Rhomboid Flap: Best Option for Skin Defects of
All Sizes? A Comprehensive Review of Literature
Ajaipal S. Kang, MD FACS and Kevin S Kang BS
1MD FACS, Department of Surgery, UPMC Hamot, United States
2BS, Geisel Dartmouth Medical School, United States
Submission:March 05, 2020; Published: April 03, 2020
*Corresponding author:Ajaipal S. Kang, MD FACS, Chairman, Department of Surgery, UPMC Hamot, Erie, Pennsylvania, USA
How to cite this article:Kang A S, Kang K S. Rhomboid Flap: Best Option for Skin Defects of All Sizes? A Comprehensive Review of Literature. Open
Access J Surg. 2020; 11(4): 555817. DOI:10.19080/OAJS.2020.11.555817.
Surgical resection remains the mainstay treatment for cutaneous malignancies resulting in skin defects. Traditionally, the concept of the reconstructive ladder suggests that primary closure and skin grafting should be considered first in reconstruction. However, these techniques may lead to increased likelihood of dehiscence, distortion of key structures, poor cosmetic outcomes and less-than-total graft acceptance. To overcome these limitations, various local skin flaps and tissue rearrangement techniques have been developed, including rhomboid flap. This flap is quickly and easily designed, does not require any special instruments and provides excellent contour, texture, thickness, color match, long-term good cosmesis and high patient satisfaction. The following article presents a comprehensive review of rhomboid flaps in the English literature. Nearly 100 years after it was first described by AA Limberg in 1928, the time has come to embrace this simple and elegant flap as the preferred method of reconstruction of cutaneous defects of any size and any part of the body.
Traditionally, the concept of the “reconstructive ladder “suggests that primary closure of a defect should be considered first in reconstruction. However, a considerable number of cases are not eligible for primary closure. In these circumstances, local flaps become the best option. Although defect size is a limiting factor, the texture, pliability and color match of a local flap favor its use. Of local flaps, a rhomboid flap is a popular flap that can be used to reconstruct defects in any part on the body .
The rhomboid flap design was first described by Professor Alexander Alexandrovich Limberg of Leningrad in 1928. The first description in English language was a chapter in Modern Trends in Plastic Surgery in 1963 . The design is a parallelogram with two angles of 120 degrees and two angles of 60 degrees. All sides are equal, and typically four flaps can be raised from one rhomboid (Figure 1). The technique of elevation is simple. The application of this flap has been described in almost all parts of the body with extreme safety and good cosmetic result . Flaps are full thickness cutaneous local flaps with random blood supply. Typically, they rely on dermal-subdermal plexus of blood supply . The final quality of the scar is related to the underlying tension. When a scar is parallel to Relaxed Skin Tension Lines (RSTL), tension is exerted along its axis, and new collagen
is oriented in this direction. Ultimately, this results in a narrower scar. Less tension at 3 weeks results in an improved scar .
Over the years, several modifications have been reported. The “diamond” flap modification was shown to be employed with no complications and no hypertrophic scars in 44 patients . Claude Dufourmental  proposed a modification which widens the pedicle width and increases flap safety . Quaba  proposed a modification to cover circular defects in 1987 .
Rhomboid flaps can be used anywhere, without any limitations that are due to defect etiology, age or other patient factors. This flap has been described in head and neck regions, and reconstruction, breast reconstruction and pilonidal sinus reconstruction .
While AA Limberg’s first publishing on the innovative rhomboid transposition flap was in 1928, his first treatise in English was a chapter in Modern Trends in Plastic Surgery, edited by Thomas Gibson in 1963 . Since that time, rhomboid flap has been widely used worldwide in clinical practice. The term flap originates from the Dutch word “flappe”, meaning something
suspended extensive and loose, attached only by one side,
referring to keeping its blood supply by the pedicle . Defect
closure by primary intention and grafts may offer satisfactory
outcomes for some locations. But rhomboid flap is easy to learn
and relatively simple to perform and can be used at any site on the
body surface . For a plastic surgeon, it embodies the artistic eye
meeting the science of cutaneous biomechanics .
The rhomboid flap is a flap of skin and subcutaneous tissue
that is rotated around a pivot point into an adjacent defect
. Traditionally, as many as four flaps can be raised from
one rhomboid, if required . The flap’s pedicle maintains subpapillary
and sub-dermal vascular plexuses to provide superior
results when compared to skin grafts of similar size and location
[10,12]. A reduction in tension on the flap decreases the likelihood
of necrosis of the donor tissue . The flap should be positioned
in the direction of minimal tension and maximum extensibility.
Placement of incisions parallel to Relaxed skin tension lines
(RSTL) allows the resulting scar to fall within the creases of the
skin along line of maximal extensibility [9,14-19].
