Inversed Bilobed Flap for Medial Canthal Reconstruction

Summary:

This article aims to define a novel approach to medial canthus defects involving the use of a superiorly based bilobed flap with donor skin primarily from the bridge of the nose—defined in this article as an inversed bilobed flap. Three cases of medial canthal surgical defects were identified, 2 from basal cell carcinoma excision and 1 from benign congenital nevus excision for cosmesis. These patients underwent reconstruction using a superiorly based bilobed flap with lateral rotation toward the defect. Clinical photographs were collected at pre-, intra-, and postoperative stages. Clinical photographs demonstrated excellent aesthetic and functional results with positive patient satisfaction. The inversed bilobed flap allows for little to no risk of disruption of the brow anatomy, a smoothly incorporated surgical scar, and an aesthetically pleasing reconstruction while using “like-for-like” tissue replacement.

Takeaways.

Question: What method can be considered for medial canthus reconstruction when seeking donor tissues that will match the delicate eyelid skin and cause minimal disruption of the intricate periocular anatomy?

Findings: A small case series describes 3 patients who underwent medial canthus reconstruction with a superiorly based bilobed flap, also referred to as the inverse bilobed flap in this article, where skin is recruited primarily from the nasal bridge. All 3 patients demonstrated excellent aesthetic and functional outcomes.

Meaning: The inverse bilobed flap offers an effective option for medial canthal reconstruction, resulting in excellent cosmetic results with “like-for-like” tissue matching and minimal brow disruption.

INTRODUCTION

Medial canthal surgical defects created by excision of skin cancer lesions can be closed by secondary intention for smaller defects, or by using skin grafts and local rotational or advancement flaps for larger defects.^1–3 The glabellar flap is the most commonly used local flap in medial canthal reconstruction.² The bilobed flap is another local flap that uses 2 lobes on a shared pedicle that are transposed to fill an adjacent cutaneous defect, often used for cutaneous defects on the nose, cheek, and forehead.⁴

In 1995, Sullivan and Bray⁵ first demonstrated the bilobed flap for medial canthus reconstruction, where they primarily reported inferiorly based bilobed flaps. In this study, we report a distinct approach to the reconstruction of the medial canthus using a superiorly based bilobed flap, defined in this study as an inversed bilobed flap. This flap orientation recruits the thinner skin of the nasal bridge so that the advanced tissue blends well with the medial canthal region.

This study adheres to the ethical principles outlined in the Declaration of Helsinki. Written informed consent was obtained for the publication of clinical photographs. This study was exempt from full review by the Vanderbilt University Medical Center institutional review board.

CASE DESCRIPTION

We retrospectively identified 3 patients with medial canthal surgical defects. The patient in case 1 was a 67-year-old man who underwent staged repair of a left medial canthal defect resulting from resection of a recurrent basal cell carcinoma. A superiorly based bilobed flap was used after the primary surgeon noted the patient’s excessive hair growth between the brows, which could create an unfavorable aesthetic result if a local glabellar flap had been used. He was followed up in the clinic regularly with no complications related to the repair, with satisfactory results up to 22 months after surgery. (See figure, Supplemental Digital Content 1, which displays the patient in case 1 at 22 months after left medial canthus reconstruction, https://links.lww.com/PRSGO/F348.) The patient in case 2 was a 16-year-old woman who underwent elective excision of a benign 16 × 8 mm right medial canthal congenital nevus. The inversed bilobed flap was chosen to minimize the degree of tissue rotation and to use skin similar in character to the medial canthal region. She was followed up for 5 months with satisfactory results before being lost to follow-up. (See figure, Supplemental Digital Content 2, which displays the patient in case 2 at 5 months after right medial canthus reconstruction, https://links.lww.com/PRSGO/F349.) The patient in case 3 was a 56-year-old man who underwent Mohs surgical excision of an 8 × 6 mm basal cell carcinoma followed by reconstruction of the right medial canthus surgical defect with the inversed bilobed flap. The patient returned for an 11-month follow-up with excellent results (Fig. 1).

