Rhombic Flap Research Articles

The Local Rhombus-Shaped Flap-An Easy and Reliable Technique for Oncoplastic Breast Cancer Surgery and Defect Closure in Breast and Axilla.

Primarily, breast-conserving therapy is an oncological intervention, but eventually it is judged by its cosmetic result. Remaining cavities from tumor resection can promote seromas, delay healing and cause lasting discomfort. Additionally, volume loss, dislocation of nipple/areola and fat necrosis lead to (cosmetically) unfavorable results, aggravated by radiotherapy. Oncoplastic surgery can reduce these sequelae. A local flap that has rarely been used in breast cancer surgery is the Limberg rhombic flap. The tumor defect is planned as a rhombus. The sides of the rhombus are of equal length and ideally have an angle of 60° and 120°. The flap that closes the defect is planned as an extension of equal length of the short diagonal. The second incision of the flap is placed according to the defect angle of 60°, running parallel to the defect at the same length. This creates a second rhombus. The flap is transposed into the defect, and the donor area is primarily closed. It is axially perfused and safe with a 1:1 length-to-width ratio. Compared to local perforator flaps, defect closure is easily managed without microsurgical skills. In the breast, the flap can be used in volume replacement and volume displacement techniques as an all-layer flap to cover defects, or it can be deepithelialized and buried. In the axilla, it can cover full-thickness defects when skin is involved. The advantages of the rhombic flap are its safety and simplicity to add volume and close defects, thus reducing the complexity of oncoplastic surgery.

Teaching Models for Correct Rhombic Flaps.

The aim of this study was to introduce teaching models for correct rhombic flaps. For the line of maximal extensibility (LME) and flap design, surgical fabric (model 1), scored corrugated cardboard (model 2), and scored polyethylene sheet (model 3) were used. For choosing the correct flaps, a silicone face (model 4) was used. Seven participants in the Plastic Surgery Department were recruited for the workshop. In models 1 to 3, a 2-cm diameter circle and relaxed skin tension line were indicated. Participants were requested to design Limberg flaps. Each flap was elevated, transposed, and fixed with sutures (model 1) or cellophane tape (models 2 and 3). In model 4, a 1-cm diameter circle was indicated on the cheek. Participants were requested to design correct Limberg flaps. Although participants were not provided an article describing how to create correct Limberg flaps, they eventually created correct flaps through trial and error. Participants drew 2 parallel lines tangential to the defect and following the LME, perpendicular to the relaxed skin tension lines, which are the same as the scoring marks. They then drew 2 other sides of 2 possible parallelograms by tilting them medially and laterally with angles of 60 and 120 degrees each. Thus, 4 possible Limberg flaps to close the defect were drawn. Among the 8 possible flaps, 4 flaps that did not follow the LME were eliminated. Scored polyethylene sheet had the best extensibility and least distortion among the 3 models. Through this workshop, participants learned to design rhombic flaps correctly, using 2 parallel LMEs.

Simulation and optimization of reconstructive surgery procedures on human skin

The complex procedures involved in the reconstructive surgery of human skin to minimize post-operative scarring are here modeled by means of an automated computational tool. A finite strain no-compression membrane model accounting for the tendency to develop wrinkling regions in the skin is presented. The constitutive behavior of the material is then described by a suitable hyperelastic incompressible potential. Transpositions of skin flaps during surgery procedures are here computationally described by a general mapping technique of the internal boundary corresponding to surgery cut. The archetypal reconstructive surgery of a Z-plasty, where a rotational transposition of the resulting triangular flaps is involved, is considered in details, along with multiple Z-plasty and rhombic flap transposition. The results are discussed in terms of optimal deformation parameters, related to stress/strain localization, displacement discontinuities and wrinkling.

Double-Opposed Rhombic Flaps for the Closure of Mohs Micrographic Defects on the Anterior and Distal Lower Leg.

