Prof KW Ah-See, MD FRCS
FRCS(ORL-HNS),
Consultant ENT Head and
Neck Surgeon, NHS Director of
Undergraduate Medical Education,
Department of Otolaryngology
Head and Neck Surgery, Level5,
Ward 210, Aberdeen Royal
Inrmary, Foresterhill, Aberdeen
AB25 2ZN, UK.
T: +44 (0)122 455 2117
How I Do It
SECTION EDITOR
Random-pattern skin flaps:
part 2 - rhomboid and bilobed
flaps
BY CHRISTOPHER THOMPSON AND MILES BANNISTER
In the second of our series on local skin aps, the authors
describe more techniques and examples of various skin
aps that trainees should nd very interesting.
Rhomboid ap
This remains our ‘workhorse’ ap and is useful
over the cheeks, temples and upper neck. It
can also be used for smaller areas over the
nasal dorsum and lateral nasal subunits. The
ap can reconstruct a defect from four
directions, providing options for concealment.
The defect can remain circumferential in
pattern to preserve skin with the rhomboid
transposing in without aecting closure
(Figures 1-4) [1].
Figure 1. The ap transposes over a 45
o
angle, with A and B being
positioned to the A1 and B1 points. Uniform defect and ap
length measurements (x) permit adequate closure.
Figure 2. Excision beneath the reticular dermis ensures
preservation of the skin’s blood supply. Flap depth should
match that of the defect to ensure aesthetic closure.
Figure 3. Surrounding skin is undermined to close the secondary
defect and is sutured at the ap’s base.
Figure 4. Vertical mattress
sutures placed outside of
the ap to minimise trauma.
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AUTHORS
Christopher Thompson, BSc(Hons)
MBChB MRCSEd,
ST5 Specialist Registrar, Victoria Hospital,
Fife, UK.
Miles Bannister, BSc(Hons)
FRCS(ORL-HNS) MBChB,
Consultant Otolaryngologist-Head & Neck
Surgeon, Victoria Hospital, Fife, UK.
Bilobed ap
We use the Zitelli modication of the original Esser design, as the
narrower angles between lobes allow greater skin preservation [2].
This is especially useful in reconstruction on the external nose and
can be used across all its subunits as well as where large defects are
formed in thinner skin e.g. the supraclavicular fossa.
Tissue adjacent to the lesion on the y-axis must be excised to
allow transposition of the base of the rst lobe into the primary
defect. The shared base of the rst and second lobes should be kept
as wide as possible to maintain the blood supply to the ap. The skin
surrounding the primary defect and rst lobe defect may require
considerable undermining to achieve a tension-free wound closure,
though very little undermining is required to close the second lobe
defect due to its narrower width (Figures 1-7).
References
1. Quaba AA, Sommerlad BC. ‘A square peg in a round hole’: a modied rhomboid ap and
its clinical application. Br J Plast Surg 1987;40(2):163-70.
2. Zitelli JA. The bilobed ap for nasal reconstruction. Arch Dermatol 1989;125(7):957-9.
Figure 5. The dimensions of the rst lobe are approximately equal to
that of the defect, whereas the second lobe may need to be up to
twice as long, though half as wide. The rst and second lobes share
a long base to maintain a satisfactory blood supply and number of
perforator vessels.
Figure 6. Excision of an additional triangle of skin
adjacent to the defect is essential to allow unobstructed
transposition of the rst lobe of the ap.
Figure 7. The defect with the triangle of skin excised. When raised,
the lobes of the ap can appear inadequate for closing their
respective defects due to both contracture towards their base
and curling of their edges but redesign is usually unnecessary.
Figure 8. Deeper dissection towards the base will broaden it, preserving blood
supply and facilitating transposition.
Figure 9. Wider ap bases maintain decent blood
supplies to the lobes of the ap. Gentle handling with
skin hooks reduces trauma to the lobes, particularly the
small vessels.
Figure 10. Closure of the second, then
rst lobe defects facilitates closure of
the larger, primary defect.
Figure 11. Completed bilobed ap.
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