Tissue reconstruction with a flap

Disease Description (Causes and Symptoms)

• Definition and indications: Reconstructive surgery that covers skin and soft-tissue defects that cannot be closed with primary closure by transplanting tissue with a blood supply (a flap) from another site. It is needed for trauma, resection of malignant tumors (such as sarcoma and melanoma), crush injuries, and extensive skin cancer excision.
• Summary of pathophysiology: When the defect exposes bone, tendons, joints, or deep tissue, or when blood flow is insufficient, reconstruction through natural healing or a skin graft is difficult. A flap containing blood vessels is used to restore tissue blood flow and structure, thereby providing coverage and restoring function.
• Major clinical symptoms (signs suggesting the need for reconstruction):
  • Extensive skin and soft-tissue defect
  • Exposed bone, tendon, or joint
  • Increased risk of infection at the wound site (large amounts of exudate, redness, warmth)
  • Impaired walking and function due to a defect in an area requiring cushioning, such as the sole of the foot

Treatment Methods

• Treatment goals: To close and restore the skin, soft tissue, and, when necessary, functional structures (tendons, fascia, bone fragments) at the defect site, reduce the risk of infection and necrosis, and promote early functional recovery.
• Main surgical methods
  • Local flap
    • Tissue from an area adjacent to the defect is moved while maintaining its blood supply to cover the defect.
    • Advantages: Similar color and texture, relatively simple, and favorable when primary closure of the donor site is possible.
    • Indications: When the defect is relatively localized and surrounding tissue is available for use.
  • Free flap (microvascular free tissue transfer)
    • Tissue, including its blood vessels, is completely separated from the donor site, connected to blood vessels at the defect site through microvascular anastomosis, and then secured.
    • Advantages: The desired tissue can be selected freely, including the thickness, muscle, and bone fragments, making it advantageous for large defects and functional reconstruction.
    • Disadvantages: Long surgery time, high technical difficulty, and a high risk of complications (anastomosis failure).
• Preoperative evaluation and preparation
  • Confirm the size and depth of the defect; evaluate the condition of surrounding blood vessels (CT angiography, Doppler, etc.); assess general condition and anesthesia risk; and manage nutritional status, diabetes, and blood coagulation status.
  • Smoking cessation is recommended (reduced blood flow increases the risk of necrosis).
• Postoperative care
  • Close observation in the early period (intensive monitoring during the first 48–72 hours): Check signs of blood flow (color, temperature, capillary refill, and Doppler blood-flow sounds), bleeding or hematoma, and signs of infection.
  • Dressing and drainage management; antibiotics are determined according to the risk of infection.
  • Pain control, anticoagulation (a small dose of heparin if necessary), and strategies to maintain blood flow should follow the surgical team’s instructions.
  • Rehabilitation: Physical therapy to preserve joint and muscle function, along with a long-term plan for functional recovery.
• Medications and adjunctive treatment
  • Pain medication, antibiotics if necessary, and medications for transfusion or blood coagulation management (individualized).
• Precautions and risk of complications
  • Flap necrosis (anastomosis failure), bleeding or hematoma, infection, scarring or functional impairment at the donor site, nerve damage, and long-term cosmetic or functional problems.
  • Contact the hospital immediately if abnormal blood flow in the flap is suspected.

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to bring
  • List of currently used medications (including anticoagulants and antiplatelet drugs)
  • Records of previous surgery and anesthesia, and allergy history
  • Copies of recent test results (blood tests, blood glucose, blood coagulation tests, imaging tests, etc.)
  • Photographs of the wound (for comparing diameter and depth), and a record of when symptoms began and how they have progressed
  • Information about smoking and alcohol use, and chronic diseases (diabetes, peripheral arterial disease, heart disease)
• Symptoms to record before the visit
  • Redness, warmth, exudate (amount and color), and whether there is bleeding
  • The nature and changes in pain, and the degree of limitation in motor function
• Example questions (items for the patient to record personally)
  • Time of the last meal before surgery / date smoking cessation began
  • Recent blood glucose control status (fasting blood glucose, HbA1c)

General Example Questions to Ask the Doctor

• "What type of flap (local or free) is recommended in my case, and why?"
• "What are the risks of complications after surgery, and what precautions can reduce them?"
• "How long is the expected recovery period after surgery, and when can I expect to return to daily activities?"
• "Can I continue taking this medication (or anticoagulant)?"

Example Questions Tailored to the Condition

• "How will the blood flow in the flap be monitored in real time (Doppler, clinical signs, etc.)?"
• "If the flap undergoes partial or complete necrosis, what will the next treatment plan be (such as revision surgery or a skin graft)?"