Overview of Rhombic Flaps

Rhombic flaps are a type of skin graft used mainly to replace skin lost during the removal of skin cancer, particularly on the face and neck. However, their use is not limited to this purpose; they’re also used in other areas of the body and for other health conditions, including repair from burns, spina bifida, hand and breast reconstruction, and long-term conditions like pilonidal sinuses (a small hole or tunnel in your skin). Rhombic flaps work by using spare skin near to where skin was removed. This means the new skin is similar to the old skin, helping maintain a natural look.

The name “rhombic” comes from the shape of the flap. Just like the geometric shape (a four-sided shape where all sides are equal in length and the opposite angles are equal), these skin grafts are cut into an equal-sided shape. The idea of using a rhombic shaped flap was first presented by Russian surgeon Alexander Limberg in 1945. His design allowed for easy replacement of skin and is still used in surgery today.

Over time, other surgeons have made slight changes to Limberg’s original rhombic flap design, to further improve the process. For example, some variations include narrower flaps for easier closure, different angles for improved blood supply, and adaptation of the flap to fit circular skin defects. These improvements can help reduce the appearance of scars and lead to better results overall.

Designs using more than one rhombic flap have been developed to cover larger areas or those that are tough to work with. They’ve been used with success in a variety of situations, from pilonidal sinus treatment, to spina bifida repair. However, the original rhombic flap that Limberg developed remains a common procedure, especially for replacing skin on the face and neck after skin cancer removal.

Anatomy and Physiology of Rhombic Flaps

The rhombic flap procedure involves a flap of skin that relies on unnamed blood vessels located under the skin for its nourishment. This blood supply system under the skin is called the subdermal plexus, and it feeds the skin and its outermost layer. Given the rich network of these vessels, they can support the flap without needing a major artery in the flap itself.

It’s important during this procedure to keep the subdermal plexus healthy. This is done by leaving a thin portion of fatty tissue beneath the flap and avoiding any vigorous cutting at the base of the flap, which remains attached to the surrounding skin. Successful flap movement depends on careful placement according to the skin’s natural lines of tension. The rhombic flap should be aligned so that its shorter diagonal line is directly across from these natural lines of skin tension.

Especially on the head and neck, fitting incisions into existing skin folds or the boundaries between aesthetic sections can result in less noticeable scars. Also, taking into account nearby facial features with free edges can help to avoid distortion and reduce potential complications like unnatural pulling of the lower eyelid (ectropion), irregularities in the nasal nostril (nasal alar notching), and uneven eyebrows.

Why do People Need Rhombic Flaps

If someone has a small to medium-sized wound that cannot be closed right away, doctors can use a technique called local flaps or free skin grafts for repair. Picture it like a ladder climbing up your skin, hence, it’s often referred to as the ‘Reconstructive Ladder’. These methods are usually better than skin grafting because they use skin nearby the wound. This gives a better color, texture match, and less wound sites. These flaps work well for different body areas, especially facial wounds involving the cheek, eyelids, chin, temple, and nose.

The decision between different flap types – advancement, rotation, transposition, or interpolation flaps, is usually based on factors like the wound’s size and location, its position to nearby structures, aesthetic unit boundaries, and current wrinkles or scars. For instance, if a transposition flap (where skin is moved from a healthy area to the wound area) is seen as the best method, the choice to use a bilobed flap, a rhombic flap, or a variant is usually based on surgeon preference.

When a Person Should Avoid Rhombic Flaps

In skin cancer surgery, it’s usually not advised to use a process known as flap reconstruction if all the cancer hasn’t been completely removed. This could lead to waiting until tests can confirm that all of the cancer has been removed, or until a specific type of surgery, called Mohs micrographic surgery, is done.

There are also certain circumstances that could make flap reconstruction less recommended. These include if the patient smokes a lot, has not well-controlled diabetes, unchecked high blood pressure, is on blood thinners, has had radiation treatment before, has a large amount of sun-damaged skin in the area, or if they have a disease of the blood vessels in their arms or legs. All of these things could increase the chance of the reconstructed flap of skin dying and problems with the wound healing.

