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British ffournal of Plastic Surgery (197’0, zS, 3oo-3 ~4

CLOSURE OF RHOMBOID SKIN DEFECTS: THE FLAP~,OF LIMBERG AND DUFOURMENTEL

By G. D. LISTER, M..B., F.R.C.S.(Ed. & Eng.)and T. GIBSON, D.Sc.,/VLB., F.R.C.S.(Ed. & Glasg.)

West of Scotland Regional Plastic and Oral Surgery Unit,Canniesburn Hospital, Bears&n, Glasgow

IN excising the majority of skin lesions, surgeons create an ellipticalcan be closed directly. As the lesions increase in size, however, there comeswhen either the long axis of the ellipse becomes too long for the localcosmetic result, or the short axis too wide to permit direct suture. Ininstances the excisional outline may be replanned and closure obtained withflap, until of course the defect becomes so large that cover can only beimported skin.

Designing such local flaps, particularly when the secondary defect is todirectly, can tax the skill of the most experienced plastic surgeon. Onlytrial and error does he learn intuitively to judge the maximum tension undercan suture the pardy devascularised flap and the absolute limits to whichstretch the surrounding skin ; the art of designing such flaps takes long tois hard to teach.

There are, however, 2 exceptions to which we would like to drawthe flaps designed by Limberg (I 946, 1966, and 1967) and by Dufourmentelto close rhomboid defects. A rhombus is an equilateral parallelogram andregarded as an" ellipse with straight sides .". Rhomboid excision has soover elliptical excision particularly when the defect is to be closed with aFor example, less normal skin needs to be excised in the long axis, the design andof a straight-sided flap is far simpler than that of the round flap and rhomboidlends itself to the technique recommended by Borghouts (1964) of histologicallion of the specimen margins to check mmour clearance.

The Limberg flap and the Dufourmentel flap are different in design andand will be described and discussed separately.

THE !LIMBERG FLAP

The flap which Limberg designed for a rhomboid defect is one extensionclassical studies on transposed triangular flaps. Thus in Figures I and 2 thedosed by interchanging the unequal flaps TLW and UVW. The design mayregarded as a rhomboid flap XUVW of the same size and shape as the defect intoit is to be rotated.

The flap when used singly is suitable for closure only of rhomboidangles of 60° and I2O° ; in this paper such a defect is called a 60° rhomboid.rhombus is thus composed of 2 equilateral triangles and the short axis islength as each side.

In constructing the flap (Fig. I) the short diagonal is extended in one direction by its own length to the point V. A further incision VW parallel toequal to each of the sides completes the design. It will be evident that theUW is also equal to the short diagonal[ of the defect and therefore to all otherin the plan. All attractive aspect of this Limberg flap is that, once the lendiagonal has been determined, the. remainder of the design may be completed bycalipers set to that length.

3oo

For an’.~s shown inrotated thr.care aP~=: ,-x~these pointsin turn de~~onsideratie¢xtensibilit)at right angas at right a

its own lenl

t~p the skin~hould ifprimaryFig. 4, a).with the po:ttowever, v

&r the rho:Lirnbe

angles andl.imberg’s :models prc~aut, slight:~hornboid

FLAPS

~tical,~ere comes iilocal

z. Inained withbe

%ct is toOnly

on underto which~long to

mentel)gram andas some=l wit_ha local~i~ design and[rhomboid ex’~i~.lstologlcal ex~

;ign and appli~~

~ne extensionthe defee~jli~c and 2

: design may .a~.~:he defect into

omboid defe~~6o° rhomboid.~ort axis is the

~ded in one orgr parallel to!ent that the dii~: to all other~he length of th~)e completed by.~

CLOSURE OF RHOMBOID SKIN DEFECTS 301

For any given 6o° rhomboid defect there are theoretically 4 Limberg flaps availableshown in FigUreo3. Once the most appropriate flap has been chosen and raised it is--~ ,hrou~h 6o and placed in the defect (Fig. 2). It will be seen that U and

totat~u " o~ a~proximated in closing the secondary defect. If Nllows that the ease with which~k~ts can be apposed determ~es whether or not the design is appropriate ; t~smrn dcpends on the relative availabfiky and ex[ensib~ity of the skin. A major~nsiderafion. in planing should therefore be to seek out the d~ecfion of maxim~~tensibilit~ xn t~e skin ~r2und,~ defect (gibso~ et ~l., z~69~. This line is usually

right angms to ~anger s ~mes ~umson et at., ~97~) ana on me race it may be regarded~ at right angles to the crease ~es. It may be readily determ~ed clinically by pic~g

V

Fro. i. Design of a Limberg flap. STUX represents a 60° rhomboid defect. SU is extended by,ts ox :~ ;:ngth to V. "qW is then drawn parallel and equal to UX. Note that the distance between

any 2 adjacent points in the design is identical.

