Flaps: An invaluable Tool for the Reconstructive Surgeon

While treating a wound, the reconstructive surgeon has many options. These options are traditionally described in terms of a reconstructive ladder (Fig 1). The lower rungs of the ladder are occupied by simple measures such as stitching the wound or allowing it to heal on its own. Flaps occupy the higher rungs of this ladder and are the most robust forms of reconstruction. They are invaluable when encountered with a complex defect.

So, what are ‘flaps’? In simple terms ‘flap’ is when a tissue is moved along with its blood supply. Or in other words, the moved tissue brings vascularity along with it. Vascularity is important because it carries nutrition, wound healing cells as well as antibiotics to the wound, aiding its healing. This is in contrast to ‘graft’ which is another common surgery used for wounds. ‘Graft’ by definition is when a tissue is moved without its blood supply. Therefore a graft is dependent on the wound bed to derive its nutrition and survival, whereas a flap can survive on any wound bed.

Not all wounds need a flap. Some wounds can be closed with stitches, some can be closed with a skin graft. A simple rule of thumb dictates that flaps are needed in wounds with exposed bare tendons, nerves, bones or hardware. If the wound bed is made up of muscle or healing tissue (granulation tissue) a skin graft may suffice as it can support the graft. Any wound bed that cannot sustain a graft would need a flap.

Flaps can be ‘harvested’ from various areas. The tissues can be moved locally as a ‘local flap’ (Fig 2), or from the same extremity as a regional flap (Fig 3), or from other parts of the body as a ‘distant flap’ (Fig 4). In some instances, the tissue can be completely separated and then its blood vessels reattached to the wound site- called a free flap (Fig 5,6; Video 1). Free flaps require attaching the flap’s tiny blood vessels at the wound site. These vessels are typically 1-3mm in diameter and are stitched under a microscope with very fine sutures that are almost invisible to the naked eye. Flaps can be made up of different tissues such as skin, muscle, fat, bone or a combination of the above.

Flaps have many advantages. As mentioned previously, flaps can be applied irrespective of the wound's vascularity. Flaps can also be done to provide sensation and in some cases function. They are more robust and resistant to infection than grafts. They are truly invaluable when coverage over an implant is needed. The drawbacks of a flap is that surgery is more complex. The tissues taken as a flap seldom produce any significant functional loss, but would leave scars at otherwise normal parts of the body. Sometimes the ‘donor’ site may need a skin graft for closure.

Flaps are an integral and invaluable part of the reconstructive surgeon. Various flaps are done for defects of the hand and upper extremity depending on the wound size, location, components requiring restoration and patient’s condition.

Figure legends

Fig 1: Reconstructive ladder.

Reconstructive Ladder

Fig 2: Local flap done for a wound on back of thumb following an infection. Tissues adjacent to the wound were moved (as shown by the arrow) to cover the defect.

Local flap done for a wound on back of thumb following an infection

Fig 3: Regional flap done for a hand defect due to a gunshot wound. Tissues from the back of the forearm were moved (As shown by blue arrow) to cover the defect. This flap is called posterior interosseous flap.

Regional flap done for a hand defect due to a gunshot wound

Fig 4: Distant flap was done to cover an elbow defect following an infection. Tissues were moved from the abdomen and attached to the elbow. The elbow was left attached to the abdomen for 3 weeks following which it was separated In a second surgery.

Distant flap was done to cover an elbow defect following an infection

Fig 5: Free flap was done to cover a defect on the dorsum of the hand sustained after forklift injury. Tissues from the arm were detached and reattached to the dorsum of the hand with stitching the blood vessels. This flap is called lateral arm free flap.

Free flap was done to cover a defect on the dorsum of the hand sustained after forklift injury

Fig 6: Free flap was done to cover a defect on elbow and forearm following an infection. Tissues from back were used to cover the defect by a flap called Latissimus dorsi myocutaneous flap.

Free flap was done to cover a defect on elbow and forearm following an infection

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