J AM ACAD DERMATOL

APRIL 2013684 Letters

might be in daily practice, which may includeconsideration of clinical consequences in assign-ment of grade.

We thus agree that the risk inherent in the decisionnot to re-excise probably relates less to whethermelanoma may develop in residual dysplastic nevusthan to the poor diagnostic reliability of high-gradedysplastic nevus versus melanoma, well captured bythe phrase ‘‘one dermatopathologist’s moderatelyatypical nevus may be another’s melanoma’’ in theletter by Elston et al. Indeed, this ‘‘diagnostic uncer-tainty’’ underscores the value of primarily removingpigmented lesions with a clinical margin of normal-appearing skin. Perhaps interobserver concordancewould improve, and the rate of upgrading to inducere-excision might decrease, if studies on diagnosticreproducibility were performed only on melanocyticlesions removed with generous (at least 5-mm)margins of normal-appearing skin. Concern aboutpotential underdiagnosis (ie, moderately rather thanseverely atypical nevus or melanoma), may factormore in the eye and mind of the pathologist whenthe melanocytic proliferation is at or close to aspecimen edge.

As Dr Elston4 aptly expressed in a recent editorial,‘‘I have witnessed a variety of terms for these lesionsevolve and have been impressed that none of themseem willing to fade away peacefully’’. We hope thatour study and others on the subject will lead not toelimination of the terms ‘‘atypical’’ or ‘‘dysplastic’’ asapplied to nevi but to more restricted, evidence-based applications. If low-grade histologically dys-plastic nevi have either no malignant potential orrarely progress to melanoma, perhaps the terms‘‘dysplastic’’ and ‘‘atypical’’ should fade from reportson such lesions, allaying patient concerns andreducing re-excisions.

Thomas L. Hocker, MD,a Ali Alikhan, MD,a NnekaI. Comfere, MD,a,b and Margot S. Peters, MDa,b

Departments of Dermatologya and Laboratory Med-icine and Pathology,b Mayo Clinic, Rochester,Minnesota

Funding sources: None.

Conflicts of interest: None declared.

Correspondence to: Margot S. Peters, MD, Depart-ment of Dermatology, Mayo Clinic, 200 First StSW, Rochester, MN 55905

E-mail: peters.margot@mayo.edu

Fig 1. Foam template of bilobed flap. Transposed flappushes down on foam template at inferior and distalaspect of first lobe.

REFERENCES

1. Hocker TL, Alikhan A, Comfere NI, Peters MS. Favorable long-

term outcomes in patients with histologically dysplastic nevi

that approach a specimen border. J Am Acad Dermatol

2013;68:545-51.

2. Goodson AG, Florell SR, Boucher KM, Grossman D. Low rates of

clinical recurrence after biopsy of benign to moderately

dysplastic melanocytic nevi. J Am Acad Dermatol 2010;62:

591-6.

3. NIH Consensus Conference. Diagnosis and treatment of early

melanoma. JAMA 1992;268:1314-9.

4. Elston D. Practical advice regarding problematic pigmented

lesions. J Am Acad Dermatol 2012;67:148-55.

http://dx.doi.org/10.1016/j.jaad.2012.11.036

The bilobed flap versus the AIRNS flap forrepair of distal nose defects

To the Editor: Hafiji et al1 recommend the advance-ment and inferior rotation of the nasal sidewall(AIRNS) flap as an acceptable alternative to thebilobed flap for repair of distal nose defects. In theirreport, the authors contend that the AIRNS flap issimpler in both design and execution than a bilobedflap. However, the authors fail to mention that thisflap lacks the distinctive characteristic that makes thebilobed flap an ideal choice for defects of the lowerthird of the nose.

Unlike the AIRNS flap proposed by the authors,the bilobed flap uses tissue transposition to repairboth the primary and secondary defects (Fig 1). As adouble transposition flap, it combines the movement

Fig 2. Foam template of bilobed flap with double Z-plastycomponent illustrated. Lengthening effect of doubleZ-plasty pushes down on base of foam template simulat-ing downward directed force on alar rim.

J AM ACAD DERMATOL

VOLUME 68, NUMBER 4Letters 685

of a rotation flap with 2 Z-plasties. The lengtheningeffect of the Z-plasties preserves the position of thefree alar margin by creating a force aimed toward thealar rim (Fig 2). By avoiding an upward-directedtension vector, the bilobed flap alleviates tension onthe primary defect and results in little to no alar rimdistortion. The disadvantage of the AIRNS flap is thatit does not benefit from the lengthening effect of aZ-plasty, making it more likely to elevate the alar rimdespite using a similar arc of rotation.

An appropriately designed and executed bi-lobed flap can provide excellent results for distalnose defects involving the lateral tip, supratip, alanear the tip, or any other defect close to a freemargin.2 The authors correctly identify that certaincomplications, such as pincushioning, can be min-imized through proper technique. Other variablesthat can influence the results include orientation ofthe secondary defect, size of the primary and/orsecondary flaps, and proper alignment of sutureswhen transposing the primary flap.3 Although theAIRNS flap does not share all of these designchallenges, it also requires the same meticuloussurgical technique to minimize pincushioning. Inconclusion, the inherent flap dynamics of thebilobed flap make it a superior choice for the lowerthird of the nose.

E. Brent Kirkland, MD, and John A. Zitelli, MD

Zitelli & Brodland PC, Pittsburgh, Pennsylvania

Funding sources: None.

Conflicts of interest: None declared.

Correspondence to: E. Brent Kirkland, MD, Zitelli &Brodland PC, 5200 Centre Ave, Suite 303,Pittsburgh, PA 15232

E-mail: brentkirkland@gmail.com

REFERENCES

1. Hafiji J, Salmon P, Hussain W. The AIRNS flap: an alternative to

the bilobed flap for the repair of defects of the distal nose. J Am

Acad Dermatol 2012;67:712-6.

2. Zitelli JA. The bilobed flap for nasal reconstruction. Arch

Dermatol 1989;125:957-9.

3. Zitelli JA. Design aspect of the bilobed flap. Arch Facial Plast

Surg 2008;10:186.

http://dx.doi.org/10.1016/j.jaad.2012.10.062

Reply to: ‘‘The bilobed flap versus the AIRNSflap for repair of distal nose defects’’

To the Editor: We thank Drs Kirkland and Zitelli1 fortheir interest in our article regarding the advance-ment and inferior rotation of the nasal sidewall(AIRNS) flap.2 The repair of nasal tip defects isfrequently encountered by the dermatologic surgeonand, in our opinion, one can never have too manyoptions for repairing this site. Although one cansimply highlight particular nuances and possiblebenefits of one technique over another, the choiceof repair, as on any other site, will depend on the sizeand depth of a defect coupled with the surgeon’sown choice. Claiming superiority, therefore, of aparticular technique over another will always be amatter of personal preference.

The Z-plasty lengthening that occurs with thedouble transposition flap of the bilobed repair is wellknown. However, if incorrectly designed and exe-cuted, this lengthening may contribute towarddepression of the ipsilateral alar rim. To date, wehave not experienced a single case of alar elevationwhen performing the AIRNS flap and, furthermore,have not seen any cases of inferior ‘‘bulldozing’’ ofthe ipsilateral alar rim that may occur in patients withthick, inelastic sebaceous skin.

We believe that our success with the AIRNS flap isinherently linked to its design, which enables agreater margin for error to occur if executed incor-rectly. The advancement limb of the flap offsets thesecondary defect created by the rotational limb of theflap thus mitigating the risk of alar elevation referredto by Drs Kirkland and Zitelli. Indeed, because of the