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The bilobed flap in skin cancer of the face: Our experience on 285 cases
Journal of Cranio-Maxillo-Facial Surgery (2010) 38, 460e464 Ó 2009 European Association for Cranio-Maxillo-Facial Surgery doi:10.1016/j.jcms.2009.10.022, available online at http://www.sciencedirect.com
The bilobed flap in skin cancer of the face: Our experience on 285 cases Attilio Carlo SALGARELLI, MD, DDS1, Alessandro CANGIANO, MD2, Francesco SARTORELLI, MD2, Pierantonio BELLINI, MD1, Marco COLLINI, MD, DDS2 1 2
Department of Head and Neck, University of Modena and Reggio Emilia, Via del Pozzo, 71, 41100 Modena, Italy; Department of Maxillo-Facial Surgery, Carlo Poma Hospital, Via Lago Paiolo, 1, 46100 Mantova, Italy
SUMMARY. Background: This article describes how many of the defects caused by oncological surgery can be closed with an easily estended flap. Patient and Method: The Zitelli bilobed flap was used to treat 285 consecutive patients with basal cell carcinomas (BCCs) or squamous cell carcinomas (SCCs); 167 men (58.60%) and 118 women (41.40%) between 45 and 98 years of age. Histologically, 247 BCCs (86.6%) and 38 SCCs (13.4%) were documented. Regarding the site, 148 (51.9%) involved the nose, 51 (17.9%) the cheeks, 36 (12.6%) the preauricular region, 27 (9.5%) the perilabial region and chin and 23 (8.1%) the periorbital region. To measure long-term satisfaction patients responded to a telephone survey consisting of a single global question. Results: The size of the defect following tumour removal was between 1 and 4 cm. Carcinomas up to 1 cm were treated using a one step procedure with a cryostat test of the surgical margins; all others cases were treated using two step procedure after excision and histological in sano resection. Completely acceptable aesthetic and functional deficits were obtained in 275 (96.4%) patients over a 6e72-month follow-up. Ten (3.6%) patients suffered postoperative complications. Two cases of local infection; one case of completely flap necrosis and seven cases of partial revision due to flap necrosis occurred. The level of satisfaction with the surgical long-term result reported by the patients was high. Conclusion: In our experience the bilobed Zitelli flap for covering defects in the area of the face showed very few complications and good aesthetic results. Ó 2009 European Association for Cranio-Maxillo-Facial Surgery
Keywords: bilobed flap, skin, cancer
compared to the 180 of the original design. This notably reduces the onset of postoperative deformities, making the flap an excellent reconstruction technique for facial defects. This paper presents the good visual and functional results obtained when using the Zitelli bilobed flap to repair skin defects of the face.
Skin cancer is the most common tumour of which basal cell carcinomas (BCCs) constitute 77%, squamous cell carcinomas (SCCs) 20%, and melanomas and other rare tumours 3% (Fleming et al., 1995). BCCs often arise in parts of the skin chronically exposed to sunlight (Silverstone and Gordon, 1996). Subjects most at risk of these carcinomas are those with skin types I and II on the Fitzpatrick classification scale. Generally, elderly subjects are affected, although patients less than 40 years old, especially women, are not uncommon. The women affected are often smokers who have histories of either repeated sun burn or having repeated tanning treatments (Boyd et al., 2002). In 86% of cases, the face skin is affected and 25.5% is in the nasal area (Schanoff et al., 1967). The treatment of tumours that involve the skin of the head and neck requires radical oncological resection and satisfactory morphological and functional reconstruction of the defect. Repairing skin defects is the oldest form of reconstructive plastic surgery (Nichter et al., 1983). Although the resection technique is well documented, the literature describes various reconstruction methods (Schliephake et al., 1994). In 1989, Zitelli (Zitelli, 1989) adapted the design of Esser’s bilobed flap (Esser, 1918) by reducing its rotation angles. The flaps are rotated by 45e55 , with a total rotation of 90e110
PATIENTS AND METHODS Patients We collected the case histories of patients who underwent surgery at the Department of Maxillo-Facial Surgery at Carlo Poma Hospital, Mantua, Italy. We found 285 consecutive cases in which bilobed flaps were used to repair facial skin defects due to the removal of skin carcinomas between January 2001 and December 2007. The subjects comprised 167 men (58.60%) and 118 women (41.40%) between 45 and 98 years of age. Histologically, 247 BCCs (86.6%) and 38 SCCs (13.4%) were documented. Regarding the site, 148 (51.9%) involved the nose, 51 (17.9%) the cheeks, 36 (12.6%) the preauricular region, 27 (9.5%) the perilabial region and chin and 23 (8.1%) the periorbital region (Table 1). The patients were followed up for 7e72 months. 460
The bilobed flap in skin cancer of the face 461 Table 1 e Distribution for different facial areas. (BCC: basal cell carcinoma; SCC: squamous cell carcinoma)
N (%) BCC 247 (86.6) SCC 38 (13.4)
Nose
Cheek
Preauricolar
Perilabial and chin
Periorbital
Total
148 (51,9)
51 (17,9)
36 (12,6)
27 (9,5)
23 (8,1)
285 (100)
124 (43.5) 24 (8.4)
44 (15.4) 7 (2.5)
32 (11.2) 4 (1.4)
27 (9.5) 0 (0)
20 (7.0) 3 (1.1)
Female 118 (41.4) Male 167 (58.6)
Fig. 1 e (a) Flap design; (b) Skin defect after tumour resection; (c) Suturing.
