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The rhomboid flap: A simple technique to cover the skin defect produced by excision of a mucous cyst of a digit

Authors:
Danish Imran at care skin UK ltd
Danish Imran
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C Koukkou
C Koukkou
C Koukkou
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Christopher Bainbridge at Derby Hospitals NHS Foundation Trust
Christopher Bainbridge
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Abstract and Figures

Rhomboid flaps were used rather than rotation flaps for skin cover after excision of mucous cysts of the finger in six patients. The rhomboid flap is a safe, reliable technique which is more easily taught and applied than the rotation flap.
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860 THE JOURNAL OF BONE AND JOINT SURGERY
Hand
The rhomboid flap: a simple technique to cover
the skin defect produced by excision of a
mucous cyst of a digit
D. Imran, C. Koukkou, L. C. Bainbridge
From Derbyshire Royal Infirmary, England
D. Imran, FRCS, Fellow in Hand Surgery
C. Koukkou, Research Fellow in Hand Surgery
L. C. Bainbridge, FRCS, Consultant Plastic and Hand Surgeon
Pulvertaft Hand Centre, Derbyshire Royal Infirmary, London Road, Derby
DE1 2QY, UK.
Correspondence should be sent to Mr D. Imran at the Education Centre,
University Hospital of North Durham, North Road, Durham DH1 5TW, UK.
©2003 British Editorial Society of Bone and Joint Surgery
doi:10.1302/0301-620X.85B6.14061 $2.00
homboid flaps were used rather than rotation flaps
for skin cover after excision of mucous cysts of the
finger in six patients. The rhomboid flap is a safe,
reliable technique which is more easily taught and
applied than the rotation flap.
J Bone Joint Surg [Br] 2003;85-B:860-2.
Received 3 December 2002; Accepted 25 April 2003
When a skin lesion is small it can be excised in an ellipse
allowing direct closure. This may not be possible with a
larger lesion, when a skin graft or a local flap may be neces-
sary to cover the defect. This is often difficult for mucous
cysts of a digit since the flap can neither be raised from the
volar skin nor obtained distal to the cyst because of the pos-
sibility of injury to the nail or its germinal matrix.
1
The clas-
sical teaching has been to use a rotation flap to cover the
defect created under these circumstances, but designing
such a flap can be difficult for someone with limited experi-
ence of plastic surgery. The size and depth of the flap may
cause concern, as may deciding on the maximum tension
under which the partly devascularised flap can be sutured.
The rhomboid flap, the technique of which is easy to
learn and apply, gives a better cosmetic result. There are two
varieties, the Limberg and the Dufourmentel,
2
which are
different in design and application. We used the Limberg
flap
3
which is the easier and is more commonly used.
Patients and Methods
The flap was used on the dorsum of the finger in nine digits
in nine patients by the senior author (DI). There were six
R
men and three women with a mean age of 61 years (47 to
72). Six had mucous cysts, two had a giant-cell tumour of
tendon sheath and one had a histiocytoma. Three patients
had mild to moderate deformity of a nail because of com-
pression of the germinal matrix by a mucous cyst.
A rhombus is an equilateral parallelogram with opposite
acute and obtuse angles. The former are planned 60˚ and the
latter 120˚. Therefore, in Figure 1, points S-T-U-V represent
the rhomboid defect. The axis of the rhomboid is planned
after consideration of two factors. If the cyst is oblong, the
short diagonal of the rhomboid should fall along its width. If
the cyst is round, the short diagonal can be chosen to lie
along the maximum extensibility of the skin.
4
After consid-
ering the shape and the axis of the defect to be created, the
edges of the lesion are marked and a rhomboid is delineated
around it (Fig. 2).
In planning the flap, the short diagonal of the rhomboid
is extended by its own length to point W (Fig. 1). This can
be done from either points S or U, but preferably towards
lax skin and, if possible, away from the nail where the skin
is less extensible. Another line, WX, is drawn parallel and
equal to UV or ST taking into account the laxity of the skin,
to complete the planning of the flap.
T
S
V
U
W
X
Fig. 1
Diagram showing the design of the rhomboid.
S-T-U-V represents a 60˚ rhomboid defect. S-U
is extended by its own length to W. W-X is then
drawn parallel and equal to U-V.