Griffith, James L. MD, MS*,†; Mitkov, Mario V. MD*,†; Dyson, Mary E. BS†,‡; Kimyai-Asadi, Arash MD*,†,§ Author Information

Ruptured meningomyelocele reconstructed with rhombic flap

Meningomyelocele (MMC) is one of the adverse birth outcomes in Jamaica related to a low socioeconomic status and health care limitations. We present a case of a male neonate with a ruptured lumbar MMC, hydrocephalus, Chiari type 2 malformation and talipes equinovarus. Surgical repair of the MCC accompanied by reconstruction of the skin defect with a transposition flap was accomplished within 48 hours. Subsequently there was the insertion of a ventriculoperitoneal shunt. The reconstructive surgeon is posed with a challenge to select the ideal method of closure that is tailored to the shape and size of this large defect while working in a multidisciplinary team.

Revisiting Rhombic Flaps for Aesthetic Facial Resurfacing: Addressing a Surgical Conundrum.

Background:Facial resurfacing is a surgical and aesthetic challenge, as it requires soft, pliable, and stretchable donor skin with a good match of color, texture, and thickness and minimum donor scarring. Rhombic flap is a highly versatile flap that has the aforementioned properties. Careful flap planning and execution is vital for successful outcomes.Aims:The aim of this work was to study the geometry of the classic rhombic flaps; to evaluate their versatility and technical finesse as well as their application to resurface defects over various regions of the face.Materials and Methods:Overall, 42 patients with facial scars due to trauma, malignancies, small nevi, and mature scars of the face were studied and operated on. Of the four rhombic flaps that were possible, choosing the best option required careful attention to camouflage of scar and proximity to vital deformable anatomical structures. Geometrical planning of the flap was the essence of the entire surgical exercise.Results:Outcome of rhombic flaps were meticulously and critically analyzed. The study consisted of 36 females (85.71%) and only 6 males with a mean age of 23 years. Defects were created on 27 mature scars (64.29%) and 11 burn scars (26.19%). Defects over the cheek and lateral canthus of the eye were especially problematic. It is a safe flap with excellent results as far as visible scarring and traction deformities are concerned. Scars elsewhere on the face fared better than on the bony prominence.Conclusion and Significance:Rhombic flaps offer an excellent alternative to resurface facial scars and defects in a selected subset of patients.

Rhombic Flap: A Useful Flap for Small-to-Medium Defects of the Medial Canthus.

Medial canthal defects are frequently encountered yet present specific challenges for the reconstructive surgeon. Surgical repair in this area may inadvertently lead to canthal webbing, ectropion, and/or epiphora. The rhombic flap is a versatile workhorse in the reconstructive armamentarium for canthal defects. To describe the use of the inferiorly based rhombic flap for reconstructing defects on the medial canthus. A retrospective analysis of the Mohs micrographic surgery cases was performed. All cases in which an inferiorly based rhombic flap was used for canthal reconstruction between 2012 and 2017 were identified. Defect size, location, and any postoperative complications were noted. Surgical scars were scored using the Vancouver Scar Scale. There were 34 cases (17 men and 17 women). Age ranged from 38 to 86 (mean 69). Defect size varied from 0.6 to 2.1 cm in diameter. Postoperative complications were uncommon and minor. The rhombic flap is a versatile and useful option for reconstructing surgical defects of the medial canthus.

The Contralateral Double Transposition Flap

Classic transposition flaps (TF) consist of a single random pattern lobe, which is elevated (rotated) over an area of normal skin to reach the primary defect. Frequently mentioned modifications are the rhombic flaps according to Limberg and Dufourmentel as well as the unilateral multi lobed ("bilobed" and "trilobed") flaps 1, 2, 3, 4, 5, 6. The contralateral double TF presented here is a modification rarely mentioned in the literature 4.

Would you mind doing some modifications to the classical rhombic flap?

Would you mind doing some modifications to the classical rhombic flap?

Simplified approach to the design of rhombic flaps

The rhombic transposition flap is an important method used in the repair of facial defects. 1 Miller C.J. Design principles for transposition flaps: the rhombic (single-lobed), bilobed, and trilobed flaps. Dermatol Surg. 2014; 40: S43-S52 Crossref Scopus (16) Google Scholar The design of this flap can be a challenge for the practicing dermatologist, and there are limited articles illustrating a stepwise approach to designing this flap on patients. We propose a simple 4-step method using sterile wooden dowel ends of commonly available cotton swabs or sterile rulers to assist in design and measurement of the Limberg variant of the rhombic flap.

