Limberg Flap Is Rhombic, Not Rhomboid

Abstract

In 1948, the Russian maxillofacial surgeon Alexander A. Limberg published his monograph “Mathematical Principles of Local Plastic Procedures on the Surface of the Human Body,” in which he described flap plasty techniques for the coverage of rhombus-shaped defects.1 This work was published in Russian. In 1966, a description of the mathematical principles of his flaps for coverage of rhombus-shaped defects was published for the first time in English in the “Design of Local Flaps” chapter of the book Modern Trends in Plastic Surgery.2 Limberg described the coverage of a rhombus-shaped defect using a paper model. In this model, the opposite angles are 60 degree and 120 degrees, and the lengths of all sides are identical. Unfortunately, he describes the defect as rhomboid. This flap became internationally known and was subsequently referred to as the Limberg flap. For a long time, this option for plastic surgical coverage was used mainly in facial and plastic surgery. In 1984, Azab3 first adopted this transpositional flap for the treatment of pilonidal sinus disease. Numerous subsequent studies achieved very good results with this procedure in patients with pilonidal sinus disease, and it is now recommended in the current United States guideline4 and guidelines from other countries. In the process of translating a recent publication that describes use of the Limberg flap to treat sacrococcygeal pilonidal sinus,5 we noticed that the procedure actually involves the use of a rhombic flap, not a rhomboid flap. The definitions of geometric shapes likely originate from the Greek mathematician Euclid of Alexandria, who lived in the third century B.C. Both the rhombus and rhomboid (also known as a parallelogram) are four-sided figures with opposite angles of the same degree. In a rhomboid, the opposite sides are of equal length, whereas in a rhombus, all four sides are of equal length. Unfortunately, countless publications have referred to the Limberg flap as a rhomboid flap while actually describing a rhombic flap. This error was adopted in the current American and German guidelines for the treatment of pilonidal sinus disease. To honor the pioneer of this procedure and avoid confusion, we recommend referring to this flap simply as the Limberg flap. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Michael Ardelt, M.D. Utz Settmacher, M.D. Department of General, Visceral, and Vascular Surgery University of Jena Jena, Germany