Limberg Flap Research Articles

Design of the Limberg flap by a specially designed ruler: a personal approach.

Belgrade, Serbia From the Department of Plastic and Reconstructive Surgery, Belgrade University School of Medicine, and the Institute for Burns, Department of Plastic and Reconstructive Surgery, Clinical Center of Serbia. Received for publication January 15, 2003. Milan D. Jovanović, M.D., M.Sc. Institute for Burns Department of Plastic and Reconstructive Surgery Clinical Centre of Serbia Zvecanska 9 11000 Belgrade, Serbia [email protected]

The use of the Limberg skin flap for closure of large lumbosacral myelomeningoceles.

Closure of the skin defect in myelomeningocele repair is an essential step that determines the quality of the surgical result. In large myelomeningoceles, however, adequate skin coverage may not be accomplished by direct closure or skin undermining. In such cases, the skin defect is best repaired using flaps. To evaluate whether the Limberg skin flap is effective for the repair of large round or oval lumbosacral myelomeningoceles, we studied the records of 25 children. Surgical repair was carried out within 24-36 hours of birth in all 25 patients, with the defect size ranging from 36-72 cm(2). Durable, stable soft tissue coverage of the defect was obtained in 23 of 25 patients, with a postoperative follow-up of at least 2 years. Reoperation became necessary in the remaining two patients, but flap necrosis occurred in only one. We suggest that Limberg flap repair may have some advantages in patients with large round or oval lumbosacral myelomeningoceles, including minimal invasivity, short hospitalization, and improved cosmetic results.

Axillary hidradenitis suppurativa: a further option for surgical treatment.

Hidradenitis suppurativa is a chronic inflammatory disease of the cutis with furuncles, fistulas, and abscesses. The disease is mostly located in groin and axilla. As conservative treatment can usually not prevent recurrence, surgical treatment is the method of choice. We report on 20 patients with axillary hidradenitis suppurativa. The inflammatory region was excised in a rhomboid shape and immediately covered with a transposition flap according to Limberg. Postoperatively, all patients received antibiotic treatment and immobilization of the arm. Physiotherapy started after 2 weeks. No flap complications occurred. The functional and aesthetic results were very satisfactory. Movement of shoulder showed no restrictions. A recurrence with single fistulas was seen in 3 patients. Conservative treatment of hidradenitis suppurativa is followed by a high rate of recurrence. Only radical debridement offers a cure. The therapy of choice is the radical excision of the affected region and immediate coverage with a flap. Open granulation or split skin grafting often results in a prolonged hospitalization, higher morbidity, and functional problems. Thus, open granulation is inferior to primary closure by a transposition flap. Using the Limberg flap, the donor site is allowed to be closed primarily.

Axillary Hidradenitis Suppurativa: A Further Option for Surgical Treatment

Background: Hidradenitis suppurativa is a chronic inflammatory disease of the cutis with furuncles, fistulas, and abscesses. The disease is mostly located in groin and axilla. As conservative treatment can usually not prevent recurrence, surgical treatment is the method of choice. Methods: We report on 20 patients with axillary hidradenitis suppurativa. The inflammatory region was excised in a rhomboid shape and immediately covered with a transposition flap according to Limberg. Postoperatively, all patients received antibiotic treatment and immobilization of the arm. Physiotherapy started after 2 weeks. Results: No flap complications occurred. The functional and aesthetic results were very satisfactory. Movement of shoulder showed no restrictions. A recurrence with single fistulas was seen in 3 patients. Conclusions: Conservative treatment of hidradenitis suppurativa is followed by a high rate of recurrence. Only radical debridement offers a cure. The therapy of choice is the radical excision of the affected region and immediate coverage with a flap. Open granulation or split skin grafting often results in a prolonged hospitalization, higher morbidity, and functional problems. Thus, open granulation is inferior to primary closure by a transposition flap. Using the Limberg flap, the donor site is allowed to be closed primarily.

Long-term results of limberg flap procedure for treatment of pilonidal sinus: a report of 200 cases.