THE RHOMBOID FLAP: A SIMPLE TECHNIQUE TO COVER THE SKIN DEFECT PRODUCED BY EXCISION OF A MUCOUS CYST OF A DIGIT 861
VOL. 85-B, No. 6, AUGUST 2003
Usually, a ring block and a finger tourniquet are suffi-
cient. Excision of the lesion is performed (Fig. 3) and the
rhomboid-shaped flap of the skin and subcutaneous tissue is
raised keeping the extensor tendon intact. Raising the flap
before excising the stalk of the cyst may allow more expo-
sure for a radical excision if required. The finger tourniquet
can be released at this stage to check the perfusion of the
flap and to perform haemostasis. The flap is then rotated
through 60˚ and transposed into the defect closing the donor
area directly (Fig. 4).
Results
All the patients were reviewed after six months. The mean
finger tourniquet time required to perform the procedure
was 15 minutes. All the flaps healed well. There was no
T
W`
U
X
W
V
U`
S
Fig. 2
Photograph showing marking of the mucous
cyst and flap in the left thumb.
Fig. 3
Photograph showing excision of the mucous cyst.
Fig. 4a Fig. 4b
Photograph showing insetting of the flap and closure of the donor defect (a). The flap designed in Figure 1
has been raised and transposed into the defect (b).
862 D. IMRAN, C. KOUKKOU, L. C. BAINBRIDGE
THE JOURNAL OF BONE AND JOINT SURGERY
recurrence of a mucous cyst and the deformity of the nail
improved in two patients. The scar was scarcely visible
(Fig. 5) and movement of the distal interphalangeal joint
was unimpaired.
Discussion
Mucous cysts of the fingers are dorsal ganglions and are
commonly found in association with osteoarthritis of the
distal interphalangeal joints.
5
The cysts are subcutaneous
but the overlying skin is usually thin and occasionally may
be ulcerated. In an undamaged specimen the attenuated skin
of the cyst comprises thinned dermis and epidermis with
numerous satellite ducts or lakes filled with mucinous mate-
rial which must be removed to avoid recurrence.
6
Mucous cysts in the fingers are usually small but
unsightly and may cause considerable discomfort.
7
Treat-
ment has ranged from total excision of the joint to multiple
needling and expression of the contents.
8
It was not until the
1970s that communication of the cyst into the joint space
was demonstrated,
9
establishing the need to trace the
pedicle into the joint space combined with osteophytectomy
with appropriate skin cover
10,11
in order to prevent recur-
rence.
12
Designing local flaps when the secondary defect is to be
closed directly in an unforgiving area like a finger can tax
even the skill of an experienced plastic surgeon.
13
For those
who are less familiar with planning and raising flaps, this
can be a real difficulty. The advantage of the Limberg flap is
its geometrically accurate design. A single measurement can
be used to eliminate the defect and construct the flap. No
attempt is made to engineer a rhomboid defect and the flap
is made smaller than the defect.
14
All the above parameters led us to try using the rhomboid
flap for the treatment of nine lesions on the dorsum of distal
phalanges, of which six were mucous cysts. The results of
this prospective study after a mean follow-up of six months
support the safety, reliability and efficiency of the flap.
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
References
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5. Loder RT, Robinson JH, Jackson WT, Allen DJ. A surface ultrastruc-
ture study of ganglia and digital mucous cysts. J Hand Surg [Am]
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8. Epstein E. A simple technique for managing digital mucous cysts. Arch
Dermatol 1979;115:1315-6.
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ment of the so-called mucous cyst of the finger. J Bone Joint Surg [Am]
1972;54-A:1455-8.
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flap. J Hand Surg [Br] 1990;15:113-4.
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Fig. 5
Photograph showing the appearance six
months after operation.
... Many authors believe that the risk of skin necrosis is reduced by skin flaps such as a rhomboid flap, digital artery perforator flap and rotation flap, which allow excision of mucous deposits invading the thin skin overlying the cyst. Therefore, many authors advocate skin excision and the use of local flaps to cover the resulting defect [5][6][7][8][9]. Although the function of skin flaps is often more satisfactory than that of skin grafts, most of the designs and procedures for skin flaps are relatively complex. ...
