A surgical flap is a technique in reconstructive surgery that involves moving a section of living tissue from one area of the body to another. This transferred tissue maintains its own blood supply from its original location, which is crucial for its survival in the new site. Unlike a skin graft, which relies on new blood vessels growing into it, a flap brings its own vascularity, allowing for the transfer of larger and more complex tissue structures.
Why Flaps Are Used
Surgical flaps are used when a wound or defect is too large or complex for basic closure or a skin graft. They are particularly useful when underlying vital structures, such as bone, nerves, or blood vessels, are exposed and require protective coverage. Flap surgery primarily reconstructs missing tissue after trauma, extensive cancer removal, or other conditions.
Flaps provide stable, well-vascularized tissue for effective repair, especially in areas treated with radiation therapy where surrounding skin may be damaged and slow to heal. This reconstructive approach restores both the form and function of a damaged body part, improving appearance and enabling better mobility or use. For instance, flaps are commonly used in breast reconstruction following mastectomy, offering a more natural look and feel than implants.
Different Kinds of Flaps
Surgical flaps are categorized by how they maintain their blood supply and their proximity to the defect.
Local Flaps
Local flaps involve tissue moved from an area directly next to the wound. This tissue remains attached at one end, allowing it to pivot or slide into the defect while keeping its original blood supply intact. Examples include advancement flaps, which slide tissue forward, or rotation flaps, which rotate a semicircular piece of tissue into the wound.
Regional (Pedicled) Flaps
Regional, or pedicled, flaps use tissue from a nearby area, but not directly adjacent to the defect. This tissue is transferred with a “pedicle,” a stalk containing the blood vessels that keep the flap alive. The pedicle might be tunneled under intact skin or laid over it until a new blood supply establishes itself at the recipient site, after which it can be detached in a second procedure. These flaps are often used for larger defects and can include deeper layers of tissue, such as muscle.
Free Flaps
Free flaps represent the most complex type, where tissue is completely detached from its original (donor) site and transferred to a distant recipient site. The tiny blood vessels supplying the flap are then meticulously reconnected to blood vessels at the new location using microsurgery. Free flaps can be comprised of various tissue components, including skin and fat (cutaneous), muscle (myocutaneous), bone (osseous), or combinations of these, depending on the reconstructive need.
How a Flap is Performed
Flap surgery begins with assessment and planning. The surgeon identifies the defect and selects a suitable donor site based on the tissue needed and its proximity. Imaging may map blood vessels in the chosen donor area, aiding planning.
During the procedure, the surgeon dissects the flap from the donor site, preserving its blood supply. For local and regional flaps, the tissue remains partially attached. For free flaps, it is fully removed along with its supplying blood vessels.
The flap is then transferred to the recipient site. Once positioned, it is secured with sutures. For free flaps, the microscopic blood vessels are meticulously reconnected to recipient vessels at the new site for the flap’s survival. Finally, the donor site is either closed directly or repaired with a skin graft or another small flap, depending on its size and location.
After Flap Surgery
Following flap surgery, monitoring the viability of the transferred tissue is a key concern. Healthcare providers closely observe the flap’s color, temperature, and capillary refill to ensure adequate blood flow. Patients need to rest and limit movement to the surgical areas to allow the flap to establish itself and heal properly.
Healing times vary, but recovery can range from six weeks to three months, depending on the flap type and wound complexity. Potential complications, though rare, include infection, bleeding, fluid accumulation (seroma), or partial or complete flap failure due to blood supply issues. Patients receive detailed instructions on wound care, pain management, and activity resumption, with follow-up appointments to track healing progress.