The transnasal bilobed flap for medial canthal reconstruction

Reconstruction of the eyelids, especially medial canthal area, is one of the greatest challenges faced by the oculoplastic, head and neck surgeons. A patient with a medial canthal defect, following oncological resection involving the medial canthus, upper and lower eyelids, and nose is presented. The defect was reconstructed using a transnasal bilobed fl ap. The transnasal bilobed fl ap is a simple and effective for medial canthal reconstruction and provides in one-time reconstruction and preserves the local anatomy. Case Report The transnasal bilobed fl ap for medial canthal reconstruction Corredor-Osorio Rafael*, Massaro-Corredor Martha Gabriela and Buitrago-Corredor Vanessa Gabriela Oculoplastic and Orbit Service, Eye Center Specialized Ophthalmology Corredor, Valera (Trujillo) Venezuela *Address for Correspondence: Rafael CorredorOsorio, Eye Center Specialized Ophthalmology Corredor. Av. Bolívar, CC Acacias local 31, Valera (Trujillo) Venezuela, Tel: 582712310571; Email: rafi corredor@yahoo.com Submitted: 25 October 2017 Approved: 03 November 2017 Published: 06 November 2017 Copyright: 2017 Rafael CO, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Rafael CO, Gabriela MCM, Gabriela BCV. The transnasal bilobed fl ap for medial canthal reconstruction. Heighpubs Otolaryngol and Rhinol. 2017; 1: 088-091. https://doi.org/10.29328/journal.hor.1001014 Introduction The medial canthal region is a common site for tumors, particularly basal cell carcinoma (BCC) [1]. BCC accounts for 70-80% of all cutaneous malignancies in the head face and neck region [2]. The medial canthal region represents a multicontoured area with great variation in skin thickness, color, texture, and appendage density, and it includes contributions from the orbital and tarsal portions of the upper and lower eyelids, the nasal sidewall, the glabella [3,4], brow, cheek [4,5], the bony attachments of the medial canthal tendon, the lacrimal puncta, and arteriovenous and neural bundles that supply and innervate the region [4-6]. Existing therapeutic strategies include direct suture, free skin grafts and skin laps [7]. The surgical medial canthus is much larger than the anatomical medial canthus, and extends vertically into the sub-brow region, medially to the side of the nose and close to the midline, and inferiorly onto the cheek [4,5]. We describe the usefulness of the transnasal bilobed lap for medial canthal sreconstruction, and highlight some key features, which are illustrated in this case. Case Report A 49-yeard old woman presented to us with a complaint of an asymptomatic ulcer located in right medial canthus, the lower lid and the adjoining nasal region for 2 years duration which was slow growing in nature (Figure 1). The 2x3 cm ulcer was of insidious onset and gradually increased in size; it was not well demarcated and had a black pigmented crusted surface. Her visual acuity and eyelid movements were normal. Surgical technique The lap is made from the dorsum and contralateral aspect of the nose, taken across horizontally oriented relaxed skin tension lines [8]. The two lobes of the skin lap are then planned and outlined adjacent to the lesion. The angle between the two lobes can be varied from 30° to 120°, to take advantage of areas with lax skin and to ensure closure of incisions along relaxed skin tension lines [9]. The irst or primary lobe diameter must be similar to the vertical length of the defect. The secondary lobe or distal is half The transnasal bilobed fl ap for medial canthal reconstruction Published: November 06, 2017 089 the size of the primary and is slid into defect created by rotating the primary lobe. The axis of rotation is closer to the irst that the second lobe, thus introducing an element of advancement to the rotation. The skin and subcutaneous tissue on the dorsum of the nose are undermined widely, and a radial reliving incision may be made at the distal end of the secondary lobe to aid rotation [8]. A suitable bilobed lap is marked on the skin (Figure 2A) before the subcutaneous injection of bupivacaine 05% with 1:200.000 epinephrine and then apply irm pressure for 5 minutes. The lesion is then excised with 3 mm security margins and sent for pathology to verify clear margins (Figure 2B). The lap boundaries are cut, dissected and mobilized with blunt scissors beneath the lap and across the dorsum of the nose. The primary lobe is then elevated, rotated and positioned in the defect to con irm that the size of the lap approximates of the defect. Three deep invert Vicryl (polyglactin 910; Ethicon) sutures are placed to position the lap with minimal tension (Figure 2C). While, 7/0 Prolene (polypropylene; Ethicon) sutures are placed to close the epidermis in simple fashion (Figure 2D,2E). A bolster is applied over lap to push the skin gently against the recipient bed. The sutures are removed in 10 days and topical ointment is applied twice daily .Histological examination revealed un BCC with a separate focus of in iltrative tumor, con irmed that the margin was free of tumor. The patient has been followed up for 1 year with no evidence of recurrence and has no concerns with eyelid function, visual ield and epiphora (Figure 3). Figure 1: Lesion of the right canthal medial region.


Introduction
The medial canthal region is a common site for tumors, particularly basal cell carcinoma (BCC) [1]. BCC accounts for 70-80% of all cutaneous malignancies in the head face and neck region [2]. The medial canthal region represents a multicontoured area with great variation in skin thickness, color, texture, and appendage density, and it includes contributions from the orbital and tarsal portions of the upper and lower eyelids, the nasal sidewall, the glabella [3,4], brow, cheek [4,5], the bony attachments of the medial canthal tendon, the lacrimal puncta, and arteriovenous and neural bundles that supply and innervate the region [4][5][6]. Existing therapeutic strategies include direct suture, free skin grafts and skin laps [7]. The surgical medial canthus is much larger than the anatomical medial canthus, and extends vertically into the sub-brow region, medially to the side of the nose and close to the midline, and inferiorly onto the cheek [4,5]. We describe the usefulness of the transnasal bilobed lap for medial canthal sreconstruction, and highlight some key features, which are illustrated in this case.

