The Hatchet and Bilobed Flaps Revisited: Shedding New Light on Traditional Concepts

January 2012 | Volume 11 | Issue 1 | Original Article | 99 | Copyright © January 2012


Isaac Zilinsky MD,a,b Nimrod Farber MD,b Josef Haik MD,b Oren Weissman MD,b Tal Friedman MD,c Eyal Winkler MDb

aMohs unit, the Chaim Sheba Medical Center, Israel bDepartment of Plastic and Reconstructive Surgery, the Chaim Sheba Medical Center Tel Hashomer, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Israel cAssaf Harofeh Medical Center, Zerifin, Israel

Abstract
Background: The bilobed and hatchet flaps are well-accepted reconstructive options for the correction of defects of the lower third of the nose. Optimal utilization of these flaps depends on understanding the characteristics of each flap as well as anatomic considerations related to the distal nasal area. Disregarding the limitations of either method may lead to flap failure and unacceptable aesthetic results.
Objective: We present three original ideas: 1) a bilobed flap may be considered as a hatchet flap with a Z-plasty; 2) the trap door deformity (TDD) associated with a bilobed flap can be used as an advantage; and 3) an easy method for preoperative planning of a bilobed flap.
Methods: We collected data from patients who underwent excision of basal cell carcinoma (BCC) of the distal third of the nose and reconstruction with a hatchet or a bilobed flap within the last 20 years.
Results: Favorable cosmetic results were achieved when a hatchet flap was used to reconstruct defects of the inferior third of the nasal side wall, above or bordered with the alar crease, and when a bilobed flap was used to reconstruct nasal tip para-medial defects above the lower lateral cartilage convexity.
Conclusions: We suggest choosing between the hatchet and bilobed flaps for nasal reconstruction according to the defect location as outlined by our findings.

J Drugs Dermatol. 2012;11(1):99-102.

INTRODUCTION

Reconstruction of the nose requires careful preoperative planning and meticulous surgical technique to avoid disfigurement of the most prominent facial feature. Nasal tip defects are usually corrected by local flaps or skin grafts, the former giving superior aesthetic results because of well-matched tissue characteristics (e.g., surface texture and color). Categorically, the two commonly used types of flaps are transposition flaps like the Limberg, Nasolabial, Banner and the Bilobed flaps, and rotation-advancement flaps like the Reiger-Hatchet rotation-advancement flaps. This paper shares more than two decades of the principle author ’s surgical experience to provide an in-depth discussion of the advantages, differences and indications of both the Hatchet and the Bilobed flaps, as reflected by hundreds of successful reconstructions.

MARTERIALS & METHODS

We collected data from patients treated between 1990 and 2010 for defects on the distal third of the nose after excision of basal cell carcinoma (BCC) with either hatchet or bilobed flaps. The tumors were all excised using Mohs micrographic surgery, and all defects were less than 1.5 cm in diameter. Technically, all flaps were elevated in the sub-dermal plane and underwent defatting and undermining of the skin surrounding the defect to allow better adaptation of the margins at the suture line and to minimize the chance of trap door deformity (TDD). Regardless of the reconstructive technique, the affected nostril was packed for mechanical support with paraffin gauze, or a nasal cannula size 7 or 8. Packing the nostril fixed the flap to the underling tissue in a way that minimized nasal valve collapse and dysfunction. All patients received a prophylactic regimen of antibiotics for one week. Evaluation of the cosmetic results was carried out at regular intervals, starting one week after surgery and for at least for two years postoperatively.

RESULTS

Between 1990 and 2010, two hundred cases were reconstructed with hatchet and bilobed flaps (85% and 15%, respectively). Approximately five percent of the cases had minimal dehiscence of the suture line after removal of stitches. Partial distal necrosis was demonstrated in merely a handful of cases from both groups, predominately with the hatchet flap. There were no cases of total flap failure. TDD, defined as bulging of the flap above the surround
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