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Introduction

Flap surgeries can be a critical treatment for various wounds to provide bulk tissue. It is a tad more detailed than skin grafts, as it involves a circulatory supply from a donor site to a recipient site. It is important to recognize what flap surgery entails, the indications, and types of flap surgeries. Nurses should be knowledgeable on care plans and assessment for flap surgery, positioning techniques, patient education topics, and how to identify possible complications such as infection or flap dehiscence. Are you ready to dive into the interesting course topic of flap surgery?

Flap Surgery: What is it?

Flap surgery involves removing healthy, live tissue from one location of the body and transporting it to another area that needs it for healing purposes. Flap surgeries are commonly used to transfer this healthy tissue to areas of lost skin, fat, muscle movement, and/or skeletal support (9). A tissue flap has its own system for vascularization and does not depend on the recipient’s wound bed to perfuse the donor tissue, which differs from non-vascularized skin grafts (8). Essentially, a flap is tissue with a substantiated blood supply that is transferred from a donor site to a recipient site. If the flap surgery was a party, the damaged host site would send out an invite saying “BYOB- Bring Your Own Blood-Supply!”

The flap continues to be fed by the same blood supply from where it was taken, until new blood vessels grow from the recipient site and the wound heals completely. The recipient site is called the primary defect and the wound that is created by cutting, lifting, or sliding the flap to fill the primary defect is called the secondary defect (8). The base, or pedicle, of the flap is the tissue that remains attached to the skin adjacent to the defect, it contains the vascular supply required for initial flap survival (8).

Surgeons have used skin flaps to repair wounds and tissue damage for centuries. The term “flap” was derived from the Dutch word “flappe” during the 16th century (8). Around 700 B.C., the Sushruta Samhita (an ancient text on surgery and medicine) first documented a technique of reconstructing a large nasal tip defect with a flap of cheek tissue (8). New techniques are constantly being developed to meet various needs. Flap surgeries are used for a variety of wounds from pressure ulcers to breast reconstruction following mastectomy.

Types of Flap Surgeries 

Flap surgeries are classified in the following ways: (9) 

• Blood supply  

• Type/composition of tissue  

• Distance of the healthy site from the recipient tissue  

• Locations of donor and recipient tissue 

• Movement 

Figure 1: Classification of Flaps 

Classification by Blood Supply 

Flaps can be named based on the supply of blood. The understanding of the circulation of blood to the donor tissue is critical when describing the type of flap. The terms random and axial are used to categorize the blood supply. 

• Random Flaps 

• Not based on a specific vessel 

• Uses subdermal plexuss (network of blood vessels between the deep reticular portion of the dermis and subcutaneous fat tissue beneath it) (7) 

• Axial Flaps 

• Single, direct cutaneous artery in the axis of the flap 

• Named according to the pathway 

Classification by Tissue Type 

Flaps can be named according to their composition. The tissue composition may be skin, fascia, muscle, bone, nerve, cartilage, or a combination. Fascia is the thin lining of connective tissue that surrounds and holds each blood vessel, bone, nerve fiber, and muscle in place (7). Cutaneous refers to the layers of skin. Pedicle flaps are those that are still attached to the original site and the other end is moved to cover the recipient area; a free flap is an area of tissue completely removed from one part of the body and surgically placed in another area (8). 

Common flaps: (5) 

• Skin Flap: Skin and superficial fascia 

• Fascio-cutaneous Flap: Skin and deeper layer of deep fascia 

• Fascial Flap: Deep fascia only 

• Muscle Flap: Muscle only 

• Myo-cutaneous Flap: Muscle and skin 

• Osteomyocutaneous Flap: Muscle, bone, and skin 

• Bone Flaps: Bone (vascularized) 

• Innervated Flaps: Flaps that contain a motor or sensory nerve and function 

Fascio-cutaneous Flap  

This flap includes the skin, subcutaneous tissue, and the underlying deep fascia (5). The musculocutaneous perforators or direct septocutaneous branches of major arteries act as vascular supply (5). Perforator flaps are named based on their location, arterial supply, or the muscle of origin. The indications for fasciocutaneous flaps are based on its advantages of being more simple, reliable, thin, and easily mobilized (8). These flaps can come from many potential donor sites (8). 