Case Report
A 49-yeard old woman presented to us with a complaint of an asymptomatic ulcer located in right medial canthus, the lower lid and the adjoining nasal region for 2 years duration which was slow growing in nature ( Figure 1). The 2x3 cm ulcer was of insidious onset and gradually increased in size; it was not well demarcated and had a black pigmented crusted surface. Her visual acuity and eyelid movements were normal.

Surgical technique
The lap is made from the dorsum and contralateral aspect of the nose, taken across horizontally oriented relaxed skin tension lines [8]. The two lobes of the skin lap are then planned and outlined adjacent to the lesion. The angle between the two lobes can be varied from 30° to 120°, to take advantage of areas with lax skin and to ensure closure of incisions along relaxed skin tension lines [9]. The irst or primary lobe diameter must be similar to the vertical length of the defect. The secondary lobe or distal is half the size of the primary and is slid into defect created by rotating the primary lobe. The axis of rotation is closer to the irst that the second lobe, thus introducing an element of advancement to the rotation. The skin and subcutaneous tissue on the dorsum of the nose are undermined widely, and a radial reliving incision may be made at the distal end of the secondary lobe to aid rotation [8].
A suitable bilobed lap is marked on the skin (Figure 2A) before the subcutaneous injection of bupivacaine 05% with 1:200.000 epinephrine and then apply irm pressure for 5 minutes. The lesion is then excised with 3 mm security margins and sent for pathology to verify clear margins ( Figure 2B). The lap boundaries are cut, dissected and mobilized with blunt scissors beneath the lap and across the dorsum of the nose. The primary lobe is then elevated, rotated and positioned in the defect to con irm that the size of the lap approximates of the defect. Three deep invert Vicryl (polyglactin 910; Ethicon) sutures are placed to position the lap with minimal tension ( Figure 2C). While, 7/0 Prolene (polypropylene; Ethicon) sutures are placed to close the epidermis in simple fashion ( Figure 2D,2E). A bolster is applied over lap to push the skin gently against the recipient bed. The sutures are removed in 10 days and topical ointment is applied twice daily .Histological examination revealed un BCC with a separate focus of in iltrative tumor, con irmed that the margin was free of tumor. The patient has been followed up for 1 year with no evidence of recurrence and has no concerns with eyelid function, visual ield and epiphora ( Figure 3).

Discussion
Esser in 1918 irst described and used the bilobed lap to repair nasal tip cutaneous defects [10][11]. Reconstruction of the medial canthus defects is an oculoplastic challenge to attain the optimal surgical and cosmetic results. Brie ly, an ideal procedure does no exist; therefore, a variety of different surgical procedures is in use, each of which has its advantages and disadvantages [7]. An ideal rotation lap involves skin of the same epidermal characteristics as the medial canthal area [8]. The dorsum of the nose has this advantage, and techniques using V-Y advancement laps, rhomboid laps or rotational transnasal advancement laps are described [4,8]. The bilobed lap is commonly used rotational lap for plastic reconstruction especially in situations with tight skin, e.g., dorsum of the nose, sole of the foot [8]. Its oculoplastic use has been limited to reconstruction of anterior lamella defects of the lower eyelid and medial canthal like our case.
The bilobed lap originally consisted of a lap of 2 lobes of the same size, angled at 90° and 180° to the site of the defect. Then, the bilobed lap was classi ied into 2 types: type 1 with a center of rotational in the second lobe, primarily a rotational lap, and, type 2 with the center of rotational between the 2 lobes, making it both a rotational and advancement lap [8]. In our case the bilobed lap was type 2, consisting of skin and subcutaneous rotated into adjacent defect, with a large primary lobe and smaller secondary lobe. By using the infraglabellar region for the second lobe, the thickness of the skin of the secondary defect will be uniform because the tissue would rotate from skin with similar thickness. The healing of the scar from the transnasal secondary lobe follows the natural lines of the nasal bridges [8]. In our case, the second lap was only half diameter of the primary lap to achieve adequate closure of the defect. Bilobed lap may be used to reconstruct mayor defects in different anatomical regions.
Due to the high lexibility and freedom of movement of the lobes, the bilobed design has been demonstrated to be versatile, reliable technically practical in microsurgery [11] and provides good cosmesis.

Conclusion
In summary, we presented a case report demonstrating the application of the bilobed lap in the medial canthal reconstruction. This is a surgical technique which can be performed with ease under local anesthesia and hence avoid post-surgical complications such as ectropion and dog ear deformities. In the bilobed lap, the incision of the secondary lobe should be avoided until the primary lobe is elevated and undermining the tissue of the defect primary to avoid complications. A bene it of this lap for medial canthal reconstruction is that provides superb color, tissue thickness and texture match.as the original defect and does not require of a second surgical procedure. Other of the advantages of the technique described in this paper are related to the use of the skin taken from the second lobe from the infraglabellar transnasal because it follows the natural lines of the nasal bridge reason why it doesn't left visible scars on the glabellar region. The tension is reduced thus improving the quality of the scar and decreasing the possibility of relapse. The bilobed lap has its own blood supply; therefore, there is a faster healing and a low risk of necrosis and infection. One of the disadvantages is due to his localization on the lower eyelid can generate ectropion, in this case the surgeon can decide which lap or combination of laps is appropriated either the cheek advancement or the lower eyelid advancement lap. The bilobed lap technique is useful to physicians as otolaryngology, plastic surgery, surgical dermatology and head and neck surgeons excising super icial skin cancers followed by anatomical reconstruction.

Informed consent
Written informed consent was obtained from the patient for the publication of this case report and accompanying images.