The tubed flap or tubed pedicle flap is generally designed as a delayed bipedicle flap (Fig. 3.29a). Transfer is delayed for approximately 3 to 4 weeks to promote the development of a central vascular supply. First the flap is cut with a 5: 1 or 6: 1 length-to-
Fig. 3.28 Turnover flaps are used for tracheostoma closure, closing a tracheal groove, or reconstructing alar defects (see Fig. 5.39).
a A flap of appropriate size is outlined lateral to the tracheostoma and dissected to its margin. Skin triangles are excised above and below the defect and are discarded. The tracheostoma margin on the opposite side is freshened. b The flap is hinged over and sutured to the freshened epithelial border. The long laryngeal muscles are mobilized to cover the turnover flap (middle layer ^ c A Z-plasty is performed to close the wound and place the scar in the RSTLs (dashed red line).
Fig. 3.29 Delayed transfer of a tubed bipedicled flap (see text). a The bipedicled flap is raised and its bridge segment is tubed. The donor defect is closed.
b Appearance after closure of the defects. c About 3 weeks later, the distal end of the bridge segment is clamped off with a Nelaton catheter and clamp. d The distal end of the flap is detached and inset into the defect. In a second operation 3 weeks later the residual tube is divided, insetting at the recipient site is completed, and the unused portion of the flap is returned or discarded.
width ratio (Fig. 3.29a) and tubed, preferably by sewing epithelium to epithelium. The proximal end of the flap is preserved as a nutrient pedicle for the "long flap." The defect below the tube can be mobilized and closed by direct suture (Fig. 3.29b). After 3 to 4 weeks, the distal end of the bridge segment is clamped off with a thin rubber tube (Nelaton catheter). If livid discoloration occurs, the catheter is applied only briefly as a tourniquet (Fig. 3.29c). The tourniquet times are then gradually lengthened each day until the entire flap receives its blood supply from the proximal end. Finally the other end is detached (Fig. 3.29d) and sutured into the defect. This process is repeated, and in about 3 weeks the residual tube flap is removed and insetting is completed (see Figs. 5.17, 5.18, and 10.12c).
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