Comparison of Various Techniques in the Reconstruction of Mohs Chin Defects

Introduction: Defects of the chin after Mohs resection of skin cancer are relatively uncommon yet technically challenging. This is due in part from the numerous topographic features and multiple soft-tissue components such as the underlying muscle layers, the well-defined submental crease, and the bony gonion, all of which contribute to the intricacy of the reconstruction. We review our results over an 11-year period to assess the most commonly used closure techniques and to provide a simplified algorithm for closure of chin defects. Materials and Methods: Retrospective chart review. Approval was obtained by the Institutional Review Board of the University of Texas Southwestern Medical Center for this retrospective medical chart review. All patients undergoing reconstruction of chin defects by the senior author (J.T.) following Mohs excisional chemosurgery from 2005–2013 were included. Pre- and postoperative photographs were reviewed in addition to defect size, location, operative technique, and postoperative complications. Photograph consent forms were obtained at the time of surgery. Patients were excluded if the defect involved the lower lip. One patient was excluded for incomplete data. Results: A total of 35 patients were identified over the period in question. There was a wide range with regard to patient age and race. Both sexes were operated on in roughly equal proportions. The average defect size was 4.29 cm (range, 2–15 cm). Linear closure was performed on 26 patients (72%). Other choices for repair included rhombic flaps (n = 3), submental perforator V to Y advancement flaps (n = 3), bilobed flap (n = 1), and rotational flap (n = 1). All patients achieved a good final aesthetic result with complete functional maintenance of the lower lip with no lower lip retractions. Scars were well healed by the second and third follow-up appointments. Conclusion: Optimal chin reconstruction, defined by successful wound closure, careful scar placement, and minimal postoperative complications, may be accomplished by taking advantage of the inherent characteristics of the chin. In most small defects of the chin, primary closure is attainable. In larger defects of the chin, recruitment of flaps from the cervical region is preferred, with preference toward submental island flaps when allowed.

Klassische Rautenplastik nach Limberg zur Behandlung einer sakrokokzygealen Pilonidalsinuserkrankung – Erklärung der OP-Technik

Sacrococcygeal pilonidal sinus disease is frequently encountered in surgical practice. Besides excision only, the current pilonidal sinus guideline of the Association of the Scientific Medical Societies in Germany (AWMF-S3) also recommends plastic surgical procedures such as the cleft-lift operation described by Bascom, the Karydakis flap procedure and, due to the low recurrence rates, the Limberg flap procedure, for the treatment of this disease. In our case we show the surgical procedure performed on a 23-year-old male patient, who was previously treated for an acute abscess-forming sacrococcygeal pilonidal sinus. Our video shows the fasciocutaneous rhombic flap procedure described by Limberg step by step. The Limberg flap procedure is a simple operation for the treatment of sacrococcygeal pilonidal sinus disease.

From the rhombic transposition flap toward Z-plasty: An optimized design using the finite element method

In this paper, an optimized design for rhombic transposition flaps is created using a reliable finite element model that assures convergence for stress and deformation results. Defining a general configuration for rhombic flaps, the surgical process of wound closure is simulated for a wide variety of patterns. To address the intrinsic uncertainties associated with modelling skin's mechanical properties, four different sets of material parameters are considered, to investigate statistical measures. The results suggest that implementing the rhombic flap technique in a way similar to Z-plasty leads to an optimized surgical technique. The proposed flap, which can be employed for 60° to 90° rhombic defects, can reduce the maximum von Mises stress by 53% (on average) with respect to the Dufourmentel flap, and, in the case of a 60° defect, 43% with respect to the Limberg flap. To avoid any depressed area such as dog-ear formation, the maximum compressive principal stress is examined to assure that it remains within the limits of the stresses in the existing surgical techniques. The deformed configuration is also taken into consideration. Ease of implementation, in terms of both construction and orientation with respect to the relaxed skin tension lines, is another design feature offered by the proposed flap.

