Originally described by Esser in 1918 for reconstruction of nasal tip defects (14), it consists of two lifting-type random-pattern transposition flaps that pivot into position. The first flap fills the defect and the second flap fills the donor site (Fig. 9).
The release of tension by raising the second flap is analogous to that associated with a Z-plasty. The angles between the defect and each lobe of the flap should be narrow enough to limit the transposition arc to 90 degrees to avoid standing cutaneous and trapdoor deformities common to Esser's original design using an arc of 180 degrees (15). The technique begins by changing a circular defect into a teardrop by excising a Burow's triangle. Arcs are then created centered along the base of the defect; the first arc crosses the outside limit of the defect and the second arc bisects the defect. The first arc marks the height of the primary donor flap, the
second arc marks the base of both donor flaps. The secondary donor flap is twice the height of the first. Closure begins with the donor site of the secondary flap.
The bilobed flap is very useful for limited defects (1-1.5cm) of the nose (Fig. 10). The arc is 90 degress and the diameter 2.5D.
It is the flap of choice for limited defects (1-1.5 cm) on the lower two-thirds of the nose. The primary flap is placed with little tension and little tendency to distort surrounding structures such as the alar rim or nasal tip. This flap is ideal for alar-tip defects: the base of the flap can be positioned laterally and primary closure of the secondary defect is accomplished through recruitment of skin lateral to the nasal sidewall subunit.
As with many of these local flaps, the curvilinear design creates scars that cross the RSTLs.
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