... Johnson SM [12] reported a local advancement skin flap and did not observe skin necrosis during the follow-up. Imran D [7] reported a rhomboid flap and observed no skin necrosis. Although these flaps can sufficiently repair skin defects after DMC removal and lead to excellent results, the procedure is challenging in terms of significant donor site morbidity and requires intensive postoperative monitoring, microsurgical skill, appropriate equipment and many operating room resources [13]. ...
The Bipedicle Advancement Flap on Skin Coverage After Mucous Cyst Excision: A Retrospective Study of 18 Cases.
Preprint
Full-text available
  • Jan 2020
Background Many patients have skin defects after digital mucous cyst (DMC) excision, and this study aimed to assess the clinical outcomes of using a bipedicle advancement flap to cover such defects. Methods From January 2016 to January 2018, DMCs on 18 fingers of 15 patients (4 males and 11 females, with a mean age of 64 years) were treated with cyst and osteophyte excision and a bipedicle advancement flap to cover the resultant defect in this retrospective study. Postoperative flap survival, healing and infection were evaluated. The pre- and postoperative ranges of motion (ROMs) of the distal interphalangeal (DIP) or thumb interphalangeal (IP) joints were recorded. The patients were followed up for 12-36 months (mean, 20 months). Results All the flaps survived, the incisions healed well without infection, and no cyst recurrence occurred. The postoperative ROM of the affected fingers was restored to the preoperative ROM by two months after surgery. No difference was found between the preoperative and postoperative ROMs. Conclusions The bipedicle advancement flap is a simple and effective technique for covering skin defects following DMC excision.
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... Así, se ha utilizado en los recubrimientos de piel tras mastectomías parciales 24 , quistes pi-lonidales 25 y/o úlceras sacras por decúbito 26 . A nivel de la mano, especialmente después de la resección de quistes de los dedos, se encuentra el trabajo de Imran et al. 27 quienes lo emplearon en 9 pacientes, seis de ellos con quiste mucoide, dos con tumor de células gigantes de vaina tendinosa y uno con histiocitoma. Sus resultados fueron homogéneamente buenos y sin tener ningún caso de recidiva. ...
... En nuestra serie de 30 casos, se siguió el mismo procedimiento que el descrito por Imran et al. 27 , obteniendo también unos excelentes resultados. Sin embargo, hemos de comentar algunas pequeñas dificultades, todas ellas derivadas de la tensión del colgajo, lo que obligó en 4 casos a retirar algunos puntos de sutura para garantizar la viabilidad del mismo. ...
El colgajo romboidal de Limberg en el tratamiento del quiste mucoide
Article
Full-text available
  • Nov 2008
Objetivo: Valorar los resultados obtenidos mediante el colgajo romboidal de Limberg en pacientes con quiste mucoide. Material y Método: Se analizan un total de 30 pacientes (18 mujeres, 12 hombres) con quiste mucoide situado en el dorso de la articulación interfalángica distal. En todos los casos el tratamiento fue el mismo, mediante la resección en bloque del quiste y piel suprayacente, y cubrimiento del defecto mediante colgajo romboidal de Limberg. El seguimiento mínimo de estos pacientes fue de 13 meses, con un mínimo de 6 meses y un máximo de 32 meses. Resultados: Todos los pacientes estuvieron satisfechos con el resultado cosmético conseguido. No hubo que lamentar ningún caso de recidiva, infección ni de necrosis cutánea. Conclusiones: Dentro de las opciones quirúrgicas existentes para el tratamiento del quiste mucoide, creemos que el colgajo romboidal de Limberg, por su sencillez, resolución y aspecto estético, constituye una alternativa válida en este tipo de patologías.
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... Several reconstructive procedures for defects of the dorsal fingertip have been reported [1][2][3][4][5][6][7][8][9][10][11]. We previously reconstructed minor nail fold lesion defects due to digital mucous cyst (DMC) excision using a rotation flap [3,10,11]. ...
... Additionally, a long and visible scar remains. Imran et al. reported a rhomboid flap which is easy to harvest, to reconstruct skin defects after DMC resection [4]. However, the flap size is limited because the donor site is the groove of the DIP joint. ...
The reconstruction for proximal nail fold mucous cyst using reverse and island flap
Article
Full-text available
  • May 2017
We performed nail fold reconstruction after digital mucous cyst (DMC) excision using an island-type lateral finger flap on seven patients (four males and three females). Our procedure is a simple and useful method to repair minor nail fold lesion defects after DMC excision.
