Tubed Abdominal and Chest Skin Flaps

EDITORIAL COMMENT

The time-honored techniques of tubed flaps should he studied in light of our present understanding of the blood supply. In fact, the authors have made an effort to include an axial vessel in the tubed flap, be it perforating from the epigastric arcade or the internal mammary or axillary vessels. If the axial contributions are not included in the design, obviously the flaps are subject to the haphazard effects of chance.

Until the early 1970s, abdominal and thoracic tubed skin flaps were some of the main methods of skin transfer. Advances in our knowledge of the blood supply of the skin (1, 2), subcutaneous tissue, and underlying muscles (3, 4) have led to the development of much safer and more rapid methods of skin transport, dramatically reducing the indications for the use of the tubed skin flap.

INDICATIONS

The abdominal tubed skin flap can be used to provide skin cover anywhere in the body, although it requires several stages and may take months to complete. Chest-tubed flaps, although uncommon in present practice, may be used for reconstructive surgery of the head and neck following excision for malignancy or release of burn contractures. This flap was most beneficial to the patient illustrated in Figure 131.4, who developed high and low esophagocutaneous fistulas following radiotherapy and laryngectomy. Use of the flap allowed the repair of both without compromising the airway.

The horizontally oriented chest-tubed flap is rarely used since it has been supplanted by the deltopectoral flap (see Fig. 131.2B). The thoracoabdominal tubed flap is also rarely used at present. The main indication for this flap is the release of burn contracture where full-thickness skin is needed and only the back is available as the donor site. A similar flap has been used to close the defect left by a hindquarter amputation (5).

ANATOMY

Although short tubed skin flaps can be raised in any axis, longer flaps must be raised along the axial patterns of flow of the vessels supplying the subcutaneous compartment (Fig. 131.1). A standard vertically based abdominal tubed skin flap is based inferiorly on the superficial epigastric vessels and superiorly on terminal branches of intercostal vessels (Fig. 131.2A). The horizontally oriented flap is more hazardous because it is raised on a convex surface and is thus subject to greater tension. It is based on the terminal branches of the segmental vessels (Fig. 131.2A).

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