How Flap Techniques Are Used in Reconstructive Plastic Surgery

A flap is a piece of tissue that is still attached to the body by a major artery and vein or at its base. This piece of tissue with its attached blood supply is used in reconstructive surgery by being set into a recipient site (injured area onto which a flap or graft is placed). Sometimes, the flap is comprised of skin and fatty tissue only, but a flap may also include muscle from the donor site (the area from which the flap is raised).

Plastic surgeons performing surgery in operating room
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Who Might Need Flap Surgery?

If you have suffered tissue loss over any area of your body, you may be a candidate for flap surgery. This type of reconstructive plastic surgery is typically used to repair defects left behind after traumatic injury or mastectomy. Flap techniques can also produce excellent results in facial reconstruction after skin cancer excision.

Types of Flaps

There are as many types of flaps as there are types of injuries which might require the use of a flap. Flaps come from many different locations and are used in many different ways to accomplish the desired result. However, flaps used for reconstructive plastic surgery can be broken down into two main categories.

Local (pedicled) flap: Tissue is freed and rotated or moved in some manner from an adjacent area to cover the defect, yet remains attached to the body at its base and has blood vessels that enter into the flap from the donor site. The type of flap movement required determines which of the four main types of local flaps is used.

The four major types of local flaps include 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 is different from the others in that it rotates around a pivot point to be positioned into a nearby (but not adjacent) defect. The result is that a portion of the flap passes above or below a section of intact tissue, forming a sort of “skin bridge.” This type of flap is intended to be sectioned (separated) from the donor site in a subsequent procedure.

Free flap: Tissue from another area of the body is detached and transplanted to the recipient site and the blood supply is surgically reconnected to blood vessels adjacent to the wound.

Flap Risks and Complications

Complications possible from flap surgery include general surgical risks such as:

  • infection
  • unfavorable scarring and/or skin discoloration
  • excessive bleeding or hematoma
  • skin or fat necrosis (tissue death)
  • poor wound healing or wound separation
  • blood clots
  • anesthesia risks
  • deep vein thrombosis
  • cardiac and pulmonary complications
  • persistent edema (swelling) or fluid accumulation
  • persistent pain
  • temporary or permanent change/loss of skin sensation
  • unsatisfactory aesthetic results requiring revisional surgery
  • breakage or leaking of the expander

Call your surgeon immediately if you have chest pain, shortness of breath, unusual heartbeats, excessive bleeding.

Why Use a Flap Instead of a Skin Graft?

Because flaps have their own blood supply, they are more resilient than skin grafts and usually produce much better results from a cosmetic standpoint because they can provide a better match for skin tone and texture. Skin flaps are also a better choice when tissue “bulk” is needed to fill contour defects. However, in cases where there have been very large areas of tissue loss, the use of a skin graft may be necessary.

Why Use a Flap Instead of Tissue Expansion?

While tissue expansion can produce superior results in terms of matching skin color, texture, and sensation, it has its disadvantages. Tissue expansion always requires, at least, two surgical procedures, plus repeated visits to your surgeon to further inflate the expander. In the meantime, the expander is left in place, creating what can in many cases be an unsightly bulge under the skin where the expander is placed. However, in the case of breast reconstruction, this extra volume can be desirable.

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4 Sources
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  1. Andree C, Munder BI, Seidenstuecker K, et al. Skin-sparing mastectomy and immediate reconstruction with DIEP flap after breast-conserving therapy. Med Sci Monit. 2012;18(12):CR716-20. doi:10.12659/msm.883598

  2. Patel UA, Hernandez D, Shnayder Y, et al. Free Flap Reconstruction Monitoring Techniques and Frequency in the Era of Restricted Resident Work Hours. JAMA Otolaryngol Head Neck Surg. 2017;143(8):803-809. doi:10.1001/jamaoto.2017.0304

  3. Patel SA, Abdollahi H, Ridge JA, Chang EI, Lango MN, Topham NS. Asymptomatic Deep Peroneal Vein Thrombosis During Free Fibula Flap Harvest: A Review of the Literature, Strategies for Preoperative Assessment, and an Algorithm for Reconstruction. Ann Plast Surg. 2016;76(4):468-71. doi:10.1097/SAP.0000000000000355

  4. Gassman AA, Yoon AP, Maxhimer JB, et al. Comparison of postoperative pain control in autologous abdominal free flap versus implant-based breast reconstructions. Plast Reconstr Surg. 2015;135(2):356-67. doi:10.1097/PRS.0000000000000989

Additional Reading
  • Tschoi M, Hoy FA, Granick MS. Skin Flaps. Clinics of Plastic Surgery; 2005; April; Volume 32(2), p261-273.

  • Basic Principles of Skin Flaps; Fisher J., Georgaide GS, Georgaide NG, Riefkohl R, Barwick WJ; Textbook of Plastic, Maxillofacial, and Reconstructive Surgery. Volume 1, 2nd edition,1992, p 29-40.
  • Interview with Board Certified Facial Plastic and Reconstructive Surgeon, Andrew Jacono, MD, New York, NY.
  • Skin Cancer and Your Plastic Surgeon, Patient Information Sheet, American Society of Plastic Surgeons.