SURGICAL GEM Two-Lobed Advancement Flap for Cutaneous Helical Rim Defects MURAD ALAM, MD, n AND L EONARD H. GOLDBERG, MD, FRCP w z n Department of Dermatology, Section of Cutaneous and Aesthetic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, and w DermSurgery Associates and z Department of Medicine (Dermatology), University of Texas, MD Anderson, Cancer Center, Houston, Texas BACKGROUND. Bilobed flaps, transposition repairs used primar- ily on the nose, recruit tissue from an area of laxity via rotational motion. A variant of the bilobe, the two-lobed flap based on the W-plasty, is a transposition flap that shifts tissue predominantly via advancement. OBJECTIVE. To apply the two-lobed advancement flap to the problem of reconstructing cutaneous helical rim defects of the ear. METHODS. Helical two-lobed advancement flaps were designed and implemented to correct small- to medium-sized defects. RESULTS. The ear helix was successfully repaired with two- lobed advancement flaps. There was minimal distortion of the ear architecture or cartilage, and blood supply was sufficient to ensure flap viability. CONCLUSIONS. In selected cases, cutaneous helical rim defects of the ear can be aesthetically repaired with a two-lobed advancement flap derived from the posterior auricular surface. M. ALAM, MD, AND L. H. GOLDBERG, MD, FRCP HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. CREDITED TO Esser in 1918, the bilobe flap has become a standard reconstructive approach for defects of the nasal supratip. 1 Refinements have been described by Zitelli 2 and others, 3 and the rhombic bilobe, 4,5 which substitutes straight geometric lines for the typical curved incision, has been advocated for slightly more mobile wounds. As it is a random pattern flap, 6 the bilobe lacks a large-caliber blood vessel in its base. On the nose, the flap recruits skin laxity from higher on the dorsal nose and transmits this to the more rigid skin near the tip. Flap movement entails not only transposi- tion but also a substantial degree of rotation. Apart from the nasal tip, the nasal ala may be a viable site for a bilobe. Bilobe forehead flaps, 7 temporal bilobes, 8 scalp bilobes, 9 and other bilobes of the head and neck 10,11 have been reported. On the sole of the foot, as on the nose, the bilobe may facilitate closure in an area of stiff, unyielding skin. Massive wounds on the trunk may be covered with a trapezius myocuta- neous bilobe 12 or a deltopectoral bilobe. 13 Some of the bilobe flaps described at nonnasal sites are traditional bilobes. That is, their secondary lobe is positioned to exploit a region of laxity. With the defect, the primary and the secondary lobes angled apart, rotational movement of the flap permits transmission of this distal laxity to the site of the defect. Other so-called bilobe flaps may be more correctly described as analogous to a sliding W- plasty. 14–17 In this latter type of closure, the primary and secondary lobes are parallel, not angled. Instead of rotation, the key movement consists of advancement, and consequently, there is no realignment of force vectors from that of a primary closure, as would occur in a traditional bilobe. Both traditional bilobe flaps and two-lobed ad- vancement flaps of the W-plasty type have applications for the repair of helical rim defects. In the traditional design, the secondary lobe must be placed in the postauricular sulcus, the only nearby source of loose tissue. In the two-lobed advancement repair, there is greater potential variability as to the location of the second lobe. Shortening, the so-called pivotal restraint problem, is more likely in the traditional bilobe, as it occurs during rotation, and thus, slight excess length is necessary in this case. For all flaps behind the ear, overthinning may result in vascular compromise. In terms of potential benefits, both the traditional bilobes 17,18 as well as the two-lobe advancement flaps offer excellent color and texture match, one-stage repair, and inconspicuous closure of the donor site. The zigzag and arced suture line of both flaps may be less noticeable than geometric straight lines, but this is less important behind the ear. Finally, both flaps are not very difficult to design and elevate. r 2003 by the American Society for Dermatologic Surgery, Inc.  Published by Blackwell Publishing, Inc. ISSN: 1076-0512/03/$15.00/0  Dermatol Surg 2003;29:1044–1049 Address correspondence and reprint requests to: Murad Alam, MD, Dermatology, 675 North St. Clair, Ste. 19–150, Chicago, IL 60611, or e-mail: murad@alam.com.