Fig. 2 e (a) Flap design; (b) Skin defect and flap mobilization; (c) Suturing.
To measure long-term satisfaction (after scar remodelling was complete), patients responded to a telephone survey consisting of a single global question, ‘‘I am completely satisfied with the treatment of my skin problem’’. This item was derived from the general satisfaction items of the Patient Satisfaction Questionnaire (SPQ-18); scores varied from 1 (strongly disagree) to 5 (strongly agree), higher scores indicate greater satisfaction with medical care (Asgari et al., 2009).
We used a global item because we reasoned that, after a long time, patients would probably remember overall impressions rather than the details of their experience. Methods The Zitelli bilobed flap involves two transfers: the first lobe is used to close the defect, whilst the second serves
462 Journal of Cranio-Maxillo-Facial Surgery
to close the donor site of the first lobe. The donor site of the second lobe is closed by directly suturing. Surgery can be performed under general or local anaesthesia. The flap is always drawn on the skin before infiltrating the anaesthetic (Figs. 1a, 2a, 3a). First, the radius of the defect is measured, and point R is marked that distance from the edge of the defect. This is the point of rotation for the entire flap. Then two arcs of a circle with a single centre are drawn at point R. The first arc passes through the centre of the defect, whilst the second is tangential to the distal edge of the defect. The first arc represents the basis of the two lobes, and the size of the first lobe is the same as that of the defect; the second triangular lobe is the same size or slightly smaller than the first lobe. The axes passing through the respective lobes must be at a 45 angle to each other, at between the first lobe and the centre of the defect (Fig. 1b). Dissection must include the superficial musculoaponeurotic system (SMAS) or upper cervical fascia, and in certain areas such as the nose, extend as far as the supraperichondral or supraperiosteal plane (Fig. 2b). Sufficient underminnig is always important to prevent tension and dog ears. The triangle that appears above the second lobe is removed, as is the skin between the edge of the defect and the rotation point of the flap. The wounds are sutured with 4-0 resorbable thread for the subcutaneous layer and 5-0 or 6-0 Nylon for the cutis (Figs. 1c, 2c, 3b). The application of Steri-Strips to the skin reduces suture traction, improving healing. The sutures are usually removed on day 6. RESULTS
Fig. 3 e (a) Flap design; (b) Flap sutured; (c) One year after surgery.
Table 2 e Patient long-term satisfaction. ‘‘I am completely satisfied with the treatment of my skin problem’’ Scores varied from 1 (strongly disagree) to 5 (strongly agree) 100
patients
The size of the defect following tumour removal was between 1 and 4 cm, and was smaller when it involved nasal skin. Carcinomas up to 1 cm (95 cases 33.3%) were treated using a one step procedure with a cryostat test of the surgical margins. All others cases (190 patients, 67.7%) were treated using two step procedure after excision and histological in sano resection. Completely acceptable aesthetic and functional deficits were obtained after healing in 275 (96.4%) patients that we treated. Ten (3.6%) patients suffered postoperative complications. We observed two cases of local infection, which were treated with specific antibiotic therapy, one case of total flap necrosis most probably due to its compression by a haematoma in a patient with a haemorrhagic diathesis, and seven cases of revision due to partial flap necrosis, most likely due to excessive tension on the margins of the wound caused by insufficient mobilization. Considering the site and size of the defects, there were no significant differences. The level of satisfaction reported by the patients based in a telephone survey consisting of simple statements to which each patient had to rank her or his level of agreement. The patients responses to the questionnaire were 176 (62%); overall, mean long-term satisfaction was high (mean score 4.22). To the question: ‘‘I am completely satisfied with the treatment of my skin problem’’, 154 (87.5%) patients answered ‘‘I strongly or very
80 60 40 20 0
86
mean 4.22
1
5
1
2
68
16 3 score
4
5
strongly agree’’ and 16 (9.1%) patients answered ‘‘I agree’’. Only 6 (3.4%) patients answered ‘‘I strongly or very disagree’’ (Table 2). An example of one postoperative result are given in Fig. 3c.