Muscle Flap 

Muscle tissue can be used as donor tissue in flap surgery. Surgeons may utilize the benefits of flap surgery in wound closure following major surgeries. For example, median sternotomy (vertical inline incision through the sternum of the chest) is the most commonly used approach for cardiac surgery (6). Cardiac surgeons face the risk of deep sternal wound infections following surgery, which is associated with significant morbidity and mortality rates. The use of soft tissue flaps for sternal closure is helpful for patients with extensive tissue deficits after debridement (6). It can be used for immediate or delayed closure. Options for donor tissue for sternal flap closure include the pectoralis major, rectus abdominis, and latissimus dorsi muscles, or an omental flap (6).  

Remember, flaps are transplanted with blood supply intact, so it’s important to know the supply. For instance, if tissue from the pectoralis major muscle is used, the nurse must recognize that this muscle’s primary and secondary blood supply is the thoracoacromial artery and perforators from the internal mammary artery (6). 

Musculocutaneous Flap 

This type of flap, which includes muscle and skin layers, is often used when the area to be covered needs more bulk and an increased blood supply. Musculocutaneous flap surgery is frequently used to rebuild a breast after a mastectomy (5). 

Bone Flap 

A bone flap is comprised of bone with a vascular supply. An example of this flap surgery is for a surgical site infection (SSI) following a craniotomy; in this procedure, operative debridement occurs, and the bone flap is removed, cleaned, and replaced (4). An alternate therapy for this is titanium cranioplasty (implant instead of native bone flap), which has similar outcomes. 

Classification by Location and Movement 

• Local flap: Donor tissue is located next to the area receiving the tissue; the skin remains attached at one end to allow the blood supply to be left intact (5). 

• Regional flap: Donor tissue is a section that is attached by a specific blood vessel.  

• Distant flap: Donor and recipient tissues are distally located from each other. This flap surgery involves detaching and reattaching skin and blood vessels from one site of the body to another site; microsurgery is used to connect the blood vessels (5).  

Figure 2: Example of Flap Type 

The movement of the flap is also used to describe flap surgery. You may hear terms such as advancement, sliding, rotation, and pivotal. Sliding flaps is when the tissue is moved or "slid" directly into the adjacent defect without "jumping" over other tissue (5).  Advancement flaps are considered simple movements for local flaps and fall within the group of sliding flaps. Pivotal (geometric) flaps include rotation, transposition, and interpolation (5). Local, random pattern flaps are common for the reconstruction of cutaneous defects. 

Image 1: Image of a local flap surgical procedure to cover nasal tip defect/wound (9) 

Indications for Surgery 

There is an incredible breadth of possibilities for flap reconstructive surgery, from small, skin-only defects to large, multi-tissue defects. There is a wide range of etiologies, such as traumatic, oncological, and congenital (9). The transferred tissue flap can contain multiple types of tissue, including skin, muscle, nerve, fascia, and bone (9). The larger the volume of tissue transferred, the greater the need for perfusion. A common indication is the need for a large bulk of tissue. Flaps are helpful when wounds are large, complex, or need large amounts of tissue for closure.  

General Indications: 

• Protection of the greater vessels 

• Correction of congenital defect 

• Abdominal wall reconstruction 

• Deep, gaping wounds 

• Reconstruction after tumor excision 

• Trauma 

• Debridement procedure to remove infected or necrotic tissue 

• Venous ulcers (non-healing) 

• Pressure ulcers (non-healing) 

• Breast reconstruction 

• Rhinoplasty 

• Scar Revision 

• Skin Cancer 

• Burns 

Each type of wound has unique indications. Commonly, skin flap surgery is required when a wound is too big for the edges to be brought together directly, so the flap covers the area and depth of the wound (10).

