Correspondence: Dr Zitelli, 5200 Centre Ave, Suite 303, Pittsburgh, PA 15232-1306 (email@example.com).
In this issue of the Archives, Cho and Kim1 discuss a modification of the bilobed flap that involves the lengthening of the primary flap compared with the standard design that I published2 for common use in nasal reconstruction. Their discussion is accurate for some defects but should not be considered a new standard for use in most situations. The standard bilobed flap is most useful for lateral nasal tip defects of 1 cm in diameter and in some cases up to 1.5 cm in diameter. In this location it recruits skin from the medial cheek and nasofacial sulcus by medial movement to close the secondary flap donor site and allow for medial movement of the primary flap. This motion is important in order to understand when it is necessary to lengthen the primary flap, as described in the article by Cho and Kim.1 The examples used by Cho and Kim are not the classic and most useful defects for the standard bilobed flap. First, their 1.5-cm defects approach the upper limits of usefulness for this flap, especially in patients with tight nasal skin. Second, when the defect is large and the secondary flap is closer to the tight and immobile skin of the inner canthus (their Figure 7), there is no longer adequate loose skin for medial motion, and the pivotal restraint issue does restrict movement of the primary flap. Thus, in cases with large defects where there is little loose skin to close the secondary donor site, this lengthening of the flap may prevent upward retraction of the ala.
Zitelli JA. Comments on a Modified Bilobed Flap. Arch Facial Plast Surg. 2006;8(6):410. doi:10.1001/archfaci.8.6.410