST to be the first to get more information! 8 CMEs earned!

 

Serving with GRATITUDE,

~ Theresa Talens, DNP, FNP-C (TheresaSurgDermNP)

Check out our Website for more FREE RESOURCES ➡️ P.U.L.S.E. Dermatology & Procedures

 

(Source: Mole, R.J., Hohman, M.H., Sebes, N. (2023). Bilobed Flaps. https://www.ncbi.nlm.nih.gov/books/NBK470355/.)