Risks versus Benefits 

Flap survival depends on factors of blood flow, angiogenesis (formation of new blood cells), vascularization, edema, wound closure tension, postoperative complications (hematoma/seromas) and infection (8). Before the initial incision, the flap is fully vascularized and viable, but once the flap is raised, it is immediately ischemic. The tissue can survive up to 12 to 13 hours of avascularity at 37°F and many research studies have proven it is viable even longer (8). This time is invaluable to preserve the tissue. Sufficient blood flow through attachment of the base of the flap is essential in the initial 24 to 48 hours after surgery (8). There is a risk for loss of tissue with no meaningful contribution to the needed area, along with a new wound. This risk reminds me of a neighbor who once removed carpet from a closet to patch carpet in a bedroom, only to find the cutting was too small and they were left with two gaping carpet holes.  

There is also risk for bleeding, infection, or necrosis at both sites. A recent study found that more than 27% of patients will experience a minor complication (wound dehiscence, infection, fistula, and donor-site problems) after surgery, and 6% of patients will suffer a major complication (flap failure, pneumonia, and cerebrovascular accidents) following surgery (11). Chronic flap complications can also be aesthetic in nature; include scarring, contracture, color/texture mismatch, and lack of hair growth. Patients may experience pain or numbness at the sites on a chronic basis as well (9). 

Most flap surgeries are considered safe with a low complication rate, and surgeons report that flap surgery is not avoidable in certain circumstances. However, the surgery preparation itself and anesthesia presents considerations for elderly patients or those with heart disease, uncontrolled diabetes, smokers, or bleeding disorders (2). Nutrition is a key factor in these surgical procedures. Poor nutritional status has been linked with a greater incident of negative outcomes (11). The healthier the patient is before surgery increases, the chances of reduced complications, so glucose control and weight management are examples of risk reduction strategies. 

Preparing for Surgery 

Patients undergoing flap surgery need an abundance of education on what to expect throughout this procedure. There are many opportunities to optimize patient outcomes before going to the operating room. Preoperative education, for example, has been suggested to have an important, positive effect on clinical outcomes (11). Many patients are also experiencing other issues, such as cancer diagnoses, poor circulation, comorbidities, bed sores, among others. Taking time to holistically prepare each patient is essential.  

Addressing Comorbidities and Other Conditions 

Multiple studies have found an increased surgical complication rate in patients with diabetes mellitus, older age, female gender, malnutrition, anemia, and nicotine intake (11). Prior to surgery, the goal is to improve and optimize the modifiable conditions as much as possible, for instance, reduction in nicotine or improvement in glucose control and anemia. Further, patients with advanced cancer can have hypothyroidism affecting postoperative healing if left uncorrected (11). Non-modifiable factors such as a history of radiotherapy, age, advanced cancer stage, or chronic kidney disease, cannot be altered prior to surgery, but can guide care planning and education following the surgery. 

Adequate nutrition before and after flap surgery has been demonstrated in numerous studies to improve outcomes. An estimated 35% of patients with head and neck cancers present in a state of malnutrition, and the Enhanced Recovery After Surgery (ERAS) Society recommends that all patients undergo a comprehensive preoperative nutritional assessment and consult with nutritionist (11). Improved nutrition status can hopefully yield enhanced wound healing problems and reduction in risk of infection. 

Lab assessment is key to preparation before flap surgery. An example is assessment for anemia prior to surgery. Patients who are anemic at the time of free flap surgery have been found to have poor outcomes (11). Remember, hemoglobin transporting the oxygen to the sites of flap insertion and removal is vital to the survival of the flap. Preoperative hemoglobin values below 10 g/dL have historically been a significant predictor of flap failure and thrombosis (11). A hematocrit level of 30 to 40% with normovolemic hemodilution is ideal to optimize patient outcomes.  

Blood transfusions during or following surgery impacts flap success as well.  Transfusion can increase blood viscosity and immunosuppression, thus leading to decreased blood flow and flap compromise from poor perfusion (11). Studies also show a link between blood transfusions and increased wound infections (11). Steps and treatments should be taken prior to surgery to improve anemia or blood component abnormalities to give these patients a greater chance for successful flap surgery. 