In the past, various methods of surgical or nonsurgical treatment of sacrococcygeal pilonidal sinus have been used. The most common problem in the treatment of this disease is recurrence. In the present study, our aim was to determine the long-term results of the Limberg flap procedure. We present 200 consecutive patients with pilonidal sinus who underwent the Limberg flap procedure between 1992 and 2001. Twenty-six (13 percent) of the 200 patients were operated on because of recurrent pilonidal sinus. Under general or local anesthesia, all sinus tracts were resected en bloc, and the Limberg flap was prepared from the gluteal region. We used a suction drain. We met all patients and recorded their complaints and complications of treatment. Five sinuses recurred (2.5 percent). Minimal flap necrosis occurred in only six patients (3 percent). In three patients (1.5 percent), seroma developed. Wound infection occurred in three patients (1.5 percent). The mean hospital stay was 3.1 days, whereas the mean time to return to work was 12.8 days. The Limberg flap procedure is a good treatment choice for pilonidal sinus because of its low complication rate, the short time to return to normal activity, and good long-term results. This procedure has good postoperative results and is a comfortable surgical method for the patient.

Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap

Background Pilonidal sinus is a common chronic disease of the sacrococcygeal region. Although many surgical methods have been suggested, an ideal method is still lacking because of high recurrence rates. Methods This prospective study was conducted in 63 patients who were treated with the use of a rhomboid excision and Limberg flap closure for sacrococcygeal pilonidal sinus. The follow-up period ranged from 4 to 52 months (mean, 25 months). Results The mean hospital stay was 3 days (range, 2-7 days) and the mean time to return to work was 15 days (range, 12-26 days). Early wound complications and recurrence were encountered in 6% and 3%, respectively. Nineteen percent had numbness at the operation site and 63% were not pleased with cosmetic appearance of the scars. Conclusions The results favor rhomboid excision and Limberg flap closure in the treatment of sacrococcygeal pilonidal sinus, especially in recurrent cases and in patients with extensive involvement. Low recurrence rates, shorter hospital stay, and time off from work may outweigh the disadvantages related to unfavorable cosmetic appearance.

Local anesthesia and midazolam versus spinal anesthesia in ambulatory pilonidal surgery

Study objective To evaluate two anesthetic techniques, namely, local anesthesia with sedation, and spinal anesthesia, with respect to recovery times, postoperative side effects, pain scores, patient satisfaction, and hospital costs for ambulatory pilonidal disease surgery. Design Prospective, randomized study. Setting University Hospital of Pamukkale. Patients 60 consenting patients scheduled for pilonidal disease operation with Limberg flap technique. Intervention Patients were randomly allocated into two groups: Group 1 (n = 30) received spinal anesthesia with hyperbaric bupivacaine 1.5 mL 0.5%, and Group 2 (n = 30) received local infiltration with a 50-mL mixture containing 10 mL bupivacaine 0.5%, 10 mL prilocaine HCl 2%, and 30 mL isotonic solution with 1:200 000 epinephrine in combination with intravenous (IV) midazolam sedation. Measurements Perioperative and postoperative side effects, patient satisfaction, preoperative visual analog scale (VAS) pain scores, and VAS scores from the fourth hour postoperatively until the seventh day were assessed. Anesthesia, operation, surgery, and total hospital time, and costs (drug, resources, and labor) were recorded. Main results No difference was found between groups in the frequency of side effects. Urinary retention was diagnosed in two patients in the spinal anesthesia group. There was no statistical significant difference seen in satisfaction scores between groups. No statistical significance in VAS pain scores between groups was noted except for the fourth postoperative hour values. The average time spent in the operating room (OR) was greater in the spinal anesthesia group. All Group 2 patients achieved fast-tracking criteria in the OR and were able to bypass the postanesthesia care unit (PACU). Total hospital time and total cost were significantly higher in the spinal anesthesia group than local anesthesia-sedation group (p < 0.05). Conclusion The use of local anesthesia-sedation for ambulatory anorectal surgery resulted in a shorter hospital time, lower hospital costs, and no side effects compared with spinal anesthesia.

Earlobe reconstruction using a Limberg flap in six ears

Many methods of earlobe reconstruction using one or two stages have been described. These have used (i) the superimposition of two flaps, (ii) a single flap lined with a skin graft or (iii) doubled-over single or bilobed flaps. We present a new method of earlobe reconstruction using a doubled-over Limberg flap, which we have used in six ears. This produces a good-looking earlobe, which needs defatting after 3–4 months and suffered minimal necrosis at the tip of the folded flap in three cases. There was no earlobe shrinkage on long-term follow-up.

Rhomboid excision and Limberg flap for managing pilonidal sinus: results of 102 cases.

