Facial plast Surg 2017; 33(05): 526-529
DOI: 10.1055/s-0037-1606333
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A Comparison of the Double-Half Bilobe Flap to the Traditional Bilobe Flap: Cohort Analysis of a Single Surgeon Experience

Brandon J. Baird1, Sami P. Moubayed1, Sam P. Most1
  • 1Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
Further Information

Address for correspondence

Sam P. Most, MD
Division of Facial Plastic and Reconstructive Surgery
Stanford University School of Medicine
801 Welch Road, Stanford, CA 94305

Publication History

Publication Date:
29 September 2017 (online)

 

Abstract

The double-half bilobe flap was initially described by the senior author (S.P.M.) in 2012 to address defects of the midline nasal tip typically after ablative carcinoma resection. It is a unique reconstructive option for the nasal tip, as it does not depend on a unilateral tissue advancement vector, instead using bilateral and opposing vectors to maintain symmetry. In this retrospective cohort series, we evaluated patient- and physician-derived outcomes and baseline characteristics from a group of 17 patients that underwent reconstruction with the double-half bilobe flap. A control group of 65 patients that underwent traditional bilobe reconstruction for defects of one nasal subunit (tip, side wall, or dorsum) was used for comparison. Outcome measures included infection, symmetry, pin-cushioning, scarring, reoperation, and adjunct procedures. Also, patient satisfaction was evaluated by using frequency of follow-up as a surrogate for patient discontentment with aesthetic outcome. The double-half bilobe flap provides improved symmetry and otherwise similar overall outcomes compared with the traditional bilobe flap, and should be considered as a primary option for the reconstruction of midline nasal tip defects less than 15 mm in diameter.


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Reconstruction of nasal defects after resection of nonmelanoma skin cancers has become an ever-evolving field.[1] [2] [3] [4] [5] Before ablative resection of the lesion, a careful discussion must take place with the patient about expectations for outcome including function and form of the reconstructed area.[3] Of significant importance is a thorough understanding of adjacent immobile structures, nasal aesthetic subunits, tension vectors, and methods of recruiting tissue for symmetric reconstruction.[5] [6]

The double-half bilobe flap was described by Most et al[7] as a means by which the nasal tip could be reconstructed without significant asymmetry. As previously described, the double-half bilobe flap is a superiorly based flap that symmetrically recruits tissue from the lateral supratip region. It is unique in that it recruits an equivalent area of tissue from each side to allow symmetric tension vectors during the reconstruction of a midline defect. In its initial description, it was theorized that it might have a decreased risk of tip malposition. Given the increased number and length of incisions, there was a theoretical concern for the more conspicuous scar.

The double-half bilobe flap is created in a fashion much like the traditional bilobe flap. To begin, the post-Mohs wound is converted to a circular defect.[7] Then a point ×1 radius length from the superior aspect of the defect is identified and used as a central reference point for three semicircular guidelines at ×2, ×3, and ×4 radius from that superior most point ([Fig. 1]). The first lobe of the double-half flap is extended to the point ×3 radius length away, with a width of ×1 radius from the defect. The second lobe on either side is extended in a triangular formation to the line drawn to ×4 radius. The width of this flap is also ×1 radius. Bilateral flaps are rotated medially into the defect, in a similar fashion to the traditional bilobe flap.

Zoom Image
Fig. 1 Diagram representing the design and execution of the double-half bilobe flap. (Modified slightly from original with permission[7].)

Since its initial description in 2012, there have been no follow-up studies to assess the outcomes of this flap when compared with the traditional bilobe flap. The purpose of this retrospective cohort study is to define and compare outcomes and complications for the double-half bilobe flap with respect to its predecessor, and the traditional bilobe flap for nasal reconstruction.

Methods

Patient Selection

An institutional review board-approved protocol (IRB-38702) to study the single surgeon experience of the bilobe flap was undertaken. Patients were retrospectively identified using the local tissue advancement code to identify all 284 patients that had undergone nasal reconstruction. Of these, 16 patients had a midline nasal tip or supratip defect which was reconstructed with the double-half bilobe flap. The control group underwent reconstruction for nasal lesions using the traditional bilobe flap, and consisted of 53 total patients.


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Data Acquisition

Medical records for the patients mentioned earlier were identified and reviewed for demographic, past medical, pathological, and operative data. Prior medical assessment included evaluation of diabetes, coronary artery disease, hypertension, smoking history, and previous nasal surgery ([Table 1]). Operative reports were used to identify the size of the primary lesion, the nasal subunit involved, the pathology, and the depth of the lesion, if reported (or exposure/involvement of underlying cartilage). Postoperative progress notes were reviewed, and outcome measures including asymmetry, scarring, pin-cushioning, and tip narrowing were assessed at 1 week, 6 weeks, 6 months, and 1 year from the time of surgery.

Table 1

Demographic data and past medical history of bilobe and double-half bilobe patient cohort

Bilobe

Double-half bilobe

p Value

Number

53

16

Age (y)

60.8

61.0

0.96

Sex

Female: 56.6%, Male: 43.4%

Female: 62.5%, Male: 37.5%

0.683

Size

11.5

11.4

0.91

Location

Midline tip

Variable

Flap based

Superior

Variable

Diabetes mellitus

7.6%

0.0%

0.25

Coronary artery disease

9.4%

12.5%

0.79

Hypertension

35.8%

31.2%

0.74

Smoking

39.6%

12.5%

0.044

These subjective measures were also complemented by a collection of data identifying postoperative infection and secondary procedures. Patient satisfaction was indirectly measured through patient attrition. If patients had a higher number of postoperative visits after their reconstruction, it was presumed to be due to dissatisfaction with the aesthetic outcomes of the reconstruction. Also, if they did not complete all four postoperative clinic visits, it was presumed that the patients had adequate satisfaction with the reconstruction.


