eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Rhombic Flaps: Treatment

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

Treatment

Surgical Therapy

The Limberg flap is conceptually the easiest of the 3 flaps to construct. The Limberg flap is a series of communicating equilateral triangles. All angles are 60°, which means that every side of both the defect and the flap is equal in length. This orientation creates a flap that is the same size as the defect to be excised. Any flap angle other than 60° theoretically involves either widening or compression of the flap. An elliptical defect at the donor site remains after the flap is rotated to fill the rhomboid defect. This defect can be closed primarily with appropriate undermining of the surrounding tissue.

The Dufourmentel flap is more versatile than the Limberg flap. The Dufourmentel flap can be used to close a rhomboid with any acute angle from 60-90°; however, it is slightly more complicated to construct. With rhomboid defect angles of less than 60°, the Dufourmentel flap is narrower than a Limberg flap. This makes donor site closure much easier.

The Webster, or 30° flap, improves upon some of the limitations inherent to Limberg and Dufourmentel flaps. This technique combines a 30° rotation flap with an M-plasty at the defect base, thereby minimizing chances of creating a standing cone at the turning point of the flap and also reducing the tension associated with closure. Tension is more evenly distributed along the length of the flap.

Closure of an ellipse with 60° angles often produces unsightly dog ears, especially in young patients or individuals with thick skin. Webster observed that 30° angulations could be closed in all patients without creating a standing cone. Extending the base of a rhomboid to produce a more acute angle lengthens the resulting scar and unnecessarily removes healthy tissue.

Preoperative Details

When planning a reconstruction, every rhombus can be closed with 1 of 4 distinct flaps (see Image 4). Outcome depends on the appropriate positioning of the defect's base and on proper flap choice.

Three important aesthetic and/or functional considerations must be balanced in the flap design: (1) using relaxed skin tension lines, (2) preserving the integrity of neighboring landmarks, and (3) observing aesthetic subunits.

Intraoperative Details

The flap and surrounding tissue are undermined in the subdermal plane after creating the rhombus defect. When possible, take skin from a donor site where it will have the greatest relative laxity. Lines of maximal extensibility lie perpendicular to skin creases.

Tension is greatest at the closure point of the donor defect (see Image 5). The tension vector here has been described as 20-90° from the short diagonal of the rhomboid defect. The size and degree of undermining do not change the relative tensions of closure. Place the line of maximal flap tension, also called the line of closure of the donor site, in a line of maximum extensibility of the face. Primary tension of closure must never displace a neighboring structure. Flap planning should avoid distortion of prominent landmarks like the eyelid, lip margin, or the nasal ala. Respect boundaries of aesthetic units when designing a flap. When possible, match the skin color, thickness, and presence/absence of hair.

Limberg flap

First, a parallelogram with angles of 60° and 120° is drawn around the lesion to be excised (see Image 1).

Next, a line (equal in length to the short diagonal of the parallelogram) is extended from the parallelogram as a continuation of the short diagonal (see Image 2). This becomes the superior-medial side of the rotation flap.

Drawing a second line from the distal end of the first line forms the apex of the rotation flap. This second line must be equal in length and parallel to one of the adjacent defect sides (see Image 3).

Dufourmentel flap

Beginning with such a parallelogram, extend imaginary lines from the short diagonal and from one adjacent defect side.

Bisect the angle formed by these lines with a line equal in length to one of the sides of the defect.

Draw a line parallel to the long diagonal of the defect equal in length to a defect side (see Image 6).

Webster flap

Incorporating an M-plasty into the lengthened base defect spares tissue and shares the arc of rotation between the 2 30° angles rather than one 60° angle. Tension distribution upon closure is improved, resulting in less distortion of surrounding tissue and less scar widening in specific areas of closure.

Webster flaps also incorporate a 30° angle at the apex of the rotation flap. Reducing the flap angle from 60° to 30° makes the angle significantly narrower. This, in turn, creates a smaller donor site to be closed and reduces the tension required to close the defect.

Complications

Flap failure is uncommon. Nevertheless, partial necrosis of the distal tip of the flap can occur if the angle is too acute. More commonly, imperfections such as standing cones or widened scars result from transposition of such a flap. Standing cones are created when the rotation point of a rhomboid flap approaches 60°, especially in young people or in individuals with dense or thick skin.

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