Rhomboid Flap

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

Local skin flaps provide a superior approach to closing skin defects with like-appearing skin from nearby areas. The common fusiform (elliptical) excision (Fusiform Excision) is the technique most commonly employed for simple lesion removal, but nearby structures (e.g., nose, ear, orifices) can limit its use. The long straight scar line produced by the fusiform also tends to draw the eye more and thus be less cosmetically appealing than procedures that produce a less noticeable, broken line. 
Nearby skin generally better approximates the needed color, hair pattern, and texture to close a defect than skin brought in from a distant site (i.e., skin graft). Local transposition skin flaps, such as the rhomboid flap (Limberg flap), can provide both excellent functional and cosmetic outcomes. They also allow closure of skin defects near orifices and fixed structures that limit the amount of skin that can pulled from those areas. 
Preventing complications is an important aspect of performing flap surgery. Proper skin prep (see Appendix E) and strict sterile technique is necessary to avoid wound infections. Excessive handling of skin should be avoided because necrosis may ensue. Wide undermining of the tissue around a flap aids the closure without flap-necrosing tension. Do not pull on the skin edges with forceps or roughly handle the skin edges; gentle handling promotes healing. Excellent hemostasis is required for proper healing, so bleeding vessels should be clamped or suture-ligated before the flap is sutured. Pressure bandaging is advocated following the procedure. 

Equipment

  • Surgery tray instruments are listed in Appendix G. Consider adding skin hooks to gently handle the skin flaps. Have at least three fine (mosquito) hemostats to assist with hemostasis while developing large skin flaps.

  • Suggested suture removal times are listed in Appendix J, and a suggested anesthesia tray that can be used for this procedure is listed in Appendix F. All instruments can be ordered through local surgical supply houses.

  • Also see Appendix E: Skin Preparation Recommendations.

Indications

  • Closure of skin defects that have limited skin that matches the area to be removed

  • Closure of defects around eyes/eyebrows

  • Closure of defects on the lips

  • Closure of a defect over the glabella

  • Closure of a large hand defect

  • Closure of cheek defects

Contraindications (Relative)

  • Practitioner’s unfamiliarity or inexperience with the techniques

  • Cellulitis in the tissues

  • Skin unable to be stretched to cover the defect

  • Chronic steroid use (and steroid skin effects)

The Procedure

Step 1

The rhomboid flap has several potential uses, especially around the eyes, lips, and glabella. Lay out the flap to minimize pull applied to structures that may be distorted by the added tension. 

Step 2

The rhomboid flap is based on geometry of the rhomboid or diamond. When planned and executed correctly, it is an equilateral parallelogram with the oblique angles equaling 120 degrees and the acute angles equaling 60 degrees. The length of all of the lines (labeled “L”) will vary, but each line will be exactly the same length. The horizontal line that extends to the side (labeled “C”) is the same length as the all of the other lines, and if it were extended into the diamond, it would bisect both 120 degree angles. 

Step 3

One of the advantages of the rhomboid flap is that the flap can be created in any of the four directions that come off of the line (line “X”) that splits the diamond through the obtuse angles (line “C”). Thus, there are four potential sources for a flap to close the diamond-shaped defect (see Layout of Skin Excision Procedures). 

Step 4

Align the excision so that lines “C” is parallel with the lines of least skin tension. The flap placement must also take into account structures that will be distorted if the flap causes tension in this area (e.g., eyes and eyebrows) and structures that anchor the skin (e.g., ears and nose). 
  • PEARL: Consider using a permanent skin marker to mark the cut lines for the flap before the procedure, even if you do not normally need to mark flaps. The correct geometry of the rhomboid flap is critical to its success.

Step 5

The rhomboid flap technique is started after administration of a field block (see Field Block Anesthesia). The lesion is removed in a diamond shape, with a margin of normal-appearing skin (see Appendix D). 

Step 6

Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry (see Appendix E). The flap is incised, making sure the correct geometry is maintained. 
  • PEARL: When checking the geometry of the cuts, always release any tension being held on the skin, because it can distort the geometry.

  • PEARL: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

Step 7

The flap is undermined with a horizontally held scalpel blade or iris scissors. 
  • PITFALL: Do not excessively undermine the flap base, because this can compromise blood flow to the flap.

