Biomechanics of the rhombic transposition flap.

OBJECTIVE To develop a computational model of cutaneous wound closures comparing variations of the rhombic transposition flap. STUDY DESIGN A nonlinear hyperelastic finite element model of human skin was developed and used to assess flap biomechanics in simulated rhombic flap wound closures as flap geometric parameters were varied. SETTING In silico. METHODS The simulation incorporated variables of transposition angle, flap width, and tissue undermining. A 2-dimensional second-order Yeoh hyperelastic model was fit to published experimental skin data. Resultant stress and strain fields as well as local surface changes were evaluated. RESULTS For the rhombus defect, closure stress and strain were minimized for the transposition flap with a distal flap angle of 30° by recruiting skin from opposing sides of the defect. Alteration of defect dimensions showed that peak stress and principal strain were minimized with a square defect. Likelihood of a standing cutaneous deformity was driven by the magnitude of angle closure at the flap base. Manipulation of the transposition angle reoriented the primary skin strain vector. Asymmetric undermining decoupled wound closure tension from strain, with direct effects on boundary deformation. CONCLUSIONS The model demonstrates that flap width determines the degree of secondary tissue movement and impact on surrounding tissues. Transposition angle determines the orientation of maximal strain. Local flap design requires consideration of multiple factors apart from idealized biomechanics, including adjacent "immobile" structures, scar location, local skin thickness, and orientation of relaxed skin tension lines. Finite element models can be used to analyze local flap closures to optimize outcomes.