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Resection of cutaneous malignancies may result in substantial skin defects. Often, skin grafting is a first-line option for reconstruction of such defects but may be limited by poor cosmetic outcomes and incomplete graft acceptance. Accordingly, skin flaps, tissue rearrangement techniques, and more complex procedures may be needed. This case report presents the successful use of a combination of nasolabial flap and rhomboid flap for reconstruction of a 3 cm × 2 cm-sized left nasal sidewall and ala skin defect left after a Basal Cell Cancer Mohs resection. The flaps were quickly and easily fashioned, did not require any special instruments, and resulted in a good cosmetic outcome. There were no wound complications and the flaps healed completely with excellent contour, texture, thickness, color match, and complete patient satisfaction. This case is an example of technical aspects of successful planning, elevation and inset of a nasolabial flap and rhomboid flap.
The origin of “reconstructive ladder” is believed to be in ancient Egyptian medical texts that were written between 2600 and 2200 BCE. The principle implies that the simplest effective technique should be considered first in reconstruction. The first description of the advancement flap was reported in Rome between 25 BCE and 50 CE1.
Rhomboid flap was first described by Alexander Alexandrovich Limberg in 1928. The traditional design consists of a parallelogram with 2 angles of 120° and 2 angles of 60°. This transpositional flap design consists of skin and subcutaneous tissue rotated around a pivot point into an adjacent defect2,3. This full-thickness cutaneous local flaps typically relies on dermal–subdermal plexus blood supply2,4. The rhomboid flap is popular and can be used to reconstruct defects in most parts of the body. Over the years, several modifications have been reported2,5. Traditionally, rhomboid flaps have been safely used to reconstruct small to moderately sized skin defects6,7.
This report presents a case where a large 3 cm × 2 cm left nasal defect was successfully reconstructed with a combined nasolabial flap and rhomboid flap.
An 82-year-old female who presents with a several month history of a nonhealing lesion of the left nasal ala. She had noted that the lesion was progressively getting larger, ulcerated and more noticeable. She reported a past personal history for a Basal Cell skin cancer, but family history was negative for skin cancer. She noted moderate sun exposure and no sunblock use. Her past medical history was consistent with hypertension, kidney disease, and atrial fibrillation. She had undergone prior pacemaker placement. She was a nonsmoker and current medication included Rivaroxaban, Flecainide, and Diltiazem.
On physical examination, she was a Fitzpatrick class 2 skin type, elderly healthy woman with a height of 5 feet 3 inches, weight of 140 pounds, and body mass index of 24.8 kg/m3. The examination of the left nasal ala skin a 2 cm x 1.5 cm diameter diffuse minimally pigmented, scaly, suspicious lesion was noted. A punch biopsy was performed, and Basal Cell Cancer was diagnosed. Given the size, location, and clinical findings, I referred the patient for Mohs extirpative excision. Following that procedure, she returned with negative margins but with a large 3 cm x 2 cm defect of the nasal ala and left inferior nasal sidewall. Mucosa seemed largely intact, and I was unable to assess the viability of the cartilage.
My plan was reconstruction with two local flaps: Nasolabial flap from the superior portion of left nasal sidewall and rhomboid flap from left medial cheek and nasolabial fold. I also prepped the ear for potential donor cartilage graft. The other potential treatment was full-thickness skin graft.
Under general anesthesia, a bilobed flap was marked adjacent to and superior to the left nasal sidewall defect. The mucosa defect was closed with two 5-0 chromic interrupted sutures. The left lower lateral cartilage was explored and was found to be intact. The nasolabial flap was raised at the level of the underlying cartilage and once mobilized was rotated inferiorly and medially to obliterate the anterior portion of the original defect and was inset using a 4-0 Biosyn interrupted sutures and 4-0 nylon interrupted sutures. At this point the anterior portion of the surgical defect was closed and reconstructed. However, the posterior portion was still open and needed a rhomboid flap. Accordingly, a rhomboid flap was marked along the inferior aspect of the defect. Incision was made, the flap was raised at the level of the underlying fascia. The flap was rotated superiorly and medially to obliterate the defect. The flap was inset with 4-0 Biosyn interpret sutures and 4-0 nylon interrupted sutures. At the conclusion of the procedure, both flaps were viable, and the defect was obliterated. Antibiotic ointment and dry dressings were applied. Patient tolerated the procedure well and left the operating room in stable condition.