The bilobed flap in skin cancer of the face 463
DISCUSSION Oncological surgery involving the skin of the head and neck must satisfy two essential principles: oncological radicality and reconstruction that restores morphology, whilst allowing satisfactory function and an acceptable appearance. The surgical treatment of skin carcinomas permits healing in 90% of cases (Dubin and Kopf, 1983). Since smaller skin carcinomas can be treated surgically with complete success and often with little scarring or deformity, all tumours should be diagnosed and treated as early as possible (Pesic et al., 2008). Eighty per cent of skin carcinomas affect the head and neck and are readily visible. General practitioners should be well educated in this regard, as well as patients and their family members. All subjects at risk should have their skin inspected for carcinomas annually. BCCs can relapse at between 1 and 4 years after treatment, so follow-up should be performed for at least 5 years (Netscher and Spira, 2004). A further advantage of such a long follow-up aimed at identifying relapses is the possibility of intercepting new tumours (Robinson, 1987). Between 20 and 33% of patients affected by BCC will develop a new tumour within 1 year of treatment of the first lesion (Robinson, 1987). Post-therapy surveillance is especially important in patients with skin types 1 and 2 who are exposed to the sun’s rays. A meta-analysis conducted in 1987 (Robinson, 1987) evaluated the risk of developing multiple skin carcinomas. Three years after the diagnosis of SCC of the skin, the risk of developing another SCC of the skin is 18%, whilst the risk with BCC is 44%. The risk of developing a BCC in patients with a previous SCC is about equal to that of patients with a previous BCC (about 33%), whilst the risk of developing a SCC for patients with a BCC is 6%. Considering the severity of SCC and the high risk that these patients will develop another SCC or BCC, we believe that patients should to be taught to check themselves, possibly with the help of a family member, and that they undergo 6-month check-ups and a 5-year follow-up. Importantly, meticulous evaluation and demarcation of the clinical margins using magnification has been shown to reduce the rate of positive surgical margins (Wettstein et al., 2006). For BCC and SCC a margin of 0.4 cm will yield a 95% or greater cure rate for lesions that have a low risk of subclinical extension (Brodland and Zitelli, 1992). Low-risk lesions are well-defined lesions (ie, clear clinical margins), less than 2 cm in diameter, have nonaggressive histology, which are located in low or intermediate-risk areas (cheeks, forehead, scalp, neck), and are primary lesions (Huang and Boyce, 2004). With regard to the issue of the size of the primary lesion, the greater the lesion diameter, the greater the surgical margin has to be in order to maximize the probability of achieving a complete excision. For tumours less than 1 cm, a 0.5 cm margin was required. This increased to 0.8 cm for tumours between 1 and 2 cm in diameter and to 1.2 cm for tumours greater than 2 cm in diameter
(Ge et al., 2009). The probability of invasion into subcutaneous fat increased with both histological grade and tumour diameter (Breuninger and Dietz, 1991). When the margins are uncertain, it is considered indispensable to perform an on-the-spot cryostat test of the surgical margins to guarantee complete excision of the tumour. The reparative stage of treatment for facial skin carcinomas should consider the size and location of the defect if we are to design the flap as effectively as possible (Wanyura et al., 2008). Esser (1918) designed the first bilobed flap in 1918 and applied it to the reconstruction of defects of the nasal tip. In 1953, Zimany (1953) described the use of bilobed flaps in various areas, and in 1981, Mcgregor and Soutar (1981) outlined indications for its use. The original design involved a rotational axis of 90 per lobe with a 180 rotation of the entire flap. This rotation was accompanied by skin tension that caused deformity. By reducing the degree of total rotation, Zitelli (1989) made it possible for the bilobed flap to be used far more widely (by virtue of the flap itself). The Zitelli flap was essentially conceived to repair nasal skin defects of up to 1.5 cm. We believe that the bilobed flap has many advantages over other flaps. It is simple to design and the surgical technique is relatively easy. It consists of well vascularised tissue, with a colour and texture that matches the area to be repaired. Moreover, the curved scars that remain are less visible than linear scars. Belmahi et al. (2003) suggested that a bilobed flap was a better alternative for small skin nasal defects in 20 patients. Using this method, skin defects were reconstructed aesthetically without any distortion of the local anatomy of the nose, and the skin had the same colour and texture (thickness). Results reported by Copcu (2004), El-Marrakby (2005) and Rustemeyer et al. (2009) indicate the bilobed flap is versatile, simple, and easy to harvest and can cover a variety of defects on the face and in the nasal region. In 2003, we redesigned the flap to extend the indications to such larger defects. The first lobe was made slightly larger than the defect to further reduce postoperative tension. This permitted suture without tension and obtained healing that would otherwise not have been possible without causing deformity and retraction, particularly of the nasal wing. This variation on Zitelli’s original design was published in a study by Cho and Kim (2006). The design of the flap is essential for good aesthetic results. It should be positioned so that the linear scars correspond to grooves or wrinkles, or follow the release skin tension lines (Borges, 1984). Mobilization should be sufficient to redistribute tension and reduce the traction, which is particularly harmful to certain anatomical structures such as the eyebrow or nasal wing. Our experience has shown us that the bilobed flap can be used successfully in all cutaneous areas of the face. The level of satisfaction with the surgical long-term result reported by the patients was high; 154 (87.5%) patients were ‘‘strongly satisfied’’ or ‘‘very satisfied’’ and 15 (9.1%) patients ‘‘satisfied’’. Only 6 (3.4%) patients were ‘‘dissatisfied’’ or ‘‘absolutely dissatisfied’’.
