Review of Rhomboid Flaps and Their Modern Modifications

Alexandra Grammenos, MS,* Ana M. Rivas, BS,* Jacqueline A. Thomas, DO,** David L. Thomas, MD, JD, EdD***

*Medical Student, 2nd Year, Nova Southeastern University College of Osteopathic Medicine, Ft. Lauderdale, FL **Assistant Professor of Dermatology and Mohs Surgery, Nova Southeastern University College of Osteopathic Medicine, Ft. Lauderdale, FL ***Professor and Chair of Surgery, Nova Southeastern University College of Osteopathic Medicine, Ft. Lauderdale, FL

Abstract Background: First proposed by Alexander Limberg in 1945, the rhomboid flap has been modified to accommodate a variety of different surgical settings. Rhomboid flaps have proven to be integral in a variety of sub-specialties. Objective: The aim of this review is to examine the rhomboid flaps of Limberg, Dufourmentel, Webster, and Quaba and report the appropriate surgical context and advantages of each flap type. Methods & Materials: A literature search was performed of PUBMED, SCOPUS, and MEDLINE for articles assessing the proper surgical context and subsequent outcomes of the Limberg, Dufourmentel, Webster, and Quaba/Sommerlad flaps. Results: The use of rhomboid flaps proves optimal for closure of large defects because of the reduced risk of distal-end necrosis. Conclusion: This review details a thorough examination of modification of rhomboid flaps and their effectiveness as an alternative to primary closure. The original Limberg flap was further modified success, as compared to the width-to-length ratio Introduction by Richard Webster in 1960 to include a 30° of the pedicle as traditionally thought.10 Vascular Following the formation of a surgical defect, a 1,5 closure type is chosen to suit the surrounding transposition flap with an M-plasty closure. testing methods, such as dermal bleeding pricks The addition of the M-plasty allowed for a better and reperfusion time testing, are performed prior tissue characteristics and defect size. While 11 primary closure is often the first choice, simple distribution of tension, reducing the strain on to closure to ensure adequate perfusion. suturing may not be sufficient to appropriately the distal tip of the flap. In 1987, Awf Quaba close the defect. Size is the most common designed a modified rhomboid flap to address Discussion deterrent from primary closure, where the long or closing a circular defect with minimal healthy skin Limberg Flap short axes of the defect are either too long or too loss. While all four flaps are widely useful, it is The simplicity and efficacy of the Limberg flap wide, respectively.1,2 Rhomboid flaps maintain imperative to not distort the anatomy or maintain 3 makes it versatile, allowing for adequate cosmesis continuity of texture, color, and vascularity skin laxity. Limberg, Dufourmentel, Webster, with few complications. The excision is made up with the surrounding tissue, eliciting the most and Quaba flaps are types of transposition flaps of two equilateral triangles with 60° and 120° successful aesthetic outcome.3 Rhomboid flaps that are generally smaller in size than both the 7,8 angles, respectively. The flap is then created by are most commonly used for tumor resection in advancement and rotational flaps. extending a line of equal length from either of head and neck surgeries but are widely applicable The varieties of rhomboid flaps provide superior the 120° angles. At the end of this extended line, in fields such as general and plastic surgery, results when compared to skin grafts of similar a second line is created at an angle of 60° (Figure ophthalmology, and otolaryngology.1,3 size and location because the sub-papillary and 1a). It is important to ensure this line is parallel In 1946, Alexander Limberg first designed a sub-dermal vascular plexuses are maintained to the side of the rhomboid defect.2,12 The flap through the flap’s pedicle, which is absent in skin surgical protocol for transposition of a rhomboid 4,7 is then transposed and ready for closure (Figure flap 120° onto a proximal skin defect.4 This was grafts. The enhanced vascularization established 1b). innovative and successful due to the retention through the pedicle lends the rhomboid methods The placement of the Limberg flap greatly of local vascularity via the pedicle.5 Claude to successful treatment in post-burn defect 9 influences its survival and aesthetic appearance Dufourmentel later modified this in 1966, using treatment. Even when adequate blood supply (Figure 1c). The flap should be positioned in a reduced angle size to ≤ 60° to limit the amount is maintained, the surgeon must be cautious the direction of minimal tension and maximum of disruption of healthy tissue during closure of the tension on the distal end of the flap in 4 extensibility. The flexibility of the skin in the area while increasing pedicle width.1,2 This closure order to reduce the likelihood of necrosis. It 6 is important to note that the maintenance of to be excised can be inspected by pinching the is compared to that created by primary closure. 13 perfusion pressure is the critical aspect to flap skin with the forefinger and thumb. Placement A B C

