A Guide To Using Bilobed Flaps In Lower Extremity Surgery

Peter A. Blume, DPM, FACFAS

   After addressing the bone pathology and carefully dissecting the flap, the surgeon should pulse irrigate the entire area with at least 4 liters of normal saline. A separate closure table should be available. When lavage of the surgical site is complete, redrape the area with uncontaminated linens. At this point, a glove and gown change would be appropriate in order to reduce any previous contamination from the open wound and possibly exposed bone. One should avoid using any previous equipment that had entered the field with respect to the chronic wound. Then inset the flap again and suture it with nylon as stated above. Surgeons should always avoid using any deep sutures in this region.

   The conclusion of the procedure will include the appropriate management with minimal compression and the incorporation of immobilization. One can evaluate the flaps at one-week intervals and remove sutures at three to four weeks.

A Closer Look At The Research On Bilobed Flaps

Yetkin and colleagues in 2003 described the utilization of bilobed flaps for non-healing ulcer treatment.9 The average size of the ulcers treated was approximately 1.6 cm. There was a minimal follow-up period of one year with an average of 19.5 months. The authors concluded that one can treat non-healing foot ulcers with a bilobed skin flap of healthy tissues rotated from non-weightbearing parts of the sole.

   My colleagues and I described the use of a bilobed flap for excision of recurrent digital mucoid cysts in 2005.10 This retrospective review described the utility of a bilobed flap in conjunction with resection of the head of the middle phalanx for mucoid cyst pathology. In our study, there were no recurrences, flap failures or significant complications with this technique. The bilobed flap allowed for greater exposure than traditional semi-elliptical incisions while providing a template for wide excision of the defect and primary closure.

   Jager and coworkers published on the Zitelli design for bilobed flaps.11 The retrospective review examined the application of bilobed flaps on skin defects after digital mucoid cyst excision. The authors also described the unique indication in the geometric design, which allows for fast wound healing and excellent outcomes. The design is easy, safe and reproducible.

   My colleagues and I also published another retrospective study evaluating single-stage surgical treatment of non-infected diabetic foot ulcers, which did include bilobed flap reconstruction.12 This single-stage approach consisted of total excision of the ulcer with broad exposure, correction of the underlying osseous deformity and immediate primary closure with a local random flap. We analyzed 400 cases of pedal ulcers via chart review. Of those cases, 67 cases had a single-stage surgical treatment and we analyzed them for length of hospital stay, postoperative complications, time to heal, recurrence of the ulcer and post-procedure ambulatory status. The age of the ulcers before surgery was 12 ± 12 months with a range of one to 60 months. The median perioperative hospital stay was 5 ± 7.6 days. We followed all patients until the wounds were healed or to amputation.

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