Flap Surgery: Classification, Surgical Methods and Recovery

Overview:

A flap is a segment of tissue that is moved from donor site to recipient site while maintaining an intact blood supply. Flaps are present in different shapes and forms. They vary from simple advancements of skin to composites of different types of tissue. These composites comprises of soft tissues like skin, muscle, bone, fat, or fascia. Flaps and grafts are not synonyms. A flap is transferred with its blood supply intact, and a graft is a transfer of tissue without its own blood supply. Thus a success of the graft depends completely on the blood supply from the recipient site.

Skin flaps are performed to help more serious wounds heal, including:

• Surgery after skin cancer
• Wounds that are too big to heal on their own
• After mastectomy or amputation
• Burns
• Skin loss from a serious skin infection
• Venous ulcers, pressure ulcers, or diabetic ulcers that do not heal easily

Criteria for choosing donor sites for flaps are listed below:

• How closely the skin matches the area of the wound
• How visible the scar will be from the donor site
• How close the donor site is to the wound

Classification of flaps:

Many methods have been used to classify flaps. Listed below are the most commonly used classifications based on the following categories: location of donor site, type of tissue to be transferred, and type of blood supply.

• Location of donor site

Local Flaps: Tissue may be transferred from an area adjacent to the defect

The local flaps comprises of the advancement flap (moves directly forward with no lateral movement), the rotation flap (rotates around a pivot point to be positioned into an adjacent defect), the transposition flap (moves laterally in relation to a pivot point to be positioned into an adjacent defect) and the interpolation flap.

The interpolation flap rotates around a pivot point to be positioned into a nearby defect. As a result is that a portion of the flap passes above or below a section of intact tissue, forming a “skin bridge.” This type of flap is intended to be separated from the donor site in a subsequent procedure

Distant Flaps: Tissue transferred from different part of the body

• Tissue to be transferred

Cutaneous flaps: Includes the full thickness of the skin and superficial fascia. Used for small defects

Fasciocutaneous flaps: Comprises of subcutaneous tissue and deep fascia. Used to fill a larger defect.

Musculocutaneous flaps: Contains a layer of muscle to provide bulk that can fill a deeper defect.

Muscle flaps: Constitutes bulk or functional muscle.

Bone flaps: Used to replace bone.

• Type of blood supply

Random Flaps: If the blood supply is not originated from a recognized artery but, comes from many little unnamed vessels.

Axial Flaps: If the blood supply comes from a recognized artery or group of arteries.

Surgical Methods:

It is a method in cosmetic and reconstructive surgery. In this technique a part of tissue is lifted from a donor site and transferred to a recipient site with an intact blood supply. Surgery is preferred if there is tissue loss in any area of the body. This type of plastic surgery is ideally used to reconstruct defects left behind after traumatic injury. Flap techniques are also used successfully in dental procedures, facial reconstruction or breast reconstruction.

Principles of Surgery

One of the basic principles of the procedure is to replace like with the like (muscle for a muscle or bone for a bone). If this is not feasible, the next most similar tissue is used as a substitute. The surgeon should have a sound plan which should be rehearsed well to avoid any mishap during the procedure. The donor site should also be taken care of during the procedure.

Recovery:

The recovery period range from few days (for periodontal procedure) to a year (facial reconstruction). There will be a mild to moderate amount of pain and discomfort associated with the surgery. This should be easily controlled with oral medications.

Categories of Surgery:

• Periodontal Flap

In this is technique the gums are separated from the teeth and folded back temporarily and is used to treat periodonditis.

• Breast Reconstruction

Breast reconstruction helps to reinstate shape to your breast after mastectomy (surgery that removes breast tissue to treat or prevent breast cancer).It usually requires more than a surgery and is a very complex procedure.

• Facial Reconstruction

Facial reconstructive surgery is done in case of skin cancer recovery  and also for aesthetic purposes. It is a very challenging procedure which requires thorough knowledge of skin anatomy and physiology, proper analysis of the defect, contemplative consideration of multiple options for donor tissue, and skillful and diligent soft tissue handling techniques. Cost of flap surgery in India depends on the type of treatment used and the type of hospital opted for. You may get a detailed overview here.

Wound Care:

It is very important to take proper care for the flap and the donor site. Keep the wound free from germs. This reduces the risk of infection. Always keep the wound clean and dry. Limit strenuous activities to avoid bleeding and further complications. Also protect flap site from sun to avoid burning of skin.

Contact your doctor if the following symptoms appear:

• Pain gets severe or does not improve even after taking pain medications
• If you notice bleeding that won’t stop after 10 minutes with mild, direct pressure
• The  dressing comes loose
• Edges of the  flap begin to come up
• You feel something bulging out of the flap site

Immediately contact your doctor if you notice signs of an infection, such as:

• Increased drainage from the wound
• Drainage becoming thick, tan, green, or yellow, or foul smelling
• The body temperature is above 100°F (37.8°C) for more than 4 hours
• Red streaks appear that lead away from the wound

Cost of surgery in India:

The cost of Flap surgery in India depends on the type of flap you are undergoing. For example a periodontal flap may cost from 15000 to 75000 INR where as facial reconstruction and breast reconstruction may range from 60,000 to 2, 00,000 INR.