Even if a patient has any of these problems, it’s not always impossible to do the procedure. Sometimes changes can be made to the patient’s medical treatment ahead of time to make the procedure safer. This could involve quitting smoking, pausing certain blood-thinning medications, or better controlling a diabetic’s blood sugar levels. There are also certain locations on the body where it might be better to avoid this type of reconstruction because the skin is too tight or it’s near important structures that could be damaged due to tension from the procedure.

Equipment used for Rhombic Flaps

When your doctor is performing rhombic flap surgery, they will use the following tools and supplies:

Before the operation (Preparation):

* A marker is used to mark the surgical site on your skin.
* A tape measure or caliper to measure the size of the area being treated.
* Local anesthesia such as lidocaine mixed with adrenaline to numb the area. This is administered with a syringe and needles.
* Antiseptic solution like 1% chlorhexidine solution or povidone-iodine is used to clean the area and prevent infection.
* Surgical drapes are used to cover your body and keep the surgery area sterile.

During the operation (Intraoperative):

* Your surgeon uses a scalpel which is a razor-sharp knife, in this case with a #15 blade, to make incisions.
* Forceps, similar to tweezers, for gripping or holding things.
* Dissecting scissors, specifically tenotomy scissors, used for cutting tissues.
* Suture scissors for cutting the sutures.
* Skin hooks is a simple tool for lifting or holding skin away.
* An instrument called bipolar electrocautery that sends electric current is used to stop bleeding. Thrombin, a protein, is used to make blood clot.
* A saline solution (sterile salt water) is used to clean the wound.
* Sutures (medical stitches) are used to close the wound; the size and type of sutures will depend on the location of your surgery and your surgeon’s preference.

After the operation (Postoperative):

* Sterile tape strips are used to secure dressings or bandages.
* A skin adhesive (medical glue) is used to help seal the wound.
* Surgical dressing tape to secure bandages.
* Additional dressings might be applied, depending on the need.

Who is needed to perform Rhombic Flaps?

A specific type of skin graft called a rhombic flap transfer is usually done by specialized doctors such as plastic surgeons, maxillofacial surgeons (doctors who work on the face, mouth, and jaws), dermatologists (skin doctors), or otorhinolaryngologists (also known as ENTs, doctors who specialize in conditions related to the ear, nose, and throat). The team of people who work with the surgeon in the procedure depends on where it is being done.

If the procedure takes place in an outpatient clinic – a medical facility where patients are not admitted overnight – there might only be one assistant helping the main surgeon. But if the procedure takes place in an operating room, there will be more medical staff involved. This team could include a surgical technician (a healthcare professional who assists during operations), a circulating nurse ( a nurse who makes sure all needed equipment and supplies are available and used correctly), an anesthesia provider (a person who ensures you do not feel pain during surgery), and potentially a surgical first assistant (another doctor or nurse who helps the surgeon). These professionals all play a vital role in making sure the procedure goes smoothly and safely.

Preparing for Rhombic Flaps

Before a doctor performs a rhombic flap procedure (a type of skin surgery), they need your consent. This happens when your doctor explains everything you need to know about the surgery in detail. They will talk about what will happen during and after the procedure, how it will help you, possible risks, and other ways the issue might be addressed. After hearing all the information, you have a chance to think about it, before you agree and sign a consent form.

Your doctor will also typically take pictures before the procedure. These pictures become part of your file and will help your doctor to monitor progress and recovery.

Usually, this skin transfer surgery is performed using local anesthesia (you’re awake but can’t feel pain) when the skin defect is small to medium-sized, especially on the face. But, if the area to be treated is larger or more complex, or if you have other health conditions, you may need general anesthesia (you’re completely asleep) or sedation (you’re awake but relaxed and may not remember the procedure). In these cases, your doctor will need to evaluate you beforehand to make sure you’re safe to receive anesthesia. In other words, your doctor will check to see if your body can handle the medicines that make you sleep or keep you from feeling pain during the procedure.