Staged Treatment of a Traumatic Cheek and Jowl Avulsion: Using a Purse-String Technique, Rhombic Flap, and Rhytidectomy

Introduction: This article describes a 3-stage treatment modality for a traumatic cheek and jowl avulsion consisting of a purse-string technique, rhombic flap, and face-lift. This approach has not been previously published. Materials and Methods: This case report and literature review discusses the management of a complex left cheek wound consisting of a 6-cm-diameter avulsion and a 5-cm-linear extension. Primary closure was not possible, and a staged treatment modality was selected. The avulsed portion was reduced with a purse-string suture. Primary closure was achieved 3 weeks later with a rhombic flap. Asymmetry was addressed at 6 months postinjury with bilateral rhytidectomy and liposculpture. Successful outcome was determined through patient satisfaction, clinical examination, and comparison of perioperative photographs. Results: The initial defect was reduced in size by more than one-half, from 6 cm to 2.5 cm in diameter, with the purse string. Primary repair was achieved with a smaller local flap, preserved facial landmarks and central oval, and a satisfactory scar. Jowl and nasolabial fold symmetry was effectively restored with bilateral rhytidectomy. No major complications occurred, including flap necrosis, infection, or facial nerve injury. Conclusions: For facial soft-tissue avulsions that are not amenable to primary closure, a purse-string technique allows for circumferential tissue recruitment, creep, and expansion. This creates a smaller defect and potentiates a more conservative definitive closure. Residual nasolabial and jowl asymmetry may be improved with bilateral rhytidectomy. Patients must be fully informed of the complexities of staged treatment including multiple surgeries, increased wound care and appointments, and delayed results.

The rhombic bilobed flap, a simple, geometrically designed flap.

We describe a combination of the common rhomboid flap and bilobed flap and provide an example of its use. The rhombic bilobed flap is simple to use and is associated with fewer complications, such as pin-cushioning and standing cone deformities, while minimizing the risk of skin necrosis and tension on the flap.

Hypertrophie cicatricielle précoce post-chirurgicale de la région nasale : intérêt des injections de corticoïde retard

"Pincushioning" is a complication of post-surgical scarring following use of transposition flaps particularly when surgery is performed on the nasal region. The transposition flap technique is very useful for the repair of certain defects of the tip of the nose, the medial canthus or of the ala nasi. The aim of this study is to define the clinical characteristics of this scarring dystrophy, which we propose to call "early hypertrophy scarring", to clarify the nature thereof and to assess the efficacy of intralesional injection of corticosteroids at the first signs of hypertrophy. A prospective, open, non-comparative, single-centre study examined the clinical and histological characteristics of early hypertrophy scarring and the effectiveness of therapy with one or two injections of corticosteroids performed on the 15th day post-operatively and optionally repeated at D45 depending on the outcome. From January 2011 to January 2013, 12 consecutive patients with early hypertrophy scarring were included (ten men and two women - mean age: 64 years). All had undergone surgery for basal cell carcinoma under local anaesthesia with one-stage repair by means of a rhombic flap or a bilobed flap located in the nasal area. Scars were injected strictly intra-lesionally with triamcinolone acetate (40 mg/1 mL) until whitening occurred. A single injection was performed in three cases of rhombic flap while a second injection was given at D45 in the remaining nine cases. Complete regression of the early hypertrophy scarring was obtained in ten of the 12 patients by D90. Incomplete regression was observed but with a marked improvement in the other two patients. Early hypertrophy scarring is distinguished by its clinical characteristics of hypertrophic or keloid scars. Biopsy performed in two cases showed the fibrous but non-fatty nature of early hypertrophy scarring. Biomechanical factors particular to the nasal region and the transposition flap technique could account for the early and excessive collagen production causing early hypertrophy scarring. Early injection of corticosteroids, which was consistently effective in our study, could represent a simple treatment for early hypertrophy scarring, thus avoiding surgical correction. These preliminary results in a small number of patients require confirmation by a comparative, multicentre, prospective controlled study.