Figures 1a - 1c. Steps employed in the Limberg flap.

Page 16 REVIEW OF RHOMBOID FLAPS AND THEIR MODERN MODIFICATIONS A B C

Figures 2a – 2c. Steps employed in the Dufourmentel flap. of the flap becomes more challenging on the face, flap does not require as great of a transposition modification to the Limberg flap is the excess where anatomical features may create boundaries. movement of the flap covering the primary defect healthy tissue that is lost.33 A study conducted The incisions should not be placed on relaxed as the Limberg method.7,18 If a defect is less than by Kaya proposed a modification to the Limberg skin tension lines; instead, incisions should be 60° and cannot be closed via primary closure, the flap that included a complete lateralization of the made parallel to the relaxed skin tension lines.13 defect angle is enlarged and a Limberg flap is rhomboid from the intergluteal cleft.32 Placement of incisions parallel to Langer’s lines employed. The Dufourmentel flap is also used for the allows the resulting scar to fall within the creases 34 Further alterations to the Dufourmentel flap treatment of pilonidal sinus disease. Yildar of the skin.12 A reduction in tension on the flap were applied to address certain limitations of this et al. applied a modified Dufourmentel flap for decreases the likelihood of necrosis of the donor type of transposition flap. One modification, a wider defects of pilonidal sinus disease. This tissue.14 The parallelogram-shaped defects are “diamond flap,” is used to decrease the amount modification involved using an S-type oblique ideal for the use of a Limberg flap.15 of healthy tissue excised from a Dufourmentel excision along with a modified Dufourmentel Limberg flaps have been used in a variety of flap.19 The diamond flap modified one of the acute flap that placed the excision lateral to the areas of the body. Particularly, this flap has been corners of the rhomboid excision following initial midline of the intergluteal sulcus.35 A modified, practical for defects on the face, neck, and back. completion of the Dufourmentel flap design. asymmetrical Dufourmentel flap can be used However, the usefulness of the Limberg flap One of the acute corners is transformed into a to treat pilonidal sinus disease with low rates of makes it easy to employ and modify for defects in circular shape. In order for the flap to close the necrosis and complications.36 other parts of the body, such as the oral mucosa, new circular shape, an arc of the same dimension 13,16,17 19 A literature review of pilonidal sinus surgery the floor and ala of the nose, and the lips. is created on the part of skin that is transposed. found the use of the Limberg flap to be the Dufourmentel Flap Advantages of Limberg and Dufourmentel quickest and least complicated treatment for The design of a Dufourmentel flap allows for Flaps wound healing.20-22 Pilonidal surgical procedures closure of rhomboid defects of differing angles, Considering the tension of the skin, primary that healed with tension-free primary closure had such as acute angle closure, when compared to closure can cause an increase in dehiscence greater disadvantages than wounds that healed closure with a Limberg flap.2 The angles of the and infection in defects.25 A similar trend was using the Limberg flap.23,24 rhomboid do not need to equal 60° as in the observed comparing secondary-intention healing 26 Webster Flap Limberg flap. Upon bisection of the parallelogram, and the use of the Limberg flap. Secondary The Webster flap was developed in 1960 as a a plumb line is placed at 90°. A second line is intention requires greater care and increases the further adaptation of the original Limberg flap, created parallel to one of the sides of the defect. risk of infection of the open wound compared to The angle that is created from the two extended the closed sutures of a Limberg flap. In areas of lines is bisected with a line that is the same length the body where skin may not have great laxity, as a side of the rhomboid. The bisected line creates secondary-intention closure may be preferred a smaller tip angle of the flap.7 From the end of the over a rhomboid flap such as the Limberg bisected line, another line is created that is parallel method.15 to the longitudinal axis of the parallelogram 2 The Dufourmentel flap is advantageous