Introduction
Successful treatment is the most desired outcome in everyone’s case, especially in the case of plastic surgery, as it is primarily intended to meet the aesthetic needs of an individual. However, the adequacy of a healed surgical site is equally important to esthetics. Providing a favorable environment at the operative site is necessary for a better prognosis. Here, skin flap necrosis is the term given to damaged or hypoxic (lack of oxygen) tissue that has been harvested and placed at the site that needs rehabilitation. The main reason for the skin to be necrosed is due to a lack of oxygen and blood supply to the tissues, which is seen two to four days after surgery. A compromise in the outcome of a successful flap is also seen when there are associated systemic conditions like diabetes mellitus or radiation and habits like smoking.
How Does Skin Flap Necrosis Occur and How Commonly Is It Seen?
A successful skin flap is often associated with a superior blood supply that favors the survival rate and longevity of the above. Although the occurrence of a flap failure is possible in almost all the sites, the common site of skin necrosis is seen concerning the distal end or posterosuperior aspect of the flap. The necrosis of the skin flap is normally seen within two to three days after the surgery as a result of poor blood or oxygen supply, making the flap lose its vitality.
The other possible cause is those that induce tension on the wound when there is a large clot formation or improper surgical techniques that end up damaging the microvasculature at the site of the flap placed, compromising its blood supply at the site, associated medical conditions like atherosclerosis, vascular collagen disease like Raynaud’s syndrome, vasculitis, inflammation of the blood vessels, etc. Apart from the possible medical conditions, a major external cause affecting the outcome of the surgery is “smoking “; all the tobacco products and the nicotine present in them damage the flap up to twelve times more than any other factors damaging it.
What Are the Factors Causing Skin Flap Necrosis?
The potential factors that cause necrosis of the skin flap are:
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The Thickness of the Flap - Thicker flaps are debatably more likely to cause less viability of the tissues than the tinner flaps, where perfusion is easier.
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Habits - Habits like smoking, alcohol, or any nicotine substance decrease the blood flow to the skin of the flap, so it is advised to stop or reduce such habits during the healing period.
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Poor Hygiene - An under-maintained surgical site leads to flap failure as it may result in secondary infection. Hence, care should be taken to debride the wound in adequate intervals and keep the area hygienic.
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Improper Dressing - Wet or unchanged dressing can cause secondary infection.
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Movement - Any movement to the site of flap surgery may disturb the blood supply to the tissue, delaying the healing.
How Is Skin Flap Necrosis Managed?
Management of flap necrosis can be done in two ways: one when it is treated superficially through ointments, lotions, and creams, and the other is through surgical management. Here lets us know the way a skin flap is managed:
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Non-surgical Management of Skin Flap Necrosis: The non-surgical management of skin flap is done by providing a therapeutically inducing blood flow. This is done by locally administering growth factors that favor the longevity of the flap. The agents preferred are vascular endothelial growth factors (VEGF) and fibroblast growth factors (FGF - 2). Usage of estrogen as a supplement also accelerates wound healing, increasing the vitality of the flap. This is followed by limited debrimentation of the necrotic tissues.
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Surgical Management of Skin Flap Necrosis: The surgical management of the flap is done by dissecting the superficial layer of the flap placed, followed by limited debrimentation of the necrotic tissues. Another preferred method is by treating the de-vascularized tissues with hyperbaric oxygen therapy. Hyperbaric oxygen therapy (HBOT) is done by providing 100 percent oxygen to the patient through a hyperbaric chamber, which helps replenish and revitalize the tissue cells, accelerating the process of healing.
How Is Skin Flap Necrosis Prevented?
Necrosis of the skin flap can be a major complication in the case of plastic and rehabilitative surgery and may require extensive debridement of the wound or re-operative surgeries. Hence, proper care and patient education are very important for a favorable outcome. The ways to prevent flap necrosis are:
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An adequate resting period is essential for favorable wound healing.
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Proper dressing and post-operative care are essential as they play a crucial role in preventing reinfection of the surgical site.
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Maintaining hygiene around the area in proximity to the wound, especially from sweat or accumulation of dirt.
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Maintaining a dry area near the dressing site and leaving the dressing undisturbed. The dressing is usually changed once a week post-surgery.
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Avoid smoking for a period of two to three weeks post-surgery.
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Avoid any strenuous physical movements that may injure the flap.
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Avoid applying any un-prescribed creams or lotions that may create redness or itching at the site of infection.
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Patients are advised to have a sponge bath two to three times post-surgery during the initial healing period.
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The site of the flap is gently patted while drying and never advised for vigorous rubbing as it may affect the healing environment, thus affecting the viability of the flap.
Conclusion
Skin flap necrosis is a common procedure carried out as a surgical rehabilitation technique that, when not managed with care, may lead to defective treatment outcomes and complicated healing. Although the factors causing this are predominantly preventable, they help us achieve a successful outcome. Therefore, proper knowledge regarding the prevention, awareness, and management of the disease, on both the patient's and physician's side, might lead to a comfortable treatment and healing process. In order to achieve this, a combination of superior surgical techniques along with thoroughly managed post-operative care prevents flap necrosis from a minor to a major level, resulting in a long and sustainable skin flap.