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... 7 Besides, rhomboid flaps have the benefit of simple planning but are limited by size as they are elevated from the skin fold at the DIPJ. 8 Furthermore, the digital artery perforator flap and reverse island flap from the lateral finger showed satisfactory results; however, the dissection technique takes time and microsurgery training. 9 Distal-based lateral finger flaps ranging from digital artery perforator flaps may offer an easier flap with no vessel dissection needed. ...
A Modified Type III Keystone Flap for Digital Mucous Cyst of the Eponychium
Article
Full-text available
  • Dec 2022
Digital mucous cysts (DMCs), also known as myxoid cysts, periungual ganglion cysts, and myxomatous cutaneous cysts, commonly occurr at the distal interphalangeal joint (DIPJ) of the fingers and toes. Due to the dense and inflexible skin at the dorsal fingertip, wound dehiscence and necrosis may sometimes be caused by tension sutures. The keystone flap (KF), designed as a curvilinear-shaped trapezoidal keystone with two V-Y advancements at the exterior peripheral corners, has been gaining popularity as a local flap that can close defects with a lower tension. In the reported case, while facing the DMC at the eponychial fold, we applied a modified type III KF with minimal elevation of the eponychium and internal rotation of the opposite flaps to cover the triangular defect. Postoperative outcomes showed that the flap was viable with sufficient perfusion and no wound dehiscence or infection. During follow-up, the grooving deformity of the nail was corrected, and no tumor recurrence was noted. Moreover, there were no restrictive scars or limited range of motion on the DIPJ.
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... Imran The recurrence of DMC is another challenge. It is widely accepted that recurrence after mucous cyst excision may result from incomplete removal of either the pedicle or the osteophyte 18,20 . Therefore, complete removal of the pedicle and osteophyte are two important steps in treating DMC. ...
Bipedicle Advancement Flap for Skin Coverage after Digital Mucous Cyst Excision: A Retrospective Study of 18 Cases
Article
Full-text available
  • Dec 2020
Objectives To assess the clinical outcomes of using a bipedicle advancement flap to cover the skin defects after digital mucous cyst (DMC) excision. Methods Data for 15 patients (18 fingers) with DMC, admitted to the Department of Orthopaedics and Surgery of the Affiliated Zhongshan Hospital of Dalian University from January 2016 to January 2018, were analyzed retrospectively. This study included 4 men and 11 women, with a mean age of 64 ± 7.8 years (range, 47–77 years). A total of 5 cases involved the thumb, 4 involved the index finger, 5 involved ithe middle finger, and 4 involved the ring finger. Among a total of 18 digital mucous cysts, 7 cases were in the left hand and 11 were in the right hand. Approximately 77.8% of cases had osteophytes. The cysts ranged in size from 0.5–1.0 cm to 0.7–1.2 cm. All patients underwent cyst and osteophyte excision and a bipedicle advancement flap to cover the resultant defect. The same surgical procedure was applied to all patients. Postoperative flap survival, healing, and infection were evaluated. The preoperative and postoperative ranges of motion (ROM) of the distal interphalangeal (DIP) and thumb interphalangeal joints (TIPJ) were recorded. Postoperative patient satisfaction was assessed by the visual analog scale (VAS, 0–10) during follow‐up visits. The Shapiro–Wilk test was used to determine whether the data for the difference between the preoperative and postoperative ROM of the DIP/TIPJ were normally distributed or not. The homogeneity of variance was expressed as mean ± standard deviation. A paired t‐test was used to compare the preoperative and postoperative ROM of the DIP/TIPJ. Results The patients were followed up for 20 ± 6.0 months (range, 12–36 months). All the flaps survived after surgery, and the incisions healed well. The sutures were removed 2 weeks postoperatively. No infections occurred and there was no cyst recurrence at follow up. After systemic physical therapy and functional exercises, the ROM of all the fingers was restored to the preoperative ROM by 1 month after surgery. The scores for patient satisfaction with surgery by means of the VAS were 8.5 ± 1.0 points, 2.8 ± 1.4 points, 2.0 ± 1.6 points, 1.5 ± 1.2 points, and 1.1 ± 1.3 points preoperatively, and 1, 3, 6, and 12 months postoperatively, respectively. The data for the difference between preoperative and postoperative VAS scores were normally distributed. There were significant differences between the preoperative and postoperative VAS scores. The preoperative DIP/TIPJ ROM was 71.7° ± 14.0°, and the postoperative ROM at 1, 3, 6, and 12 months were 69.3° ± 15.3°, 70.4° ± 12.7°, 71.5° ± 15.6°, and 71.8° ± 15.6°, respectively. The data for the difference between preoperative and postoperative ROM of the DIP/TIPJ were normally distributed. No difference was found between the preoperative and postoperative ROM. Conclusion The bipedicle advancement flap provides a simple and effective technique for covering skin defects following DMC excision.
