When is a flap procedure recommended for reconstructive surgery?

From the Guidelines

A flap procedure is recommended for reconstructive surgery when there is a need to repair significant tissue defects that cannot be adequately addressed with simpler techniques like primary closure or skin grafts, particularly in cases where functional or aesthetic outcomes are paramount, such as in breast reconstruction following mastectomy, as supported by the most recent evidence from 2022 1.

Key Considerations for Flap Procedures

• The decision to use a flap procedure should be based on the individual patient's needs and the specific characteristics of the defect, including its size, location, and depth.
• The patient's overall health status, including factors such as smoking history and comorbidities, should be taken into account when planning a flap procedure, as these can impact the risk of complications, as noted in the 2015 guidelines 1.
• The choice of flap type depends on various factors, including the defect's characteristics, the patient's anatomy, and the surgeon's expertise, with options including pedicled, free, and perforator flaps, as discussed in the 2014 guidelines 1.
• Preoperative imaging, such as CT angiography or MR angiography, can be useful in planning the flap procedure, particularly for complex cases like deep inferior epigastric perforator (DIEP) flaps, as highlighted in the 2022 update 1.

Benefits and Outcomes of Flap Procedures

• Flap procedures can offer superior outcomes in complex reconstructions by providing a reliable blood supply to the transferred tissue, which can lead to better healing and integration at the recipient site.
• The use of flap procedures can also improve functional and aesthetic outcomes, particularly in cases where simpler techniques are not sufficient, such as in breast reconstruction following mastectomy, as supported by the evidence from 2017 1.
• However, flap procedures can be associated with increased morbidity and complications, particularly if not properly planned and executed, emphasizing the need for careful patient selection and surgical expertise, as noted in the 2024 evaluation 1.

From the Research

Indications for Flap Procedure

A flap procedure is recommended for reconstructive surgery in the following situations:

• Exposed vital structures after tumor resection 2
• Wound bed unsuitable for skin grafting 2
• Planned postoperative radiation 2
• Compromised grafts or flaps due to poor wound beds, radiation, random flap necrosis, vascular insufficiency, or ischemia-reperfusion injury 3, 4
• Traumatic avulsions and amputated composite tissues 3

Benefits of Flap Procedure

The benefits of a flap procedure include:

• Providing immediate coverage of large surgical defects after tumor resection 2
• Allowing wide tumor resection that improves palliation and chance for cure 2
• Tolerating postoperative radiation well and not obscuring recurrence if careful follow-up examination is given 2
• Enhancing graft and flap survival by increasing oxygenation, improving fibroblast function, stimulating angiogenesis, and inhibiting ischemia-reperfusion injury 4

Complications and Salvage

Complications can occur after a flap procedure, including:

• Wound breakdown 5
• Flap loss 2, 6
• Thrombosis 6 Salvage options are available, including hyperbaric oxygen therapy 3, 4, vascular reanastomosis 6, and reconstruction with a pedicled flap 6