How is Rhombic Flaps performed

When you have a area of damaged or problematic skin, one way to repair it is by using a flap of skin from a nearby area. This process is called a rhombic flap transfer. The doctors first step is to establish where to find this flap of skin. Factors to consider when selecting an area include assessing the areas with the loosest skin, proximity to features that might be affected by the procedure such as the eyelids, earlobes, lips, eyebrows, and nostrils, the direction of skin tension lines and lines where the skin can flex or stretch the most, and if there are any aesthetic features or wrinkles that could hide a scar.

After deciding where to find the flap of skin, the doctors then identify how the skin flap should be cut out, usually in a rhombic (diamond) shape. The shape and size of the diamond varies depending on the type of rhombic flap planned. For a Limberg flap, the diamond should have two opposing angles of 120 degrees, and two of 60 degrees. The short axis (the smallest diameter) of the defect is between the two 120-degree angles. The first cut of the flap continues along this short axis, with a length equal to the sides of the defect. The second cut is drawn at a 60-degree angle from the first cut.

Similarly, a Dufourmental flap is also a diamond shape, but the first incision is made at an angle between the defect’s shorter side and a line extending from the defect’s side. A Webster flap’s flap on the other hand make the 60-degree angle at the peak of the diamond, and divides the opposite angle into a shape called an M-plasty.

No matter what type of flap, the diamond is marked out with the short axis of the flap running parallel to the lines of maximum flexibility and perpendicular to skin tension lines to allow for the easiest transfer. Though each diamond allows for four possible flap designs, only two are relevant to ensure that the short axis of the flap runs parallel to the lines where the skin extends the most.

Once the flap has been drawn, the doctor applies local anesthetic to numb both the area that’s receiving the flap and a small area surrounding it. They then clean the area and prepare it for the procedure.

If needed, the doctor can convert the problematic skin area into a diamond shape by removing skin down to the subcutaneous layer. The flap is then cut with a surgical knife and raised from the underlying tissues with a pair of dissecting scissors, ensuring that it’s cut thick enough to stay viable. While doing this, they undermine (cut underneath) the skin for a few cm around the flap and the defect to allow for easy movement and relieves tension when the flap is moved to the new location. However, undermining more than a few cm may increase tension on the wound.

Once the new skin flap has been cut out, the doctors will use tools to control bleeding and minimize the chance of any blood clots forming. However, they do this carefully to avoid damaging the small blood vessels supplying the flap. The flap is then moved over the defect. The area that donated the skin flap is then stitched together, as this will be the most tense part of the closure. They then stitch the rest of the wound closed in layers, burying sutures deep into the dermis and using simple sutures on the surface of the skin.

After everything is stitched up, doctors check to make sure the new skin graft is supplied with blood and healing well. A gentle compressive dressing is applied and left in place for 1 to 2 days. Finally, any non-absorbable sutures are removed around a week after surgery to avoid any long-term suture marks. A special surgical glue may also be applied to areas with a lot of motion to prevent the wound from reopening and the scar from growing wider.

Possible Complications of Rhombic Flaps

Before having surgery that involves a rhombic flap reconstruction, which is a type of skin closure after removing an area of affected skin, patients need to understand that complications might occur. Just like with any surgical procedure, there’s a chance of pain, bleeding, bruising, infection, wound not healing properly, an unpleasing scar or damage to close body parts, and being unsatisfied with how it looks afterwards.

Though it’s not common, there can be specific problems with the procedure. For example, the area of skin used in the surgery (the flaps) might not take hold, due to issues like too much thinning of the flap or pulling it too tight during closure. Other things can also affect flap success, like if a patient smokes, has blood vessels that don’t work well or messes with the surgical area.

If blood collects under the flap, it can cause swelling and inflammation. This could block blood flow and congest the flap. In such a case, it’s important to promptly identify and drain the collected blood. If blood flow is blocked but there’s no blood accumulation, it’s usually because of a blockage in the veins. A cream that widens blood vessels might help, but sometimes it may be necessary to use medicinal leeches to improve blood flow. This might sound strange, but these leeches can really help by sucking extra blood out and making the blood thinner. However, if you have this treatment, you’ll also get certain antibiotics to prevent an infection you could get from the leeches.

