Local flap reconstruction

Why are we operating?

Closing a defect by moving neighbouring skin on its own blood supply, rotation, transposition or advancement, the middle rung of the reconstructive ladder between graft and free tissue.

Indication: Defects too big or too poorly bedded for primary closure or graft, after tumour excision or trauma, where adjacent tissue can be borrowed without new deformity.

The operation in 4 steps

1. 01Planning the flap

   The defect is measured, the laxity and relaxed skin tension lines of the neighbourhood read, and a flap designed, rotation, transposition or advancement, with its base preserving a blood supply.

   Why: A flap is a promise that its base can feed its tip. The design is where that promise is kept or broken: length-to-base ratio, the direction of laxity, and where the donor scar will fall are all decided before the knife.

2. 02Raising the flap

   The flap is incised and elevated in the planned plane, usually subcutaneous or subfascial, handling the tissue by its edges and keeping the base fat and unkinked.

   Why: Every unnecessary pass of the diathermy near the base is a percentage off the tip's survival. The plane is the flap's territory; wandering out of it is how random-pattern flaps lose their pattern.

3. 03Transposition and inset

   The flap is moved into the defect without tension or twist at its base, and sutured in from its tip backward; the donor site closes directly or takes a small graft.

   Why: Tension is the flap's second enemy after ischaemia, and they are the same enemy: a tight inset squeezes the very vessels the design protected. If it will not sit easily, the plan changes, not the pull.

4. 04Monitoring

   Colour, capillary refill and warmth are watched over the first days; congestion or pallor are escalated early, and sutures released at the bedside if the flap tightens.

   Why: Flaps rarely die suddenly; they fade in stages that the eye can catch. A congested flap released tonight survives; one reviewed at tomorrow's round does not.

Anatomy you need

The organ being borrowed from: a local flap is this surface moved on its own blood supply, so laxity and tension lines decide the design.

What can go wrong

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.