~p the skin between finger and thumb. Having fi~und that line, the points U and W*h0uld if possible be placed on it ; they lie on the same line as one of the sides of theprimary defect and ~ flaps can be designed in this fashion for any one 6o° rhomboidFig. 4, A). If the lesion is circular, the rhomboid can be rotated giving ~ more flaps"*’ith the points U and W in the same line of maxim,am extensibility (Figs. 4, B and 4, c).ttowever, when the shape of the lesion already determines the positioning of the rhom-Mid these remarks are not appropriate and one selects the most suitable flap available’.’or the rT, omboid so positioned.

Limberg pointed out that moving any flap inwflves but 2 processes, opening woundingles and closing wound angles. Closing a wound angle produces a dog-ear or, inI.imberg’s more precise term, a standing cone. Opening an angle in Limberg’s papermodels produces a lying cone. This cannot forra in skin ; what usually occurs is a:aut, slightly depressed area around the angle. If for example one were to close the:homboid defect shown in Figure I directly, dog-ears would form at points T and X

302 BRITISH JOURNAL OF PLASTIC SURGERY

and depressed areas at S and U. By adding the rhomboid flap for closureavoids any movement of angles T and S. This can bc of cosmetic value,i~ the deformations around the other angles can bc placed in less obtrusive

v

B CFIG. 12. A, the flap designed in Figure I has been cut and transposed into the defect.

post-operatively. C, z weeks post-operatively.

PRACTICAL APPLICATIONS

Excisional Surgery. In most cases it is possible to decide in advanceskin lesion will require elliptical excMon and direct closure, excision withclosure or excision and distant skin cover.

Where doubt exists about the practicabilky of direct closure k is wise toonly the lesion with appropriate clearance as the initial step. If apposition thenthat direct closure is feasible further excision to create an ellipse suitably long to

LME

Fro. 4. \VFig. I) lie,

~a ~e so s

losure

[ue,;lV~


FIG. 3. In theory achoice of 4 Limbergflaps is available forany 6o° rhomboid

defect.

~tefect. B, 6

vancea with local

is wise to;ition thenbly long to

LME

LME __ J__~ _

t;I..~. 4. With roughly circular lesions the rhombus should be so positioned that points U and Wrlg: I) lie on the line of maximum extensibility. There are ~ possible ways in which the rhombus~n t~e so sited (A and B) and thus 4 flaps of this kind are available (C). This of course is

applicable if the shape of the lesion dictates the position of the rhombus.


Fro. 5. A, Two alterna-tive Limberg flaps havebeen designed. The 2others theoretically avail-able would encroach uponthe ear. B, Direct closure~va8 felt to involve sutur-ing under undue tension.C, The more suitable flapwas chosen, cut, transposedand sutured, (D and E)

with good result.

the formation of permanent dog-ears is performed. If direct closure is forminapplicable no normal tissue has been discarded needlessly and a flapdesigned can be cut and rotated into position (Fig. 5).

At the other extreme of applicability, it may be found that U and W

.~ :s. 6. A defect in the form of a parallel-:,r:am, having acute angles of 60° and long~,3~ twice that of the short, cart be closed,.:.~., Limberg flaps. The 5 possible designs

are shown.A

OSLlre JSad a flap

U and WB C

~" "- A parallelogram defect created by excision of a rodent ulcer closed by ~ Limberg flaps.distortion of the eyebrow or irregularity of the hairline was avoided by the choice of flaps.

Any

306 BRITISH JOURNAL OF PLAsTIc SURGERY

approximated even after undermining. The flap must then be replacedalternative means of skin cover found. With a little experience, however,Occurs.

The Simultaneous Use of 2 Limberg Flaps. Any defect which can beas a parallelogram the long side of which is twice as long as the short side,angles of which are 6o°, may be closed with 2 Limberg flaps.

FiG. 8. A circular defect maybe considered as a hexagon.Each side equals the radius of

the original circle in length.