A lesion should be excised as necessary without considering
the shape of the defect produced . Although reconstructive
ladder provides a basic framework, there are no established
guidelines for reconstruction of tissue defects. For any given
defect, a host of closure techniques are available; experience
and personal preference must be the deciding factors [20-23].
After excision, primary closure should be considered but if that
would lead to distortion and contour deformity of key structures,
a local flap should be considered .
Although a very common pattern of management of skin
tumors is fusiform elliptical excision and primary closure, there
are several problems with this technique. The major issue is
central depression leading to a flat contour, and unsightly dog ears
with peaking on both ends. If the dog ears are excised, it leads
to a longer scar [7,25,26]. In addition, to avoid dog-ear deformity,
length to width ratio of 3:1 is needed but leads to a much longer
linear scar and also leads to loss of reconstructive options .
Direct primary closure can result in scars that are 3-4 times
longer than the original length of the lesion. According to another
study, compared with original defect size, a mean of 130% of
healthy skin is wasted in an elliptical design [27,28]. These
problems are even more exacerbated in areas of insufficient skin
redundancy and more tension, such as near the joint [7,25,26].
Considering the tension of the skin, primary closure can cause an
increase in dehiscence and infection in defects. Also, the longer
conspicuous scars may have considerable impact on the quality of
life of the patient .
These are some of the problems that have led to the
development of local flaps as an alternative to fusiform excision
of small skin lesions [25,26,30]. Rhomboid flaps have shown
great effectiveness over primary closure in the literature [31,32].
One explanation for superiority of rhomboid flap closure versus
elliptical excision and direct closure is better distribution of
tension in the former. The tension at point of maximum tension
is less in rhomboid flap because it allows the surrounding skin to
participate in closure . Also, the line of donor closure is placed
along line of maximal extensibility leading to less tension on the
flap . Studies reveal that the pilonidal surgical procedures
that healed with tension-free primary closure had greater
disadvantages than wounds that healed using the rhomboid flap
Another explanation is avoidance of distortion of key
structures. Rhomboid flaps allow the tension force to be cancelled on the medium portion of the defect, minimizing the risk of
distortion of the anatomic architecture [10,22]. If the defect is
close to a structure or an organ, the flap design should consider
appearance and function of the organ [16,35,36]. Borges suggested
that in facial reconstructions, even for small lesions, cutaneous
flaps are preferable to primary closure and/or grafting, with the
purpose of avoiding distortions of adjacent structures and breaks
in scar lines [37,38].
The only landmark article for comparison of rhomboid
flap and primary closure was published as a meta-analysis
of randomized controlled trials. The authors used the defect
left behind after excision of sacrococcygeal pilonidal disease.
641 patients were included with rhomboid flaps demonstrating
statistically significant trend towards lower wound infection and
dehiscence. Primary wound closure resulted in significant wound
tension resulting in wound dehiscence and final conclusion was
that the rhomboid flap was superior to primary closure . These
considerations lead Chasmar  to propose that the rhomboid
flap, single or multiple, can be applied with extreme safety and
should be the “first choice for many full thickness defects” .
The local flaps are often preferred due to their similarity in
skin characteristics to the adjacent defect. The local flaps entail
transposition or rotation flap designs. Local rhomboid flap is an
example of such a transposition flap and has historically been
used in small defects . Flaps are developed to protect the
function of surgical area, reduce the tension and postoperative
complications and beautify the appearance .
A well-planned rhomboid flap with scars parallel to tension lines
maintains continuity of texture, color, thickness and vascularity
with the surrounding tissue, eliciting the most successful
functional and aesthetic outcome [15,17,18]. This single flap
design can be used to close defects almost anywhere on the body
. While certain closure techniques are invasive and involved,
rhomboid flaps are associated with a good prognosis and rapid
healing time . The technique of its elevation is simple. Its
minimally invasive, quick to perform, and suitable to be easily
performed in a single stage under local anesthesia . The
elevated flap requires sufficient subcutaneous fat, and dissection
must be carried past its base to prevent an elevated bump when
it is transposed .
Also, the resultant scar is geometric broken lines that is less
noticeable than longer linear primary closures [10,20,21]. The
scar’s acute “broken” angles, make the risk of scar complications,
such as trapping and hypertrophy, extremely low. This makes it an
attractive option for pediatric patients and/or those with a history
of pathological scarring [15,22].The position of the scars resulting
from the flap transposition is highly foreseeable and the secondary
defect scar can be hidden in a relaxed skin tension line (RSTL),
making it less apparent [18,21]. The advantages are closure of
defects that otherwise close under high tension or distort the
nearby structures leading to functional or aesthetic impairment.
The rhomboid flap has a low rate of complications, including
epitheliolysis with partial necrosis of the flap, hematoma and
bacterial infection [18,22]. Such advantages are a common reason
why these flaps are one of the first techniques used by surgeons
. Chasmar  reports on the versatility of Rhomboid flaps
and demonstrates how a single flap can be used to close defects
almost anywhere on the body .