with This parallel line must still be equal 12 (Figure 2a). smaller defects because of the narrow flap. in length to a side of the rhomboid. The design Application of the Dufourmentel flap has shown of the Dufourmentel flap allows two flaps to be satisfactory cosmetic results with a decrease in created from each of the four angles of a square flap rotation, compared to the Limberg flap, and defect. In the case of an asymmetrical rhomboid, adequate survival from vascularity from sub- four flaps can be created from a rhomboid defect dermal plexus.27,28 (Figures 2b-c).2 Rhomboid Flaps for Pilonidal Sinus Surgery The ideal scenario for the use of a Dufourmentel The Limberg flap has shown to be one of the flap is with an acute angle defect of greater than quickest and least complicated treatments for 60°. Other factors besides defect angle should be 29,30 wound healing in pilonidal sinus surgery. considered in the application of the Dufourmentel Through placement of the most inferior angle flap over other methods. The presence of laxity of of the rhomboid slightly lateral to midline, the the tissue favors the use of a Dufourmentel flap Figure 3. Initial step employed in the Webster recurrence and maceration of the defect was flap. over the simpler Limberg flap. A Dufourmentel decreased.31,32 A slight disadvantage of this GRAMMENOS, RIVAS, THOMAS, THOMAS Page 17 utilizing a 30° angle of rotation and an M-plasty A B closure at the base of the defect (Figure 3, p. 17).37 The original protocol describes the procedure of removing triangular-shaped areas of both skin and subcutaneous tissues along the nasolabial folds, allowing for medial movement of the cheek tissues.38 Webster flaps have commonly been used on the lower lip following carcinoma removal where the defect size is greater than 80% of the total area.39 This technique prevents microstomia and poor aesthetic outcomes, as well as maintaining good oral competence and sensation.10 Webster flaps retain good sensation and muscle tone of the upper lip, with special attention to retention of facial grooves and blood supply.9 With the reduction of the flap’s angle of rotation from 60° to 30°, there is less disruption and removal of healthy tissue when compared to the aforementioned flaps. Additionally, the utilization of the M-plasty closure allows for a more uniform distribution of tension across the flap. This reduction in tension promotes better revascularization to the most distal ends of the flap, ensuring a more rapid healing time with less Figures 4a – 4b. Steps employed in the Quaba/Sommerlad flap. chance of distal-flap necrosis. There have been several modifications of need to create a rhomboidal defect, and (2) a flap defects following skin-cancer excision. One study 42 the Webster flap technique described in the smaller than the defect size. The predominate by Murillo et al. examined the use of skin-cancer literature, all of which utilize the reduced angle advantage to this is a reduced sacrifice of healthy ablation in conjunction with flap transposition of rotation for more favorable surgical outcomes. donor tissue. In the case of Quaba/Sommerlad, a for complete resection of the malignancy while 44 One such modification is the combination of the diagonal is extended to be two-thirds the size of maintaining optimal aesthetic outcomes. Due to 39 Webster and Johanson techniques for closure of the defect (Figure 4b). Although most simple the variety of skin thicknesses and compositions defects greater than 80% with a staircase scar. The to achieve, the Quaba/Sommerlad flap taken throughout the head and neck region, this study Johanson technique was originally designed as a from shortest diagonal does not always achieve mapped the anatomical areas and based closure 39 staircase suture for a defect no larger than two the most aesthetically pleasing outcome. In protocols on where the cancer was located. For thirds of the total area with improved scarring contrast to the other rhomboid flap designs, the instance, a rhomboid flap was utilized in the aesthetic when compared to the linear suture Quaba/Sommerlad flap is raised less than the medial aspects of the cheek because of the ease .44 of Webster.10 As with rhomboid flaps, the step size of the defect and donor tissue is allowed of transposition of the attached skin Closure of technique