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Treatment of Mucous Cyst of the Distal Interphalangeal Joint With Osteophyte Excision and Joint Debridement
Article
Full-text available
  • Jan 2022
Background Mucous cyst of the distal interphalangeal joint (DMC) or interphalangeal connection of the thumb is common in middle-aged and elderly people, and it often occurs in the fingers of people with osteoarthritis (OA). Although there are many conservative treatments, DMC is usually treated by surgery. The common complications of surgical treatment are recurrence of DMC and skin necrosis. This article introduces the method and clinical effect of osteophyte excision and joint debridement in the treatment of DMC of the distal interphalangeal (DIP) joint. Methods In total, 19 cases of affected fingers made an 'S' incision in the DIP joint under local anesthesia to remove the osteophyte of the DIP joint, clean the dorsal joint capsule, wash the joint, and retain only the bilateral collateral ligament and extensor tendon device. It is suspected that the injured finger of the extensor tendon should be protected by external fixation. Results Out of 15 patients, 1 patient presented with partial skin necrosis that healed after dressing changes while the other patients recovered well. The visual analog scale (VAS) scores of all affected fingers after surgery were lower than those before the surgery (VAS score: 4.93 ± 0.88 vs. 4.07 ± 1.03, p < 0.05). The range of motion (ROM) of the affected finger decreased in one patient, and the post-operative activity of the other fingers increased in varying degrees (ROM: 67.60 ± 5.40 vs. 71.27 ± 7.06, p > 0.05). Conclusions Using osteophyte excision and joint debridement to treat DMC can avoid skin necrosis caused by cyst removal and can avoid the recurrence of DMC to the greatest extent, so it is a safe and effective way of treatment.
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The Outcome of Minimally Invasive Surgery for Digital Mucous Cyst: A 2-year Follow-up of Percutaneous Capsulotomy
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  • May 2020
Background: Digital mucous cyst(DMC) is the most common tumor or cyst of the hand. Although many operative methods have been proposed to treat DMCs and lower the recurrence rate, many patients hesitate to have surgery. A minimally invasive treatment using percutaneous capsulotomy for the DMCs could be an alternative choice. However, the clinical results of using this method are still uncertain. Objectives: Here, we introduce the percutaneous capsulotomy method and assess the clinical outcomes and the associated complications of this method. Methods: A total of 42 digits were finally included. All patients accepted percutaneous capsulotomy under a digital ring block. Functional and radiographic assessments were made pre- and postoperatively, with a mean of 28.8 months (range, 24–33 months) of follow-up. Results: The mean duration of the appearance of DMCs before treatment was 11.6 months. Of the 19 digits with nail deformity, 14 showed an improved nail appearance. There were no skin complications. The average visual analogue scale (VAS) satisfaction score was 9.4, only two cases had experienced recurrence at the final follow up. Conclusions: This study reported that percutaneous capsulotomy could be an effective method for DMCs treatment. The recurrence rate was low and patient satisfaction was good. Nail deformities could be improved with treatment.