464 Journal of Cranio-Maxillo-Facial Surgery
CONCLUSION In our experience the bilobed Zitelli’s flap for covering defects in the area of the face showed very few complications and good aesthetic results. The reduced rotation angles decrease postoperative deformities, making the flap an excellent reconstruction technique for skin defects. It can be used successfully in all cutaneous areas of the face. The design of the flap is essential for good aesthetic results. The mobilization should be ample to redistribute tension and reduce the traction. Believe that the bilobed flap has many advantages over other flaps. It is simple to design and draw and the surgical technique is relatively easy. It consists of well vascularised tissue, with a colour and texture that matches the area to be repaired. References Asgari MM, Bertenthal D, Sen S, Sahay A, Chren MM: Patient satisfaction after treatment of nonmelanoma skin cancer. Dermatol Surg 35: 1041e1049, 2009 Belmahi A, El Mazouz S, Gharib NE, Bencheikh R, Ouazzani S: The bilobed flap: a very efficient method in aesthetic reconstruction of small skin defects at the alar and tip regions of the nose. Ann Chir Plast Esthet 48: 211e215, 2003 Borges AF: Relaxed skin tension lines (RSTL) versus other skin lines. Plast Reconstr Surg 73: 144e150, 1984 Boyd AS, Shyr Y, King LE: Basal cell carcinoma in young women: an evaluation of the association of tanning bed use and smoking. J Am Acad Dermatol 46: 706e709, 2002 Breuninger H, Dietz K: Prediction of subclinical tumor infiltration in basal cell carcinoma. J Dermatol Surg Oncol 17: 574e578, 1991 Brodland DG, Zitelli JA: Surgical margins for excision of primary cutaneous squamous cell carcinoma. J Am Acad Dermatol 27: 241e248, 1992 Cho M, Kim DW: Modification of the Zitelli bilobed flap. A comparison of flap dynamics in human cadavers. Arch Facial Plast Surg 8: 404e409, 2006 Copcu E: Trilobed skin flap on the face: for reconstruction of fullthickness or commissural defects. Dermatol Surg 30: 915e921, 2004 Dubin N, Kopf AW: Multi-variant risk score for recurrence of cutaneous basal cell carcinomas. Arch Dermatol 119: 373e377, 1983 El-Marrakby HH: The versatile naso-labial flaps in facial reconstruction. J Egypt Natl Canc Inst 17: 245e250, 2005 Esser Jfs: A bilobed transpositional flap for nasal reconstruction. Dtsch Z Chirurg 143: 335e339, 1918 Fleming ID, Amonette R, Monaghan T: Principles of management of basal and squamous cell carcinoma of the skin. Cancer 75(Suppl. 2): 699e704, 1995
Ge NN, Mc Guire JF, Dyson S, Chark D: Nonmelanoma skin cancer of the head and neck II: surgical treatment and reconstruction. Am J Otolaryngol 30: 181e192, 2009 Huang CC, Boyce SM: Surgical margins of excision for basal cell carcinoma and squamous cell carcinoma. Semin Cutan Med Surg 23: 167e173, 2004 Mcgregor JC, Soutar DS: A critical assessment of bilobed flap. Br J Plast Surg 34: 197e205, 1981 Netscher DT, Spira M: Basal cell carcinoma: an overview of tumor biology and treatment. Plast Reconstr Surg 113: 74Ee94E, 2004 Nichter LS, Morgan RF, Nichter MA: The impact of Indian methods for total nasal reconstruction. Clinic Plast Surg 10: 635e647, 1983 Pesic Z, Mihailovic D, Krasic D, Cosic A, Buric N: Advanced recurrent skin carcinomas of face e survival rate. J Craniomaxillofac Surg 36(Suppl. 1): S148, 2008 Robinson JK: Risk of developing another basal cell carcinoma: a fiveyear prospective study. Cancer 60: 118e120, 1987 Rustemeyer J, Gu¨nther L, Bremerich A: Complications after nasal skin repair with local flaps and full-thickness skin grafts and implications of patients’ contentment. Oral Maxillofacial Surg 13: 15e18, 2009 Schanoff LB, Spira M, Hardy SB: Basal cell carcinoma: a statistical approach to rational management. Plast Reconstr Surg 39: 619e624, 1967 Schliephake H, Neukam FW, Schmelzeisen R, Reiche C: Reconstruction of facial soft tissues after resection of skin tumors. J Craniomaxillofac Surg 22: 342e348, 1994 Silverstone H, Gordon D: Regional studies in skin cancer 2. Wet tropical and subtropical coasts of Queensland. Med J Aust 2: 733e740, 1996 Wanyura H, Stopa Z, Maciejak M: Surgical treatment of skin tumors of the head and the neck. J Craniomaxillofac Surg 36(Suppl. 1): S150, 2008 Wettstein R, Kalbermatten DF, Rieger U, Farhadi J, Harr T, Pierer G: High magnification assessment improves complete resection of facial tumors. Ann Plast Surg 57: 517e520, 2006 Zimany A: The bilobed flap. Plast Reconstr Surg 11: 424e434, 1953 Zitelli JA: The bilobed flap for nasal reconstruction. Arch Dermatol 125: 957e959, 1989
Attilio Carlo Salgarelli, MD, DDS, Prof. Department of Head and Neck University of Modena and Reggio Emilia Via del Pozzo, 71 41100 Modena Italy Tel.: +39 5 94223103 Fax: +39 5 937 3428 E-mail: [email protected] Paper received 17 March 2009 Accepted 21 October 2009
The bilobed flap in skin cancer of the face: Our experience on 285 cases Attilio Carlo SALGARELLI, MD, DDS1, Alessandro CANGIANO, MD2, Francesco SARTORELLI, MD2, Pierantonio BELLINI, MD1, Marco COLLINI, MD, DDS2 1 2
