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Pearls

  • Always use Diligence (careful and persistent work) and intelligence.
  • Have a Plan A, B and C in case the recipient vessel is not usable.
  • Practice using magnifying glasses (loup glasses).
  • Train yourself to look after perforator vessels near the defect using ultrasound before a standard resection.
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Step 1: Bilobe flap design

Pivot point of the rotation arc is placed at distance of 1x radius from the lateral border of the defect. Lobe 1 is placed at approx. 45 degrees and lobe 2 at 90 degrees following the arc from the tip of the defect.

  • Lobe 1 width equals the defect, while the height extends beyond the arc with a few millimeters
  • Lobe 2 width is slightly smaller than lobe 1, while the height is 1,5x lobe 1
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Step 2: Bilobe flap raised

The tumor has been excised with free histologic margins. A circular excision defect of 11x12mm is to be reconstructed. The bilobe flap is raised in the sub-fascial plane and transposed into the defect.

  • Further sub-fascial undermining of nasal skin is often necessary
  • Avoid tension on lobe 1 on the nasal tip
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Step 3: Closure

Closure is performed using a few absorbable vicryl 5-0 sutures and then nylon 5-0 sutures. First, the lobe 2 donor site on the proximal nose is closed. Thereafter the lobe 1 donor site defect and at last the primary defect are closed.

  • Skin correction by excision of redundant skin by a burrows triangle is often necessary
  • Nylon sutures are removed after 7-8 days
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