From the Guidelines
A failing skin flap requires immediate surgical intervention to salvage the tissue, with the primary goal of addressing the underlying vascular compromise and preventing further tissue loss. The first step is to identify and address the cause of the compromise, which is most commonly arterial insufficiency, venous congestion, or both 1. For arterial insufficiency, removing any constrictive dressings, ensuring proper positioning, and maintaining normothermia and adequate blood pressure are essential. For venous congestion, elevation of the flap and removal of any compressive forces are critical.
Some key considerations in managing a failing skin flap include:
- Identifying and addressing the underlying cause of vascular compromise
- Implementing measures to improve tissue oxygenation, such as hyperbaric oxygen therapy 1
- Using pharmacologic interventions, such as aspirin and low-molecular-weight heparin, to inhibit platelet aggregation and prevent thrombosis
- Considering surgical interventions, such as releasing sutures or evacuating hematomas, to restore blood flow and prevent further tissue loss
The timing of intervention is critical, with tissue survival decreasing significantly after 6-12 hours of ischemia, making early recognition and treatment essential for flap salvage. In addition to these measures, prophylactic antibiotics, such as ciprofloxacin, may be used to prevent infection, particularly if medicinal leeches are applied to the flap 1. Overall, a comprehensive approach that addresses the underlying cause of the failing skin flap and incorporates multiple strategies to improve tissue oxygenation and prevent further tissue loss is essential for optimizing outcomes.
From the Research
Causes of Failing Skin Flap
- Intrinsic vascularity of a flap is the most important determinant of success 2
- Common causes of flap failure include pedicle kinking, hematoma, pressure/tension, systemic patient factors, and poor surgical technique 2
- Ischemia-reperfusion injury (IRI) is a complication that can lead to skin flap failure 3
Prevention and Management of Failing Skin Flap
- Good surgical techniques, including flap design, delicate tissue handling, and tension-less closure, help reduce the risk of flap compromise 2
- Determining the etiology of compromise, including arterial, venous, hematologic, or infectious, is the first step in salvaging a failing flap 2
- Swift action to restore perfusion or venous outflow through numerous strategies is required 2
- Various cellular and molecular mechanisms, such as reducing inflammation, promoting angiogenesis and blood perfusion, and inducing apoptosis and autophagy, can be employed to improve skin flap survival 3
Types of Skin Flaps and Their Vascular Supply
- Different types of skin flaps have unique vascular supplies, which is essential for their survival 4
- Knowledge of skin anatomy and flap physiology is crucial for performing adequate reconstruction 4
- Local flaps, such as the "top ten" local "workhorse" flaps, can be used to restore skin integrity when skin grafts are contraindicated 5
Strategies for Improving Skin Flap Viability
- Pharmacological interventions, such as pre/post-conditioning with surgical and pharmacological modalities, can improve skin flap survival 3
- The use of multiple stem cell lineages has emerged as a promising approach to improve skin flap viability 3
- Prevention and management of complications, such as donor and recipient complications, are essential for successful reconstructive surgery 6