HOW WE DO IT

Bilobed Flap for Reconstruction of Small Alar Rim Defects

NATHANIEL J. JELLINEK, MD,*
AND

KATHARINE B. CORDOVA, MD*

The authors have indicated no signicant interest with commercial supporters.

he bilobed ap is a well-established reconstructive technique for many small to mediumsized defects on the nose.1,2 Its use in large defects involving the ala has also been demonstrated.3 This ap is useful in areas near facial free margins such as the lower eyelid and alar rim. It functions as a pushing rather than pulling ap, minimizing the risks of ectropion and ecnasion. These particular properties, when applied on the nose, also have the unintended potential to bulldoze and depress nasal free margins in the setting of thicker, sebaceous skin, oversized or incorrect ap design, or conservatively undermined aps.2

True alar rim defects encountered after Mohs surgery present multiple challenges: restoration of the external nasal valve; aesthetic considerations; and lack of an adjacent, mobile tissue reservoir on a free margin. Traditional reconstructive options include full-thickness skin grafts, composite grafts, combined cartilage and skin grafts, wedge excision, VY advancement aps, turn-down hinge aps, and cheek-to-nose or paramedian forehead interpolation aps. Second-intention healing and fullthickness skin grafts risk alar notching associated with wound healing and contraction, yet for shallower alar defects away from the free margin, they remain a viable option.4 Composite grafts are an attractive option and provide structure and cosmesis yet remain a challenging and less-reliable

reconstruction with frequent necrosis or partial take. Combined cartilage and skin grafts can mitigate these risks. Wedge excision, perhaps the simplest option, by denition will reduce the aperture of the nares and external nasal valve. VY advancement aps lack a mobile pedicle, and necrosis can occur. The authors have found this ap to be useful more superiorly on the alar lobule and not along the rim. Any ap or graft necrosis can result in free margin compromise, ecnasion, and constriction of the nasal valve. Cheek-to-nose interpolation aps are a reliable reconstructive option for many of these defects, albeit at the expense of a staged surgery, cheek scar, and potential nasolabial fold asymmetry. The authors present a technique used in six patients with small defects (<1 cm) on the alar rim that were reconstructed immediately after Mohs surgery. The bilobed ap has several attributes that make it a reliable reconstructive option in this location: robust perfusion, predictable pushing movement of the ap toward the free margin, restoration of contour over a convexity, and limiting the repair to a single cosmetic subunit, the ala. Technique Sterile surgical preparation and inltrative anesthesia are performed in standard fashion. It is

*Department of Dermatology, Warren Alpert Medical School, Brown University, Providence, Rhode Island; Division of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts; Dermatology Professionals, Inc., East Greenwich, Rhode Island
2013 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc.  ISSN: 1076-0512  Dermatol Surg 2013;39:649652  DOI: 10.1111/dsu.12055
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important to assess the inherent elasticity and inelasticity of the nasal tissue and the natural resistance of the ala to collapse before injection of anesthesia. If anteriorly located, the defect should be made full thickness through dermis and muscle although not through-and-through. The ap is designed with a muscular pedicle. If anteriorly located, the defect should be made full thickness through dermis and muscle although not throughand-through. Converting the defect from partial to full thickness minimizes ap protuberance once healed and minimizes tension during ap movement. The ap is designed with a muscular pedicle. The ap is usually laterally based, although larger defects and those laterally located can be medially based. It is designed as a Zitelli-modication bilobed ap, with total arc of rotation of approximately 90, the tertiary defect relatively perpendicular to the alar rim, and the standing cone

excised as a part of the ap designin this instance along the alar rim. The standing cone is excised rst, then the ap is incised and undermined in the submuscular plane, taking care to establish and maintain the appropriate plane of dissection. Given the small size of the surgical eld, sharp undermining using a scalpel blade or ne-tipped gradle or tenotomy scissors is preferred. Undermining in the caudal-most portion of the ap in type III nasal skin is limited because of the anatomic turn of this skin posteriorly toward mucosa. Hemostasis is obtained with care to avoid electrosurgery on the tissue edges and walls; such cautery creates focal areas of necrosis and predisposes to more prominent and inverted suture lines.

(A) (B) (C)

(D)

(E)

(F)

(G)

Figure 1. (A) Preoperative basal cell carcinoma located on the left ala bordering the alar rim. (B) Postoperative defect with bilobed ap designed in surgical marking pen. The standing cone is excised medially on the alar rim. The lobes are sized equally and have a total arc of rotation of approximately 90. (C) Immediate postoperative image. (DG) Two-month followup photographs.