It can be used in virtually any part of the body, and it is widely
used in facial and breast reconstruction, neurosurgery, hand
surgery, ophthalmology, and proctology . Rhomboid flaps can
be used anywhere, without any limitations that are due to defect
etiology, age or other patient factors [1,3,15]. Tumor resections is
the primary etiologic factor for this flap and this flap is commonly
used in hand, breast and pilonidal sinus reconstruction .
Chasmar  gives examples of its application in skin cancer,
lupus, cystic acne, spina bifida. The special application for eyelid,
floor of nose, alar rim and chin defects are highlighted [3,15].
Alvarez et al.  reports the face was the most commonly
affected, followed by the lumbosacral region, and by the dorsal,
inguinoscrotal regions, anterolateral arm, thorax, shoulder,
and supraclavicular region . Another study shows success
of local flaps in thigh, upper arm, forearm and back [22,25].
The Rhomboid flap has shown to be one of the quickest and
least complicated treatments for wound healing in pilonidal
sinus surgery [40,41]. Tissiani et al.  reports a series of this
flap used for reconstruction of face, trunk, lower limb and upper
. Its commonly agreed that skin defects of extremities are
difficult to cover. Therefore, these flaps are used for reconstruction
for extremity defects .
Becker stated that skin flaps have become the preferred
method of facial reconstruction [14,20]. There are numerous
reports in the literature reporting use of rhomboid flap for closure
of small to large defects in several anatomical areas, achieving
satisfactory results. Aydin et al reports a series indicating
that rhomboid flaps can be safely used to reconstruct small to
moderately sized skin defects . Quaba  in his rhomboid flap
series of 400 patients, calls this versatile flap the “workhorse for
facial reconstructions” .
The predictability, high safety degree, low complication rate
and tension free closure, makes rhomboid flap the first option
for great majority of reconstructions [15,22]. A single institution
experience in 70 patients treated for facial malignancies, revealed
local flaps gave the best results and were the first choice of
reconstruction of the face. The study notes that smooth contour and scar quality are very important for Plastic Surgery patients.
The proper execution does require considerable technical skills
and expertise [41,43-45].
Li et al.  published a series of 48 patients, 25 cases of
benign pigmented nevi, with defect diameters of 0.9cm to 11cm
which were treated with local flaps where 41 patients achieving
satisfactory postoperative results . Another series of 21
patients, with small benign skin lesions with defect diameters
of less than 1 cm were treated with local flaps with all patients
achieving satisfactory postoperative results . A series of 27
patients who underwent a medial canthal reconstruction with a
rhomboid flap showed healing with no major complications and
Alvarez et al states that the great number of facial
reconstructions in the temporal-zygomatic and malar regions
(44% of the facial defects) demonstrates the versatility of the
rhomboid flap in this area, and that it is the preferable technique
in these facial units. There were very few complications in this
study, which demonstrates the safety of the rhomboid flap for the
most varied reconstructions of defects .
A series of 35 flaps for reconstruction after cutaneous
malignancy resection, revealed excellent outcomes.44 A
series of 30 patients of rhomboid flaps healed without any
significant complications . Tissiani et al.  published a
series of 45 double transposition flap used for reconstruction
of face, trunk, lower limb and upper limbs revealed a 15%
complication rate. Small defects accounted for 70% of the cases
and major defects constituted 11% of cases with largest defect
being 107 cm . Another series of 175 reconstructions reported
a complication rate of 9.1%. The more common complications
included infection, hematoma, partial necrosis and partial
We believe every case should be approached in an individual
manner as no two patients, nor two defects are the same .
Reconstruction of each defect should be tailored to the unique
characteristics of the defect, patient expectations and surgeon
experience . Patients, particularly Plastic Surgery patients,
have shown a tendency to focus on both cosmetic and functional
outcomes after surgery, thus the choice of reconstructive
technique should focus on cure while minimizing scars [47,48].
Of note, the senior author has extensive successful experience
in using rhomboid flap design in reconstructing various sized
defects on all parts of the body. We agree with other authors in
literature that Rhomboid and local flap should be considered as
the first line of reconstructive strategy for various sized defects
and body locations for best patient satisfaction, reconstructive,
cosmetic outcomes and minimal complications .
We believe that with proper patient selection, rhomboid
flaps should be considered a first-line option for reconstruction
of almost any defect caused by any etiology. In summary, the
technical ease, aesthetic outcome, continuity of function, short
operation time, matching skin texture and color, safety, early
functionality, and fewer out-patient clinic visits are some of the
reasons to justify extensive application of rhomboid flaps.
Rao Jk, Shende KS (2016) Overview of Local Flaps of the Face for Reconstruction of Cutaneous Malignancies: Single Institutional Experience of Seventy Cases. Journal of Cutaneous and Aesthetic Surgery (4): 220-225.