Successes, Revisions, and Postoperative Complications in 446 Mohs Defect Repairs

To determine factors predictive of complications and the need for adjunctive treatments repair of facial Mohs defects. Charts of patients undergoing repair of facial defects from 2000 to 2010 in an academic facial plastic surgery practice were reviewed for patient medical history, tumor type, defect site and size, method of repair, postoperative sequelae, and adjunctive treatments. A total of 446 Mohs defect repairs were analyzed. Average patient age was 61.54 ± 14.81 years. The average defect size was 17.55 ± 10.48 mm. Overall complications were fairly uncommon and required intervention in only 18.74%; other than postoperative corticosteroid injections, additional procedures were necessary in only 6.95% of patients. Female sex; Fitzpatrick skin type 3; upper lip and nasal defects; glabellar, superiorly based nasolabial, bilobed, and rhombic flaps; and dermal suture extrusion were associated with increased complications. The most common complications seen were scar erythema and flap pincushioning. The most common revision techniques performed/recommended were selective laser photothermolysis (3.59%) and scar excision (3.59%). Repair of Mohs defects uncommonly requires adjunctive/revision techniques to reach satisfactory appearance. By understanding certain factors related to the patient, the defect, and the method of repair, surgeons can better choose reparative techniques and anticipate patient postoperative needs.

Analysis and Optimization of the Rhombic Flap Wound Closure

Objective: 1) Develop a hyperelastic computational model of skin viscoelastic properties for analysis of wound closures, and 2) Apply the model to variations of the rhombic skin flap to quantify closure force vectors and optimize wound closure tension. Method: A computational model employing the finite element method was created to simulate skin defect closure employing rhombic transposition flaps. Variables of transposition angle, flap width, and tissue undermining were analyzed. Outcome measures of tissue stress, strain, and wound distortion were evaluated and optimized for a standard defect. Results: A second order Yeoh hyperelastic model was fit to previously published experimental skin data with good approximation of observed properties. In the analysis of transposition flap closures of the 60 to 120 degree rhomboid defect, the model suggests that a biomechanically ideal flap design is constructed with distal flap angle of 30 degrees, as is employed in the Webster flap, with the donor site near margin oriented parallel to the short axis of the defect, as in the traditional Limberg flap. This configuration minimizes tissue stress and strain and most evenly distributes wound tension across the closure line. Conclusion: The model quantitatively demonstrates several recognized principles of the rhombic flap. Square defects, as compared with rhomboid defects, close with lower tissue strain, but form a larger standing cutaneous deformity. The Webster flap best distributes wound tension across the incision line, and the Dufourmental modification alters the closure force vector.

Assessing Fundamental 2-Dimensional Understanding of Basic Soft Tissue Techniques

To develop a written practical examination and scoring system for assessing trainee skills in basic soft-tissue techniques. A brief written practical examination was developed to assess the ability of trainees to sketch preoperative plans and postoperative results for common soft-tissue techniques: simple-excision, M-plasty, geometric broken line closure, Z-plasty, V-to-Y flap, and rhombic flap. A scoring system was developed to assign 0 to 5 points to each of 10 items on the examination for a total score of 0-50. The 15-minute examination was administered as a pretest, posttest, and 3-month posttest assessment as part of a soft-tissue course at our institution. University of Minnesota, Otolaryngology Department. Three raters reviewed all examination answer sheets independently. The pretest scores of examinees correlated strongly with their level of training; the average pretest for junior residents (PGY 1-2) compared with senior residents (PGY 4-5) was 17.3 (of 50) versus 26.0 (p < 0.01). The scoring system showed a high intrarater reliability and high interrater reliability with correlation coefficients of r = 0.99 and r = 0.95, respectively and agreement coefficients of κ = 0.82 and κ = 0.77, respectively. This written practical examination and scoring system may be used to assess the skills of trainees accurately in basic soft tissue techniques and to expose areas of deficiency that can be addressed in future training sessions.

Simple algorithms for calculating the total operative area for proper coding of rhombic transposition flaps

Simple algorithms for calculating the total operative area for proper coding of rhombic transposition flaps