described by Johanson is of clinical to contribute to the wound closer. Key stitch these defects produced great aesthetic outcomes. importance due to maintenance of tissue texture locations are integral to adequately distribute between the donor and lesion sites, retention the tension to ensure good vascularization to the Conclusion 39 of intact muscle fibers and innervation, and distal aspects of the flap. The extensive application and versatility of rhomboid flaps contributes to their success better aesthetic outcomes along the lateral The Quaba/Sommerlad method has been 40 and popularity among physicians. Several lower lip. The proposed modification allows especially helpful in the closure of hand defects for the combination of closure of a larger defect where the cutaneous branch of the dorsal different types of and modifications to flaps (Webster) with the more aesthetically pleasing metacarpal artery serves as the perforator artery better tailor this small surgical procedure for staircase sutures ( Johanson). supplying blood to the flap from the pedicle.43 In certain defects. The Limberg flap was the initial flap used for rhomboid defects, with effective In 2011, Minagawa et al. further modified the hand surgery, in order to increase flap vascularity, Webster flap, altering the flap formation itself, Bailey et al. prosed a modification that starts the healing and acceptable cosmetic appearance. including the formation of the flap on the perforator artery at the junction of the dorsal The simple design of a Limberg flap gave rise contralateral side of the defect versus bilaterally in metacarpal artery and the dorsal communicating to more advanced and complex flaps such as 37 concert with a nasolabial flap.41 The combination branch of the common digital artery. This the Dufourmentel, Webster, and Quaba flap. of closure via the modified Webster method increases the ability to cover the dorsal aspect of Rhomboid flaps have shown great effectiveness and nasolabial flap ensured optimal aesthetic the finger past the proximal interphalangeal joint. over alternative methods of healing such as 45,46 outcome of the lower lip with good donor site The increased blood flow makes this technique primary closure. Such advantages propel their matching in color and texture. The unaffected especially helpful when treating defects on use and are a common reason why these flaps 37 oral commissure remained untouched, and the burned or grafted areas. are one of the first techniques used by surgeons. formation of horizontal suturing between the Advantages of the Quaba/Sommerlad Flap While certain closure techniques are invasive mouth and nasolabial groove was avoided.38 and involved, rhomboid flaps are associated There are numerous advantages to the Quaba/ 47 Quaba/Sommerlad Flap Sommerlad flap, the most obvious being the with a good prognosis and rapid healing time. The Quaba/Sommerlad flap was first described in decrease in excision of healthy donor tissue when Continued modifications and advances in 39 1987 as a rhomboid-flap modification for closure raising the flap. In addition, this protocol dermatologic surgery will further improve the of circular defects (Figure 4a). Because circular permits more variability of the donor site, outcomes of rhomboid flaps. 39 defects are the most common types encountered allowing for better concealment of scarring. in facial surgeries, their closure is of great clinical 19 Ablation and Rhomboid Flaps significance. This flap uses the basis of the Rhomboid flaps are commonly used for closure of Limberg flap with two key modifications: (1) no

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Thomas, DO; by surgical excision and immediate reconstruction. ScientificWorldJournal. 2013 Jun 17;2013:459147. Nova Southeastern University, 3200 South Dermatol Surg. 2006;32(12):1526-9. doi: 10.1155/2013/459147. Print 2013. 36. Friedl P, University Drive, Ft. Lauderdale, FL 33328; Ph: Rappold E, Jager, C. Effective and minimally painful 800-356-0026; F: 954-262-3981; 19. Tamborini F, Cherubino M, Scamoni S, et al. surgery of pilonidal sinus-asymmetric transposition [email protected] A modified rhomboid flap: The “diamond flap.” flap according to Dufourmentel. J Dtsch Dermatol Dermatol Surg. 2012;38(11):1851-5. Ges. 2011;9(4):333-5. GRAMMENOS, RIVAS, THOMAS, THOMAS Page 19