Bilobed Flap
Facial and Nose Reconstruction With a Nasolabial Flap, Skin Cancer, Kevin Kavanagh
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  • Slide 1.  Surgical Defect After Skin Cancer Removal
  • Slide 2.  Outline of A Superior Based Nasal Labial Flap
  • Slide 3.  Flap Sewn Into Position
  • Slide 4.  One Day Post-Op Result
  • Slide 5.  One Month Post-Op Result
  • Slide 6.  One Month Post-Op ResultNote the edema of the flap. This is common with superiorly based flaps. This may imporve with time or a revision to debulk the flap may be needed.
Superior Nasalabial Flap Reconstruction in
a Patient With a Nasal Skin Carcinoma

This flap is difficult to achieve a good cosmetic result in a single stage.  Due to both swelling and the thickness of the flap most patients will require a second-stage reduction rhinoplasty.  With wide flaps the closure of the secondary defect can also distort the nose.  With superiorly based flaps, the defect is next to the nasal ala and closure under tension may spread the nasal opening laterally.  With inferiorly based flaps, the defect is superiorly, and this can result is notching or wrinkling of the nasal ala as the superior nasal skin is pulled laterally. 
 
Indications for use of this flap is the loss of the nasal rim, loss of the nasal supporting cartilages (only nasal mucosa lines the depths of the resection), and a through and through defect.   If the resection is not deep, a skin graft, if possible a full thickness graft,  may be the better option since nasal distortion and flap swelling are then avoided.  Full thickness skin grafts give a better cosmetic result than a nasal labial flap but should only be used for small superficial defects.

This flap is often classified as an axial flap because there is a named artery which runs deep to the flap (angular artery).  However, when used for nasal reconstruction the flap is thinned and does not contain the artery which is much deeper in the tissues.  In general, random flaps should not have a length to width ratio greater that 2.5 to 1.  Flaps wider than 1.5 cm may create a donor site which is difficult to close primarily.  In one patient, a width to length ratio of 3 to 1 was used, which resulted in partial loss of the tip of the flap.  The angular artery, a branch of the facial artery (external carotid artery system) runs deep to this flap.

Superiorly based nasolabial flaps can reconstruct a wide range of defects.  If possible, they should be constructed so the base is high up along the nose so the angle of rotation is small.  This will result in smaller (or no) dog-ear formation.  In addition, the patient must be warned not to wear eyeglasses which rest on the pedicle base, otherwise flap loss and edema may occur.  Flap swelling may occur even months after the operation from wearing eyeglasses.  Thus, the nasal rest of eyeglasses may have to be modified and in the short term, the eyeglasses should be taped to the forehead to relieve any nasal pressure.    Most superiorly based nasal flaps will need a second stage reduction rhinoplasty to obtain a good cosmetic result.
 

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