Cervical and Clavicular Tubed Skin Flaps

B. C. MENDELSON

J. K. MASSON

These flaps are predominantly of historical significance (1). The current management of skin malignancies occurs earlier and is more appropriate and the indications for radiotherapy are stricter than in the past. These facts have dramatically reduced the need for nasal reconstructions. During the years when major nasal reconstruction was more common, clavicular and cervical tubed pedicle flaps were used frequently. That era corresponded to the time in which tubed pedicle flaps were in general use by plastic surgeons.

INDICATIONS

Both cervical and clavicular tubed skin flaps provide skin of quite good color match with facial skin (second only to that of forehead flaps), but the texture is softer and finer than either forehead or nasal skin.

In general, forehead flaps provide the best nasal reconstructions (2), but where such flaps are prohibited because of preexisting scarring or extensive facial radiation, the healthy tissue provided by distant flaps may be required (3).

The major advantage of these distant flaps over forehead flaps is the avoidance of further facial scarring. The clavicular flap, unlike the cervical flap, has the advantage of not leaving any visible scarring when the patient is clothed (4).

Because these flaps require initial attachment to the nasal bridge, there is some difficulty in molding the details of columella and nostrils satisfactorily when the distal end is later transected (5). Accordingly, their best use is for coverage. The clavicular flap, without the size limitation of forehead or cervical flaps, can provide sufficient tissue for much larger defects extending onto the adjacent cheek and lip.

The major limitation of these flaps is the need for multiple operations and a long time for completion. While some of the cervical flaps can reach directly to the nose, most of these distant flaps have insufficient reach and require migration via an intermediate attachment, with several weeks extra preparation time (6). There is a real risk of major complications in the use of these, as well as other, tubed pedicle flaps.

Both flaps are contraindicated in the presence of heavy scarring of the skin of the neck or clavicular region. In males, a heavy growth of hair in these regions is also a contraindication.

ANATOMY

Both these flaps are based on a random pattern of circulation.

FLAP DESIGN AND DIMENSIONS

Clavicular Tubed Flap

The flap is usually designed parallel to and just below the clavicle (7). Its dimensions are determined by the size of the nasal defect and the distance to the nose. Traditional teaching strongly advises a maximum length-breadth ratio of 3:1 (6).

At least four surgical procedures are necessary for transfer of one end of the clavicular tube to the nose. Previously, either end of the flap was used for nasal coverage, but it is now known that the acromial skin of the lateral end can be safely transferred to the nose without delay, carried on the medially based deltopectoral flap (see Chapter 127).

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