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 Table of Contents  
Year : 2020  |  Volume : 53  |  Issue : 4  |  Page : 140-144

Versatile rhomboid flaps in paediatric surgical practice

Department of Paediatric Surgery, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Date of Submission03-May-2020
Date of Decision02-Jun-2020
Date of Acceptance29-Jun-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Sandip Kumar Rahul
S/o. Shri Kapil Kumar Jha, Qr. No. - BN-2/b, Indira Gandhi Institute of Medical Sciences Campus, Patna - 800 014, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_61_20

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Background: Tension-free closure of large cutaneous defects after excision of primary pathology poses a challenge to the operating surgeon. The objective of the study was to review the use of rhomboid flaps (RFs) in the closure of surgical defects at different locations and of varying pathology.
Materials and Methods: A retrospective study on all cases of surgical wounds closed with RFs from January 2014 to December 2019 was conducted in the department of pediatric surgery at a tertiary care center. Data regarding the demographic details of the patient, location of the wound with its shape and size, details of the primary lesion, and any postoperative complications were noted and analyzed.
Results: RFs were used in 73 large defects with the ratio of transverse to longitudinal dimensions ranging between 0.67 and 1.49. These defects had variable pathology and different location (59 - neural tube defects; 9 - arteriovenous malformation; 2 - amniotic bands; 2-pilonidal sinus; and 1 - coccydynia with ulcer). Different modifications of RFs included variation in the direction towards which they were raised, multiplicity of the flaps, variation in the angle at which the flap was fashioned (Dufourmentel modification), and lessening the flap length to match the short diagonal of the wound (Quaba modification). Minimal complication in the form of wound infection (5/73), dehiscence at the tip of the flap (2/73), and hematoma (3/73) was observed which were managed conservatively.
Conclusion: Versatile and universal RFs offer tension-free closure of large wounds at different anatomical locations with minimal complication and are indispensable tools in the hands of a pediatric surgeon.

Keywords: Modification, rhomboid flaps, wound closure

How to cite this article:
Chaubey D, Rahul SK, Prasad R, Hasan Z, Keshri R, Kumar S. Versatile rhomboid flaps in paediatric surgical practice. Formos J Surg 2020;53:140-4

How to cite this URL:
Chaubey D, Rahul SK, Prasad R, Hasan Z, Keshri R, Kumar S. Versatile rhomboid flaps in paediatric surgical practice. Formos J Surg [serial online] 2020 [cited 2022 Jun 29];53:140-4. Available from: https://www.e-fjs.org/text.asp?2020/53/4/140/292727

  Introduction Top

Large skin defects following excision of any pathological lesion of significant size involving the skin or subcutaneous tissues are at least as frequent as the cumulative incidence of such lesions. The operating surgeon faces not only the challenges of the pathologic lesion and its natural course but also of the esthetic closure of the surgical defect resulting from its excision. Tension-free closure of such defects is of prime importance to attain complication-free healing and cosmetic results. Local flaps prove beneficial if primary closure cannot be done safely without tension. We present our experience with the use of rhomboid flaps (RFs) at different anatomical sites during the past 5 years.

  Materials and Methods Top

A retrospective cohort study was performed on all patients who underwent wound closure using RFs for pathologies at different anatomical sites from January 2014 to December 2019 in the department of pediatric surgery at a tertiary care center after approval from the institutional ethics committee. Approval from Institutional ethics committee was taken before conducting the study (Approval letter no. 478/Acad.) and consent was taken from the parents of all pediatric patients included in this study.

Data regarding the demographic details of the patient, location of the wound, and its anatomical details including its shape and size, details of the primary lesion, and any postoperative complications were collected from their records. Data thus collected were analyzed by calculating the mean and range of data for different measures.