FIG. 9- All equilateral hexagonsare made up of three 6o° rhom-boids. Three Limberg flaps canbe constructed to close a hexagonaldefect. Preferably the peripheral

FtG. 8

limbs should point in the samedirection.

FIG. IO. Construction where 2of the flaps have peripheral limbspointing towards one another.This may be necessary anatomic-ally, but the angle closed at A is12o° and will produce a dog-ear.

>

FIG. 9 FIG. IO

There are 5 possible constructions (Fig. 6) ; the choice will depend anatomy and the availability of skin. A clinical example is shown in Figure 7.

The Simultaneous Use of 3 Limberg Flaps. A circular defect closelyto the form of a hexagon, the length of the radius equalling the length of eachsides (Fig. 8). All such equilateral hexagons are made up of three °

3 Limberg flaps can therefore be designed to close the defect (Fig. 9). In thisthe calipers are invaluable ; set to the radius of the circular defect 18

measured a~limbs pointishould 2 sh~positio.n,,anis crc’:. :.ulcer o’~occurred.

On oc~undesirableGillies fan f

teukoplakia othat no furttwhich was n:a common b

Altho,u.~h itflap of~uc~have -. a d/

i’:;;2er P,and free skirbacks whilebecause of tl:ts divided inand further

replacedhowever,

h can bert side, and i

ar defectS athe radius

:le in length.

ateral hexagonshree 60° rhom-~nberg flaps can::lose a hexagonaly the peripheralint in the sameion.

~ction where

s one another.essary anatomic-;e closed at A is’~duce a dog-ear.i~

CLOSURE OF RHOMBOID SKIN DEFECTS 3O7

tneasured and marked and the design completed. The flaps should have the peripherallimbs19ointing in the same direction as in Figure 9. Only in s ecial circumstances- p~hould ~ share a common base (as at a in Figure IC.) since, when they are rotated into

~POScrition, an angle of ~:zo° is closed and a pronounced and probably permanent dog-eareared. In the case illustrated in Figure ~, excision and raftin of a " "¯ ~ . . g g radlonecrotlculcer , .: back had previously been performed, but the graft failed and further necrosis~x-currcd. "fhe ulcer was again excised and successfhlly closed with 3 Limberg flaps.

On occasion closure of a defect may be quite feasible technically but may haveundesirable results. In the case shown in Figure ~:z the patient had previously had aGillies fan flap rotated at the left angle of his mouth and now presented with active

A

FIG. IO

rill depend onwn in Figure 7.:ct closely-, length of eacharee 6o°~Fig. 9). Indefect 18

Flc,. z t. A, A circular radionecrotic ulcer of the back was excised as an equilateral hexagon and 3I.i:. flaps designed as in Figure xo. B, The defect excised and the flaps cut. C, Flaps tran-

sposed and sutured with, later, (D) sound healing.

l,’ukoplakia of the opposite commissure. While excMon was indicated, it was important:hat no further narrowing of the mouth should result. Three Limberg flaps, one ofahich was mucosal, gave an acceptable solution. The 2 skin flaps were designed with~ common base, however, and this resulted in the ,creation of a dog-ear as predicted.¯ }tthough it cannot be easily appreciated in black and white photographs, the use of the:Up of buccal mucosa served to reconstitute the vermilion in a manner which wouldbare been difficult to achieve by other means.

1 .,. IVebs. Moderate degrees of finger webbing are usually treated by release¯ nd flee skin graft or by Z-plasty. However, a free graft has certain inherent draw-Ncks while a Z-plasty may not introduce sufficient tissue into the line of the webbecause of the limitation in length of the central limb. It was noted that, when a web’-~ divided in the midline (Fig. ~3) and the fingers separated, the defect is rhomboida~ad further that there is frequently sufficient skin on the sides of the fingers adjacent

FIG. 12. A, Excision of leukoplakia of the .commissure is planned. Two skin flaps and (B)mucosal flap designed. C, The 2 skin flaps with a common base as in Figure I I has resulted in adog-ear. D, Further narrowing of the stoma has been avoided by reconstructing the vermilion’

commissure with the buccal mucosal flap.

the wefavor is

In ol~ave,k-sign ar:rod the f.~upply is.my of

,:k~cd~’~ndar,

readihhair

=any di£:F~n witk

The

~mcourag,

~re aIf co

:~ults


W the web to supply a Limbcrg flap large enough to give good correction. The limitingfactor is again the amount of skin available, but this is easily assessed in advance.