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Reconstruction of Extraoral Fistula of Dental Origin
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  • Aug 2019
Odontogenic extraoral fistulas often lead to intense levels of patient discomfort and incidence of complications, which are relieved by treatment. However, the cosmetic outcome following treatment may not meet the expectations of the patient. A 51-year-old male presented with a chronically draining lesion on his left cheek. Clinical examination revealed necrosis in the mandibular left first molar and a panoramic radiograph demonstrated periapical abscess surrounding the root apex. A diagnosis of extraoral fistula of odontogenic origin was made, and the affected tooth was extracted. The extraoral fistula disappeared but the defect on the cheek exhibited no improvement over the 2 month follow-up period. Surgical revision of the defect was therefore necessary. A Limberg flap was designed and then transposed to the defect region, followed by primary closure of the donor region. The 6-month follow-up visit revealed satisfactory results for both the patient and the surgeon. This manuscript is the first case report focusing on residual defect elimination of an extraoral fistula with the use of a transpositional flap in the cheek region.
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The Zitelli Bilobed Flap on Skin Coverage After Mucous Cyst Excision: A Retrospective Cohort of 33 Cases
Article
  • Apr 2017
Purpose: To study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cysts using the Zitelli modified bilobed flap. Methods: We surgically treated 33 patients from January 2006 to June 2015. We assessed demographic data, comorbidities, location and size of the cyst, time to wound healing, and complications. Results: The most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. The mucous cyst recurred in 1 of 33 cases. There were no major complications. Conclusions: The Zitelli bilobed flap can provide good-quality skin coverage over the distal interphalangeal joint in a short period. Type of study/level of evidence: Therapeutic IV.
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Flap advancement coverage after excision of large mucous cysts
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  • May 2008
Mucous cysts are common problems seen by hand surgeons. Surgical excision of symptomatic cysts is the most commonly accepted treatment. Removal of large mucous cysts often requires simultaneous flap coverage or skin grafting for the resulting defect. We present the use of a dorsal advancement flap to permit excellent skin coverage after cyst excision with a tension-free closure.
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Etiology and Treatment of the So-Called Mucous Cyst of the Finger
Article
  • Oct 1972
A series of thirty-six so-called mucous cysts of the finger were reviewed. A new form of surgical treatment for this lesion is presented which includes excision of the cyst, synovectomy, and debridement of osteophytes of the distal interphalangeal joint. Closure of the skin defect was accomplished by a rotational flap created by the initial incision. There were no recurrences when this technique was employed. In all cases a definite pedicle was found connecting the cyst to the distal interphalangeal joint. This finding along with the histological appearance seems to indicate that the lesion is analogous to a ganglion.
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A Simple Technique for Managing Digital Mucous Cysts
Article
  • Dec 1979
  • ARCH DERMATOL
Digital mucous cysts can be effectively managed by multiple needlings and expression of contents. This simple technique cures about two thirds of the lesions. Most of those remaining are reduced to small asymptomatic nodules. (Arch Dermatol 115:1315-1316, 1979)
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Directional variations in the extensibility of human skin
Article
  • May 1977
When an extending load is applied to human skin in vivo or in vitro the skin stretches with small increases in load until a limit is reached (limit strain) after which much greater increases in load are required to extend it further (terminal stiffness). At many sites there are marked directional variations, the direction of maximum limit strain being the same as that of minimum terminal stiffness and vice versa. The directional variations of extensibility at constant load on a young male body have been measured and recorded.
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Mucous Cyst of the Distal Interphalangeal Joint: Treatment by Simple Excision or Excision and Rotation Flap
Article
  • Mar 1990
  • J Hand Surg
Thirty-five patients who had thirty-seven mucous cysts excised from the distal interphalangeal joints were reviewed not less than one year later. Seven out of 25 which had been treated by simple excision recurred, whereas only one out of twelve treated by excision and skin closure with a rotation flap recurred.
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A surface ultrastructure study of ganglia and digital mucous cysts
Article
  • Oct 1988
  • J HAND SURG-AM
Three digital mucous cysts and three dorsal wrist ganglia were studied by light and scanning electron microscopy. Both exhibited the same findings, namely a porous network of collagenous fibers forming the wall and a fibrillated inner surface composed of a random arrangement of collagen fibers. An intermittent thin membrane was observed on the inner surface, but no evidence of a cellular lining was apparent. This anatomic study lends support to a shared cause.
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“A square peg into a round hole”: A modified rhombic flap and its clinical application
Article
  • Apr 1987
Two modifications to the classic design of the rhomboid flap are described. Firstly, no attempt is made to engineer a rhomboid defect and, secondly, the flap is made smaller than the defect to be reconstructed. The advantages of these modifications are discussed and their application in 175 reconstructions is reported.
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