Fig. 1.

The patient in case 3 underwent Mohs resection of a basal cell carcinoma in the right medial canthus (A), followed by primary resection (B) and inversed bilobed flap reconstruction (C). D, He returned to the clinic for an 11-month follow-up.

Similar steps were used in all cases, with variations in laterality and the size of the flap created based on the original deformity. The proposed inversed bilobed flap was marked with the first lobe tangential to the medial edge of the surgical defect, arching as a curvilinear lobe and forming a Valentine-heart-shaped curve to the second lobe over the base of the nasal bridge. The angle between the defect and the primary lobe, and the angle between the primary and secondary lobes, were approximately 45 degrees each. The flap was dissected with the base of the proposed flap perfused by the ipsilateral supratrochlear artery. The flap was further lifted to allow for good lateral movement of the first lobe into the medial canthal defect and the second lobe into the defect created by mobilization of the first lobe. The 2 lobes were secured in place, and the medial canthal anatomy was recreated using a quilting suture to secure the medial canthal concavity. Postoperatively, all patients had minimal scarring, with no instances of complications that would require revisions, including, but not limited to, ectropion, webbing, or brow distortion.

DISCUSSION

The bilobed flap was first used for the reconstruction of small- to moderate-sized cutaneous nasal defects and was first described by Esser in 1918 for nasal tip reconstruction.⁴ Bilobed flaps have since been used in oculoplastic and facial reconstruction, including for reconstruction of medial canthal,⁵ lateral canthal, and inferior periorbital defects.⁶

When selecting a reconstructive flap, donor tissue characteristics are an important consideration for optimal cosmetic outcomes. For large defects crossing multiple aesthetic units, reconstruction is best achieved with “like-for-like” replacement.¹ Glabellar flaps and classic inferiorly based bilobed flaps both recruit donor tissue that originates from the thick forehead skin that does not match the delicate skin of the medial canthal region. The glabella may also contain eyebrow hair, which could extend medially, causing a hairy flap recipient site. Additionally, deep furrows from vertical glabellar wrinkles can limit the amount of usable skin for a flap.⁷

Mehta and Olver⁸ have also demonstrated a surgical design that aimed to avoid the glabellar region while still maintaining the inferior base with the infraglabellar transnasal bilobed flap. Although this allowed for “like-for-like” tissue reconstruction, the technique required large rotational angles that could lead to tissue distortion, which could pull up the contralateral nostril.⁸ Additionally, Perry and Taban⁹ demonstrated “like-for-like” replacement using thin tissue from the dorsal nose to reconstruct primarily the nasal sidewall and nasojugal fold regions with a superiorly based bilobed flap. However, this article focused mainly on defects inferior to the medial canthus rather than at the canthus. Our 3 patients had defects involving the entirety of the medial canthal convexity—an area prone to webbing and distortion, as well as cicatricial ectropion with symptomatic epiphora, if the defect is not appropriately reconstructed. Our superiorly based flap allows the lobes to be rotated in such a fashion as to allow for reconstruction of this concavity.

The flap can be considered for patients with superficial defects centered over the medial canthal tendon and involving the medial canthal concavity. Complications such as venous congestion, pin-cushioning, trapdoor deformity, and scar widening over the nasal bridge are minimized with this technique, as the small size of the flap does not disturb the deep venous drainage of the medial canthal area, avoids the thicker sebaceous skin of the glabellar region, and allows for minimal traction on the wound. The technique is superior to skin grafts or healing by secondary intention, as it provides superior color, texture, and thickness while avoiding loss of the medial canthal concavity or an obvious alteration in the periocular anatomy.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article. The Vanderbilt Eye Institute has received an unrestricted grant from Research to Prevent Blindness.

PATIENT CONSENT

The patient provided written consent for the use of his image.