,s and (B) oneesulted in

the vermilion

FIG. 13. A, Midline in-cision of a finger web burncontracture resulted in arhomboid defect when thefingers were separated. B,A flap designed on theadjacent finger was cut,transposed and sutured

into place (C).

DISCUSSION

In our experience of over 5° cases in which the Limberg flap has been used, wehave found it safe, reliable and versatile. One great merit of its geometrically precisedesign and the fact that only one measurement is needed to construct both the defectand the flap, is that it is so easily taught. The trainee has the assurance that the blood~upply is adequate and that the edges to be apposed will fit together precisely withoutany of the adjustment so often required in placing other flaps ; in other words, thettap vi!! " work ".

¯ ,, :.major limitation of the Limberg flap is that the secondary defect must beclosed directly and flap placement cannot be eased by the use of free grafts on the~condary defect ; the size depends directly on the awdlability of skin in the area. Afurther limitation, common to all local flaps, is that the correct quality of skin may notbe readily available, for example after excision of lesion’,; of or near the eyelids and closeto hair margins. At the same time because the Limberg flap can be designed in soraany different directions, it is more often possible to construct a flap of the right skinthan with less versatile designs.

The final scar follows a slightly bizarre line which cannot all be lost in crease lines,but ;., ~aost cases the quality of the scar has been good without spreading or hyper-:ropl:. ad the result has certainly been better than that obtainable by the simplest~hernadve, a full thickness graft. Theoretically the shape of the Limberg flap shouldencourage the formation of a raised " trap-door " scar. Whether the increased tension~mposed on the flap prevents this is not known, but we have only seen it on one occasion,:~here a rather small flap was used.

If correctly executed and if good primary healing occurs, the Limberg flap produces:esults which, for colour and texture match and overall[ appearance, are excellent.


THE DUFOURMENTEL FLAP

Whereas the Limberg flap can only be constructed for a 6o° rhomboidDufourmentel flap, " ’ le lambeau en L pour losange ’ dit ’ LLL’ ", can, inused for any rhomboid. The rhombus is thus composed of two isoscelesunlike the Limberg construction, the short axis of the defect need not equalits sides. The procedure may be regarded again as transposition of twoflaps or more obviously the rotation of an irregular quadrilateral flap into adefect.

In planning the Dufourmentel flap, the short diagonal LN (Fig. 14)other of the adjacent sides of the defect KN are extended and the angle so!bisected by a line (NQ) equal in length to each of the sides of the defect.line (QR) is then drawn parallel to the long axis of the defect and again equalseach side of the defect. Calipers are: of some use in constructing the flapincisions are of equal length, l:.ut a protractor is necessary to place theaccurately. Once raised, the flap KNQR is transposed into the defect.in Figure 15, 4 Dufourmentel flaps can be planned for any rhomboidthe 4 angles of the defect come to equal one another, as the rhomboidshape of a square, flaps may be designed at each of the 4 angles giving 8(Fig. 16).

The merit of placing the equivalent points N and R in the line ofextensibility has already been discussed in considering the Limberg flap.complicated with the Dufourmentel design ; indeed, on initial consideration,to be quite impractical, since the relationship of the baseline of the triandefect varies as the shape of the rhomboid varies. However, as the geometricalof the design given as an appendix to this paper shows, the angle betweenaxis of the flap (NR) and the short axis of the defect (LN) changes by degrees from 15o° as the acute angle of the defect varies from 6o° to 9o°. Thisimay be ignored and, in practice, having determined the line of maximum skinbility, points N and R may be placed upon it and the short axis of theangle of I5o° to that line. Tiffs applies only to those cases in which thethe rhombus is not dictated by the shape of the lesion.

As the acute angle of the defect falls below 6o°, the Dufourmentel flapprogressively wider than the primary defect. Little is to be gained thereforeuse of the flap in these circumstances and direct closure is to be preferred.

As the acute angle of the defect increases from 6o°, the defect becomeswider than the flap and when it reaches a square the short axis of the flap isquarters the length of the short axis of the defect. It is in this range that theclinical value.