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JELLINEK ET AL

The tertiary defect is sutured rst. A single buried suture is sufcient to set the ap into position and relieve any tension on the free margin. One or two more buried vertical mattress sutures are sufcient to stabilize the ap in position and evert the skin edges. All buried sutures are placed in muscle to muscle, which may minimize the scar contraction that leads to a trapdoor deformity.5 Supercial sutures nish the repair and are usually removed at 57 days. Postoperative antibiotics are frequently prescribed as cotton-tipped applicators introduced intranasally during the procedure in a nasal region that can be prepared and scrubbed with antiseptic as can be done with cutaneous surfaces. A correctly designed ap will restore the natural bulk and three-dimensional fullness of the ala and curvature of the alar rim. The small but complex suture lines, although initially conspicuous, tend to fade signicantly in the setting of appropriate contour restoration, as demonstrated in the images (Figures 1, S1, S2). There are potential pitfalls of faulty ap design, typically under- or oversizing of the ap. The former will lead to contraction along the ala and ecnasion. The latter can bulldoze the free margin, leading to alar asymmetry and depression. Any tension along the ap, particularly if the ap is undermined too supercially, can lead to ap tip necrosis along the free margin. Care must also be taken to avoid internal valve constriction when suturing the tertiary defect. This physiologic valve, located most closely under the alar groove, can collapse from swelling associated with ap movement. When the ap is undermined and open, the surgeon must test the ipsilateral nasal breathing of the patient, and then repeat the test after the rst key suture. If there is constriction with this suture, a simple pexing suture from the depth of the alar groove, xed to the sidewall periosteum, will open the valve and prevent collapse. This ap is more difcult to perform on patients with soft, oppy alae, which tend to collapse

with minimal pressure and simplest in patients with rm alar margins. We have not needed to use a cartilage batten graft to buttress the alar free margin during our series and would likely choose a different reconstructive option if such a situation arose. Similarly, if the defect is larger than 1 cm, it is possible that the tissue movement would distort the free margin. Given the stiff skin of the alae in patients for whom this repair is indicated, subtle alar base asymmetry may be appreciated; this asymmetry has been subtle and not distressing to patients. The authors have found that the bilobed ap is a reliable technique to reconstruct small alar rim defects after Mohs surgery. This procedure addresses all of the unique functional and aesthetic complexities of the ala: maintenance of the nasal valve, contour restoration, and reconstruction of the free margin.

References
1. Zitelli JA. The bilobed ap for nasal reconstruction. Arch Dermatol 1989;125:9579. 2. Cook JL. A review of the bilobed aps design with particular emphasis on the minimization of alar displacement. Dermatol Surg 2000;26:35462. 3. Cook JL. Reconstructive utility of the bilobed ap: lessons from ap successes and failures. Dermatol Surg 2005;31:102433. 4. Collins SC, Dufresne RG Jr, Jellinek NJ. The bilobed transposition ap for single-staged repair of large surgical defects involving the nasal ala. Dermatol Surg 2008;34; discussion: 1379 85. 5. Ricks M, Cook J. Extranasal applications of the bilobed ap. Dermatol Surg 2005;31:9418. 6. Neuhaus IM, Yu SS. Second-Intention Healing of Nasal Alar Defects. Dermatol Surg 2012;38:697702. 7. Teltzrow T, Arens A, Schwipper V. One-stage reconstruction of nasal defects: evaluation of the use of modied auricular composite grafts. Facial Plast Surg 2011;27:2438. 8. Ewanowski CD, Cook J. Using cartilage and skin grafts concurrently: an alternate route to repair. Dermatol Surg 2009;35:180917. 9. Asgari M, Odland P. Nasalis island pedicle ap in nasal ala reconstruction. Dermatol Surg 2005;31:44852. 10. Fader DJ, Baker SR, Johnson TM. The staged cheek-to-nose interpolation ap for reconstruction of the nasal alar rim/lobule. J Am Acad Dermatol 1997;37:61419.

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11. Nguyen TH. Staged cheek-to-nose and auricular interpolation aps. Dermatol Surg 2005;31:103445. 12. Cook JL. The undesirable inuence of reconstructive procedures on the symmetry of the nasolabial folds. Dermatol Surg 2005;31:140916. 13. Zitelli J. Commentary. Dermatol Surg 2008;34:13856.

bilobed ap designed with a standing cone laterally along the alar margin and a total arc of rotation of approximately 90. (F) Bilobed ap sutured into place. (GJ) Three-month follow-up photographs demonstrate well-camouaged scar lines and symmetric alar margin. Figure S2. (AC) Small surgical defect on the right alar rim. (DF) Two-month follow-up photographs demonstrate wellcamouaged scar lines and preserved free alar margin.

Address correspondence and reprint requests to: Nathaniel J. Jellinek, MD, 1672 South County Trail, Suite 101, East Greenwich, RI 02818, or e-mail: winenut15@yahoo.com

Supplementary Material Additional Supporting Information may be found in the online version of this article: Figure S1. (AB) Preoperative photograph demonstrating a basal cell carcinoma on the right alar rim. (CD) Surgical defect after two stages of Mohs surgery, clear of tumor. (E) Laterally based

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