Preoperative considerations should include: (9) 

• Patient age  

• Diabetes status 

• Smoking history 

• Atherosclerosis 

• Peripheral vascular disease 

• Steroid use 

• Previous surgeries 

• The extent and location of the defect 

Providing Preoperative Instructions 

A lack of education, difficulty in understanding complex medical information, fear and anxiety about the surgery, and language barriers are some of the challenges a patient for surgery may have. Patients may also have limited access to reliable health resources or be unable to recall important information due to stress or preoperative medications. As a result, they may not be fully informed about the surgical process, potential risks, and postoperative care.  

Preoperative education list: 

• Assess the patient’s level of understanding. 

• Each facility should have a preoperative teaching program with specific content on surgery, but you must assess if the patient understands this information. 

• Review specific pathology and anticipated surgical procedure.  

• Verify that consent has been obtained / signed. 

• Informed surgical choices and consent for the procedure is required, not only a signature. 

• Use resource teaching materials, and audiovisuals as available on flap surgery and implement an individualized preoperative teaching plan.  

• Preoperative or postoperative procedures and expectations, output (urinary and bowel) changes to expect following surgery, dietary considerations, anticipated intravenous (IV) lines and tubes (nasogastric [NG] tubes, drains, and catheters). 

• Preoperative instructions: NPO guidance prior to surgery, shower or skin preparation, medications to take and hold, prophylactic antibiotics or anticoagulants, anesthesia premedication. 

• Discuss postoperative pain management plan and options.   

• Some patients may expect to be pain-free or are hesitant to take narcotic agents. 

• Provide education and encourage practice of coughing and deep breathing. 

• Confirm and recheck the surgery schedule, patient identification band, chart, and signed operative consent for the surgical procedure. 

• Offer pastoral spiritual care or counseling. 

Post-Operative Considerations 

This section will cover assessment, drains, positioning, and negative pressure wound therapy during the post-operative period. 

Assessment 

Frequent monitoring of free flaps in the acute postoperative period is important. It is strongly recommended that flap assessments are performed at least hourly for the first 24 hours postoperatively, then continued at a reduced increment for the duration of the patient's hospitalization (11). Each facility should have standing orders for flap assessment based on the directive of the surgeon or regulatory body.  

In addition to conventional assessments of flaps (physical exam of flap warmth, turgor, capillary refill, color, and Doppler assessment of the vascular pedicle), many adjuncts have been developed including implantable Dopplers to assess blood flow (11). Assessments should include a head-to-toe physical assessment and a focused wound assessment. A focused cardiovascular (circulation and perfusion) and integumentary assessment is appropriate. Review of lab work indicative of healing status, hemodynamics, and infection should be a priority. Standard post-operative assessments following anesthesia, such as respiratory and orientation, should be performed according to facility protocol. 

Assess circulation of the flap: 

• Color of the flap (dusky, blue, pink, pale) 

• Warmth 

• Dry/Intact? Leaking Fluids? 

• Changes in size 

• Edema 

• Indications of hematoma (sutures over the flap pulling apart, or palpable crepitus beneath the skin) 

Assess amount and type of exudate (drainage): (3) 

• Amount (scant, small/minimal, moderate, or large/copious)  

• Color and thickness: (7) 

• Sanguineous: fresh bleeding  

• Serous: clear, thin, watery plasma 

• Serosanguinous: serous drainage with small amounts of blood noted 

• Purulent: thick and opaque; color can be tan, yellow, green, or brown (this is an abnormal finding and should be reported to physician or wound care provider) 

Use of Doppler to assess deeper circulation of flap: (11) 

• Color duplex ultrasound 

• Near-infrared spectroscopy 

• LASER Doppler flowmetry 

• Implantable Doppler (useful for buried flaps) 

Assess circulation distal to the flap: 

• Capillary refill 

• Color  

• Temperature 

• Pulses  

• Edema 

Drains 

Drains may be used for removal of fluid around both the donor and recipient surgical areas to enhance healing (7). 

Patients may have the following drains after flap surgery: 

• Jackson Pratt (JP) drains 

• JP drains are closed-suction devices that remove fluids from the surgical sites. 