In the immediate postoperative period, the incisions were clean, dry, and intact. Both flaps remained viable. The healing was completely uneventful. Long-term follow-up also showed that the flaps healed completely without problems or limitations.
Plastic surgery is a unique specialty where numerous acceptable options may exist for reconstruction of a single defect6. Each reconstruction should be tailored to the unique characteristics of the defect, patient expectations, and surgeon's experience8. The reconstructive ladder framework suggests using first the simplest technique that proves effective1,8. At times, primary closure and skin grafts may lead to distortion, contour deformity, or unacceptable scarring. Such instances, even for small lesions, are more suitable for skin flaps6,9.
An elliptical excision with primary closure may leave a central depression, flat contour and “dog ear” peaks on both corners5,10. To avoid this deformity, an incision length-to-width ratio of 3:1 is required, creating a longer linear scar10,11. Unfortunately, larger portions of healthy skin around the defect are sacrificed, and aesthetic outcomes may be compromised10,11. Well-designed local flaps avoid these limitations6.
Nasolabial and Rhomboid flap designs are chosen such that line of donor closure is placed along the line of maximal extensibility closure resulting in better distribution of tension. The participation of surrounding skin also reduces tension5,6. Less tension means improved chances of healing and less risk of distortion of adjacent anatomic architecture6. The “broken” geometric final scar appearance also makes it less noticeable6,12. A recent meta-analysis comparison with primary closure, for sacrococcygeal pilonidal surgeries, showed rhomboid flaps resulted in a lower relative risk of dehiscence and wound infection13.
The presented case further highlights a successful reconstruction of a large 3 cm × 2 cm-sized cutaneous left nasal sidewall and ala defect. Primary closure was simply not an option given the local size of defect and potential distortion of key structures. Skin graft would have left a permanent prominent, hypopigmented, depressed area at the recipient site.
Our results are consistent with other reports in the literature that note the successful applicability of nasolabial and rhomboid flaps in almost all parts of the body. We believe for high safety, high patient satisfaction, and best cosmetic outcomes, rhomboid and other local flaps should be considered as a first-line reconstructive strategy for covering defects of various sizes and locations.
The nasolabial and rhomboid flap design is simple, flap elevation is quick, and no special instrumentation is required, making these techniques suitable even in a resource-limited environment.
This case details the operative technical aspects of evaluation of defect, flap design, flap markings, flap elevation, flap rotation, flap inset, and post-operative management to aid readers in utilizing this technique. The final flap healed with excellent contour, texture, thickness, and color match.
No special instrumentation needed.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Kang A.S., Kang K.S. Expanding the scope of rhomboid flap: large cutaneous defect reconstruction: Case report. Ann Med Surg (Lond)., 62 (2021), pp. 369-372.
- Aydin O.E., Tan O., Algan S., Kuduban S.D., Cinal H., Barin E.Z. Versatile use of rhomboid flaps for closure of skin defects. Eurasian J. Med. 2011; 43:1–8.
- Chasmar L.R. The versatile rhomboid (Limberg) flap. Can. J. Plast. Surg. 2007; 15:67–71.
- Alvarez G.S., Laitano F.F., Siqueira E.J., Oliveira M.P., Martins P.D.E. Use of the rhomboid flap for the repair of cutaneous defects. Rev. Bras. Cir. Plást. 2012; 27:102–107.
- Quaba A.A., Sommerlad B.C. A square peg into a round hole”: a modified rhomboid flap and its clinical application. Br. J. Plast. Surg. 1987; 40:163–170.
- Kang A.S., Kang K.S. Rhomboid flap for large cutaneous trunk defect. Plast. Reconstr. Surg. Glob. Open. 2020;8(6)
- 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, 11 (4) (2020), p. 555817
- Janis J.E., Kwon R.K., Attinger C.E. The new reconstructive ladder: modifications to the traditional model. Plast. Reconstr. Surg. 2011; 127:205S–212S.
- Borges A.F. The rhombic flap. Plast. Reconstr. Surg. 1981; 67:458–466.
- Kang A.S., Kang K.S. A systematic review of cutaneous dog ear deformity: a management algorithm. Plast. Reconstr. Surg. Glob. Open. 2020;8(9)
- Tilleman T.R., Neumann MH M.H., Smeets N.W., Tilleman M.M. Waste of skin in elliptical excision biopsy of non-melanomatous skin cancer. Scand. J. Plast. Reconstr. Surg. Hand Surg. 2006; 40:352–356.
