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BILOBED FLAPS

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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.

image 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.

image 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.

image Don’t 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.

image 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.

image 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.

image 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.

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.

HISTORY AND EVOLUTION OF THE BILOBED FLAP

Although classified as a double transposition flap, the bilobed flap was actually ...

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