When it comes to pressure injuries, surgical treatment is a last resort. The risks of complications are high – between 11-20%, depending on the type of surgery – and the recovery time is considerable. Yet when conservative treatments have failed, surgery may present the best option for an advanced pressure injury. Flap surgery can cover the wound, replace the damaged underlying tissue, and facilitate healing.
Flap surgery: a background
Flap surgery uses “a piece of tissue that is still attached to the body by a major artery and vein or at its base.” Ideally, the tissue comes from a site on the body (the “donor site”) adjacent to the site on which it is placed (the “recipient site”). That way, the blood vessels enter the flap directly from the donor site, and there is no need to surgically connect blood vessels. The flap may consist of skin and fatty tissue only, or may include the muscle as well. The healthy tissue in the flap takes the place of the diseased and/or removed tissue in the recipient site.
Flap surgery has many different uses, ranging from pressure injury treatment to gum disease treatment to reconstruction after cancer removal surgery.
When does a pressure injury need flap surgery?
Surgery is only considered as an option for advanced stage pressure injuries (stage 3 and 4), explains Dr. Casper Sommeling from Ghent University Hospital, Belgium. Even for advanced pressure injuries, conservative measures will be tried first: changes in support surfaces, repositioning, dressings and other therapies. The goal is to avoid surgery if at all possible.
If all else fails, however, flap surgery will likely come up as an option. Additionally, other related conditions might raise the need for surgery. Osteomyelitis, an underlying infection and inflammation of the bone that can be brought on by infected deep tissue injury, may require surgery to treat.
The patient, however, needs to meet certain criteria in order to be a candidate for surgery. He must have normal healing potential, indicated by serum albumin at or over 2g/dL. He must not have an invasive bacterial infection, indicated by more than 105 m.o./ gram in a debridement specimen from the wound.
The patient must undergo other evaluations – blood count, MRIs to establish or rule out osteomyelitis, proximity of the wound to the bowel and the need for a colostomy – to ensure that the surgery will go as successfully as possible.
Goals of surgery for pressure injuries
Unlike flap surgery for plastic surgery or purely reconstructive purposes, flap surgery for treatment of pressure injuries has much more to accomplish. One major goal is removal of all dead and diseased tissue and bone. Other goals include obliteration of dead space, relieving pressure and achieving a tension-free closure to prevent, among other complications, the recurrence of pressure injuries in this location in the future.
Ideally the flap should be as large as possible, but where it is taken from depends on the size and depth of the pressure injury, the quality and pliability of surrounding skin, the presence of scars or other flaps in the vicinity and the ambulatory status of the patient.
Post-operative management
Flaps must be intensively monitored in the first 24 hours following the surgery, specifically for blood flow issues. For the flap to be viable, it’s critical that blood be moving normally in and out of the tissue. Temperature (within 2 degrees of the rest of the body) and a normal skin color are positive indicators. If there is a problem with arterial blood flow, or inflow, the flap will be white, floppy and cold. If there is a problem with venous blood flow, or outflow, the flap will turn blue.
The patient should be placed on a pressure relieving support surface for 3 to 6 weeks following the surgery, with careful attention to avoid pressure on the surgical site. She should be repositioned every 2 hours. Results from a bacterial culture done during the surgery will determine what type of antibiotics are needed. In order to prevent muscle spasms post-op, antispasmodics will probably be prescribed.
An important part of recovery is getting the patient back to her former level of health and activity as quickly as is safely possible. She should be sitting (not lying down) for at least 30 minutes a day at the beginning, and increasing that amount by about 30 minutes per day, as directed by the medical professional in charge of her care. Any body parts that were not involved in the surgery should be put through a full range of motion, so as not to lose ground. The patient should be given optimal nutrition and a bowel regimen if needed.
Complications of pressure injury flap surgery
Complication rates range from 11-20%, depending on the type of flap involved in the surgery. Complications include hematoma, infection and the wound closure coming apart at the incision site. Surgery needs to be redone in about 8% of cases, often those involving patients with poor blood glucose control or poor nutritional status.
Despite high rates of complications that need to be taken into account and minimized to the greatest extent possible, flap surgery can be a life-changer for patients with advanced pressure injuries. While preventing pressure injuries is certainly the best effort we can make for the health of our patients, fortunately, we do have options for treatment even for very deep and very complex wounds.