Although many methods of surgical and nonsurgical approaches for treatment of pilonidal sinus have been proposed, an optimal treatment modality has not been achieved yet. The aim of this study was to determine advantages, disadvantages, and long-term results of rhomboid excision and Limberg flap procedure. One hundred ten patients who had been treated with rhomboid excision and Limberg flap procedure for primary or recurrent pilonidal sinus were invited to the hospital. One hundred two patients responded and were asked about their complaints and satisfaction with treatment. Physical examination was performed on each patient, and their hospital records were reviewed. Three patients developed seroma with negative bacterial cultures, two patients had partial wound dehiscence, and one patient had purulent discharge. Mean length of hospital stay was 3.7 days, and mean time to return to normal activity was seven days. Five patients developed recurrence (4.9 percent) and except for these patients, all of the patients were satisfied with the final result. Rhomboid excision and Limberg flap procedure can be performed for managing primary or recurrent pilonidal sinus with a low complication rate, short hospital stay, short time to return to normal activity, and good long-term results.

Sacrococcygeal pilonidal sinus disease with Limberg flap repair.

Sacrococcygeal pilonidal sinus disease affects younger persons, resulting in long-term loss of productive power. It also has a high rate of morbidity because there is no standard treatment approved by all surgeons. In this study, early and late results of 85 cases treated with excision and Limberg flap in our clinic were investigated. The patients were followed for 9-120 months. The complication rate was 4.7% and the long-term relapse rate was 3.5: Insufficient personal hygiene and inadequate excision were the main causes for recurrence. On the basis of the literature and our previous experiences, we conclude that the Limberg flap is the ideal treatment for sacrococcygeal pilonidal sinus disease with low morbidity, mortality and recurrence rates.

Surgical treatment of axillary hidradenitis suppurativa

Hidradenitis suppurativa is a chronic inflammatory disease of the cutis with furuncles, fistulas and abscesses, mostly located in the groin and axillary regions. A conservative treatment can not prevent a recurrence. We report on 16 patients with axillary hidradenitis suppurativa. The inflammatory region was excised, followed by immediate coverage with a transposition flap according to Limberg. Postoperatively, all patients received antibiotic treatment. After 2 weeks, physiotherapy was begun. All wounds healed primarily. Functional and aesthetic results were very satisfactory. Movement of the shoulder showed no restrictions. There was no major complication. The recurrence rate was low. Only radical debridement prevents a recurrence. The therapy of choice is radical excision of the affected region and immediate coverage by a transposition flap. Open granulation or split-skin grafting are inferior compared with a primary closure by transposition flap. Using the Limberg flap the donor site can be closed primarily.

Closure of Large Pressure Ulcers utilizing the Principles of Limberg flap

SUMMARYA prospective study of 17 patients (21 Limberg flaps in 19 pressure ulcers) was done to establish the efficacy of Limberg flap.. Limberg flaps were used in only those cases where primary closure was not possible. This flap was found to be simple to execute and short-term results were satisfactory. Also, it spares underlying muscles for future use. None of the flaps showed necrosis. Partial wound dehiscence was noticed in 7 (33.33%) cases, which was managed by secondary suturing in four cases, by split skin graft in one case and by second Limberg flap in one case.

The role of obesity on the recurrence of pilonidal sinus disease in patients, who were treated by excision and Limberg flap transposition.

Recurrence of pilonidal sinus disease after surgical intervention is not a very rare problem although sophisticated reconstruction procedures have been developed. Recurrence is thought to be related to the anatomical status of the patients, i.e., depth of the intergluteal groove. Obese patients have deeper intergluteal grooves. The aim of this study was to use body mass index (BMI) as an objective indicator of obesity to determine whether there is a relationship between BMI and recurrence of pilonidal sinus disease. BMI was calculated preoperatively in 114 patients with pilonidal sinus disease who were treated by excision and Limberg flap transposition between 1996-1999 in general surgery departments of two university hospital clinics. Fifteen patients were referred to our clinics after surgical intervention carried out at other institutions. Their average BMI was calculated by using their hospital records. The mean follow-up period was 24 months (range 10-36). Six of the 114 patients (5%) had recurrence. The mean BMI of patients with and without recurrence was 29.35 and 27.415, respectively (P<0.05). The mean BMI of 15 patients referred to us because of recurrent disease was 29.41; however, that of patients with primary pilonidal sinus disease was 27.212 (P<0.05). Their BMI before their first operation was 29.30. This was also significantly higher than patients with primary disease (P<0.05). We conclude that obese patients with high BMI have a higher risk of recurrence of pilonidal sinus disease after surgical intervention.

