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Flaps

Last updated June 1, 2021

Written by: Lester Fahrner, MD

Reviewed by: Lester Fahrner, MD

Approved by: Krish Tangella MD, MBA, FCAP

Reconstruction of skin defects with Flaps consists of a family of procedures with a common, complex goal.


Background Information:

What are the other Names for the Procedure?

  • Advancement Flaps
  • Pedicle Flaps
  • Reconstruction with Flap Surgery

What is Flaps surgical procedure?

Reconstruction of skin defects with Flaps consists of a family of procedures with a common, complex goal. The defects from skin cancer caused from Mohs micrographic surgery and other techniques, as well as trauma, can be large. Traditional suturing techniques are inadequate to restore the important functional and cosmetic components to the involved structures.

By creating, moving, and suturing Flaps, the surgeon can:

  • Fill deep defects in the skin
  • Avoid placing tension on the skin that would distort eyelids, corners of mouths, the openings of the nose, and so on
  • Match the texture, thickness, and color of the surrounding skin by using skin from within the same region
  • Move skin with an intact blood supply, arterial blood in and venous blood out, unlike a skin graft
  • Plan a graft, which can move more lax, and mobile skin into sites where the skin is bound down. An example of this is using cheek skin on a Flap to cover a nose defect
  • Move some of the suture lines to the lateral sides of the face where they are less noticeable. When we intently observe each other, most of our visual attention is focused on the central face - the eyes, nose, and mouth

What part of the Body does the Procedure involve?

The Flaps procedure frequently involves the structures of the head and neck. Flap surgery techniques are routinely used for difficult and complex skin closures anywhere on the body.

Why is the Flaps surgical procedure Performed?

There could be a variety of reasons for performing Flaps procedures. Some of these include:

  • Reconstruction of skin cancer defects
  • Reconstruction of traumatic injuries

What are some Alternative Choices for the Procedure?

Some of the alternative choices for Flaps include:

  • Skin grafting-full thickness or split thickness
  • Second intention healing
  • Prosthetic devices for restoration

What are the Recent Advances in the Procedure?

Some of the recent advances include innovative modifications of traditionally conceived Flaps.

What is the Cost of performing the Flaps surgical procedure?

The cost of the Flaps procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

  • It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Flaps procedure and what needs to be done
  • If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
  • Also, if the procedure involves multiple steps or has many alternatives, the patient may seek a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://www.aad.org/ (accessed on 05/16/2021)

https://www.mohscollege.org/ (accessed on 05/16/2021)

https://www.mohssurgery.org/ (accessed on 05/16/2021)

Prior to Flaps surgical procedure:

How is the Flaps surgical procedure Performed?

An extensive knowledge of head and neck anatomy and the structure and function of the various cosmetic subunits of the face is required. A very high level of surgical skill is required.

The Flaps procedure is performed in the following manner:

  • The many options for creating a Flap to close a defect are considered
  • The Flap design is drawn on the skin with a surgical marker
  • The lines are incised, and the base of the skin constituting the Flap is excised off the underlying subcutaneous tissue
  • All bleeding points are controlled with electrocautery or sutures
  • The Flap is draped into the defect
  • Deep and superficial sutures are placed to hold the Flap in the desired position

Where is the Procedure Performed?

The Flaps procedure is usually performed in a clinic surgical suite, an outpatient surgical suite, or a hospital operating room.

Who Performs the Procedure?

The Flaps procedure is usually performed by the dermatologist, plastic surgeon, head and neck surgeon (ENT), or oral and maxillofacial surgeon.

How long will the Procedure take?

The Flaps procedure usually takes about two hours or more. 

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the procedure and helps avoid complications.

  • Provide medical history such as diabetes, hypertension, heart disease, etc. (if any)
  • Provide a complete list of medications you are currently taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
  • If you are allergic to any specific medication or food items
  • If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
  • Any medical or family history of bleeding disorders or blood clots
  • If you have ever been diagnosed with blood clots in your leg (deep vein of lung)
  • Any unusual effects of anesthesia from prior surgery thrombosis) or lung (embolism
  • A list of all previous surgical procedures you have undergone, like for example - removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.
  • Information about any implanted electronic devices such as pacemakers, defibrillators, implanted pain control devices, deep brain stimulators for Parkinson’s Disease or seizures
  • Any artificial joint replacements

What Preparations are needed, prior to the Procedure?

The physician performing the procedure will evaluate the patient prior to the procedure and discuss the details with risks for complications and obtain his/her permission (termed informed consent).

  • Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
  • Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
  • Blood work, glucose, and pregnancy tests (if applicable) will be undertaken per physician recommendations
  • If anesthesia team is involved in the procedure, then they too will discuss details of anesthesia with risks for complications and obtain permission from the patient (informed consent)
  • Avoid application of any deodorant or topical medicines on the area, prior to the procedure
  • It is advisable to quit smoking and the use of any nicotine based products, for a while, before the procedure
  • Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
  • Generally, the patient is required to be on fast (no solids or liquids) for at least 8 hours prior to the procedure
  • Individuals with diabetes, hypertension, or other cardiac conditions, are required to discuss these (including medications taken) with their attending physician(s) well in advance
  • For individuals with diabetes, it is important that the blood sugar stays within the normal range; if not, their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

Pregnant women and individuals with severe underlying sicknesses are advised to notify the surgical team of their health status, before they undertake this procedure.

