Skin Flap Surgeries: Repairing Large Skin Defects

Have you ever wondered when there has been severe skin damage, where the skin is missing from a portion of the body, how do patients actually recover, especially if the location of injury is obvious such as the face? One of the possible treatment options is what is known as a skin flap.

A skin flap can be described as the process where a patient needs a skin transplant due to an extensive wound, resulting in missing skin and skin damage. The skin flap is taken from the same patient, and the blood supply is usually not completely severed during relocation. 

There are different types of skin flaps, depending on the severity, location, vasculature, and size of the damaged area. Taking all of this into consideration, the appointed medical professional will provide the most appropriate expertise for optimal patient outcomes and satisfaction.

Introduction to skin flap surgeries

A skin flap is a very well-known and used procedure in plastic and reconstructive surgery, as its main function is to try and cover and/or repair, to some extent, various anatomical defects.¹ Reconstructive and cosmetic surgery is not only used for improving patients' physical health but also their mental health due to the perception of their self-image after certain defects or anomalies appear. The four main methods used for reconstruction are:

• Secondary intention- when wounds are left open after surgery to heal on their own.
• Primary closure- when the skin is closed after surgery.
• Skin grafting- when skin is transferred from one body area to another.
• Skin flaps- a portion of skin is transferred to the damaged location.

Although skin grafts and skin flaps sound quite similar by their definition, there are a few thighs that differentiate between both. When a skin graft is performed, the skin portion that is used for the graft is completely removed from the donor`s site, as any connection to surrounding blood vessels is being severed. Skin flaps, on the other hand, remain attached to the blood vessels at the donor site, which is more advantaged as the tissue is constantly supplied with oxygenated blood, fulfilling metabolic processes.

A procedure that is sometimes considered instead of skin flaps is called skin grafting. However, skin flaps tend to be preferred by patients as the satisfactory outcome of patients who have had a skin flap instead of a skin graft surgery is higher. This is due to the nature of skin flap surgery. Skin flaps are especially preferred in facial reconstructive surgery due to two reasons:

• Cosmetic advantage- the donor skin has a similar structure, colour, and thickness to the site where the flap will be attached. Therefore, this would result in improved physical appearance.
• Increased survival rate- Skin flaps tend to have a higher survival rate than skin grafts.

Skin defects in need of surgery

Skin defects all over the body can be considered for skin flap surgery. Damage to the skin, such as open wounds, oncology-related, extensive burns, etc., can all be appointed for skin flap surgery.² Some of the areas that are most commonly associated with skin flap surgery are the face, torso, hands, and legs. The different types of skin flaps are classified depending on the tissue type, blood supply, and location.

Tissue types can be:¹

• Cutaneous flaps
• Fasciocutaneous flaps
• Musculocutaneous flaps
• Muscle flaps

Based on location, a skin flap can be:

• Free skin flap- skin flaps are located in a different anatomical region. For example, a skin flap from the thigh is collected for an injury in the abdominal region.
• Regional skin flap - that is, flaps that are taken from the same region as the one of the injuries (e.g., the leg). However, the collected skin flap was not located directly adjacent to the site of injury.
• Local skin flap- usually used for facial injuries and defects to the fingertips and limbs. The flap is directly adjacent to the site of injury.

Flap transfer is considered when an injury cannot undergo primary closure, and therefore a different treatment method is required.

Principles of skin flap surgery

Skin flap surgery tends to be a really complicated procedure that should be undertaken with great caution due to possible permanent complications for the patient, such as scarring. Local or general anaesthesia can be used depending on the severity of the wound and the extent and location of the injury. 

A suitable type of skin flap is chosen, after which it is cut and sewn on the injury site. A usual surgery takes between 10 and 12 hours, and great care should be taken for the patient afterwards to ensure there are no further complications. Some of the medical staff involved are nurses, anaesthesiologists, cardiologists, dermatologists, plastic surgeons, etc.

Complications and risk factors

The complications associated with skin flaps are usually separated into two different groups. That has implications concerning the donor site and the recipient site of the skin flap (flap complications).³

• Donor complications- bleeding, potential infection, scarring, functional loss.
• Flap complications- Clot formation, failed flap`s blood supply leading to necrosis (tissue death), the subsequent failure of reconstruction, and aesthetic satisfaction.

Postoperative care and rehabilitation

Statistically, following a skin flap surgery, if there are no flap-related complications after a seven day period, the skin flap is thought to have a higher survival rate. Also, frequent checks for adequate vascular sufficiency and blood supply to the flap should be carried out, especially in local and regional flaps, to ensure positive progress of the skin flap.

If a venous obstruction, e.g., clot formation, is discovered in the blood vessels supplying the flap, medicinal leeches can be used as a temporary solution to break down the obstruction and restore blood supply.⁴ When medicinal leeches are used, a fluoroquinolone antibiotic such as ciprofloxacin is prescribed in order to prevent any subsequent infection transmitted by the leeches.

Some of the risk factors are:

• Infection
• Nutrition 
• Bad blood pressure

Complications of skin flap surgery can include:⁵

• Permanent scarring
• Hair growth or lack of hair growth at the location of the flap
• Numbness
• Pain
• Flap necrosis (death)

Summary

Skin flap surgery is a procedure most commonly used by plastic and reconstructive surgeons. It has been found to have better satisfactory outcomes for patients related to external looks, compared to a skin graft, which is another type of procedure used for skin injuries and remodelling. Also, the survival rate of skin flaps is thought to be higher due to the fact that the portion of the donor`s skin used during the surgery remains attached to its vasculature and, therefore, is constantly supplied with blood and oxygen, maintaining its metabolism. There are possible complications that may arise. That is why careful consideration of the most appropriate type of skin flap for the specific injury is required. Also, a good medical team with a high level of experience is always a great option that puts the patient's mind at ease, even for a little bit. 

FAQs

What is skin flap surgery?

A skin flap surgery is where a healthy portion of the skin is cut along with its blood supply in order to be moved to a portion of the body where there is a skin defect or injury.

When is skin flap surgery performed?

A skin flap surgery is usually performed when there is no option for the site of injury to heal on its own or to be closed up.

How can I get skin flap surgery?

A consultation with a plastic surgeon is required.

Is a skin flap surgery a better option than a skin graft?

Yes. A higher percentage of patients have reported a more satisfactory outcome after a skin flap surgery because of the skin colour and texture match between the donor and the recipient site, as well as less scarring than anticipated.

What are the different types of skin flaps?

There are three different types of skin flaps, each one suitable for a different type of injury. They are Local-, Regional- and Free- skin flaps.