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Sciegienka et al. Plast Aesthet Res 2022;9:1 https://dx.doi.org/10.20517/2347-9264.2021.76 Page 5 of 14

Figure 2. O to T closure. This closure should be designed so that one-half of the defect has greater adjacent skin elasticity (inferior
aspect) (A). Half of the closure is accomplished by inferior flap 3 and the other half by superior flaps 1 and 2 equally (B).

Figure 3. Rhombic flap. The original design by Limberg describes internal angles of 60° and 120°. Note the transposition of each corner
of the rhombic flap labeled a, b, c.

Webster flap, which reduce the tissue needed to close the wound, facilitating wound closure. The
Dufourmentel flap is a rhombic flap that consists of any angle combination, while the Webster flap uses a
[10]
30-degree angle with a W-plasty at the base of the flap to improve wound closure [Figure 4] . Large
cutaneous defects can be closed with bilateral rhombic flaps. Using two flaps on opposing sides of the
wound allows the surgeon to use elastic or redundant skin from two separate areas to reconstruct the
defect .
[11]
The cosmetic outcome is typically favorable as the transposition of nearby tissues leads to good texture and
color match, and the resulting scars have tension vectors that can be predictably placed. When considering
scar placement, the short diagonal axis should be oriented perpendicular to the RSTL. Additionally,
attention should be paid to facial subunits to avoid crossing or putting tension on neighboring subunits that
could distort the area . If these principles are followed, the complication rates when using rhombic flaps are
[9]
similar to other local flaps in the head and neck. However, some have noted a possible slight increase in the
rate of trapdoor deformity after healing .
[12]

Note flap
The note flap is a triangular transposition flap, given its name based on the appearance of the donor flap,
with its defect being similar to a musical eighth note. It allows for a circular defect to be closed with a
smaller area of donor tissue. For this reason, it is not recommended for larger defects and is generally felt to
be useful in defects less than 2 cm .
[13]