Bilobed flap for the reconstruction of lower eyelid defect: a case report

Submitted on: 14/03/2023
Approved on: 01/06/2023
Financial support: None.
Conflict of interest: None.
How to cite this article: Kondo RN, Silva NER, Gonçalves NCD, Moreira CR. Bilobed flap for the reconstruction of lower eyelid defect: a case report. Surg Cosmet Dermatol. 2023;15:e20230237.

Abstract

Merkel cell carcinoma is a rare and aggressive cutaneous neuroendocrine cancer that occurs in the photodamaged skin of white and elderly patients, usually presenting as a solitary plaque or nodule in the head and neck region. When located in the lower palpebral area, reconstructing the defect resulting from its excision can become challenging for the dermatological surgeon due to the local cosmetic and functional peculiarity. We report the use of a bilobed flap for lower eyelid reconstruction with a satisfactory result, both in terms of aesthetics and the resulting functionality.

Keywords: Surgical flaps; Eyelids; Carcinoma, Merkel Cell; Case reports

INTRODUCTION

Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine cancer occurring in the photoexposed skin of white and elderly patients. It is rare in black patients and generally presents as a solitary plaque or nodule, measuring 2 cm to 4 cm, in the head and neck region.^1,2 It represents less than 1% of malignant cutaneous tumors but is the third cause of death from skin cancer.² Reconstructions in the lower eyelid region become more challenging for the dermatological surgeon due to the characteristics and locations, such as aesthetic and functional aspects.³

The bilobed flap (BLF) is one of the possibilities for closing larger skin lesions. It borrows part of adjacent skin to fill a nearby defect with little laxity, and its geometric structure (two flaps) allows better distribution of tension forces along its axis of rotation, preventing distortions and excess skin caused by other flaps or primary closure.^4,5

We report a case using BLF for reconstruction after excision of MCC in the lower eyelid region, with satisfactory aesthetic results. The objective of the case report is to exemplify and demonstrate a technique option to correct defects in the inferolateral eyelid with easy execution, in a single surgical procedure, and a good level of patient satisfaction.

METHODS

We treated a patient with MCC in the lower-lateral eyelid region.

The patient was a 75-year-old white man with a 55 mm plaque in the right infraocular region/external canthus (inferolateral eyelid on the right) compatible by histopathological examination with MCC and confirmed by immunohistochemical examination. The lesion was excised with safety margins of 4 mm. The resulting defect was 63 mm in its longest axis. The initial programming was a simple rotation, but intraoperatively, BLF was chosen for reconstruction (Figures 1 and 2).

Description of the Technique:

a) Infiltrative anesthesia with 2% lidocaine with vasoconstrictor;

b) Incision with a 15-blade and en bloc excision of the piece to the subcutaneous tissue;

c) Hemostasis;

d) Incision of the flap, starting the first flap in the external corner of the defect, with an area 10% smaller than the primary defect. The second flap is 10% smaller than the first (Figures 2A and 2B);

e) Detachment of the flap flaps at the subcutaneous level;

f) Flap transposition movement, in which the first flap moves to the position of the primary defect. The second flap moves to the location of the first flap (Figure 2B);

g) Sutures of the RBL mononylon 5.0 flaps, single stitches. The defect of the second flap is closed primarily with 5.0 mononylon, single stitches (Figure 3A);

h) Local cleaning with saline solution;

i) Occlusive dressing.

RESULTS

The patient evolved uneventfully in the first postoperative days (Figure 3B). There was good healing and accommodation, with a satisfactory aesthetic result in the late postoperative period (Figure 4).

DISCUSSION

The upper and lower eyelids are complex tissues with specific functions such as protecting the eyeball against trauma and excessive light, moving tears towards the tear drainage system, and establishing the beauty and expression of the eyes. Therefore, reconstructions in these locations are challenging for dermatological surgeons, especially when primary closure is not possible.³

Flaps can be used in lower eyelid reconstruction. The BLF is a double transposition flap that transposes the first flap into a defect and the second one, a smaller flap, to fill the secondary defect caused by the transposition of the larger flap. There is a distribution of tension forces in several directions, which reduces distortions and excess skin generated by a simple transposition flap or primary closure.⁵

Zitelli (1989) was the one who described the bilobed flap for the reconstruction of defects in the nasal tip and ala. However, other authors modified their technique, adjusting the angulations and sizes of the lobes (flaps), thus reducing the distortion of the tip and retraction of the nasal wings.⁶

Currently, the BLF has also been applied to extranasal areas as a versatile option for reconstructions in different locations.⁷ The present authors used the flap, in the case in question, for a large infrapalpebral defect, aiming to avoid ectropion through the distribution of force vectors provided by the technique (Figures 3 and 4).

Regarding the angulation between the lobes, angles of 45º to 50º between the defect and the largest lobe and between the lobes provide the best results, although there is no exact consensus. The literature recommends that the size of the first lobe should be approximately 10% smaller than that of the defect, as well as the second lobe concerning the first. Closure of the second lobe defect must be primary (Figure 5). Depending on the location, skin inelasticity, and defect size, proportions and angulations can be adjusted to adapt the flap and avoid anatomical distortions.⁷

Despite the knowledge and use of BLF for lower eyelid defects by many dermatological surgeons, literature still reports few cases. The authors consider this procedure a good surgical option, as the patient reported.

CONCLUSION

The use of BLF can be a good option for resolving defects in the lower-lateral eyelid regions, considering its versatility and resolution in a single surgical procedure, with good cosmetics and functionality.

AUTHORS' CONTRIBUTION:

Rogerio Nabor Kondo
ORCID: 00-0003-1848-3314
Approval of the final version of the manuscript; study design and planning; preparation and writing of the manuscript; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical literature review; critical review of the manuscript.
Nathalia Elisa Rosolen e Silva
ORCID: 00-0002-2104-231X
Preparation and writing of the manuscript; critical literature review; critical review of the manuscript.
Nicole Camila D’Aquila Gonçalves
ORCID: 00-0002-0314-0821
Approval of the final version of the manuscript; preparation and writing of the manuscript; critical literature review; critical review of the manuscript.
Cássio Rafael Moreira
ORCID: 00-0002-8781-1505
Approval of the final version of the manuscript; preparation and writing of the manuscript; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical literature review; critical review of the manuscript.

REFERENCES:

1. Coggshall K, Tello TL, North JP, Yu SS. Merkel cell carcinoma: an update and review: pathogenesis, diagnosis, and staging. J Am Acad Dermatol. 2018;78(3):433-42.

2. Llombart B, Requena C, Cruz J. Update on Merkel Cell carcinoma: epidemiology, etiopathogenesis, clinical features, diagnosis, and staging. Actas Dermosifiliogr. 2017;108(2):108-19.

3. Kondo RN, Singh BS, Ferreira VP, Araújo MCP. Upper eyelid transposition flap for the reconstruction of a lower eyelid defect: a case report. Surg Cosmet Dermatol. 2022;14:e20220156.

4. Subramanian N. Reconstructions of eyelid defects. Indian J Plast Surg. 2011;44(1):5-13.

5. Brodland DG. Flaps. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 4th ed. New York: Elsevier; 2018. p. 2496-516.

6. Zoumalan RA, Hazan C, Levine VJ, Shah AR. Analysis of vector alignment with the Zitelli bilobed flap for nasal defect repair: a comparison of flap dynamics in human cadavers. Arch Facial Plast Surg. 2008;10(3):181-5.

7. Ricks M, Cook J. Extranasal applications of the bilobed flap. Dermatol Surg. 2005;31(8):941-8.