- Kang A.S., Kang K.S. Rhomboid flap: Indications, applications, techniques, and results. A comprehensive review, Ann Med Surg (Lond)., Volume 68,2021,102544
- Horwood J., Hanratty D., Chandran P., Billings P. Primary closure, or rhomboid excision and Limberg flap for the management of primary sacrococcygeal pilonidal disease? A meta-analysis of randomized controlled trials. Colorectal Dis. 2012; 14:143–151.
Table of Contents
- Close Mucosal Defect
- Identify and Examine Edges of Cartilage
- Surgical Approach for Flaps
- Inject Local Anesthetic
- Raise Flaps
- Inject Local Anesthetic
- Raise Flap
This is a case presentation of an 82-year-old female who presented to my office with several months history of a non-healing lesion of the left nasal Ala. She had noticed a progressive increase in size, and the lesion had become more pigmented and raised. There was no discharge associated with it. She does have a past medical history consistent with basal cell cancer, but no family history of skin cancer. She has had moderate exposure to the sun in the past and does not use sunblock or sunscreen regularly. Her past medical history is consistent with hypertension, kidney disease, and atrial fibrillation. Her past surgical history is consistent with prior pacemaker placement. She is not a smoker, and current medications include Xarelto, Flecainide, and Diltiazem. On physical examination, this is an elderly female, who is not in any acute distress. Her weight is 140 pounds. She is five foot, three inches tall, and her body mass index is 24.8 kilograms per meter squared. Her skin exam shows that she has a Fitzpatrick type two skin, it's warm and dry, specifically, examination of the left nasal ala skin revealed approximately 2-cm by 1.5-cm diameter, diffusely pigmented, scaly lesion, which looks very suspicious. It was nontender to palpation and with no evidence of any infection. Given the clinical findings, I went ahead and performed a punch biopsy. The results of the punch biopsy revealed a basal cell cancer. Given the clinical findings, location, and the size of this issue, the decision was made to refer her to Mohs extraoperative surgery for excision. She underwent two stages of Mohs extraoperative surgery to achieve complete tumor-free margins. The size of the final defect was 3 cm by 2 cm along the left nasal ala and the inferior portion of the left nasal sidewall. The external valve was collapsed, but the mucosa was intact. I recommended a combination of nasolabial flap from the superior portion of the left nasal sidewall and the glabella and a rhomboid flap from the left medial cheek and the nasolabial fold. I also prepped the left ear for cartilage graft donor site.
So there is a defect here. We'll try to close that up. Let me see a 5-0 chromic, please. And this defect is about 3 cm by about 2 cm. It's full-thickness, skin is gone, cartilage is gone, and there's a little defect within the mucosa as well. So we'll start by approximating the mucosa. I'm just going to use chromic 5-0 and two absorbable sutures. There's a portion of the cartilage that you still see there. Do you see that? Do you want a little film? Yes, please. So two simple, interrupted sutures. And I'm going to put this suture so that the tails are actually not on the mucosa side, but on the external side.
Next, what I'm going to try to do is see where the edges of the cartilage are. Just gentle dissection to identify where was the cartilage cut? And we are talking about the lower lateral cartilage here. Still trying to dissect the cartilage to see where the cut edge is. Just going to get some hemostasis. I think it's right underneath where my - do you want me to take it out? No, let's try here. So actually, the cartilage seems to be intact. So this is where we are seeing the lower lateral cartilage, and it does seem to be intact. So, I don't think we would need to use the cartilage graft in this location.
So, what it comes down to is a cutaneous defect, and the size of this defect is fairly large, considering the location. So we'll split it up into two, and I'm going to use a bilobed flap for the medial portion and a rhomboid flap for the lateral portion. I'll just take some lidocaine with epinephrine.
So just using some local anesthesia here, and the bilobed flap is going to be based superiorly. And it's going to be a transposition flap, and it's going to be based on the blood supply from here. I'll take a 15 blade.
So raising the bilobed flap. I'll take a double hook for that.
