An 84-year-old female presented with a squamous cell carcinoma measuring 1.4×1.1 cm on the left infraorbital skin (Fig. 1A). Her personal medical history was unremarkable with the exception of hypertension and hyperlipidemia. A physical examination with a head and neck computed tomography scan found no evidence of lymph node metastasis. A wide excision with a lateral margin of 3 mm was performed; the final defect measured 1.9×1.5 cm with a tumor-free lateral and deep margin (Fig. 1B). However, the defect spanned over three cosmetic subunits: nasal sidewall, cheek, and lower eyelid. This led to difficulties in designing a suitable flap for reconstruction of the defect due to its location and a risk of ectropion. Therefore, an incomplete traditional bilobed flap was designed to reconstruct the lower eyelid defect using upper eyelid tissue (Fig. 1B). However, the distance from the pivot point of the flap to the lateral tip of the defect was longer than that of the primary lobe in the flap design, making it impossible for the primary lobe to fully cover the defect (Fig. 1C). To address this problem, a plication suture along a long axis of the defect was performed, adjusting the defect tip position by pulling it toward the pivot (Fig. 2A). This allowed the primary lobe to cover the defect and the flap was successfully performed (Fig. 2B). The flap healed well with no ectropion formed by the 5-month follow-up (Fig. 2C).

Reconstruction of infraorbital defects pose several challenges. Firstly, the infraorbital region consists of several anatomic subunits, such as the lower eyelid, nose, and cheek, with substantial cosmetic importance. Shortage and inelasticity of adjacent skin may increase the risk of ectropion and deformities of the eyelid margin1. This leads to difficulties in properly designing local flaps12. Bilobed flaps are a double transposition flap using relatively loose tissue, mainly from the glabella or nose3. Traditional bilobed flaps reduce the risk of ectropion through its upward action of the vector, while other infraorbital reconstructions using surrounding cheek tissue have a higher risk of ectropion. Additionally, it allows using the more suitable upper eyelid tissue for reconstructing the thin infraorbital skin. However, in this case study, a traditional bilobed flap design was not suitable for the defect while in a relaxed state. A proper plication suture made before the bilobed flap helped adjust the shape of the defect. Plication, a buried suture performed at the depth of the superficial muscle fascia, reduces the tension and size of the defect during wound closure4. Plication reduces closure tension by shifting the tension from the dermis to the fascia, reducing the risk of hematoma or infection by minimizing dead space4. It also modifies the defect's shape, enabling difficult types of reconstruction that cannot be applied to the original defect. Plication can therefore be a simple and useful method to complement the insufficiencies of prior repair designs, as seen in this case. We received the patient's consent form about publishing all photographic materials.