PRACTICAL APPLICATIONS

As shown above, the Dufourmentel flap has no practical value whereangle is less than 6o°. In closing a 6o° rhomboid defect, it has no advantageLimberg flap, although it has been argued in its favour that it has a safer bloodthan the Limberg flap because its base is wider. Embarrassment of the bloodof a Limberg flap, however, is rarely seen anywhere on the body and never on

It is in closing defects the acute angle of which lies between 6o° and 9o°,

that the Dufourmentel flap is of use. Such defects are not often created asexcision is usually possible to convert the defect to a 6o° rhomboid which can belwith the simpler Limberg flap. Where, however, such additional excision isindicated, for example by the proximity of vital structures, then a

may provdosed

One rbe.ing 60° ~Dufourme:learn andDufourme:l.imberg i

:homboid", can, inosceles:d not equal3n of twoflap into a

(Fig. 14)the angle sohe defect.~gain equalsing the flaplace the flaple defect.homboidnboidgiving 8

fine:rg flap. Thisnsideration,e triangularte geometricalgle betweenages by less~ tO 9O°.

aaximum skinds of thewhich the

armentel flap b~aed thereforepreferred.becomes

F the flap is only:ange that the

value whereno advantage

~as a safer bloodmt of the blood7 and never on~ 60° and 9o°,en created asoid which can be ional excision is,en a Dt

q

F), I :I

CLOSURE OF RHOMBOID SKIN DEFECTS 3I~

~rovide a satisfactory solution. Such a procedure for a defect which could not bemaYdo~edr directly without undue tension is shown in Figure x7-

~

.... ̄ ~,~, ~.,~

FIG. 14

FIG. 14. Design of a Dufour-mentel flap. LMNK representsa rhomboid defect. LN andKN are extended and the anglethus formed bisected by a lineNQ equal to each of the sides ofthe rhomboid. QR is then drawnof equal length and parallel tothe long axis of the defect MK.

FIG. 15. In theory a choice of4 Dufourmentel flaps is availablefor any defect approximating to

a 6o° rhomboid.

FIG. 16. If the defect is squarein shape a choice of 8 flaps is

available.

DISCUSSION

Fm. 16

~:~.e major merit of the Limberg flap is the simplicity of the design, all anglesbeing 6o° or ~zo°, all sides being equal. This rnakes it easy to learn and apply. TheDufourmentel flap is by no means complicated, but it is certainly more difficult tolearn and to plan than the Limberg design. Indeed, at first sight it.seems that theDufourmentel flap with its angles rarely matching those of the defect is inferior to theLimberg design, but this is too superficial a view. In both instances a defect is

312

C

FIG. 17. A, A Dufour-mentel flap has been de-signed for a plannedrhomboid excision havingan acute angle of 75°. B,Direct closure would haveinvolved suturing under

considerable tension.

Fro. 17. C, The flap wascut, transposed and sut-ured (D) with good result

(E).

BRITISH JOURNAL OF PLASTIC SURGERY

A B

D

closed an,t,znsion ;by the en,

In itsflap !"morethe defectobtuse an:the obtus~becomecited by t~m to h’,

The:

corn [" ~i ~crThe ]

dderationknowledgefortunateage groupfar-closedcosmetical

As th~trend hasfrom Figm

Varialangle of a:

by o::cl "a ria l

tcadity seeWith eachequal whet

SinceI44 , the a1l~.v plotting~zcs which

l"l,~p ,,.,..

In oth,~his is negli


dosed and in closing it the surrounding skin is stretched and put under increasedt~sion; the angles carefully planned and measured may have changed considerablyby the end of the procedure." In i,s range of usefulness between 60° and 9o°, the acute angle of the Dufourmentel

lta-; -ws more acute than that of the defect, while the obtuse angle of the flap ismore obtuse than that of the defect. But imagine point L being pulled to point N asthe defect is closed ; the acute angle of the flap would tend to become less acute, theobtuse angle less obtuse, while the acute angle of the defect becomes more acute and~he obtuse angle more obtuse. In other words the angles of the flap and the defectbecome much more congruous. Unfortunately this variation in angle size is compli-cated by the closure of the secondary defect ; app,’oximating point N to point R would.~rn to have the opposite effects on the angles than bringing L to N.

The matter is obviously very complex; even if we had simple reliable methodsof rnc:~,.wing extensibility of skin at any one site and the effect of varying tensions on~, th, , ..".y, sis and prediction of the exact behaviour of either flap would require a,-omputer rather than a plastic surgeon.

