CHAPTER NINE

### CHAPTER OBJECTIVES

After studying this chapter, the learner will be able to:

1. Describe a pedicled and a free flap.

2. Assess and determine an appropriate classification for a specific flap.

3. Distinguish the vascular anatomy of the skin, muscle, fascia, and perforator flaps.

4. Integrate the concepts of angiosomes and venosomes and their effects on flap design.

5. Discuss flap physiology, including delay phenomenon and tissue expansion.

6. Assess and monitor a flap for tissue viability.

7. Recognize common flap complications.

8. Define the types of skin grafts.

9. Recognize skin anatomy relevant to flaps.

10. Integrate skin graft healing physiology into a plan of care.

11. Recognize signs of graft failure.

12. Explain relevant elements of donor site selection.

### INTRODUCTION

Primary closure of a surgical wound is the simplest and fastest way of reapproximating wound margins. However, in many instances it is neither feasible nor desirable to close a wound with this method. Using only principles of moist wound healing can result in a wound being left open to heal by secondary intention. Primary closure results in minimal scarring and reepithelialization; wounds left to heal by secondary intention may have more extensive scarring with subsequent contraction and deformity.

When there is a relative or absolute soft tissue deficit appropriate for coverage, a flap or skin graft can be used to fill the defect. The extent of the deficit and its location, among other factors, dictate the type of coverage needed. The first section of this chapter discusses and illustrates different types of flaps, followed by a succinct description on flap monitoring and common complications. The second section demonstrates the principles of skin graft along with its usual applications.

While this chapter is not an exhaustive reference on the subject, it is intended to be comprehensive to wound care providers, focusing on essential concepts related to flaps and grafts that will help the clinician understand the indications and postoperative care. For those readers who require more detailed information on the topics presented in this chapter, a thorough reference list is provided for further study.

### FLAPS

#### Definition

A flap is a unit of vascularized tissue that may be transferred from one part of the body to another.1 It can be more simply defined as specific tissue that is mobilized on the basis of its vascular anatomy.2 A flap may contain a single tissue or a combination of tissues. Examples include skin, muscle, fascia, fat, bone, tendon, nerve, or a combination of tissues. A flap may also be comprised of enteric components such as jejunum, colon, stomach, or omentum. The critical concept to understand about flaps is the relationship to its blood supply, which is necessary for the flap to survive. Because of the thickness and/or composite nature of flaps, the tissue being transferred cannot initially survive by diffusion from the recipient bed; it must have its ...

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