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Data Analysis

Data were collected from the Stanford University Hospital electronic medical record (Epic Systems). It was analyzed using Microsoft Excel (Microsoft Inc.). The two cohorts were compared for each of the above metrics using a two-tailed Student's t-test. The null hypothesis was accepted at a p value less than 5%.


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Results

The patient population between the traditional bilobe cohort and the double-half bilobe cohort was equivalent with a mean age of 60.8 and 61.0 years, respectively (p = 0.96) ([Table 1]). Of the two cohorts, the traditional bilobe group consisted of 55.6% female patients and the double-half bilobe group consisted of 62.5%, with no significant difference between groups (p = 0.683).

The size of the defect was relatively equivalent between the two groups with the traditional bilobe group have a mean defect size of 11.5 mm and the double-half bilobe group at 11.4 mm (p = 0.91). The defect location for the double-half bilobe group was consistently midline nasal tip or nasal supratip. The lesion for the traditional bilobe group was predominantly nasal tip (32 patients). However, 11 patients had a lesion of the nasal sidewall/dorsum, and 10 patients had a defect of the nasal ala (right or left). Flap basis for all groups was typically superiorly based, apart from a single high nasal dorsum lesion.

The medical history between the groups was equivalent between the two groups ([Table 1]). Differences between the traditional bilobe and double-half bilobe flap were not significant with respect to a history of diabetes, coronary artery disease, or hypertension. There was a statistically significant difference in the number of smokers or formers smokers with the traditional bilobe group having approximately 39.6% and the double-half bilobe group having 12.5% (p = 0.44).

The physician and patient-reported outcomes including pin-cushioning, tip narrowing, scarring, and infection had no statistically significant difference between the two study groups ([Fig. 2]). There was a statistically significant difference observed between nasal tip symmetry with the traditional bilobe cohort having noticeable asymmetry 26.4% of the time compared with a 0% rate of asymmetry among the double-half bilobe group (p = 0.025).

Zoom Image
Fig. 2 Physician- and patient-derived postoperative outcomes. Asymmetry is the only statistically significant difference noted (p = 0.025).

Also, the number of secondary procedures performed to address scarring or pin-cushioning was not statistically significant at 15.1 and 21.4%, for the traditional bilobe and double-half bilobe group, respectively (p = 0.58). The secondary procedures performed included intense pulse light therapy, dermabrasion, triamcinolone injection, removal of extruded suture.

Regarding patient satisfaction ([Fig. 3]), the number of postoperative visits between the two groups was not statistically significantly different. The traditional bilobe flap group had 2.66 follow-up appointments on average, and the double-half bilobe flap group had 2.94 follow-up appointments (p = 0.52). Similarly, the number of patients who elected not to return to the clinic for their last postoperative appointment was relatively similar in the traditional bilobe and double-half bilobe groups, respectively (p = 0.11).

Zoom Image
Fig. 3 Patient satisfaction as determined by the number of postoperative visits.

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Discussion

Approach to reconstruction of the nasal tip after surgical or Mohs resection is a precise art that takes into account many variables.[3] The convex topography, tip orientation, alar free margins, skin texture of the nose, and limited mobility of the skin at the caudal one-third of the nose, all play a role in the successful reconstruction of the nasal tip.[7] [8] For midline nasal tip lesions, the reconstruction has historically been dependent on the bilobe flap as the predominant modality for reconstruction of the nose, as identified by Zitelli.[1] [9] [10] [11] At the midline nasal tip, however, the traditional bilobe carries a risk of altering the tip or alar position.[7] [12]

The double-half bilobe flap offers a unique approach to nasal tip reconstruction due to the equivalent recruitment of tissue from bilateral lateral nasal tip skin. Historically, nasal tip reconstruction with traditional bilobe flap relied on a lateral and superiorly based flap. Unfortunately, this creates an uneven tension vector in the direction of the flap base, potentially causing a resultant asymmetry. The previously held theoretical risk of increased pin-cushioning or scarring was further explored in this study and found relatively similar to the traditional bilobe flap. The senior author (S.P.M.) believes the pin-cushioning risk in either flap is mitigated with technical modifications, such as making sure the flap thickness does not exceed the recipient bed depth.

For most of the postoperative comparison between the two approaches to nasal reconstruction, there were relatively similar rates for noticeable scar, pin-cushioning, tip narrowing, and infection. Also, follow-up frequency was relatively similar between the two groups, with the double-half bilobe flap following up more with the surgeon. However, this was not statistically significant. While follow-up frequency is not an ideal metric for patient satisfaction due to confounders that may not be controlled (including follow-up elsewhere and scheduling conflicts), we used this metric for both groups and would expect any differences in cosmetic outcomes to manifest as increased visits for one or the other technique.

These data demonstrate noninferiority of the double-half bilobe flap for reconstruction of midline nasal tip defects. The outcomes described here are relatively equivalent. Also, there may be the added benefit of improved nasal tip symmetry for patients undergoing double-half bilobe flap. Comparison of patient satisfaction is relatively similar between the two groups, however further evaluation of patient perceived outcome with validated patient-reported outcome measures may be of some benefit.


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No conflict of interest has been declared by the author(s).


Address for correspondence

Sam P. Most, MD
Division of Facial Plastic and Reconstructive Surgery
Stanford University School of Medicine
801 Welch Road, Stanford, CA 94305


Zoom Image
Fig. 1 Diagram representing the design and execution of the double-half bilobe flap. (Modified slightly from original with permission[7].)
Zoom Image
Fig. 2 Physician- and patient-derived postoperative outcomes. Asymmetry is the only statistically significant difference noted (p = 0.025).
Zoom Image
Fig. 3 Patient satisfaction as determined by the number of postoperative visits.