Department of Head and Neck, University of Modena and Reggio Emilia, Via del Pozzo, 71, 41100 Modena, Italy; Department of Maxillo-Facial Surgery, Carlo Poma Hospital, Via Lago Paiolo, 1, 46100 Mantova, Italy
SUMMARY. Background: This article describes how many of the defects caused by oncological surgery can be closed with an easily estended flap. Patient and Method: The Zitelli bilobed flap was used to treat 285 consecutive patients with basal cell carcinomas (BCCs) or squamous cell carcinomas (SCCs); 167 men (58.60%) and 118 women (41.40%) between 45 and 98 years of age. Histologically, 247 BCCs (86.6%) and 38 SCCs (13.4%) were documented. Regarding the site, 148 (51.9%) involved the nose, 51 (17.9%) the cheeks, 36 (12.6%) the preauricular region, 27 (9.5%) the perilabial region and chin and 23 (8.1%) the periorbital region. To measure long-term satisfaction patients responded to a telephone survey consisting of a single global question. Results: The size of the defect following tumour removal was between 1 and 4 cm. Carcinomas up to 1 cm were treated using a one step procedure with a cryostat test of the surgical margins; all others cases were treated using two step procedure after excision and histological in sano resection. Completely acceptable aesthetic and functional deficits were obtained in 275 (96.4%) patients over a 6e72-month follow-up. Ten (3.6%) patients suffered postoperative complications. Two cases of local infection; one case of completely flap necrosis and seven cases of partial revision due to flap necrosis occurred. The level of satisfaction with the surgical long-term result reported by the patients was high. Conclusion: In our experience the bilobed Zitelli flap for covering defects in the area of the face showed very few complications and good aesthetic results. Ó 2009 European Association for Cranio-Maxillo-Facial Surgery
Keywords: bilobed flap, skin, cancer
compared to the 180 of the original design. This notably reduces the onset of postoperative deformities, making the flap an excellent reconstruction technique for facial defects. This paper presents the good visual and functional results obtained when using the Zitelli bilobed flap to repair skin defects of the face.
Skin cancer is the most common tumour of which basal cell carcinomas (BCCs) constitute 77%, squamous cell carcinomas (SCCs) 20%, and melanomas and other rare tumours 3% (Fleming et al., 1995). BCCs often arise in parts of the skin chronically exposed to sunlight (Silverstone and Gordon, 1996). Subjects most at risk of these carcinomas are those with skin types I and II on the Fitzpatrick classification scale. Generally, elderly subjects are affected, although patients less than 40 years old, especially women, are not uncommon. The women affected are often smokers who have histories of either repeated sun burn or having repeated tanning treatments (Boyd et al., 2002). In 86% of cases, the face skin is affected and 25.5% is in the nasal area (Schanoff et al., 1967). The treatment of tumours that involve the skin of the head and neck requires radical oncological resection and satisfactory morphological and functional reconstruction of the defect. Repairing skin defects is the oldest form of reconstructive plastic surgery (Nichter et al., 1983). Although the resection technique is well documented, the literature describes various reconstruction methods (Schliephake et al., 1994). In 1989, Zitelli (Zitelli, 1989) adapted the design of Esser’s bilobed flap (Esser, 1918) by reducing its rotation angles. The flaps are rotated by 45e55 , with a total rotation of 90e110
PATIENTS AND METHODS Patients We collected the case histories of patients who underwent surgery at the Department of Maxillo-Facial Surgery at Carlo Poma Hospital, Mantua, Italy. We found 285 consecutive cases in which bilobed flaps were used to repair facial skin defects due to the removal of skin carcinomas between January 2001 and December 2007. The subjects comprised 167 men (58.60%) and 118 women (41.40%) between 45 and 98 years of age. Histologically, 247 BCCs (86.6%) and 38 SCCs (13.4%) were documented. Regarding the site, 148 (51.9%) involved the nose, 51 (17.9%) the cheeks, 36 (12.6%) the preauricular region, 27 (9.5%) the perilabial region and chin and 23 (8.1%) the periorbital region (Table 1). The patients were followed up for 7e72 months. 460
The bilobed flap in skin cancer of the face 461 Table 1 e Distribution for different facial areas. (BCC: basal cell carcinoma; SCC: squamous cell carcinoma)
N (%) BCC 247 (86.6) SCC 38 (13.4)
Nose
Cheek
Preauricolar
Perilabial and chin
Periorbital
Total
148 (51,9)
51 (17,9)
36 (12,6)
27 (9,5)
23 (8,1)
285 (100)
124 (43.5) 24 (8.4)
44 (15.4) 7 (2.5)
32 (11.2) 4 (1.4)
27 (9.5) 0 (0)
20 (7.0) 3 (1.1)
Female 118 (41.4) Male 167 (58.6)
Fig. 1 e (a) Flap design; (b) Skin defect after tumour resection; (c) Suturing.
