How Flap Techniques Are Used in Reconstructive Plastic Surgery

A flap is a piece of tissue 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).

This article will review why a flap procedure may be used, as well as the different types of flaps and potential complications from the surgery.

Plastic surgeons performing surgery in operating room
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Purpose

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 commonly used to repair defects left behind after traumatic injury or following surgical removal of cancer.

These can include:

  • Flap surgery for breast reconstruction following mastectomy
  • Repair following surgery for head and neck cancers
  • Filling in tissue following a complex skin cancer surgery

Types of Flap Procedures

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.

Pedicle 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.

  • Advancement flap: The flap moves directly forward with no lateral movement
  • Rotation flap: The flap rotates around a pivot point to be positioned into an adjacent defect
  • Transposition flap: The flap moves laterally in relation to a pivot point to be positioned into an adjacent defect
  • Interpolation flap: 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 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.

Potential 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

Flap-specific complications can include:

  • Tissue rejection
  • 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 heartbeat, or excessive bleeding.

Summary

Flap reconstructive plastic surgery is a way to fill in tissue and repair areas of the body that have been significantly affected by trauma or major surgical operations, such as cancer removal.

Multiple types of flap procedures can be done, with each having certain benefits for the area of the body where the surgery will be done.

The surgery is not without risks, which should be discussed with the plastic surgeon before having the procedure.

A Word From Verywell

Living through a traumatic experience or having a major surgery that leaves you with a physical defect can be emotionally difficult. Flap surgery may be a way for you to improve the way you feel about yourself. It's important to research plastic surgeons well, and find one that is specialized in the type of surgery you need.

Frequently Asked Questions

  • What is the difference between a flap and 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.

  • What is the difference between a flap and a tissue expander?

    While tissue expansion can produce superior results in terms of matching skin color, texture, and sensation, it has 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.

11 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  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. Chorath K, Go B, Shinn JR, et al. Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis. Oral Oncol. 2021;113:105117. doi:10.1016/j.oraloncology.2020.105117

  3. Swendseid BP, Roden DF, Vimawala S, Richa T, Sweeny L, Goldman RA, Luginbuhl A, Heffelfinger RN, Khanna S, Curry JM. Virtual surgical planning in subscapular system free flap reconstruction of midface defects. Oral Oncology. 2020; 101. doi: oi.org/10.1016

  4. Yellinek S, Krizzuk D, Moreno Djadou T, Lavy D, Wexner SD. Endorectal advancement flap for complex anal fistula: does flap configuration matter? Colorectal Dis. 2019;21(5):581-587. doi:10.1111/codi.14564

  5. Christopoulos G, Deraje V, Mbaidjol Z, Kannan RY. The “snail flap”: a rotation flap in scalp reconstructionPlast Reconstr Surg Glob Open. 2020;8(1):e2599. doi:10.1097/GOX.0000000000002599

  6. Taş S. Superior-based transposition flap: a novel technique in rhinoplasty. Aesthet Surg J. 2019;39(7):720-732. doi:10.1093/asj/sjy197

  7. Abdelmofeed AM, Salama RS. Different modalities of nasolabial flaps in nasal-defect reconstruction: clinical experience in 40 cases and review of literature. The Egyptian Journal of Surgery. 2021;40(4):1192. doi:10.4103/ejs.ejs_191_21

  8. 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

  9. 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

  10. 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

  11. MacKay BJ, Dardano AN, Klapper AM, Parekh SG, Soliman MQ, Valerio IL. Multidisciplinary application of an external tissue expander device to improve patient outcomes: a critical review. Adv Wound Care. 2020;9(9):525-538. doi:10.1089/wound.2019.1112

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.

By Julie Scott, MSN, ANP-BC, AOCNP
Julie is an Adult Nurse Practitioner with oncology certification and a healthcare freelance writer with an interest in educating patients and the healthcare community.

Originally written by Natalie Kita