What is the Consent Process before the Procedure?

The physician will obtain permission for the Flaps procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the Flaps surgical procedure?

In many cases, no tests are typically necessary prior to the Flaps procedure. However, if required, the healthcare provider may recommend the following tests such as:

  • Blood and urine tests checking overall health status and the risk of bleeding complications
  • Imaging studies, if indicated

What are some Questions for your Physician?

Some of the questions that you might ask your healthcare provider are as follows:

  • What is the Flaps procedure?
  • Why is this procedure necessary? How will it help?
  • How soon should I get it done? Is it an emergency?
  • Who are the medical personnel involved in this procedure?
  • Where is the procedure performed? 
  • What are the risks while performing the procedure?
  • What are the complications that might take place during recovery?
  • How long will it take to recover? When can I resume normal work?
  • How many such procedures have you (the physician) performed?
  • Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
  • What are the costs involved?

During the Flaps surgical procedure:

What kind of Anesthesia is given, during the Procedure?

Local anesthesia by injection, and occasionally, general anesthesia by injection and inhalation are administered for the procedure.

How much Blood will you lose, during the Procedure?

The amount of blood loss is generally controlled and depends on the type of surgical approach adopted and the size of Flap required.

What are the possible Risks and Complications during the Flaps surgical procedure?

There are general factors that increase one’s risk of getting complications during the Flaps procedure, which include:

  • Obesity: Generally greater the degree of obesity, greater is the surgical risk
  • Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
  • Advancing age
  • Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
  • Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
  • Poorly functioning liver, as evidenced by increased blood liver function tests
  • Hypertension (increased blood pressure), especially if it is poorly controlled
  • Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
  • Poor lung function, as evidenced by abnormal lung function tests
  • History of bleeding disorders
  • Poor immune system due to a variety of causes

Some of the possible risks and complications that may arise during a Flaps procedure include:

  • Infection
  • Bleeding
  • Injury to the neighboring structures
  • Pain
  • Discomfort
  • Anesthetic complications
  • Need for further procedures
  • Pneumonia
  • Blood clot formation, affecting blood supply to the buttocks and lower extremities
  • Heart problems

What Post-Operative Care is needed at the Healthcare Facility after the Flaps procedure?

At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise. However, immediately following the surgery, the patient may be kept in a recovery unit for observation.

After the Flaps procedure:

What are the possible Risks and Complications after the Flaps surgical procedure?

The risks and complications that may arise after Flaps include:

  • Excessive bleeding that may sometimes require an additional surgical procedure
  • Any symptom that causes uneasiness such as nausea and dehydration
  • Low-grade fever
  • Infection of the surgical wound
  • Blood or serum accumulation under the Flap, which can compromise the survival of the Flap

What is the Prognosis after the Surgery?

In most cases, the prognosis after a Flaps procedure is typically excellent.

When do you need to call your Physician?

Do contact your physician or call 911 (or your local emergency number) based on the seriousness of any of the following symptoms:

  • Fever and chills
  • Severe pain
  • Shortness of breath
  • Bleeding or fluid discharge from the surgical wound
  • Nausea and vomiting
  • Signs of infection
  • Severe fatigue
  • Dizziness

What Post-Operative Care is needed at Home after the Flaps surgical procedure?

At home, the following post-operative care is recommended after a Flaps procedure:

  • Follow the printed guidelines provided by the respective healthcare provider(s) meticulously
  • Take the prescribed medications following the procedure
  • Avoid any strenuous activity for a period recommended by the physician
  • Do not drive (post-procedure) for a period of 24 hours
  • Avoid smoking or drinking alcohol post-procedure
  • Continue old prescribed medications after checking with your healthcare provider
  • Avoid sex until complete healing has taken place (under advice by the physician)
  • Do not sign any legal documents post-procedure for a period of 24 hours

It is important to note that the post-operative guidelines for care may vary greatly among reconstructive surgeons.

How long does it normally take to fully recover, from the Procedure?

A complete recovery from the procedure may take about several weeks to 3-4 months. During this time, the scarring process and remodeling occurs. Slight variations from optimal can be repaired with small brief procedures to obtain an optimal cosmetic result.

Additional Information:

What happens to tissue/samples (if any), taken during the Procedure?

The procedure does not involve the surgical removal of any tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Flaps procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

  • The outpatient facility or hospital
  • The surgeon who performed the Flap Surgery
  • An anesthesiologist (if anesthesia was administered)

The patient is advised to inquire and confirm the type of billing before the Flaps procedure is performed.

Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: June 1, 2021
Last updated: June 1, 2021