Fashioning a rhomboid flap

After excision of a lesion, we always aim for tension-free closure, whether it is primary closure or closure using any local flap. Hence, in all cases of large defects or wherever, a choice has to be made between primary closure under tension and closure using flaps, we choose the later to reduce the morbidity of the patient. While raising a RF, popularized by Limberg, we give an incision perpendicular to the long axis of the rhomboidal defect which is equal in length to one of the sides of the rhomboid and a second equal incision from the end of this segment but parallel to the long axis of the rhomboid.[1] The resulting flap is raised in the fasciocutaneous plane and rearranged so as to transpose over the defect to give tension-free and adequate coverage. On most occasions, we also introduce a Mini Vac suction drain anticipating any collection due to dissection done in raising a flap. This drain is removed after 2 days. The direction toward which RF is raised depends on the location of the defect and also the availability of skin on that side. Hence, depending on the side of the defect toward which RF is raised, it can be a “superior-based,” “inferior-based,” or “side-based” RF. Sometimes, multiple RF needs to be raised to deal with a circumferential lesion such as amniotic bands or a large defect closely mimicking a circle in shape like those seen in large rachischisis. A few other modifications include variations in the angle of the RF to the principal axis of the defect or lessening the flap length to match the short diagonal of the wound.[2],[3] [Figure 1] presents a collage of clinical pictures showing (a) the method to raise a RF to cover a lumbar myelomeningocele defect, (b) modification of RF in the form of double RF to cover a rachischisis defect, (c) RF to cover a sizeable scalp defect following the excision of an arteriovenous malformation, (d) RF to cover the defect left over after excision of pilonidal sinus, and (e) RF for a postthoracic meningomyelocele excision defect.
Figure 1: Picture collage showing the versatile usage of rhomboid flap. (a) Raising a rhomboid flap for a lumber MMC defect. (b) Double rhomboid flap for rachischisis defect. (c) Rhomboid flap to close AV malformation defect over scalp. (d) Rhomboid flap to close pilonidal sinus defect. (e) Rhomboid flap for thoracic MMC defect

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  Results Top

Location and Nature of cases using rhomboid flap for cover

[Figure 2] shows the number and location of cases where RF was used to give cover during this period. The different anatomical lesions and the different sites are a reflection of the universality of these flaps provided that adequate skin is available on any of the sides of the defect.
Figure 2: Location and nature of lesions where rhomboid flap was used for defect closure

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All lipomeningomyelocele could be primarily closed (and are therefore not included in this study); all rachischisis and kyphosis patients needed flap cover to achieve proper skin cover without any tension.

[Figure 3] gives the details as regards the side of the wound, toward which these flaps were raised

Depending on the side of the wound toward which ample skin is available, RF can be raised on that side. Hence, we can have “superior-based,” “inferior-based,” “side-based,” or “multiple” RF in different directions.
Figure 3: Nature of rhomboid flap or its modifications used to cover the surgical defects in the study

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In out of nine rachischisis patients, six could be closed with the use of superior based RF, while three patients needed double RF.

Wound size characteristics in the decision for primary versus flap cover of the defect

The ratio between the transverse and longitudinal dimensions of all the wounds closed using RF in this study ranged from 0.67 to 1.49, signifying that squarer defects are better closed using RFs with proper distribution of skin tension, resulting in better cosmetic outcomes with fewer complications.

Complications and postoperative stay

[Table 1] gives the summary of the postoperative complications and postoperative stay in the patients included in this study.
Table 1: Complications and postoperative stay

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Modifications of rhomboid flaps

Double RF was used in three rachischisis patients; in two patients with amniotic bands over the limbs, multiple RFs had to be used. In two patients with pilonidal sinus, Dufourmentel modification of RF was used. Other modifications included raising RF over different sides of the defect depending on the availability of the skin on that side.