The Dufourmentel flap is probably the better design in so far as it takes into con-sideration the effects of increased tension on the skin, but until we have more preciseknowledge of the latter both designs are still to some extent empirical. It is perhapsfortunate that the majority of cases in which the tlaps have been used are in the olderage group and old skin absorbs unequal angles, unequal sides, too-far-opened and too-far-closed angles in a way which makes such flaps, with their various shortcomings,~smetically so successful.

APPENDIX

MATHEMATICAL CONSIDERATIONS IN THE DuFOURMENTEL FLAP

As the angles of the defect vary so do the measurements of the flap. The generalt~¢nd has been given in the text, but the mathematical variations arc readily derivedfrom Figure 18, A.

Variation of the Acute Angle of the Flap (/3) with that of the Defect (~.). /3 is oneangle of a right-angled triangle the other angle of which is equal to Y/4. Since

y = ~8o-~ .’. /3 = 45+~/4:~as been plotted on Figure ~8, B. For each degree of change in v., ~ changes

by one quarter of a degree. They are only equal when both are 6o°.Variation of the Obtuse Angle of the Flap (8) ~with that of the Defect (y). It can

readily seen that 8 = i8o-7’/4 and this relationship is also plotted on Figure ~8, B.\rith each degree change of y, 8 varies by one quarter of a degree and the angles arerqual when both are ~44°.

Since fi fits = precisely only when both are 6o° and 8 fits y only when both are~44, the angles of the flap cannot both equal their respective angles in one construction.};y plotting ~.//3 against y/8 in Figure I8, c it is possible to determine that the angle~es .,.vhich give the closest approximation to perfect fit are ~ 5o°, y ~3o° ; /3 58°, 8 ~48°.

~ :~ion of the Angle (0) between the Short Axis of the Defect (a) and that of ~.:!ap ,i,5.

0 can be readily shown to be equal to ~ 8o°-/3/2.Substituting/~ -- 45° + e/4 and symplifying0 = I57½°- ~/8.

In other words 0 changes at a rate 8 times slower than ~ and in the clinical range:his is negligible.


Variation in Lengths of Short Axes’ of Flaps and Defect. Since the con:made up of isosceles triangles the same relationship exists between a and b and!ft. In other words a and b are equal when a is 6o°. As 0~ increases towards tshort axis of the defect (a) increases at a rate 4 times as rapid as (b).

~ 0.sTs FIG. I8. A, See appendix. B,By plotting the acute angles ofthe flap and the defect, ~ and flagainst one another a direct re-lationship is shown. A similarrelationship is obtained plottingthe obtuse angles 7 and 8 againstone another. C, If the ratio ofthe acute angles one to the other,oqfl is plotted against the ratio ofthe obtuse angles y/8 the valueat which these ratios are equal,and therefore at which the anglesare most congruent, can be

o.~ ~.o ~.s obtained.

c

REFERENCES

BORGHOUTS, J. M. H. M. (x964)- Surgical treatment of basal-cell carcinoma and cell carcinoma of the skin. Archivum Chirurgicum Neerlandicum, x6, I9-3o.

DUFOURMENTEL, C. (I962). Le fermeture des pertes de substance cutan6e limit&s lambeau de rotation en L pour losange " dit " LLL ". Annales de Chirut7, 6~-66.

DUFOURMENTEL, C. (t963). An L-shaped flap for lozenge-shaped defects. Transactionsthe Third International Congress of Plastic Surgery, p. 772. Amsterdam:Medical Foundation.

GIBSON, T., STARK, H. and EVANS, J. H. (~969). Directional variations of human skin in vivo. ffournal of Biomechanics, ~, 2oi-2o4.GIBSON, T., STARK, H. and KENEDI, R. M. (~97~)- The significance of Langer’sTransactions of the Fifth International Congress of Plastic and Reconstructivep. ~2~3. Melbourne : Butterworths.

LIMBERG, A. A. (~946). Mathematical principles of local plastic procedures on theof the human body. Leningrad : Medgis.

LIMBERG, A. A. (~966). Design of local flaps. In " Modern Trends in Plastic SurgerySecond Edition, ed. by Gibson, T. London : Butterworths.

LIMBERG, A. A. (~967). Planimetrie und Stereometrie der Hautplastik. Jena Fischer Verlag.

EVER sinfor graftidonor sitthe skina&ieved,skin is ri~ually onot alwa}

~st-auri,:~r dora,’

:-’.’-:..7,

~::G. I.~ post.:--4 inade