Reconstruction of a massive facial cutaneous defect with a bilobed transposition flap.

An 86-year-old man presented with a large squamous cell carcinoma of the left facial skin. The Lesion had been present for 2 years, and it had invaded through the superficial fascia and into the parotid gland (figure 1, A). In addition, a basal cell carcinoma was identified on the left helix. The patient's facial nerve function was normal. He underwent wide local excision with an en bloc resection of the parotid gland (figure 1, B), a bilobed cervicofacial rotation flap procedure (double transposition flap with a shared base), and a partial auriculectomy.

[FIGURE 1 OMITTED]

The large resection with negative margins left the patient with a significant primary defect (figure 2, A). The reconstructive options that were considered at the time included placing a bilobed flap, a radial forearm fasciocutaneous free flap, a pectoralis myocutaneous flap, and a local advancement/rotation flap. The bilobed flap was chosen because of its simple design and its ability to make use of the lax skin of the neck. This flap design is classically used for defects on the lower third of the nose, and it can be useful for a large defect of the cheek when a simple rotation flap will not provide enough tissue for adequate coverage (figure 2, B and C).

[FIGURE 2 OMITTED]

When designing treatment options for a particular patient, it is important to consider all reconstructive options. In this case, a simple bilobed flap best served this elderly man. who presented with locally advanced disease and significant cervicofacial laxity. The primary flap was rotated to repair the surgical defect, and the secondary flap was placed to close the primary flap donor site. The defect from the secondary flap was undermined and closed primarily.

The geometric design and biomechanics of the bilobed flap ad its release of tension are similar to those of the Z-plasty transposition flap. In this case, a triangle (Burrow's triangle) was created, with the apex serving as a point from which the remaining flap was designed. The base of the triangle was approximately one-half the diameter of the defect. Two arcs were then created to construct the donor lobes: one arc was made through the center of the defect, and the other was made through the distal end of the detect. (1) Each flap's center radius was positioned 45[degrees] from the other, thus limiting standing cutaneous deformities and pincushioning defects. The primary flap should be 20 to 25% smaller than the defect, and the secondary flap should be designed in a similar fashion. There should be considerable undermining of the flap and the peripheral tissue. Sufficient skin laxity in the local area is required to allow for adequate closure with minimal tension.

Reference

(1.) Zitelli JA, Baker SR. Bilobe flaps. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis: Mosby; 1995: 165-80.

Doug Iddings, DO; Babak Azzizadeh, MD; Ryan Osborne, MD, FACS 

From the Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, Calif. (Dr. Iddings), the Head and Neck Cancer Center, Cedars-Sinai Medical Center, Los Angeles (Dr. Azzizadeh and Dr. Osbornet. and the Osborne Head and Neck Institute, Los Angeles (Dr. Osborne).