Is tissue rearrangement the same as flap closure in wound management?

Tissue Rearrangement vs. Flap Closure: Key Distinctions

No, tissue rearrangement and flap closure are not the same—they represent distinct surgical techniques with different mechanisms, though both involve moving tissue to achieve wound coverage.

Fundamental Differences

Tissue Rearrangement (Local Tissue Advancement)

• Involves mobilizing adjacent tissue without creating a defined pedicle or transferring tissue from distant sites 1
• Includes techniques like undermining, tension-relieving maneuvers, and simple advancement of wound edges 1
• Represents the simplest form of wound closure beyond primary approximation 1
• Does not require maintaining a vascular pedicle or microvascular anastomosis 2

Flap Closure

• Specifically refers to tissue with its own blood supply that is moved to cover a defect 3
• Can be local (rotation, transposition), regional, or free flaps requiring microvascular anastomosis 3, 2
• Includes various types: tensor fascia lata flaps, rotation flaps, muscle flaps, fasciocutaneous flaps, and musculocutaneous flaps 3
• Maintains defined vascular pedicle throughout the procedure 3

Clinical Implications and Outcomes

Recurrence Rates Differ by Technique

• In hidradenitis suppurativa, flap reconstruction showed 0% recurrence compared to 69.9% with primary closure 3
• Rotation flaps demonstrated lowest complication rates (12%) compared to other flap types in pressure ulcer surgery 3
• The width of excision—not the closure technique—primarily influences therapeutic outcomes in radical excisions 3

Wound Size Considerations

• Local tissue rearrangement is more reliable for smaller wounds (<100 cm²) 4
• Free flap reconstruction becomes necessary for larger defects (150-250 cm²) where local tissue is insufficient 4
• Simple tissue rearrangement should be chosen when it is likely to succeed, as it represents the simplest effective method 1

Common Pitfalls to Avoid

Terminology Confusion

• The term "flap" specifically denotes tissue placed over an open wound with maintained blood supply 3
• Do not use "flap" to describe simple wound edge approximation or undermining 1
• Muscle flaps serve specific functions: obliterating dead space, promoting healing, increasing vascular supply, and protecting grafts 3

Inappropriate Technique Selection

• Avoid attempting flap closure in wounds infected with MRSA, Pseudomonas aeruginosa, or multidrug-resistant organisms—these require extra-anatomic approaches 3
• Primary closure and grafts show higher recurrence rates than flap reconstruction in contaminated or previously infected wounds 3
• Perianal, vulvar, and inferior breast locations have inherently higher recurrence rates regardless of reconstruction method 5

Practical Decision Algorithm

For small wounds with adequate adjacent tissue:

• Use local tissue rearrangement with tension-relieving techniques 1
• Provides faster healing and lower cost than complex reconstruction 4

For moderate wounds requiring vascularized coverage:

• Employ local or regional flaps (rotation, transposition) 3
• Muscle flaps specifically indicated when dead space obliteration needed 3

For large defects (>100 cm²) or failed simpler approaches:

• Consider free flap reconstruction with microvascular anastomosis 4, 2
• Accept longer operative times (418 vs. 100 minutes) but comparable outcomes 4

In contaminated or high-risk wounds:

• Flap reconstruction superior to primary closure or grafts alone 3
• Meticulous debridement essential before any definitive closure 3