  Discussion Top

Large skin defects following surgery are very common in clinical practice. A variety of lesions such as meningomyelocele, rachischisis, arteriovenous malformation involving the cutaneous tissue, congenital amniotic bands, pilonidal sinus, and different skin lesions over face and scalp are commonly associated with defects which cannot be primarily closed without tension. Different local flaps, grafts, and free tissue transfer techniques have been described in the literature to achieve wound closure in such cases.[4],[5],[6],[7]

Fasciocutaneous flaps are well-vascularized flaps which can be transposed on their pedicle to cover the defect in a tension-free manner by redistributing the tension of wound closure. RFs, popularized by Limberg, are simple universal fasciocutaneous flaps which can be used at any site where ample surrounding skin is available in the vicinity of the defect.[1]

Approximately, one out of four patients operated for neural tube defects (NTDs) has large defects which cannot be primarily closed safely.[8] This is reflected in our study as well where 59 patients with NTD needed closure with RF out of a total of 223 patients (26.4%). All patients who had kyphotic bony deformity associated with NTD and all rachischisis patients needed flap cover for proper closure. Contrary to this, all lipomeningomyelocele cases could be primarily closed due to the availability of excess skin.

Defects following excision of arteriovenous malformation (AVM) over regions such as face, scalp, trunk, and extremities often require flaps for closure. AVM needs early excision because they have a natural history to grow in size which will lead to a sizeable defect difficult to be closed by any local flaps and would need free tissue transfer for covering the defect adequately.[7] Free tissue transfer often has suboptimal results which are not very cosmetic and often are devoid of proper sensation. Moreover, in large AVM, if arterial occlusion has been tried, there are increased chances of ischemia of the surrounding skin which aggravates the complexity of the condition. At our institution, we, therefore, try to operate AVM early so that the defect is of the size which can be closed using local RF or their modification.

Congenital amniotic bands are rare but present with risks of ischemia of the involved limb. They, therefore, need an early release to ensure proper vascular supply to the distal limb. Surgery involves division of the tight amniotic band/scar at several places and then closing the skin by rearrangement so as to avoid a continuous constricting scar. The role of Z-plasty and RF is vital in such closure. Both patients with congenital amniotic bands in our study did well with division of the band with multiple incisions and closure using Z-plasty and RF.

Several investigators have reported the advantages of using RF in pilonidal sinus.[9],[10] These include the simplicity of its performance and design, flattening of the natal cleft with a well-vascularized pedicle which can be closed without tension; moreover, it provides good hygiene, reduces friction, prevents maceration, and avoids scar in the midline. All these benefits have translated into this flap being better than procedures such as simple excision and closure, marsupialization, and other procedures like Bascom and Karydakis as reported in the literature.[9],[11],[12],[13] Mentes et al., in a large study of 353 patients of pilonidal sinus, did not report any wound infection or flap necrosis in any patient, thereby confirming the advantages of this technique.[13] Although Can et al. found comparable outcomes with the use of RF and Karydakis flap, cases with laterally located pilonidal sinus opening did well with RF.[14] We have used RF in pilonidal sinus and in a case of coccydynia with a large ulcer over the tip of coccyx without any complications. In some cases, modifications, as described by Dufourmentel, are better particularly when the defect is small, and raised flap is intended at a smaller angle to the original defect.[2] We used this modification of RF in both patients of pilonidal sinus to achieve cosmetic results.

Modifications of RF are often needed. These may vary from raising flaps at different angles relative to the position of the primary defect to the multiple numbers of flaps needed to close the same defect. These techniques have often been described to get cosmetic results.[2],[15],[16] With several of these techniques, the shape of the primary defect needs not to be an approximate rhomboid; rather, even a circular defect may be closed using one of these modifications. In one such modification as described by Quaba and Sommerlad, the flap size can be smaller than the defect size by choosing the short diagonal of the defect as the length of the side of the RF.[3] This modification also lessens the occurrence of dog ears at the time of wound closure. We believe that keeping the flap slightly smaller than needed lessens the dog-ear formation as it causes stretching of the angles of opposition. There is, however, a small risk of local dehiscence of the tip which we encountered in two patients. Both these patients did well with conservative management of the wound. Double RF was used in three cases of rachischisis in our study. These cases had good cosmesis with no complications in the postoperative period.

Three patients had small hematoma formation in the postoperative period which was conservatively managed. We routinely introduce a small-caliber Mini-Vacuum closed suction drain in cases where a flap is raised to ensure drainage of any serous fluid or small hematoma in the postoperative period.

