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Commentary |

Design Aspect of the Bilobed Flap

John A. Zitelli, MD
Arch Facial Plast Surg. 2008;10(3):186. doi:10.1001/archfaci.10.3.186.
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Zoumalan et al1 demonstrate a very important design aspect of the bilobed flap: that closure of the secondary defect should be as vertical as possible to avoid distortion of the alar rim. In many published photographs of the bilobed flap, one can see that secondary closures that are not perpendicular to the alar rim will usually result in distortion to either the ipsilateral or contralateral alar rim.

Some clinical variables can help to predict the possibility of alar position postoperatively. First, the larger the primary defect, and therefore the larger the secondary defect, the more likely there will be distortion. This possibility is magnified if the skin is tight over the nasal dorsum and side walls, limiting the amount of skin available for closure. In the situation of large defects or tight skin, it is very important to orient the secondary defect perpendicular to the alar rim. One tip for repairing the nasal defects where the skin is tight is to undermine widely over both sidewalls to the nasofacial sulcus. There is a tight attachment of the skin to the deeper structures over the junction of the inferior margin of the nasal bone and the upper lateral cartilage. Once this fibrous band is severed during undermining, one can recruit much more skin from the medial cheeks and minimize the pull and distortion of the alar rim.

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