It is a type of plastic surgery that involves transporting healthy, live tissue from one location of the body to the areas that have lost skin, fat, muscle movement, and/or skeletal support. The site from which the tissue is obtained is called the donor site, while the site where the tissue is transferred is called the recipient site. 

Q: What is the difference between graft and flap?

Flaps are different from grafts as they have their own blood supply, that is, their own artery and vein. Grafts are also used to cover open wounds, but they do not have their own blood supply. They may undergo contractures. The donor and recipient skin may not match completely, resulting in cosmetic problems. A flap may contain a single type of tissue or multiple types depending on the tissues contained in the flap It could be bone/soft tissue flap – when bone and the overlying skin are transported to a new location, musculocutaneous flap (muscle and skin flap) – when the area to be covered needs more bulk and an increased blood supply.

Q: What are the indications of flap surgery?

There are several indications for flap surgery to cover open deep wounds in patients with burns or accident victims with major tissue loss and deeper structures are exposed like the bone, cartilage, tendon, joint, major blood vessels or nerves. Flaps may also be used in patients who have undergone surgical removal of the cancer. 

Q: What are the types of flap surgery?

There are several different types of flap surgery methods that may be utilized, depending upon the location of the flap and the structures that need to be repaired or covered. Main types include free flaps and pedicled flaps.

MICROVASCULAR FREE TISSUE TRANSFER:

The flap with its blood vessel is disconnected and then attached to a blood vessel at the recipient site.  (From one side of the body to another side). Microsurgery is used to attach blood vessels.

PEDICLED FLAP: Flap that has its blood supply with at least one artery and one vein. Types of pedicled flaps include the following:

Local flaps are used from adjacent tissues. However, they can only be used for small to medium sized defects, and only locally. 

REGIONAL FLAP: A section of tissue can be used as a regional flap that is attached by a specific blood vessel from another region of the body close to the required area.

Q: What type of work-up is required before flap surgery?

Pre-operative Check-ups and routine tests are ordered a few days before the surgery.

Routine Tests: Blood tests like hemoglobin levels, blood group, and liver and kidney function tests, urine tests, ECG, chest x-ray and detailed assessment of the heart (may be required) in older group of patients, to make sure that they are fit for surgery. Specific Tests: Doppler: The blood supply to the selected donor area is assessed using Doppler. It is a simple, painless test similar to an ultrasound that checks the blood supply to a particular part. Other tests like MRI or CT angiogram have also been used to assess the blood supply to the flap.

Need to avoid smoking cigars, pipes and cigarettes as it may affect the formation of new blood vessels on the flap and wound site. Certain medicines, such as steroids and blood thinners, may delay wound healing. Certain diseases, such as diabetes, carefully control your blood sugar carefully. People with diabetes may have poor wound healing. Admission is usually required a day before the surgery.

Flap surgery may be done under general anesthesia (overnight fasting is required and occasionally intravenous fluid may be required to keep you well) or local anesthesia depending on the extent of the procedure.

Post-operative information of flap surgery

The donor site may also be closed with sutures, with an effort to have a minimal cosmetic effect or a skin graft is placed if necessary. The donor and recipient sites are covered with dressing.

May need to keep in Intensive care unit or high dependency unit for 24 to 48 hours after surgery. Painkillers are prescribed depending on the extent of the pain. Antibiotics are also prescribed to prevent infection. Some flaps may have tubes to drain out excess fluid or blood from recipient or donor sites. For better wound healing and rapid recovery: limit movements such as stretching, to prevent bleeding, shearing, and swelling in the wound and flap sites. Taking vitamins and eating healthy foods high in protein may improve wound healing. 

Q: What are the potential problems of flap surgery?

All operations carry risks, such as bleeding and infection etc. all of these risks will be explained to you in detail before you sign the consent form. Possible complications of flap surgery include Bleeding, Infection, Seroma formation (collection of excess fluid) – required drainage, Wound edges separation (dehiscence), Donor site infection, Seroma formation, graft loss.

Reduced blood supply due to spasm of the feeding artery or development of blood clot in vessel supplying or draining the flap. Venous congestion due to reduced outflow through the veins. If this occurs, it usually happens within the first two days and means that you will have to return to the Operating Theatre to have the cloth removed. Removing the clot is not always successful and, on these occasions, the flap ‘fails and an alternative method of reconstruction sought.

Q: When do you seek care immediately after flap surgery?

If developing fever, swelling at flap site and not going back in, pain at donor or flap site that does not go away, sudden breathing difficulty or shortness of breath, dressing soakage with blood, discharge from flap site or donor site i.e. blood, pus, or a foul-smelling odor.

 

Written by:  Dr. Owais Ahmed

Copyrights: Pakistan association of Plastic Surgeons