If these treatments don’t save the flap, wound care with minimal removal of dead tissue is recommended. In some cases, the wound might heal better by itself. Or, if only the end of the flap didn’t take, doctors might just move the flap forward to fix the problem. This might be needed because the tip often has low blood pressure.

There can be other specific complications. For example, if the lymph flow gets disrupted, you could end up with a complication called “trapdoor” where the flap stays raised compared to the rest of your skin, creating a noticeable step. This typically happens with flaps that are based closer to the top because flaps lower down usually have better drainage. Another complication is the “pincushion” effect where the wound or an oversized flap looks rounded and puffy. If the orientation of the flap was planned poorly, it might lead to tightness or distortion of important facial features, such as eyelids, lips, or eyebrows. In certain areas like around the forehead, the procedure could affect muscle function.

What Else Should I Know About Rhombic Flaps?

Rhombic flaps are a very flexible type of skin graft. They can be used to improve and repair different types of skin damage. When the surgeon uses essential anatomical and mechanical knowledge, the result is not only visually pleasing but also functional.

Frequently asked questions

1. How will the rhombic flap procedure benefit me in terms of replacing lost skin and maintaining a natural look? 2. Are there any specific risks or complications associated with rhombic flap surgery that I should be aware of? 3. What factors will determine whether I am a suitable candidate for rhombic flap reconstruction? 4. Can you explain the process of the rhombic flap procedure in detail, including the tools and supplies that will be used? 5. What are the expected outcomes and recovery timeline for rhombic flap surgery, and what can I do to optimize the healing process?

Rhombic flaps can be used in surgical procedures to repair skin defects or wounds. The procedure involves creating a flap of skin that is nourished by blood vessels located under the skin. By carefully placing the flap according to the skin's natural lines of tension and considering nearby facial features, the goal is to minimize scarring and reduce potential complications.

Rhombic flaps may be needed in skin cancer surgery when flap reconstruction is not advised or recommended. This could be due to various reasons such as incomplete removal of cancer, waiting for confirmation of complete cancer removal, or the need for a specific type of surgery called Mohs micrographic surgery. Additionally, certain circumstances like smoking, uncontrolled diabetes, high blood pressure, blood thinners, previous radiation treatment, sun-damaged skin, or diseases of the blood vessels in the arms or legs may make flap reconstruction less recommended. However, in some cases, changes can be made to the patient's medical treatment to make the procedure safer.

You should not get Rhombic Flaps if all the cancer has not been completely removed or if you have certain medical conditions such as uncontrolled diabetes, unchecked high blood pressure, or if you are on blood thinners. Additionally, if you have a large amount of sun-damaged skin in the area or a disease of the blood vessels in your arms or legs, it may increase the chance of complications and problems with wound healing.

The text does not provide specific information about the recovery time for Rhombic Flaps.

To prepare for Rhombic Flaps, the patient should follow the instructions given by their doctor. This may include quitting smoking, pausing certain blood-thinning medications, or better controlling blood sugar levels for diabetics. It is also important to discuss any medical conditions or medications with the doctor to ensure the procedure can be done safely.

The complications of Rhombic Flaps include pain, bleeding, bruising, infection, wound not healing properly, unpleasing scar, damage to close body parts, and dissatisfaction with the appearance after surgery. Specific problems with the procedure can include the flaps not taking hold, blood collecting under the flap causing swelling and inflammation, blockage of blood flow, disruption of lymph flow leading to a noticeable step in the skin, the "pincushion" effect where the wound or flap looks rounded and puffy, and tightness or distortion of important facial features.

There are no specific symptoms mentioned in the text that would require Rhombic Flaps. The decision to use Rhombic Flaps or other flap types is based on factors such as the wound's size and location, its position to nearby structures, aesthetic unit boundaries, and current wrinkles or scars, as well as surgeon preference.

There is no specific information provided in the text regarding the safety of rhombic flaps in pregnancy. It is recommended to consult with a healthcare professional or specialist to determine the safety and potential risks of any surgical procedure during pregnancy.

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