Rhombic flap for cheek reconstruction.

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The rhombic (often referred to as rhomboid) flap is a transposition flap that is an excellent option for reconstruction of small to medium-sized defects of the cheek. It is a one-stage repair that can be performed with local anesthesia. In the classic Limberg design (an equilateral parallelogram), a rhombic defect is created with 60[degrees] and 120[degrees] angles; the flap is designed off the short axis of the defect to minimize the size of the secondary defect (figure 1, A). (1) The flap can be constructed in four possible directions based off the short axis, keeping the following considerations in mind (2):

* Orientation along a relaxed skin-tension line or at the junction of two facial aesthetic subunits;

* Optimal use of tissue laxity so as not to distort adjacent tissue free margins; and

* Areas of tension--that is, closure of the secondary defect (area of maximum tension [figure 1, B]) and closure of the leading tip.

In the Webster flap design, the angle at the tip of the flap is reduced from 60[degrees] to 30[degrees]. This makes the flap only half the size of the defect, resulting in less tension on donor site dosure (figure 2, A). [3] The small donor site decreases the amount of tension to close the defect. The addition of an M-plasty at the base of the defect will also minimize the risk of a standing cone deformity. These modifications are useful when two flaps are used to each close one-half of a defect.

The angles of the Dufourmental flap vary from 60[degrees] to 90[degrees], with the net effect being a more obtuse leading angle (figure 2, B). (3) Because the Dufourmental modification employs a larger flap angle and shorter arc of rotation, like the Webster modification, it results in more sharing of tension between the primary and secondary defects. The tip angle is usually 60[degrees]. The vector of maximum tension is changed to a more lateral one. Thus, the Dufourmental flap may be used in cases where vertical distensibility is lacking.

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We performed a rhomboid flap reconstruction of a 2-cm left cheek defect in a 58-year-old man who had previously undergone wide local excision and sentinel lymph node mapping for a Clark level III melanoma (figure 3, A). At 4 months, the cosmetic result was excellent (figure 3, B). The patient subsequently underwent pulsed dye laser treatment for some erythema along the closure of the secondary defect.

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References

(1.) Becker FF. Rhomboid flap in facial reconstruction. New concept of tension lines. Arch Otolaryngol 1979; 105 (10):569-73.

(2.) Pletcher SD, Kim DW. Current concepts in cheek reconstruction. Facial Plast Surg Clin North Am 2005;13(2):267-81, vi.

(3.) Bray DA. Clinical applications of the rhomboid flap. Arch Otolaryngol 1983;109(1):37-42.