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Introduction
CHAPTER 24 Bilobed Flaps
Joy Kunishige John A. Zitelli
SUMMARY
Over the past two decades, the bilobed flap has become a workhorse technique
for nasal reconstruction.
While often conceptualized as a transposition flap, it has a significant rotational
component and also incorporates a Z-plasty, making it a powerful technique for nasal reconstruction and beyond.
Beginner Pearls
To minimize the risk of distortion, the width of the secondary lobe, primary lobe, and
primary defect are all designed to be of equal size, though some authors have suggested adopting undersized primary and secondary lobes.
Laxity of the medial cheek and nasofacial sulcus skin is recruited when closing the
tertiary defect, permitting a tension-free closure.
Expert Pearls
A prototypical bilobed flap on the nose involves several unique features:
Greater movement about the pivot point because of its position near the recruitable
medial cheek
Double transposition design displacing the tension vector away from the primary
defect
Lengthening effect of the Z-plasty to overcome pivotal restraint
Less than 45 degrees of transfer between each lobe to minimize standing cone
deformity.
Donโt Forget!
Always orient the tertiary defect vertically, as any diagonal vector may cause
elevation of one of the alar rims.
The flap can be drawn freehand by imagining two hearts overlapping, which inherently
creates lobes of equal width and length.
Meticulous suturing technique is a must for minimizing the appearance of curvilinear
scars.
Pitfalls and Cautions
Extranasal bilobed flaps may have more of a tendency to pincushion than those on the
nose.
Deepen the defect on the nose to the cartilage, making room for the incoming flap. This
will prevent additional bulk adding to the temporary trapdooring or edema.
Patient Education Points
As with all flaps, warn patients that the length of the suture lines will be significantly
longer than the defect.
Always advise patients that they may have a multi-stage procedure, and that
trapdooring is likely to occur. Patients will be much more understanding regarding the need for intralesional steroid injection or other intervention if they were prewarned that this may occur.
Billing Pearls
Flap repair codes (140XX series) include the excision component, so it is not
appropriate to bill both an excision and a flap repair code simultaneously.
Mohs codes may be submitted along with flap repair codes, though they may be subject
to the multiple- procedure reduction rule.
When coding a flap, medical necessity is the ultimate arbiter of appropriateness.
CHAPTER 24 Bilobed Flaps
INTRODUCTION
Over the past two decades, the bilobed flap has become a workhorse technique for nasal reconstruction. While often conceptualized as a transposition flap, it has a significant rotational component and also incorporates a Z-plasty, making it a powerful technique for nasal reconstruction and beyond.