Although there was no necrosis of the flap in any of the cases, there was a small dehiscence at the tip of the flap in two cases exactly at the site of Burow's triangle which was fashioned to do away with the prominent dog ears. The wound healed with conservative management.

In our study, we could use RF or its different modifications to cover a wide variety of wounds after surgical excision of pathologies involving the skin and subcutaneous tissue at different sites with acceptable complication rates.

  Conclusion Top

Universal, versatile, and easy-to-perform RF with its modifications are indispensable tools in the hands of a pediatric surgeon for the management of large cutaneous defects which they commonly encounter in their clinical practice.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Limberg AA. Modern trends in plastic surgery. Design of local flaps. Mod Trends Plast Surg 1966;2:38-61.  Back to cited text no. 1
Dufourmentel C. Le lambeau en L pour losange (LLL). Interview de Claude Dufourmentel par E. Achard [The L-shaped flap for lozenge-shaped defects. Interview with Claude Dufourmentel by E. Achard]. Ann Chir Plast 1979;24:397-9.  Back to cited text no. 2
Quaba AA, Sommerlad BC. “A square peg into a round hole”: A modified rhomboid flap and its clinical application. Br J Plast Surg 1987;40:163-70.  Back to cited text no. 3
Shim JH, Hwang NH, Yoon ES, Dhong ES, Kim DW, Kim SD. Closure of myelomeningocele defects using a limberg flap or direct repair. Arch Plast Surg 2016;43:26-31.  Back to cited text no. 4
El-khatib HA. Large thoracolumbar meningomyelocele defects: Incidence and clinical experiences with different modalities of latissimus dorsi musculocutaneus flap. Br J Plast Surg 2004;57:411-7.  Back to cited text no. 5
Campobasso P, Pesce C, Costa L, Cimaglia ML. The use of the limberg skin flap for closure of large lumbosacral myelomeningoceles. Pediatr Surg Int 2004;20:144-7.  Back to cited text no. 6
Hartzell LD, Stack BC Jr, Yuen J, Vural E, Suen JY. Free tissue reconstruction following excision of head and neck arteriovenous malformations. Arch Facial Plast Surg 2009;11:171-7.  Back to cited text no. 7
Kemaloǧlu CA, Özyazgan İ, Ünverdi ÖF. A decision-making guide for the closure of myelomeningocele skin defects with or without primary repair. J Neurosurg Pediatr 2016;18:187-91.  Back to cited text no. 8
Sebastian M, Sroczyński M, Rudnicki J. The Dufourmentel modification of the limberg flap: Does it fit all? Adv Clin Exp Med 2017;26:63-7.  Back to cited text no. 9
Aithal SK, Rajan CS, Reddy N. Limberg flap for sacrococcygeal pilonidal sinus a safe and sound procedure. Indian J Surg 2013;75:298-301.  Back to cited text no. 10
Akca T, Colak T, Ustunsoy B, Kanik A, Aydin S. Randomized clinical trial comparing primary closure with the limberg flap in the treatment of primary sacrococcygeal pilonidal disease. Br J Surg 2005;92:1081-4.  Back to cited text no. 11
Azab AS, Kamal MS, Saad RA, Abou al Atta KA, Ali NA. Radical cure of pilonidal sinus by a transposition rhomboid flap. Br J Surg 1984;71:154-5.  Back to cited text no. 12
Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir M. Limberg flap procedure for pilonidal sinus disease: Results of 353 patients. Langenbecks Arch Surg 2008;393:185-9.  Back to cited text no. 13
Can MF, Sevinc MM, Hancerliogullari O, Yilmaz M, Yagci G. Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease. Am J Surg 2010;200:318-27.  Back to cited text no. 14
Webster RC, Davidson TM, Smith RC. The thirty degree transposition flap. Laryngoscope 1978;88:85-94.  Back to cited text no. 15
Becker FF. Rhomboid flap in facial reconstruction. New concept of tension lines. Arch Otolaryngol 1979;105:569-73.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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