Fig. 2 e (a) Flap design; (b) Skin defect and flap mobilization; (c) Suturing.
To measure long-term satisfaction (after scar remodelling was complete), patients responded to a telephone survey consisting of a single global question, ‘‘I am completely satisfied with the treatment of my skin problem’’. This item was derived from the general satisfaction items of the Patient Satisfaction Questionnaire (SPQ-18); scores varied from 1 (strongly disagree) to 5 (strongly agree), higher scores indicate greater satisfaction with medical care (Asgari et al., 2009).
We used a global item because we reasoned that, after a long time, patients would probably remember overall impressions rather than the details of their experience. Methods The Zitelli bilobed flap involves two transfers: the first lobe is used to close the defect, whilst the second serves
462 Journal of Cranio-Maxillo-Facial Surgery
to close the donor site of the first lobe. The donor site of the second lobe is closed by directly suturing. Surgery can be performed under general or local anaesthesia. The flap is always drawn on the skin before infiltrating the anaesthetic (Figs. 1a, 2a, 3a). First, the radius of the defect is measured, and point R is marked that distance from the edge of the defect. This is the point of rotation for the entire flap. Then two arcs of a circle with a single centre are drawn at point R. The first arc passes through the centre of the defect, whilst the second is tangential to the distal edge of the defect. The first arc represents the basis of the two lobes, and the size of the first lobe is the same as that of the defect; the second triangular lobe is the same size or slightly smaller than the first lobe. The axes passing through the respective lobes must be at a 45 angle to each other, at between the first lobe and the centre of the defect (Fig. 1b). Dissection must include the superficial musculoaponeurotic system (SMAS) or upper cervical fascia, and in certain areas such as the nose, extend as far as the supraperichondral or supraperiosteal plane (Fig. 2b). Sufficient underminnig is always important to prevent tension and dog ears. The triangle that appears above the second lobe is removed, as is the skin between the edge of the defect and the rotation point of the flap. The wounds are sutured with 4-0 resorbable thread for the subcutaneous layer and 5-0 or 6-0 Nylon for the cutis (Figs. 1c, 2c, 3b). The application of Steri-Strips to the skin reduces suture traction, improving healing. The sutures are usually removed on day 6. RESULTS
Fig. 3 e (a) Flap design; (b) Flap sutured; (c) One year after surgery.
Table 2 e Patient long-term satisfaction. ‘‘I am completely satisfied with the treatment of my skin problem’’ Scores varied from 1 (strongly disagree) to 5 (strongly agree) 100
patients
The size of the defect following tumour removal was between 1 and 4 cm, and was smaller when it involved nasal skin. Carcinomas up to 1 cm (95 cases 33.3%) were treated using a one step procedure with a cryostat test of the surgical margins. All others cases (190 patients, 67.7%) were treated using two step procedure after excision and histological in sano resection. Completely acceptable aesthetic and functional deficits were obtained after healing in 275 (96.4%) patients that we treated. Ten (3.6%) patients suffered postoperative complications. We observed two cases of local infection, which were treated with specific antibiotic therapy, one case of total flap necrosis most probably due to its compression by a haematoma in a patient with a haemorrhagic diathesis, and seven cases of revision due to partial flap necrosis, most likely due to excessive tension on the margins of the wound caused by insufficient mobilization. Considering the site and size of the defects, there were no significant differences. The level of satisfaction reported by the patients based in a telephone survey consisting of simple statements to which each patient had to rank her or his level of agreement. The patients responses to the questionnaire were 176 (62%); overall, mean long-term satisfaction was high (mean score 4.22). To the question: ‘‘I am completely satisfied with the treatment of my skin problem’’, 154 (87.5%) patients answered ‘‘I strongly or very
80 60 40 20 0
86
mean 4.22
1
5
1
2
68
16 3 score
4
5
strongly agree’’ and 16 (9.1%) patients answered ‘‘I agree’’. Only 6 (3.4%) patients answered ‘‘I strongly or very disagree’’ (Table 2). An example of one postoperative result are given in Fig. 3c.
