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03 / Plastic & Reconstructive Surgery · open

Local flap reconstruction

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.

Part of Plastic & Reconstructive Surgery →4 stages2 complications to knowopen

On the tray for this operation

Test yourself on the tray

Stage

1 / 4

Planning 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.

Watch for: A design whose tip outruns its blood supply

The surgeon asks

What separates a flap from a graft?

Why are we operating?

A local flap moves neighbouring skin, with its blood supply intact, into a defect a graft cannot serve: over bare bone, tendon or implants, or where the face's aesthetic units demand like-for-like tissue. It is the ladder's middle rung, paying for its superiority over grafts with a donor scar and a geometry exercise: the flap must reach without tension and live on its pedicle throughout.

Pulls toward surgery

Defects with exposed bone, tendon or hardwareFacial reconstruction along aesthetic unitsBeds too poor for graft adoptionLike-for-like colour and texture requirements

Gives the team pause

Tension as the silent flap-killerSmoking and radiotherapy taxing the pedicle's physiologyTumour margins unconfirmed beneath a rearranged map

Shared foundations

The reconstructive ladder

The specialty's operating system: for any defect, the simplest reliable reconstruction first, escalating only as the defect demands. Taught once here; the graft and flap pages assume it.

Understand it once, in the specialty hub

Flap physiology & the failing flap

Flaps live on plumbing, and rescuing a failing flap is a race measured in hours: the physiology every ward covering a flap patient must speak.

Understand it once, in the specialty hub

What the surgeon is thinking

  • Planning the flap

    What is being drawn before any incision?

    The whole geometry: the defect's true size (measured after excision, not before), the donor laxity mapped by pinching, the flap pattern (rotation, advancement, transposition) whose arc reaches without tension, and the scar lines laid into relaxed skin tension lines. Planning in reverse, walking the flap from inset back to design, is the discipline.

  • Raising the flap

    What plane, and why does uniformity matter?

    The flap is raised in a consistent plane (usually subcutaneous, deeper by design where named vessels run) because its circulation crosses the base: an uneven flap, thin here and undermined there, has its vascular network randomly amputated. Handling is by hooks and gentleness; forceps crush the very plexus the flap lives on.

  • Transposition and inset

    How is tension actually detected before it kills tissue?

    By look and behaviour at inset: blanching that does not recover, a white edge under closure, sutures cheese-wiring: all announce that geometry has failed physiology. The remedies are mechanical, more undermining, back-cuts, a bigger flap, never hope. A flap inset white stays white.

  • Monitoring

    What is the ward actually watching on flap observations?

    The pedicle's two failure modes: the pale, cool, silent flap of arterial insufficiency and the congested, dark, brisk, oozing flap of venous obstruction, each read against a documented baseline. Local flaps rarely need theatre again, but the congested corner declares itself early to teams that look on schedule.

Decision points

  • Graft or local flap for a nasal defect after cancer excision?

    • Local flap

      Like tissue, own blood supply, contour restored along the aesthetic unit: the face's usual answer when margins are secure.

    • Graft (or healing by secondary intention)

      For superficial defects, graft-friendly beds, or where margin certainty is pending and a simple cover keeps the map readable.

    The bed and the stakes choose the rung: exposed cartilage and aesthetic units argue for flaps; oncologic uncertainty argues for the simplest cover until pathology speaks. Rearranging tissue over an unconfirmed margin is the named error.

  • At 12 hours the flap's tip is dusky with brisk refill.

    • Decompress: release sutures, treat the causes

      Venous congestion responds to mechanical relief: a few sutures out, dressings loosened, the limb or head positioned, and the flap team called while it is early.

    • Observe overnight

      Congestion left to progress becomes tip necrosis by morning: the watch-and-wait answer is right only after decompression, not instead of it.

    Venous failure is the local flap's common enemy and it escalates by the hour: the cheap mechanical moves come first and early. The baseline photograph at inset is what makes 'darker than before' a fact rather than an argument.

Leaving the OR

The handoff

Procedure
Rotation flap reconstruction of scalp defect after tumour excision
Margins
Frozen section clear; formal histology pending
Flap state
Pink, brisk refill at inset; baseline photo in the notes
Watch for
Flap colour and refill per protocol, haematoma beneath, tension at the closure lines

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. POD 0-1Scheduled flap observations against the baseline: colour, warmth, refill. The congested corner found tonight is saved; the one found at breakfast is mourned.
  2. POD 2-5Swelling peaks and settles; small epidermal blisters at the tension points are watched; sutures respected until the schedule says otherwise.
  3. Week 1-2Histology confirmed and the margin conversation closed; sutures out to the site's timetable.
  4. MonthsScar maturation managed with massage, silicone and honesty: flaps settle over a year, and revision decisions wait for the tissue to finish its own argument.
Continue this patient as a case

Watch it done

Find Local flap reconstruction videos on YouTube

What can go wrong

Surgical-site infectionPostoperative bleeding
OR Prep this operationReview the instruments