Facial cutaneous defect closure with rhomboid Flap: Review article with case presentation
Authors : Dr. Abdul Hameed Attar .
Cutaneous defects that are too large for primary wound closure must be addressed with flaps from adjacent tissue or from distant region. The advantage of utilizing nearby tissue flaps on the face is the comparability of color, texture and composition of the tissues with the area of the imperfection to be repaired.
With appropriate planning, local flaps typically give the favored strategy for repair with the best cosmetic results and negligible mutilation of adjacent important facail structures. Face hass highly vascularised tissue supplied by internal and external carotid artery, with rich collateralization and defined vascular plexus. Depending on vascular territories and the extensive collateralization of these vessels permitsvarious local flaps outline to reconstruct facial defect.
No single flap will give best result for every defect. Reconstruction of Specific Facial Subunits some times requires combinations of these classifications. But the rhombic flap has long been viewed as a workhorse in the armamentarium of the reconstructive surgeon because of its simplicity and reliability.Rhomboid folds can be utilized, with no impediments in the reconstruction of the head and neck defect. Originally described by Limberg 1984, since than rhombic flap been used in aesthetic and reconstructive surgery. Proper planning with understanding of geometry and execution of rhombic flap it can provide excellent aesthetic outcome.
A diamond is made around the defect with internal angles 60 and 120 degrees with two equilateral triangles with 60-degree angles lined up from base to base so that all sides of the defect have the same length. The flap is designed in this manner and cut along the incision lines marked. It is undermined widely and rotated into the defect. Secondary defect created is closed by primary intention. Sometime flap have tension because of the restraint at the pivot point of the pedicle, resulting in failure of flap tip to merge with recipient area. Aviod forcefull pulling of flap to avoid schemia and necrosis. Two major sites of tension, first is at the closure of secondary defect and second site is tip of the flap.
It is a safe and versatile flap, that give the trasposition of the adjoining tissue to the defect with the same skin shading and composition with low rate of complication.Alexander A. Limberg first described the principal rhombic transposition flap. Limberg described the use of a rhombic transposition flap with internal angles of 60° and 120° to fill a rhombus-shaped surgical defect with similar internal angles. If the defect does not have the rhombus configuration described than additional tissue removed to create the rhombus with internal angle 60 and 120 degree.
The utilization of the flap portrayed by Limberg had a few constraints, Dufourmentel, Becker, and Webster modified limbergrhomboid flap to address issues of tension closure, the need to dispose of skin to make a rhombus shape defect, and standing cutaneous distortion. As with any irregular fold, care must be taken while undermining and exchanging the flap to guarantee that the dermal and subdermal plexuses are not harmed. Rhomboid flap should be avoided in heavy smokers, IDDM patients as they have microvascular pathologies. Since the donor site Is primarily closed rhomboid flap should be avoided in lager defect.
Abstract
In Todays scenario the aesthetic and functional demands of patients post reconstructive surgery is high, therefore it is a challenging task for aesthetic and reconstructive surgeon, requiring careful planning and execution to accomplish results that are acceptable to both surgeon and patient. Many a times primary closure of a deformity is incomprehensible and transposition of nearby tissue is required for repair. The advantage of using local flaps on the face is the similarity of color and texture of the tissues with the location of the defect to be repaired. The rhomboid flap is a reliable, versatile, and widely used flap for repair of defects in head and neck region.Introduction.
The face is the center of fascination for one's personality, and any deformation, or imperfection of facial segment draws undesirable consideration influencing the social stigma of person. There are numerous circumstances when facial deformity emerges, which requires reproduction. Repair of facial deformities is a standout amongst the most difficult assignments for the aesthetic or reconstructive surgeon.Cutaneous defects that are too large for primary wound closure must be addressed with flaps from adjacent tissue or from distant region. The advantage of utilizing nearby tissue flaps on the face is the comparability of color, texture and composition of the tissues with the area of the imperfection to be repaired.
With appropriate planning, local flaps typically give the favored strategy for repair with the best cosmetic results and negligible mutilation of adjacent important facail structures. Face hass highly vascularised tissue supplied by internal and external carotid artery, with rich collateralization and defined vascular plexus. Depending on vascular territories and the extensive collateralization of these vessels permitsvarious local flaps outline to reconstruct facial defect.
