From the Guidelines
Management of a failing local skin flap requires prompt intervention with surgical debridement and soft tissue reconstruction to prevent further contamination and promote fracture healing. The goal is to provide a robust antimicrobial barrier and a biological environment conducive to healing 1. To achieve this, ensure adequate perfusion by releasing any tight sutures or dressings that may be compromising blood flow. Position the affected area elevated when possible to reduce edema and venous congestion. Apply warm compresses to promote vasodilation and improve circulation to the compromised flap. Avoid any pressure, cold application, or smoking which can further impair blood flow.
Key considerations in managing a failing local skin flap include:
- Ensuring a stable osteosynthetic construct and vital soft tissue envelope 1
- Performing proper debridement, considering implant type and presence of necrotic tissues 1
- Using antimicrobials, such as gentamicin, tobramycin, vancomycin, and clindamycin, for local antibiotic delivery 1
- Achieving optimal definitive soft tissue coverage as soon as possible to prevent further contamination and promote healing 1
- Considering the use of hyperbaric oxygen therapy to enhance tissue oxygenation and pharmacological agents like pentoxifylline and low-dose aspirin to improve microcirculation and prevent microthrombi formation.
In cases of infection, initiate broad-spectrum antibiotics such as amoxicillin-clavulanate, and for severe cases with necrosis, surgical debridement of non-viable tissue followed by reconstruction may be necessary 1. The underlying pathophysiology involves inadequate arterial inflow, venous outflow obstruction, or both, leading to tissue ischemia and potential necrosis. Early recognition of flap compromise is critical, as interventions are most effective within the first 24-48 hours when tissue salvage is still possible.
From the Research
Causes of Failing Local Skin Flap
- Pedicle kinking, hematoma, pressure/tension, systemic patient factors, and poor surgical technique are common causes of failing local skin flaps 2
- Determining the etiology of compromise, including arterial, venous, hematologic, or infectious, is the first step in salvaging a failing flap 2
Importance of Flap Circulation
- Flap circulation is considered the most critical factor for the flap survival 3
- The intrinsic vascularity of a flap is the most important determinant of success 2
Prevention of Flap Failure
- Good surgical techniques, including flap design, delicate tissue handling, and tension-less closure, help reduce the risk of flap compromise 2
- Swift action to restore perfusion or venous outflow through numerous strategies is required to salvage a failing flap 2
Classification and Use of Local Skin Flaps
- Local skin flaps can be categorized based on composition, method of transfer, flap design, and blood supply 3
- Local skin flaps can be used as a reliable source of soft tissue replacement that replaces like with like 3
- Various forms of autogenous skin grafts are to be differentiated from local flaps, primarily on the basis of vascularization 4