• JP drains contain a flexible bulb that has a plug that can be opened to remove collected fluid.  

• Each time fluid is removed from the JP drain, the nurse should squeeze the air out of the bulb and replace the plug before releasing the bulb.  

• This suction creates a vacuum that pulls fluid into the drainage tubing and bulb. 

• Penrose drains: 

• A Penrose drain is a soft, flexible tube inserted into the surgical site that drains fluid away from the wound bed (7).  

• Nurses should assess the drain and express fluid when appropriate to prevent accumulation. 

Positioning 

The goal of positioning following flap surgery is to promote and improve tissue perfusion. Positioning and elevation of the flap recipient will promote venous return and reduce fluid accumulation to improve tissue perfusion. Activity, exercise, and repositioning improve tissue perfusion. Massage of the erythematous area is avoided because damage to the capillaries and deep tissue may occur (10). Patients should never lay on the wound and extremities should never “dangle” (if the donor or recipient site is on the extremities). Positioning may require creativity when there are multiple drains, NG tube, wound therapy devices, IV tubes, and multiple dressings. Positioning should be free of restrictive clothing and flap sites should be visible for assessment of dressings. It is imperative for the surrounding skin to be sanitary and free of debris.  

Negative Pressure Wound Therapy 

Negative pressure wound therapy (NPWT) is typically used for soft-tissue salvage after the development of complications after flap surgery. For example, NPWT may be applied if an infection occurs in the donor or recipient flap. Immediate postoperative application of NPWT over the flap coverage is not as common (2). However, nurses should be aware of this treatment, the application, and its mechanisms of action. 

NPWT is also known as a wound vac. NPWT uses sub-atmospheric pressure to help reduce inflammatory exudate and promote granulation tissue in an effort to enhance wound healing (4). The idea of applying negative pressure therapy is that once the pressure is lower around the wound, the gentle vacuum suction can lift fluid and debris away and give the wound a fighting chance to heal naturally. NPWT systems consist of a sterile foam sponge applied to the wound bed, a semi-occlusive adhesive cover, a fluid collection system or cannister, and the suction pump (1). The foam sponge is applied to the wound and covered. A fenestrated tube is embedded in the foam, the wound is sealed with adhesive tape to make it airtight, and the machine delivers continuous or intermittent suction, ranging from 50 to 125 mmHg (1). 

Figure 3. Negative Pressure Wound Therapy Visual 

Home Care and Patient Education 

Educating clients and caregivers about wound care and skin integrity empowers them to actively care for their flap sites. With proper wound cleaning, dressing changes, and preventive measures, individuals can confidently perform their own self-care and enhance the healing process. The use of pamphlets, printouts, websites, and referrals to specialists will give the patients a stronger foundation of knowledge. 

• Wound Assessment  

• Teach the patient and caregiver about skin and wound assessment, ways to monitor for signs and symptoms of infection, complications, and proper healing. 

• Signs of Infection 

• Signs of a localized wound infection include redness, warmth, tenderness, and abnormal purulent drainage around the wound. 

• Importance of proper nutrition, hydration, and methods to maintain tissue integrity 

• Adequate caloric intake and balance of protein and essential vitamins has been shown to improve the healing of flaps (3). 

• Dressing changes, wound cleansing, and hand hygiene 

• Methods to prevent skin breakdown 

• The flap surgery is often for the treatment of a deep pressure wound, so education is needed on impaired skin integrity due to friction. 

• Common areas: Sacrum, heels, elbows. 

• Avoidance of raising the head of bed often, causing weight to be applied to sacrum. 

• Importance of turning, mobility, and ambulation 

• Pain management 

• Medications 

• Heat/cold therapy applications and precautions 

• Negative Pressure Wound Therapy devices (wound vac) 

• Home healthcare is applicable for these devices and should be changed by a certified individual, but patients should be aware of basic care and troubleshooting. 