Step 8

The skin surrounding the excision is undermined just below the dermis with sharp or semisharp dissection. 

Step 9

Attempt to slide the flap to cover the defect using skin hooks or fingertips. If the defect cannot be covered by the flap, the area may need to be undermined more. When transposing the flap, flap tip labeled “A” is placed in corner labeled “A” and fixed using a corner suture. Then tip “B” is sutured to corner “B” and lines “C” and “D” will come together. 
  • PITFALL: The skin may bunch up (i.e., make a dog ear) near the base of the flap. If it is significant, it is eliminated by excising triangular pieces of skin at a 120-degree angle (i.e., Burrow triangles).

Step 10

Transpose the flap by using a corner suture (see Corner Suture) to anchor the first corner (both labeled “A”). 
Step 10
Step 10

Step 11

Then place a corner suture to anchor the tip of the flap into its corner (both labeled “B”). Note: The rest of the flap comes together and the closure appears more obvious. 
Step 11
Step 11

Step 12

Place a corner suture to close the last corner that is formed when the two incision lines that created the flap come together. 
Step 12
Step 12

Step 13

Use interrupted sutures to close any gaps in the suture lines to complete the flap. Place a small amount of ointment on the wound and apply a pressure dressing. 
Step 13
Step 13

Complications

  • Pain, infection, and bleeding

  • Nonunion of skin edges

  • Scar formation

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit and lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. 

Postprocedure Instructions

Have the patient keep the bandage on and the wound dry for the first 24 hours. After that, it can be cleaned with hydrogen peroxide or gently washed with soap and water as needed. An antibiotic ointment and bandage should be reapplied after each washing until the patient returns or for 2 weeks. Have the patient report signs of infection. Schedule a return appointment for suture removal (see Appendix J). 

Coding Information

These codes encompass excision or repair, or both, by adjacent transfer or rearrangement, including Z-plasty, W-plasty, V-Y-plasty, rotation flaps, advancement flaps, and double-pedicle flaps. When applied to traumatic wounds, the defect must be developed by the surgeon because the closure requires it, and these codes should not be used for direct closure of a defect that incidentally results in the configuration of one of the flaps or plasties. If the configurations result incidentally from the laceration shape, closure should be reported using simple repair codes. 

Bibliography

Becker FF. Rhomboid flap in facial reconstruction: new concept of tension lines. Arch Otolaryngol .  1979;105(10):569–573. [View Abstract]
Calhoun KH, Seikaly H, Quinn FB. Teaching paradigm for decision making in facial skin defect reconstructions. Arch Otolaryngol Head Neck Surg.  1998;124(1):60–66. [View Abstract]
Chernosky ME. Scalpel and scissors surgery as seen by the dermatologist. In: Epstein E, Epstein E Jr, eds. Skin Surgery . 6th ed. Philadelphia: WB Saunders;  1987:88–127.
Connor CD, Fosko SW. Anatomy and physiology of local skin flaps. Facial Plast Surg Clin North Am .  1996;4:447–454.
Cook J. Introduction to facial flaps. Dermatol Clin.  2001;19:199–212. [View Abstract]
Larrabee WF, Trachy R, Sutton D, et al. Rhomboid flap dynamics. Arch Otolaryngol.  1981;107(12):755–757. [View Abstract]
Ling EH, Wang TD. Local flaps in forehead and temporal reconstruction. Facial Plast Surg Clin North Am .  1996;4:469.
Lober CW, Mendelsohn HE, Fenske NA. Rhomboid transposition flaps. Aesthetic Plast Surg.  1985;9(2):121–124. [View Abstract]
Lister GD, Gibson T. Closure of rhomboid skin defects: the flaps of Limberg and Dufourmentel. Br J Plast Surg .  1972;25:300–314. [View Abstract]
Stegman SJ. Fifteen ways to close surgical wounds. J Dermatol Surg.  1975;1:25–31. [View Abstract]
Tollefson TT, Murakami CS, Kriet JD. Cheek repair. Otolaryngol Clin North Am .  2001;34:627–646. [View Abstract]
Whitaker DC. Random-pattern flaps. In: Wheeland RG. Cutaneous Surgery . Philadelphia: WB Saunders;  1994:329–352.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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