Rhombic Flaps

Excerpt

Rhombic flaps are geometric local transposition flaps and offer significant versatility within reconstructive surgery. This flap is most commonly used to fill skin cancer defects of the head and neck region. While successful outcomes have been reported in a range of anatomical locations and pathological defects such as in spina bifida, burn contractures, chronic pilonidal sinuses, hand, and breast reconstruction. This flap takes advantage of skin laxity adjacent to the defect to allow the transposition of tissue with similar characteristics to the tissue excised. This can allow a superior cosmesis when compared with skin graft reconstruction.

The term ‘rhombus’ is derived from Euclidian geometry, describing a quadrilateral shape with opposing equal acute and obtuse angles, while the term ‘rhomboid’ denotes a parallelogram. The term ‘rhombic’ is, therefore, most accurately used to describe flaps resembling a rhombus, while ‘rhomboid’ for those resembling a rhomboid or parallelogram. The rhombic flap was first described by the Russian surgeon Alexander Limberg in 1945 and published in English in 1966. The flap was defined by a characteristic quadrilateral rhombus shape, allowing transposition into skin defects designed with a corresponding shape. (Figure 1)

Common Rhombic Flap Variations

Claude Dufourmental modified Limberg rhombic flap design in 1962, describing closure of defects with a more acute flap angle allowing greater flexibility and ease of closure. Firstly, when designing the defect (Figure 2), the acute angle (alpha) may have a range of 60-75 degrees. The flap itself is designed by aligning the first incision (CE) as the bisection of the angle between the line of the short diagonal axis of the rhombus defect (AC) and the line of its adjacent side (DC). The flap angle (beta) may equal to defect angle (alpha) or decreased if necessary, allowing further flexibility. Advocates claim superiority over the Limberg flap in terms of improved blood supply and ease of donor site closure through the use of a wider pedicle width and more flexible design. The adaptability for surgical resection and reconstruction has been reported to be superior to Limberg flap by Sebastian et al. in the context of chronic pilonidal disease.

Webster further modified the design in 1978 by combining an acute 30-degree flap angle with an M-plasty to close the defect base. (Figure 3) The underlying principals stipulate that the narrower 30-degree flap angle functions to reduce donor site closure tension, and the use of an M-plasty means the rotation arc is shared between two 30-degree angles with improved distribution of tension and reduced distortion of the tissue. In the original case series, Webster et al. reported favorable outcomes in terms of reduced scar widening and reduced areas of skin excess, supposedly due to a more balanced distribution of tension.

In 1987, Quaba and Sommerlad proposed a rhombic flap modification: reconstructing a round defect with a rhomboid flap. This design (Figure 4) involved reconstructing a round defect with a rhomboid flap with sides two-thirds the diameter of the defect, but with an equivalent 60-degree flap angle to Limberg design. The authors reported a case series of 175 patients with head and neck skin defects reconstructed with ‘Quaba/Sommerlad’ flaps. The stated advantages over the classic design included flexibility in flap transposition and donor site orientation, as well as no requirement for healthy tissue to be sacrificed in creating a rhombic shaped defect.

Multiflap variants involving two, three, and four rhombic flaps have been described by Lister and Gibson, Jervis, and Turan et al., respectively. These have been applied to reconstruct larger defects and areas with reduced pliability of adjacent skin. El-Tawil et al. reported a case series of 8 patients with pilonidal sinus disease reconstructed with double rhomboid flap, with reported low recurrence and complications rate, as well as precluding the need for complex reconstruction. While the reconstruction of meningomyelocele defects with triple rhomboid flaps in a case series of 7 patients, and quadruple rhomboid flaps in a single patient case report, have both described good patient outcomes.

Although a wide range of different designs has been proposed with application to various anatomic sites, this article will focus on the most widely reported Limberg flap method applied to the reconstruction of head and neck skin defects.