• Drain maintenance 

• Showering restrictions 

• Reduction of stress and tension at wound site 

• Avoid constipation, strenuous movements, and lifting 

• Restrictions vary for location of flaps and per surgeon instructions 

• Follow-up appointments 

Flap Dehiscence or Loss 

Flap dehiscence is a complication in which the incision made to either the donor or recipient site reopens. A flap loss refers to the flap not re-establishing blood flow and surviving, leading to necrosis of the tissue. As we mentioned earlier, the survival of the flap is impacted by blood flow, new vascularization and tissue formation, edema, wound closure tension, postoperative complications (hematoma/seromas), and infection (8).   

Prevention Strategies 

Nurses should apply their basic knowledge on causes of wound dehiscence. Factors that influence dehiscence risk include the ability to synthesize collagen, strength of suture material, closure technique, and stress on the incision, such as coughing, strenuous movement, or obesity (7). Consider areas that have greater stress and tension, such as the abdomen. Dehiscence is most common following abdominal flap surgeries (7). NPWT has been shown to be a great preventative measure for wound dehiscence as studies found a roughly 50% reduction in stress and tension at the incision site with its use (7). This reduction in stress is attributed to the reduction in subcutaneous fluid accumulation and enhanced healing time.  

The location of the flap surgical sites will impact prevention. For example, immobilization and stabilization devices are unique to sites such as the abdomen, chest, extremities, and sacral region. Infection prevention measures for wounds are essential for nursing care. Incisions from flap procedures also have a higher chance of opening if the wound becomes infected (7). Prevention of hematomas is also meaningful, including the use of blood thinners. However, the safety precautions for blood thinners is different for each client. 

Management and Treatment 

It is estimated that 80% of free flaps can be salvaged if dehiscence or compromise is recognized early enough (11). As we mentioned, it is more common for flaps that are removed from (or applied to) the abdomen to open. The following terms describe the depth: 

• Superficial dehiscence: the skin wound alone opens, but the rectus sheath remains intact. 

• Full thickness dehiscence: the rectus sheath fails to heal and “bursts,” with protrusion of abdominal content. 

• This commonly occurs secondarily to intra-abdominal pressure (example: ileus) or poor surgical technique. 

The treatments for flap compromise will be determined by the provider once a cause is identified. Treatment may be a return to the operating room for additional surgical intervention or a simple evacuation of hematoma through suctioning.  

Recovery 

The focus of recovery is the healing and thriving of the flap site and surgical wounds. The time of flap healing varies, and some may heal much quicker than others. There are four phases of wound healing to recognize: hemostasis, inflammatory, proliferative, and maturation (7). 

• Hemostasis. This phase begins immediately after surgery when platelets release growth factors that alert various cells to start the repair process.  

• Inflammatory. This process involves vasodilation so that white blood cells in the bloodstream can move into the wound to begin cleaning the wound bed. Signs include edema and erythema.  

• Proliferative. This phase generally begins a few days after the injury and includes capillary repair and growth, granulation tissue formation, collagen formation, and wound contraction (7). 

• Maturation. During this phase, collagen continues to be created to strengthen the wound and fill in the wound gaps. 

The healing process can be enhanced in many ways, including nutrition therapy, topical agents, compression therapy, and hyperbaric oxygen therapy (HBOT). The recovery process for flap surgery will include management of pain and discomfort, disturbance of body image, impaired skin integrity, swelling, bruising, and gastrointestinal upset.  

Outcomes for recovery should be measurable and achievable. Each patient will have unique recovery goals, integrating comorbidities and psychosocial aspects.  

Examples of Patient Outcomes following flap surgery: (3) 

• Patient safety: Patient will be able to attain safety by maintaining intra- and extra-cellular environment. 

• Healing of wounds: Wounds should heal properly, complications will be prevented or maintained 

• Management of pain 

• Prevention of further damage or skin breakdown 

Conclusion

As discussed throughout this course on flap surgery, nurses are a key team member in the care and survival of flaps. Hopefully you now understand what flap surgery is, the indications, and types of flap surgeries. Critical knowledge includes pertinent assessment, drain or NPWT management, patient teaching, and prevention and management of possible complications.

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