Trying to get - getting some hemostasis here and raising the flap. This patient is on Xarelto at home, has stopped for a few days now. That might account for some of the bleeding that we are seeing. Okay I'm just trying to get hemostasis. Remind me what this flap is? Bilobed. Bilobed? Bilobed meaning that it has two lobes. I'll take another 4 by 4, please. So some of that is just from the skin too. I need to fix that up. Yeah, well it's right where we put this thing, it's almost like… [Indistinct]. Do you want me to take it out? Sure. Yeah, I feel like it's making… I get good control and then I move it, and… What's the cautery on Amber? It's got to be… It's on 15/15. We can go to maybe 30/30. I think there are some… And I'll take a double hook again. And a lot of times the dissection which I do is just with a cautery. Just be careful here… [Mumbling]. I'll take another 4 by 4, please. I have it right here. So still trying to raise this flap up. Into the nasolabial branches. So the plan is to kind of rotate this flap down to see if that can help close the defect. At least a portion of it. And do you have a Biosyn, please? How about a 4-0 Biosyn? I'm going to mobilize it a little bit more.
So this is the bilobed flap. This is the top part. This is the bottom part. So we're going to try to sort of like move it this way. And this is a 4-0 Biosyn. So this would be the primary defect, secondary defect, and tertiary defect. So in this case, the tertiary defect is going to be closed with advancement. So this tissue, which used to be here, is going to come and reconstruct this, and this issue, which used to be here, is going to take care of part of this. And then we'll use the rhomboid flap for this part here. So are you going to have to use cartilage to support the...? No because the cartilage was intact, and when I actually mobilized it, it was okay. Okay. Knife, please. And so there is some redundancy of the tissue that you need here. So I'm just going to trim some of the flap that you do not need anymore. And I'm going to thin this up too because you don't want it to be too thick. And then take the nylon please, the 4-0. So in a bilobed flap, what you do is take these two flaps, and kind of rotate them both down, and you use it in instances when we are talking of like a really big defect there, like this was. Can I get another 4-0 nylon, please? C13. I'll take another one. So this is the bilobed flap, but as we can see, that's not going to be enough. And then the other one's rhom- Rhomboid flap is what I'm gonna have to do. So what does that mean, like why? It's just shaped like a rhombus. Okay. Yeah, that's what I figured, but I just… I need to go back to geometry. I hear that. Yeah. But the advantage of using this over a skin graft type of that, that would have been like a postage stamp forever. And it would be like a depressed, sort of an area. If that - if it healed well too, right? Could it have healed well technically with a flap? Or not a flap, a? t may or may not have, or… I don't know. Depending on her skin condition… So how do you take it from here without it distorting like the lip? You'll see. I'll take the lidocaine again, please. Or, actually, let's put one more right here.
So this flap, I'm going to raise it as a rhomboid flap, and it's going to rotate like this, into the defect.
So this is going to rotate like that.
So in this flap, this is going to rotate superiorly and medially to kind of obliterate that, and then this will advance together to close. So I'll take the Biosyn again. We're closing the secondary defect of this rhombus flap. And this is going to come in this way to close it. And I probably will just pin this flap a little bit also, But conservatively. I'll take the Biosyn again. With this stitch I'm actually going to go down and try to get some deeper tissue as well. And the purpose is to kind of like help create a little bit of a depression here. And I'll take the nylon again, please. What kind of dressing do you want? Just, I think antibiotic cream and maybe a gauze and some paper tape. She's allergic. Oh, yeah. She's allergic. To? Triple A. And tape, actually. Bacitracin cream? How about Bactroban - mupirocin? Yeah, we should have that one. So this is approximating one flap to the other to close this defect completely. So sometimes you need more than one local flap to kind of like completely obliterate the defect. I'll take the knife, please, Carter. Again, a little bit of a redundancy there, which I'm going to conservatively remove. A little bit of a dog ear here. I'm going to excise as well. No tension at all on any of these lines that I'm closing. Do you think you're going to need the nasal trumpet to start working? I don't think so. I think it looks open to me. I'll take a wet sponge, please. So there were two different flaps. There was a bilobed flap, which was taken from here, and moved down to close this part, and rhomboid flap taken from down here to close this part of it. She has that thing in her eye. Yeah, we need BSS. Hey Jess, could we get some BSS, please? Yes. Can you give me another 4-0 Monosof? Some bruising around the periorbital area here, that's to be expected. You could use ice on this area? Yeah. So it doesn't swell up too much. I'll take that ointment, please. But first actually, if you can give me BSS. BSS.
For postoperative course, at 1-week post-op visit, the incisions were clean, dry, and intact, both flaps were viable, and there was no evidence of any seroma, infection, or cellulitis. The sutures were intact, and the contour of the nose was good. All sutures were removed at this visit. At 4-weeks post-op, the incisions were all healed, both flaps were viable, there was no evidence of dehiscence, infection, or cellulitis, the contour of the nose was very good, and the patient was very pleased with the outcome.