Limberg and Dufourmentel flaps

Rhomboid transposition flaps

Limberg and Dufourmentel flaps

The ideal treatment for pilonidal sinus disease would have a short hospital stay, low primary wound failure rate, low recurrence rate and restore quality of life. Current evidence suggests a flattened natal cleft with a lateral scar satisfies at least two of these. One way of achieving this is with a rhomboid transposition flap.

A recent study concluded: “Dufourmentel flap method could be used as an alternative to Limberg flap method in treatment of pilonidal sinus because of its lower infection and hematoma rates, although time of hospitalisation, late complications and recurrence rates are similar compared to Limberg flap method.”

Limberg flap (1946) is suitable to close a rhomboid defect with angles of 60⁰ and 120⁰. The short diagonal is extended by its own length and an incision parallel to one of the sides completes the flap. The defect can be considered as two equilateral triangles. As such, the distance between any two points on the design is the same as the short diagonal.

Dufourmentel flap (1962) is used to close a rhombus defect composed of two isosceles triangles. For practical purposes, the flap takes off at an angle of 150⁰ to one side of the defect.

Limberg flap is simpler. Dufourmentel flap has a wider base and theoretically better blood supply. The Dufourmentel flap is most useful when the acute angle of the defect is between 60⁰ and 90⁰.

Limberg Kaplan Type 6

Limberg Kaplan Type 6

Kaplan’s study suggest the vertical axis should be parallel to and away from the midline (11 to 20mm) towards the non-diseased side. The adipofasciocutaneous flap is raised from the side of the secondary fistula – this results in a Kaplan Type 6 flap as shown in the figure. Of significant concern to the surgeon and patient, 21% of patients with a recurrence had the correct “off midline closure OMC” type closure.

 

BIBILOGRAPHY

Tardu A, Haslak A, Ozcinar B, Başak F. Comparison of Limberg and Dufourmentel flap in surgical treatment of pilonidal sinus disease. Turkish Journal of Surgery (2011), 27(1), 35-40.

Karakaş BR, Aslaner A, Gündüz UR, Çalış H, Öngen AN, Öner OZ, Bülbüller N. Is the lateralization distance important in terms in patients undergoing the modified Limberg flap procedure for treatment of pilonidal sinus? Techniques in Coloproctology (2015), 19(5), 309-16.

Lister DG, Gibson T. Closure of Rhomboid Skin Defects: The Flaps of Limberg and Dufourmentel. British Journal of Plastic Surgery (1972), 25, 300-314.

Kaplan M, Ozcan O, Bilgic E, Kaplan ET, Kaplan T, Kaplan FC. Distal scar-to-midline distance in pilonidal Limberg flap surgery is a recurrence-promoting factor: A multicenter, case-control study. American Journal of Surgery. (2017). ePub.