The bilobed flap in skin cancer of the face 463
DISCUSSION Oncological surgery involving the skin of the head and neck must satisfy two essential principles: oncological radicality and reconstruction that restores morphology, whilst allowing satisfactory function and an acceptable appearance. The surgical treatment of skin carcinomas permits healing in 90% of cases (Dubin and Kopf, 1983). Since smaller skin carcinomas can be treated surgically with complete success and often with little scarring or deformity, all tumours should be diagnosed and treated as early as possible (Pesic et al., 2008). Eighty per cent of skin carcinomas affect the head and neck and are readily visible. General practitioners should be well educated in this regard, as well as patients and their family members. All subjects at risk should have their skin inspected for carcinomas annually. BCCs can relapse at between 1 and 4 years after treatment, so follow-up should be performed for at least 5 years (Netscher and Spira, 2004). A further advantage of such a long follow-up aimed at identifying relapses is the possibility of intercepting new tumours (Robinson, 1987). Between 20 and 33% of patients affected by BCC will develop a new tumour within 1 year of treatment of the first lesion (Robinson, 1987). Post-therapy surveillance is especially important in patients with skin types 1 and 2 who are exposed to the sun’s rays. A meta-analysis conducted in 1987 (Robinson, 1987) evaluated the risk of developing multiple skin carcinomas. Three years after the diagnosis of SCC of the skin, the risk of developing another SCC of the skin is 18%, whilst the risk with BCC is 44%. The risk of developing a BCC in patients with a previous SCC is about equal to that of patients with a previous BCC (about 33%), whilst the risk of developing a SCC for patients with a BCC is 6%. Considering the severity of SCC and the high risk that these patients will develop another SCC or BCC, we believe that patients should to be taught to check themselves, possibly with the help of a family member, and that they undergo 6-month check-ups and a 5-year follow-up. Importantly, meticulous evaluation and demarcation of the clinical margins using magnification has been shown to reduce the rate of positive surgical margins (Wettstein et al., 2006). For BCC and SCC a margin of 0.4 cm will yield a 95% or greater cure rate for lesions that have a low risk of subclinical extension (Brodland and Zitelli, 1992). Low-risk lesions are well-defined lesions (ie, clear clinical margins), less than 2 cm in diameter, have nonaggressive histology, which are located in low or intermediate-risk areas (cheeks, forehead, scalp, neck), and are primary lesions (Huang and Boyce, 2004). With regard to the issue of the size of the primary lesion, the greater the lesion diameter, the greater the surgical margin has to be in order to maximize the probability of achieving a complete excision. For tumours less than 1 cm, a 0.5 cm margin was required. This increased to 0.8 cm for tumours between 1 and 2 cm in diameter and to 1.2 cm for tumours greater than 2 cm in diameter
(Ge et al., 2009). The probability of invasion into subcutaneous fat increased with both histological grade and tumour diameter (Breuninger and Dietz, 1991). When the margins are uncertain, it is considered indispensable to perform an on-the-spot cryostat test of the surgical margins to guarantee complete excision of the tumour. The reparative stage of treatment for facial skin carcinomas should consider the size and location of the defect if we are to design the flap as effectively as possible (Wanyura et al., 2008). Esser (1918) designed the first bilobed flap in 1918 and applied it to the reconstruction of defects of the nasal tip. In 1953, Zimany (1953) described the use of bilobed flaps in various areas, and in 1981, Mcgregor and Soutar (1981) outlined indications for its use. The original design involved a rotational axis of 90 per lobe with a 180 rotation of the entire flap. This rotation was accompanied by skin tension that caused deformity. By reducing the degree of total rotation, Zitelli (1989) made it possible for the bilobed flap to be used far more widely (by virtue of the flap itself). The Zitelli flap was essentially conceived to repair nasal skin defects of up to 1.5 cm. We believe that the bilobed flap has many advantages over other flaps. It is simple to design and the surgical technique is relatively easy. It consists of well vascularised tissue, with a colour and texture that matches the area to be repaired. Moreover, the curved scars that remain are less visible than linear scars. Belmahi et al. (2003) suggested that a bilobed flap was a better alternative for small skin nasal defects in 20 patients. Using this method, skin defects were reconstructed aesthetically without any distortion of the local anatomy of the nose, and the skin had the same colour and texture (thickness). Results reported by Copcu (2004), El-Marrakby (2005) and Rustemeyer et al. (2009) indicate the bilobed flap is versatile, simple, and easy to harvest and can cover a variety of defects on the face and in the nasal region. In 2003, we redesigned the flap to extend the indications to such larger defects. The first lobe was made slightly larger than the defect to further reduce postoperative tension. This permitted suture without tension and obtained healing that would otherwise not have been possible without causing deformity and retraction, particularly of the nasal wing. This variation on Zitelli’s original design was published in a study by Cho and Kim (2006). The design of the flap is essential for good aesthetic results. It should be positioned so that the linear scars correspond to grooves or wrinkles, or follow the release skin tension lines (Borges, 1984). Mobilization should be sufficient to redistribute tension and reduce the traction, which is particularly harmful to certain anatomical structures such as the eyebrow or nasal wing. Our experience has shown us that the bilobed flap can be used successfully in all cutaneous areas of the face. The level of satisfaction with the surgical long-term result reported by the patients was high; 154 (87.5%) patients were ‘‘strongly satisfied’’ or ‘‘very satisfied’’ and 15 (9.1%) patients ‘‘satisfied’’. Only 6 (3.4%) patients were ‘‘dissatisfied’’ or ‘‘absolutely dissatisfied’’.
