Flap Selection

Core Principles

• Choose the simplest reliable option (“reconstructive elevator”)

• Prioritise:

  • Vascularity

  • Stability

  • Durability

Not always “ladder step-by-step”—go directly to best option

Key Factors in Flap Selection

1. Defect Characteristics

• Size (small / moderate / large)

• Depth (skin vs exposed bone/hardware)

• Location (critical)

2. Zone of Injury

• Tissue around defect may be:

  • Contused

  • Ischaemic

• Avoid using compromised local tissue

3. Patient Factors

• Comorbidities (diabetes, smoking)

• Vascular status

• Overall condition

4. Available Expertise

• Microsurgical capability

• Institutional resources

Reconstructive Options

1. Primary Closure

• Small, clean defects

• No tension

2. Skin Grafting

• Superficial defects

• Requires well-vascularised bed

3. Local Flaps

• Tissue adjacent to defect

• Maintains native blood supply

Advantages:

• Simpler

• No microsurgery

4. Regional Flaps

• Tissue transferred from nearby region

• Pedicled vascular supply

5. Free Flaps

• Tissue transferred with microvascular anastomosis

Indications:

• Large defects

• Distal limb injuries

• Poor local tissue

Flap Types

Muscle Flaps

• Highly vascular

• Fill dead space

Best for:

• Contaminated wounds

• Infection risk

Fasciocutaneous Flaps

• Better contour

• Less donor morbidity

Best for:

• Superficial defects

• Aesthetic areas

General Selection Strategy

Small, superficial defect
→ Primary closure / skin graft

Moderate defect + good local tissue
→ Local or regional flap

Large defect / exposed bone or implant
→ Free flap

Compromised local tissue
→ Avoid local flap → consider free flap

Special Considerations

• Exposed hardware → requires vascularised tissue

• Contaminated wounds → favour muscle flaps

• Distal limb → often free flap required

Complications

• Flap necrosis

• Infection

• Donor site morbidity

• Need for revision surgery

Prognosis

• Strongly dependent on:

  • Flap selection

  • Timing of coverage

  • Quality of debridement

Pits & Pearls

• “Right flap, right time, right patient”

• Muscle flaps are better for infection control

• Free flaps are the most reliable for large defects

• Always assess zone of injury before planning

Pitfalls

• Choosing flap based only on size

• Using compromised local tissue

• Delaying coverage

• Ignoring patient vascular status