eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Rhombic Flaps

Author: Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Coauthor(s): Michael Fozo, MD, Staff Physician, Department of Otolaryngology, New York Eye and Ear Infirmary, New York Medical College
Contributor Information and Disclosures

Updated: Feb 12, 2009

Introduction

A rhombus is classically defined as an oblique-angled equilateral parallelogram, whereas a rhomboid differs in that it has uneven adjacent sides. The term rhomboid is frequently used in facial reconstruction literature to mean either rhombuslike or to describe one of the popular transposition flaps used to repair rhombus-shaped defects.

History of the Procedure

In 1946, Limberg first described a technique for closing a 60° rhombus-shaped defect with a transposition flap. Dufourmentel modified this technique in 1962 to close defects with any acute angle. Webster published a third significant modification in 1978.1 The Webster, or 30° flap, uses a 30° angulation of the distal flap end along with an M-plasty closure at the defect base.

Indications

Transposition flaps are useful when the size or shape of a lesion does not permit direct closure using a standard fusiform incision. For example, attempting to close a wide defect primarily requires an ellipse with either long limbs or blunt angles. Lengthy limbs create long scars and remove healthy tissue unnecessarily, whereas blunt ends often create an unpleasant standing-cone or dog-ear appearance.

Considerations when designing any local flap are lesion diameter, amount of normal skin that needs to be discarded, scar orientation with respect to relaxed skin tension lines, arc of skin rotation, and the vector of maximal tension after closure. Rhomboid flaps have been used in reconstruction of the cheek, temple, lips, ears, nose, chin, eyelids, and neck. The aesthetic and mechanical properties of these flaps, however, make them especially useful for reconstruction of small defects in the lower cheek, mid-cheek, and upper lip.

Relevant Anatomy

Rhomboid flaps are full-thickness local flaps with a random blood supply. Rather than depend on an axial blood vessel for nourishment, rhomboid flaps rely upon the dermal-subdermal plexus of blood vessels.

Pedicle width controls the amount of circulation within the dermal-subdermal plexus to some extent. The blood supply to the head and neck is so vigorous that this variable is frequently considered to be of minor importance. Generally, the accepted safe maximum length-to-width ratio of the pedicle in the head and neck is 2-4:1, whereas in some other parts of the body with poorer circulation this ratio might fall to 1:1.

The surgeon must not violate the dermis when undermining this or any other random flap because the chances for partial or complete flap necrosis increases.

Contraindications

Heavy smokers or patients with insulin-dependent diabetes mellitus have a higher complication rate with all flaps.

If a carcinoma has been excised, use frozen sections to confirm that the margins are free of disease before any local flap is used to cover the area.

Rhomboid flaps rotate neighboring tissue to close the primary surgical defect, whereas the donor site is closed by primary closure. Do not consider these flaps for extremely large lesions or in instances where the resulting vector of tension distorts neighboring fixed landmarks such as the nasal ala, eyelid margin, or the lip.

The natural, parallel, horizontal wrinkles of the central forehead prevent good aesthetic result with this closure; therefore, rhomboid flaps are generally avoided in this area.

More on Rhombic Flaps

Overview: Rhombic Flaps
Workup: Rhombic Flaps
Treatment: Rhombic Flaps
Follow-up: Rhombic Flaps
Multimedia: Rhombic Flaps
References
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References

  1. Webster RC, Davidson TM, Smith RC. The thirty degree transposition flap. Laryngoscope. Jan 1978;88(1 Pt 1):85-94. [Medline].

  2. Becker FF. Rhomboid flap in facial reconstruction. New concept of tension lines. Arch Otolaryngol. Oct 1979;105(10):569-73. [Medline].

  3. Borges AF. The rhombic flap. Plast Reconstr Surg. Apr 1981;67(4):458-66. [Medline].

  4. Bray DA. Clinical applications of the rhomboid flap. Arch Otolaryngol. Jan 1983;109(1):37-42. [Medline].

  5. Calhoun KH, Seikaly H, Quinn FB. Teaching paradigm for decision making in facial skin defect reconstructions. Arch Otolaryngol Head Neck Surg. Jan 1998;124(1):60-6. [Medline].

  6. Connor CD, Fosko SW. Anatomy and physiology of local skin flaps. Facial Plast Surg Clin North Am. 1996;4:447-454.

  7. Larrabee WF Jr, Trachy R, Sutton D, Cox K. Rhomboid flap dynamics. Arch Otolaryngol. Dec 1981;107(12):755-7. [Medline].

  8. Ling EH, Wang TD. Local flaps in forehead and temporal reconstruction. Facial Plast Surg Clin North Am. 1996;4:469.

  9. Lober CW, Mendelsohn HE, Fenske NA. Rhomboid transposition flaps. Aesthetic Plast Surg. 1985;9(2):121-4. [Medline].

  10. Stegman SJ. Flexible rhombic flap. Plast Reconstr Surg. Mar 1987;79(3):497-9. [Medline].

  11. Townend J. A template for the planning of rhombic skin flaps. Plast Reconstr Surg. Oct 1993;92(5):968-71. [Medline].

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Further Reading

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Keywords

rhombic flaps, rhomboid flap, skin flap, skin flaps, rhombus flap, transposition flap, rhombus-shaped defect, local flap, full-thickness local flap, random flap, Limberg flap, Dufourmentel flap, Webster flap, M-plasty

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Contributor Information and Disclosures

Author

Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Anthony P Sclafani, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American College of Surgeons
Disclosure: Medicis None Speaking and teaching; Contura None Board membership; Contura Grant/research funds Independent contractor; Cascade Medical Grant/research funds Independent contractor; Cascade Medical None Board membership

Coauthor(s)

Michael Fozo, MD, Staff Physician, Department of Otolaryngology, New York Eye and Ear Infirmary, New York Medical College
Michael Fozo, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Medical Society of the State of New York, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Gregory Branham, MD, Vice-Chair, Director, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Saint Louis University School of Medicine
Gregory Branham, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals of Cleveland Case Medical Center
David W Stepnick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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