464 Journal of Cranio-Maxillo-Facial Surgery
CONCLUSION In our experience the bilobed Zitelli’s flap for covering defects in the area of the face showed very few complications and good aesthetic results. The reduced rotation angles decrease postoperative deformities, making the flap an excellent reconstruction technique for skin defects. It can be used successfully in all cutaneous areas of the face. The design of the flap is essential for good aesthetic results. The mobilization should be ample to redistribute tension and reduce the traction. Believe that the bilobed flap has many advantages over other flaps. It is simple to design and draw and the surgical technique is relatively easy. It consists of well vascularised tissue, with a colour and texture that matches the area to be repaired. References Asgari MM, Bertenthal D, Sen S, Sahay A, Chren MM: Patient satisfaction after treatment of nonmelanoma skin cancer. Dermatol Surg 35: 1041e1049, 2009 Belmahi A, El Mazouz S, Gharib NE, Bencheikh R, Ouazzani S: The bilobed flap: a very efficient method in aesthetic reconstruction of small skin defects at the alar and tip regions of the nose. Ann Chir Plast Esthet 48: 211e215, 2003 Borges AF: Relaxed skin tension lines (RSTL) versus other skin lines. Plast Reconstr Surg 73: 144e150, 1984 Boyd AS, Shyr Y, King LE: Basal cell carcinoma in young women: an evaluation of the association of tanning bed use and smoking. J Am Acad Dermatol 46: 706e709, 2002 Breuninger H, Dietz K: Prediction of subclinical tumor infiltration in basal cell carcinoma. J Dermatol Surg Oncol 17: 574e578, 1991 Brodland DG, Zitelli JA: Surgical margins for excision of primary cutaneous squamous cell carcinoma. J Am Acad Dermatol 27: 241e248, 1992 Cho M, Kim DW: Modification of the Zitelli bilobed flap. A comparison of flap dynamics in human cadavers. Arch Facial Plast Surg 8: 404e409, 2006 Copcu E: Trilobed skin flap on the face: for reconstruction of fullthickness or commissural defects. Dermatol Surg 30: 915e921, 2004 Dubin N, Kopf AW: Multi-variant risk score for recurrence of cutaneous basal cell carcinomas. Arch Dermatol 119: 373e377, 1983 El-Marrakby HH: The versatile naso-labial flaps in facial reconstruction. J Egypt Natl Canc Inst 17: 245e250, 2005 Esser Jfs: A bilobed transpositional flap for nasal reconstruction. Dtsch Z Chirurg 143: 335e339, 1918 Fleming ID, Amonette R, Monaghan T: Principles of management of basal and squamous cell carcinoma of the skin. Cancer 75(Suppl. 2): 699e704, 1995
Ge NN, Mc Guire JF, Dyson S, Chark D: Nonmelanoma skin cancer of the head and neck II: surgical treatment and reconstruction. Am J Otolaryngol 30: 181e192, 2009 Huang CC, Boyce SM: Surgical margins of excision for basal cell carcinoma and squamous cell carcinoma. Semin Cutan Med Surg 23: 167e173, 2004 Mcgregor JC, Soutar DS: A critical assessment of bilobed flap. Br J Plast Surg 34: 197e205, 1981 Netscher DT, Spira M: Basal cell carcinoma: an overview of tumor biology and treatment. Plast Reconstr Surg 113: 74Ee94E, 2004 Nichter LS, Morgan RF, Nichter MA: The impact of Indian methods for total nasal reconstruction. Clinic Plast Surg 10: 635e647, 1983 Pesic Z, Mihailovic D, Krasic D, Cosic A, Buric N: Advanced recurrent skin carcinomas of face e survival rate. J Craniomaxillofac Surg 36(Suppl. 1): S148, 2008 Robinson JK: Risk of developing another basal cell carcinoma: a fiveyear prospective study. Cancer 60: 118e120, 1987 Rustemeyer J, Gu¨nther L, Bremerich A: Complications after nasal skin repair with local flaps and full-thickness skin grafts and implications of patients’ contentment. Oral Maxillofacial Surg 13: 15e18, 2009 Schanoff LB, Spira M, Hardy SB: Basal cell carcinoma: a statistical approach to rational management. Plast Reconstr Surg 39: 619e624, 1967 Schliephake H, Neukam FW, Schmelzeisen R, Reiche C: Reconstruction of facial soft tissues after resection of skin tumors. J Craniomaxillofac Surg 22: 342e348, 1994 Silverstone H, Gordon D: Regional studies in skin cancer 2. Wet tropical and subtropical coasts of Queensland. Med J Aust 2: 733e740, 1996 Wanyura H, Stopa Z, Maciejak M: Surgical treatment of skin tumors of the head and the neck. J Craniomaxillofac Surg 36(Suppl. 1): S150, 2008 Wettstein R, Kalbermatten DF, Rieger U, Farhadi J, Harr T, Pierer G: High magnification assessment improves complete resection of facial tumors. Ann Plast Surg 57: 517e520, 2006 Zimany A: The bilobed flap. Plast Reconstr Surg 11: 424e434, 1953 Zitelli JA: The bilobed flap for nasal reconstruction. Arch Dermatol 125: 957e959, 1989
Attilio Carlo Salgarelli, MD, DDS, Prof. Department of Head and Neck University of Modena and Reggio Emilia Via del Pozzo, 71 41100 Modena Italy Tel.: +39 5 94223103 Fax: +39 5 937 3428 E-mail: [email protected] Paper received 17 March 2009 Accepted 21 October 2009