Rhomboid Surgical Incision in Dental Surgery: A Valuable Technique for Soft Tissue Reconstruction

The rhomboid surgical incision , commonly referred to as the Limberg flap, is a geometric flap design well-known in plastic and reconstructive surgery. However, its utility in dental and oral maxillofacial surgery is gradually gaining attention, particularly among surgeons managing complex soft tissue defects. Although not a routine choice in intraoral procedures, its application in selected surgical situations provides superior outcomes in terms of both function and aesthetics.

In this article, we will explore the indications, advantages, and technical considerations for using the rhomboid surgical incision in dental surgery, with a focus on real-world surgical scenarios.

Understanding the Rhomboid (Limberg) Flap

The rhomboid flap is a type of transposition flap, where a rhomboid-shaped incision is created, and a flap of skin or mucosa is rotated into the defect. It is designed based on a parallelogram with 120° and 60° angles, allowing precise geometric planning and reliable vascularity. Originally described for cutaneous defects, its principles have been adapted for the intraoral and perioral regions where tension-free closure and soft tissue mobility are critical.

Why Consider Rhomboid Surgical Incision in Dental Surgery?

In dental and oral maxillofacial surgery, surgeons frequently encounter clinical situations where conventional flap designs (such as envelope, trapezoidal, or V-Y advancement flaps) may not provide adequate mobility, vascularity, or aesthetic positioning of scar lines.

The rhomboid surgical incision offers distinct advantages:

Tension-free primary closure in areas prone to contracture.
Robust vascular support enhances flap survival even in compromised tissues.
Versatile rotation into defects of various shapes.
Realignment of scar lines along natural creases or tension lines for improved cosmetic outcomes.

While its use is still relatively rare in routine dental procedures, it becomes invaluable in cases involving soft tissue reconstruction, defect closure, and functional restoration.

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Clinical Applications of the Rhomboid Surgical Incision in Dental Practice

Let’s review key scenarios where the Limberg flap proves effective:

1. Closure of Orocutaneous and Oroantral Fistulas

Persistent fistulas, especially those involving communication between the oral cavity and the maxillary sinus (oroantral fistulas), or between oral and skin surfaces (orocutaneous fistulas), often require robust closure techniques. Traditional advancement flaps may fail in cases of fibrotic or irradiated tissue.

A rhomboid flap can be harvested from adjacent mucosa or skin to cover the fistulous tract after excision. Its geometric design enables precise movement of healthy tissue into the defect while maintaining a good blood supply—critical for reducing recurrence.

2. Excision of Oral Lesions (Mucoceles, Fibromas, Benign Tumors)

Large intraoral lesions such as mucoceles on the lower lip, fibromas on the buccal mucosa, or soft tissue tumors in the floor of the mouth can result in mucosal defects that are difficult to close without tension. Secondary healing may lead to contraction and loss of vestibular depth.

Using a rhomboid incision, the defect can be closed primarily with tissue borrowed from a nearby site, reducing healing time and preserving local anatomy.

3. Reconstruction After Skin Cancer Excision in Perioral Area

In cases of basal or squamous cell carcinoma involving the upper lip, nasolabial fold, or cheek, post-excision defects often require reconstruction that restores both form and function. The Limberg flap allows surgeons to reposition well-vascularized tissue into cosmetically sensitive zones, redirecting scars along relaxed skin tension lines.

This technique is especially relevant for oral surgeons who perform oncologic procedures involving the lips and adjacent skin.

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4. Management of Soft Tissue Defects Following Trauma

Traumatic injuries involving avulsion or deep laceration of the lip, chin, or buccal mucosa often present with irregular wound edges and tissue loss. Standard closure may not achieve optimal healing or aesthetic restoration.

The rhomboid surgical incision helps reconfigure the wound geometry, redistribute tissue tension, and prevent scar tethering—facilitating better lip mobility and facial symmetry.

5. Correction of Scar Contracture and Mucosal Deformities

Previous surgeries, burns, or trauma in the oral cavity or perioral region may lead to cicatricial contracture, impairing mouth opening, lip movement, or speech. In such cases, contracture release followed by rhomboid flap rotation provides a reliable method of resurfacing the defect with supple tissue.

This approach is especially beneficial in high-mobility zones like the oral commissure or labial mucosa, where other flaps may fail to accommodate movement.

6. Selected Use in Submucous Cleft Palate or Palatal Fistula Repair

Although rarely used intraorally, the rhomboid flap can be adapted for palatal reconstruction, particularly for small fistulae that are difficult to close with traditional palatal flaps. The flap can be raised from adjacent palatal or buccal mucosa and rotated into the defect, ensuring robust healing.

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Technical Considerations for Dental Surgeons

To successfully implement the rhomboid incision in oral surgery, practitioners must:

Understand local vascular anatomy to avoid compromising the flap.
Plan the flap orientation carefully to ensure tissue reach and rotation.
Use fine surgical instruments and magnification to preserve vascular pedicles.
Consider multilayer closure for deeper defects involving both mucosa and submucosa.
Anticipate postoperative edema and provide patients with clear post-op care protocols.

Given the rarity of this flap in routine oral surgery, hands-on surgical training or cadaveric practice is recommended before clinical use.

Final Thoughts: Expanding the Armamentarium of the Oral Surgeon

The rhomboid surgical incision in dental surgery represents a powerful yet underutilized tool in the oral surgeon’s armamentarium. Whether managing trauma, pathology, or post-surgical defects, the Limberg flap provides a means of achieving tension-free closure, functional restoration, and excellent aesthetic outcomes.

By incorporating this technique into selective cases, dental professionals can enhance surgical versatility and deliver superior patient care—especially when conventional flaps are insufficient.