## Rhombic

Description

The nomenclature surrounding this flap is inconsistent. Flaps called rhombic/ rhomboid/rhombus all share a common origin with Limberg's original flap described in 1963 (16). These designations do not reflect the shape of the flap but more literally the shape of the defect. A rhombic defect has the shape of a rhombus (an equilateral parallelogram). Limberg's flap is rhombic (i.e., a rhombic flap) with opposing angles of 60 and 120 degrees that is random-pattern and

lifting. A rhombic flap is similar to a transposition flap; however, unlike a transposition flap, the rhombic pivots and also advances toward the defect, requiring extensive undermining of skin at the base of the flap. A rhombus-shaped defect can be conceptualized as a typical elliptical defect with opposing 60 degree angles that cannot be closed primarily (17). The design of a rhombic flap involves tracing a line through the opposing 120 degree angles. Outside the rhombus, this line is followed at a distance equal to the length of the defect, and four lines are extended at 60 degree angles parallel to the side of the rhombus. This outlines four possible flaps surrounding the defect (Fig. 11). The appropriate one to use will depend upon the availability of surrounding skin, the placement of incisions, and the maximum tension vector (which is within 20 degrees along the line intersecting the 120 degrees angles) (18). Only two flaps are appropriate based on skin extensibility. The final decision as to which flap to use will be based on minimizing the distortion of surrounding structures. The classic Limberg flap is equal in size to the defect; however, as the rhombus approaches the shape of a square, the transposed flap size is reduced to 40% of the defect size (19).

A rhomboid flap is different from Limberg's rhombic flap and is designed for rhomboid-shaped defects (oblong parallelograms with opposite sides of equal length). Subsequent variations of the Limberg flap are found throughout the literature (17-20). Indications

Since much of the scar from the rhombic flap does not align with the RSTLs, it is best used in areas that have less prominent skin creases such as the cheek: the fore-

Figure 11 Rhombic flap: four possible flaps to fill the defect.
Figure 12 Potential rhombic flaps designed around a lower cheek skin defect. Flap 3 was chosen due to considerations of adjacent structures and the ability to 'borrow skin' from the neck.

head and temple areas are less favorable (17) (Fig. 12). The arc is 90 degrees and the diameters 1.5D.

The majority of the resulting skin tension is at the base of the flap, minimizing the danger of tissue ischemia in the distal part of the flap. It combines the benefits of both pivoting and advancing adjacent skin, maximizing adjacent tissue movement.

This flap may distort surrounding cutaneous structures because of the marked tissue movement involved. The resulting scar is multidirectional and much of it will not fall into good alignment with the RSTLs. This is most important in areas with prominent skin lines such as the forehead.

PERINASAL LOCAL FLAPS Dorsal nasal (Miter)

### Description

The dorsal nasal flap (miter) is a sliding rotation advancement flap that recruits tissue from the glabella and nasal dorsum to cover partial-thickness defects of

Figure 13 Dorsal nasal flap.

the lower nose (21) (Fig. 13). This is an extension of the sliding glabellar flap described by Gillies (22), which was designed for upper nasal defects. The incisions for the miter flap extend into the glabella from the medial brow and descend medial to the opposite brow along the lateral side of the nose, arching toward the defect respecting the borders of the nasal subunits. Wide subcutaneous undermining over the dorsum of the nose proceeds to the base of the flap near the medial canthus and the flap is transposed into the defect. A V-Y closure of the glabella facilitates flap transposition.

The frontonasal flap is identical to the miter flap except that the vascular pedicle (angular vessel) is dissected and the flap is islanded. This flap is therefore considered axial and provides greater freedom of tissue movement (23).

Indications

The miter flap is designed to reconstruct defects at or near the nasal tip that are less than 2 cm (Fig. 14).

The quality of skin is nearly identical to that being replaced and the flap is technically easy to use. The incisions for the flap can be created along the nasal subunit borders.

The major disadvantage is that the entire skin of the nasal dorsum is put at risk because of the wide undermining required. The nasal tip is elevated due to the limited reach of the flap and in the postoperative period due to scar contracture.

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