Selection of the appropriate Limberg flap in the reconstruction of post-excisional nasal defects

Treatment of superficial cutaneous neoplasias involving the nasal pyramid is frequent in plastic surgery. In this article the authors report their experience in the reconstruction of post-excisional nasal defects employing the local rhomboid flap, initially popularized by Alexander Limberg. From 1995 to 2000, 115 patients underwent exeresis for basalioma of the nasal pyramid at the Campus Bio-Medico University in Rome; in 98 cases the Limberg flap was the reconstructive procedure of choice. In spite of its simplicity, the flap requires accurate planning according to the location. The flap is designed for the repair of equilateral rhomboid defects and is marked extending the short diagonal of the defect in either direction for a distance equal to its own length. Two sides of the flap are thus obtained; the third side is designed at an angle of 60°, always with the same length. The fundamental principle for the application of this technique is that the flap has to be rotated and advanced along the lines of maximum extensibility which are perpendicular to the relaxed skin tension lines. Thus the short diagonal part of the flap has to be parallel to the lines of maximum extensibility; only by this careful planning is it possible to easily close the donor site where the major degree of cutaneous tension occurs. At the level of the nasal pyramid the relaxed skin tension lines are placed transversely; the lines of maximum estensibility, which are perpendicular to them, are oriented vertically, thus the rhomboid flap has to be rotated and advanced vertically in the direction of the caudal cranium. The different aesthetic nasal subunits are disthinguished and some guidelines are suggested according to the location. The simplicity of the execution and the minor trauma with respect to the other procedure, as well as the excellent aesthetic results in both young and elderly patients, make the Limberg flap a valid reconstructive procedure for nasal defects