Flaps may be classified, as follows:
- Blood supply (random, axial)
- Configuration/ Design (bilobed, rhombic,)
- Location (local, regional, distant)
- Method of transfer
No single flap will give best result for every defect. Reconstruction of Specific Facial Subunits some times requires combinations of these classifications. But the rhombic flap has long been viewed as a workhorse in the armamentarium of the reconstructive surgeon because of its simplicity and reliability.Rhomboid folds can be utilized, with no impediments in the reconstruction of the head and neck defect. Originally described by Limberg 1984, since than rhombic flap been used in aesthetic and reconstructive surgery. Proper planning with understanding of geometry and execution of rhombic flap it can provide excellent aesthetic outcome.
Flap design and technique.
Any defect that can be projected in a rhomboidal shape can be reconstructed with a rhomboid flap. The classic rhombic flap is constructed around a defect that is converted into a geometric 4-sided defect (rhombus) with equal side length and tip angles equal to 60° and 120°.A diamond is made around the defect with internal angles 60 and 120 degrees with two equilateral triangles with 60-degree angles lined up from base to base so that all sides of the defect have the same length. The flap is designed in this manner and cut along the incision lines marked. It is undermined widely and rotated into the defect. Secondary defect created is closed by primary intention. Sometime flap have tension because of the restraint at the pivot point of the pedicle, resulting in failure of flap tip to merge with recipient area. Aviod forcefull pulling of flap to avoid schemia and necrosis. Two major sites of tension, first is at the closure of secondary defect and second site is tip of the flap.
How to minimize the tension?
- Increase the leading edge of flap also increase the secondary limb.
- Make flap angle more obtuse. Greater then 1200
Clincal Case :
A 34 year old male came with the complain of depressed scar on the left side of the lower third of the face. On clinical examination there was a depressed defect / scar adhering to underlying tissue. Under the aseptic precuation and antibiotic coverage it was planned to excise the depressed scar and reconstruct the defect with rhomboid flap by mobilization of adjacent tissue.OPERATIVE TECHNIQUE
- Patient positioned.
- Preliminary drawing of the flap with marking pen.
- Antisepsis with Betadine solution.
- Infiltration anesthesia with lignocaine and epinephrine (1:50,000 IU).
- Resection with safety margins up until the deep plane (Bone),followed by rigorous electrocautery-based hemostasis.
- Preparation and positioning of the flap towards the defect.
- Skin suture carried out with Ethilon 6-0.
- Sterile dressing applied.
- Suture removed after 10 days.
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Discussion
The reconstructive option for facial imperfection emphasizes utilizing the least complex system, for example, primary closure of a deformity. Be that as it may, with increase in deformity size, it becomes difficult to close primarily. In such situation local transposition flap are the best option compared to other.The rhomboid fold has been viewed as the best option for the treatment of the facial cutaneous deformity. The rhombic flap is a cutaneous, random vascular designed fold that is exchanged fundamentally by transposition with some constrained progression movement. The flap is reliant on its dermal and subdermal plexuses for survival.
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It is a safe and versatile flap, that give the trasposition of the adjoining tissue to the defect with the same skin shading and composition with low rate of complication.Alexander A. Limberg first described the principal rhombic transposition flap. Limberg described the use of a rhombic transposition flap with internal angles of 60° and 120° to fill a rhombus-shaped surgical defect with similar internal angles. If the defect does not have the rhombus configuration described than additional tissue removed to create the rhombus with internal angle 60 and 120 degree.
The utilization of the flap portrayed by Limberg had a few constraints, Dufourmentel, Becker, and Webster modified limbergrhomboid flap to address issues of tension closure, the need to dispose of skin to make a rhombus shape defect, and standing cutaneous distortion. As with any irregular fold, care must be taken while undermining and exchanging the flap to guarantee that the dermal and subdermal plexuses are not harmed. Rhomboid flap should be avoided in heavy smokers, IDDM patients as they have microvascular pathologies. Since the donor site Is primarily closed rhomboid flap should be avoided in lager defect.
Conclusion
The Limberg flap exhibited great results. The procedure's flexibility, when consolidated with great preoperative planning and execution of the flap permits excellent aesthetic results in the head neck region.