Pilonidal sinus: experience with the Limberg flap

Pilonidal sinus: experience with the Limberg flap

Cassiopeia flap: modification of Limberg flap for saving normal skin.

Local flaps have the advantages of texture matching and increased flap survival rate. The proper local flap planning for each lesion causes the dermatologist to be reluctant to employ them. We propose a modified local flap, the "Cassiopeia flap", with three simple marking points made on the ends of the diameter and on the equidistant point along the diameter; two points from equilateral triangles form a "W (Cassiopeia)". We applied this modification to ten lesions on the face, scalp, trunk and thigh with excellent results.

Geometric limit of multiple local Limberg flaps: a flap design.

The Limberg rhombic flap is a reliable and widely used technique in head and neck surgery. Since Limberg introduced his original design in 1946, several modifications of the technique have been described. Although a single Limberg flap is frequently used at the face to close small to medium defects, multi-Limberg flap techniques can help the surgeon to cover moderate to large defects of the extremities, trunk, and back. In this study, a design of four neighboring local Limberg flaps to cover a moderate to large defect without using a skin graft is introduced. It is believed that this design is the geometric limit of multiple Limberg flaps that can entirely cover a single large rhombic defect, because one Limberg flap unit can only be adjoined by three others, one from the tip and two from the sides. This flap design of four local Limberg flaps is also the only geometrically possible design that can keep all the bases of these four flaps free of incisions if one attempts to prepare four small Limberg flaps around a large rhombic defect.

Pilonidal sinus: experience with the Limberg flap

A personal series of 162 patients with chronic pilonidal disease was treated by rhombic excision and Limberg transposition flap. Each sinus was totally excised and covered primarily by a fasciocutaneous Limberg flap. Full primary healing was obtained in 161 out of 162 patients. One patient had ischaemia which resulted in necrosis of the flap tips that healed later with a scar. Minor infection occurred in 12 patients (7%). The average hospital stay was 4.2 days, and no patient remained in hospital more than 12 days. The mean follow-up period was 18 months, and three recurrences (2%) have occurred. Surgery for pilonidal sinus should not only eradicate the presenting sinus formation but should also aim to eliminate factors that predispose to formation of another sinus. This can be achieved using a Limberg flap which reduces the depth of the cleft and ensures that all parts of the wound and all suture holes are away from the midline.

Management of pilonidal sinus with the Limberg flap.

The aim of this study was to demonstrate the advantages of rhombic excision and Limberg flap closure in the treatment of pilonidal sinus disease. We treated 24 patients who had chronic pilonidal sinus disease with rhomboid excision and Limberg flap closure. All patients were followed up for a period of 27 months. Mean hospital stay was 4.1 days, and mean time until return to work was 17.5 days. There was no surgical wound infection. Complication rate was 12.5 percent. During the follow-up period, no recurrence was found. Because other treatment methods carry a significant failure rate, this technique is an effective alternative in the treatment of pilonidal sinus disease.

The V-flap and the Berlin tulip flap: two new concepts in conventional flap techniques

Microsurgical operations are costly and technologically demanding. We have therefore developed new conventional flap techniques using state-of-the-art knowledge of skin anatomy and circulation. The V-flap is a combination of the V-Y advancement flap and two Limberg flaps [2]. Sixty patients treated by the new flap technique have shown a low rate of complication. Even when used in difficult regions of the body or in very large defects, the V flap has proven to be very effective. It has been adopted as a standard flap technique in our hospital. The Berlin tulip flap is another very reliable flap. To form the tulip flap, the outer corners of a subcutaneous pedicle flap are curved backwards. When detached, they can be transposed to the healthy tissue on the contralateral side. This completely relieves the midzone, which then can be safely closed in the same manner as a V-Y flap. The Berlin tulip flap is particularly useful for covering trunk defects and managing sacral ulcers in paraplegics.

Use of Limberg Flap for Closure of Sacral Pressure Sores

SummaryLimberg flap has been used for the closure of moderate size sacral pressure sores in 5 cases. It provides a good padded skin cover with the suture line away from the midline which is the area of ulceration. No breakdown or ulceration in the flap or donor defect suture line were seen during 1-4 years of follow up. Operative technique is briefly described and important points on flap planning are discussed.