When is Flap Surgery done?
There are several indications for flap surgery. Flap surgery is necessary to cover open deep wounds in patients with burns or accident victims. It is used when the wound or injury is associated with major tissue loss and deeper structures are exposed like the bone, cartilage, tendon, joint, major blood vessels or nerves.
Flaps may also be used in cancer patients who have undergone surgical removal of the cancer and in whom a plain graft cannot be used. With the replacement of tissue beside skin, a proper contour can be obtained. E.g. Transverse abdominis myocutaneous flap (TRAM flap) is used for breast reconstruction following surgical removal for breast cancer.
What are the Types of Flap Surgery?
Flaps are of two main types, free flaps and pedicled flaps.
Free flap : The flap with its blood vessel is disconnected and then attached to a blood vessel at a recipient site.
Pedicled flap : Flap that has its blood supply with at least one artery and one vein.
What are the Tests done before Flap Surgery?
Tests done before flap surgery include the following:
Doppler : The blood supply to the selected donor area is assessed using Doppler. Doppler is a simple, painless test similar to an ultrasound that checks the blood supply to a particular part. If you are a smoker, you may need to avoid smoking before the test. A gel is applied to the part that needs to be examined and a probe is passed over it. Images are created, which the doctor can observe on the screen. Other tests like MRI or CT angiogram have also been used to assess the blood supply to the flap.
Routine tests : Routine tests which are done before any surgery include:
Blood tests like hemoglobin levels, blood group, and liver and kidney function tests
Urine tests
ECG to study the electrical activity of the heart
Chest x-ray
In older group of patients, detailed assessment of the heart may be required to make sure that they are fit for surgery.
What is the Procedure for Flap Surgery?
Type of Anesthesia - Flap surgery may be done under general anesthesia or local anesthesia depending on the extent of the procedure.If you are under general anesthesia, you will be asleep during the procedure and will not be aware of what is going on.
Pre-operative Check-up -Routine tests as indicated above are ordered a few days before the surgery. Admission is usually required a day before the surgery.
Fasting before Surgery -Overnight fasting is required and occasionally intravenous fluid maybe required to keep you well hydrated. Sedation is sometimes required for good overnight sleep before the surgery.
Shift from the Ward or Room to the Waiting Area in the Operating Room - An hour or two before the surgery, you will be shifted to the operating room waiting area on a trolley.Once the surgical room is ready, you will be shifted to the operating room.
Shift to the Operating Room - The ambience in the operating room can sometimes be very daunting and a small amount of sedation can help overcome your anxiety. From the trolley, you will be shifted on to the operating table. As you look up, you will see the operating light console and at the head end will be the anesthesia machine. There may also be monitors to check oxygen levels, ECG and other vital parameters. A constant beeping sound may be present from the monitors, which may sometimes be irritating.
Waking up from General Anesthesia- If you have received general anesthesia during surgery, once the surgery is over you will wake up and the tube down the wind pipe will be removed. You will be asked to open your eyes before the tube is removed. You will be sedated and the voice of the anesthetist may be faint. Once the tube is out, you may have a cough and sometimes nausea.
There may be a tube going into the stomach called a nasogastric or Ryle’s tube to keep it empty. There will also be an intravenous line. You will remain on oxygen. Once fully awake, you will be shifted on the trolley and taken to the recovery room.
Recovery room - In the recovery room, a nurse will monitor your vitals and observe you for an hour or two before shifting you to the room or ward.
Post-Operative Recovery - You will remain in the hospital for a few days following the procedure. A laparoscopic surgery ensures a shorter recovery time and therefore duration of admission. Light foods may be allowed following the surgery.
Chest physiotherapy maybe started after 24 hours to prevent chest infection.
DVT Prophylaxis - Early movement of your legs and some mobilization prevents DVT or deep vein thrombosis, where a clot is formed in the deep veins of the legs. The clot can travel up to the lungs and can become fatal. Other measures like a small dose of heparin and special stockings may also be used.
Painkillers may be prescribed depending on the extent of the pain. Antibiotics are also prescribed to prevent infection.
In the postoperative period, the flap is regularly evaluated. It is usually kept at a higher level and excess compression is avoided. It is kept covered with a dressing for 48 hours during which time it is not allowed to come in contact with water. Some flaps may have drains to drain out excess fluid. You will have to revisit your doctor after 5 to 10 days for removal of the sutures.
What are the Complications of Flap Surgery?
Possible complications of flap surgery include the following:
Reduced blood supply due to spasm of the feeding artery. This can be avoided by making sure that the artery does not go into spasm during rotation.
Venous congestion due to reduced outflow through the veins
Infection
Bleeding
Partial necrosis of the flap
Seroma formation
Wound separation with eventual partial and/or complete flap loss
Fat necrosis
Donor site infection
