General Surgery - Free flap for limb injury

What is a free flap?

A free flap is block of “spare" tissue from a part of your body that is at a distance from your limb injury.

This block of tissue can include muscle, fat and skin with blood vessels. Common places for this block of tissue to come from are your thighs, your calves, or your back.

Why am I having a free flap?

You have been offered a free flap reconstruction of your limb injury because the incident that led to your injury has caused a skin and soft tissue defect on your limb, which cannot be directly closed or covered by another method at present. There is also possibly a fracture of the bone underneath the defect, sometimes with bone loss. If this defect and the underlying structures are not covered, there is a high risk of infection that could become limb or life threatening.

What does the operation involve?

You will meet with an anesthetist who will discuss the risks and benefits of a general anesthetic and assess your suitability for the operation. Once you are asleep under a general anesthetic, we will place a catheter into your bladder to monitor the amount of urine you produce during and after the operation. As you cannot get out of bed for the first few days after the surgery, we may offer to leave the catheter in place during that time for your convenience.

During the operation, that can last between 6 and 8 hours or longer if we encounter any difficulties, there may be several surgeons working at the same time. We will simultaneously prepare the injured limb to receive the free flap and possibly fix any bony fractures and to prepare the free flap. Please speak with your orthopaedic surgeon if you have any questions relating to your bony injury.

Once everything is prepared, we will perform microsurgery using a microscope and special instruments to attach the blood vessels from the free flap to your injured limb to keep the free flap alive. This is a very delicate surgery that will need close monitoring afterwards.

Finally, we may need skin grafts or local flaps to cover any remaining defects either on your injured limb or from where we have taken the free flap from.

A skin graft is a thin shaving of skin from another part of your body that we use to cover some wounds. The area that we take the shaving of skin from will heal by itself over the next few weeks.

A local flap is a block of tissue that is close to the defect we are trying to cover that is moved to cover the defect.

What are the other options?

If a free flap has been suggested to you, but you have declined the procedure, the defect on your limb may be covered with an appropriate dressing. Other reconstructive options may then be discussed However, during this waiting time, despite antibiotics, there can be a risk of infection and if this infection should become severe, you may require an amputation of the limb to save your life.

What are the risks of a free flap reconstruction surgery?

There are general risks associated with any surgical procedure, including bleeding, wound infection, adverse scarring, altered sensation in and around the wounds, and pain. There are also risks associated with a long general anaesthetic such as blood clots and death (please speak with your anesthetist for further information).

Specific risks associated with this procedure include damage to surrounding structures such as nerves and blood vessels. If the blood supply to your arm/leg has been damaged in the accident, then there is a risk that this blood supply may be affected by the free flap surgery. If this happens, there is a risk of losing your limb. If the blood supply to the free flap blocks off after the operation you may need to go back to the theatre to correct this. There is always a risk that the free flap may not survive in its new position.

We take all precautions to minimize these known risks but if they should occur, you may require further treatment, including returning to theatre for further procedures.

What can I expect after my operation?

On the night of the operation, you will be cared for in the ICU to make sure your flap is ok. Nurses looking after you will check you and the flap regularly. They will also do special tests to ensure the flap is doing well.

For the following few days, you will be very closely monitored by the nursing and medical team. You will have to remain in bed with your limb raised on supports until your surgical team are happy for you to start mobilising. Once the team are happy with your recovery progress, you will be assessed by the therapy team to ensure that you are safe for discharge from the hospital.

You will attend the Plastic Dressings Clinic within 2-3 weeks from discharge, in Fracture Clinic on Level 1.

If you have any questions or concerns whilst you are at home, please contact the Plastic Dressings Clinic on 0161 206 5898 Monday to Friday 8am - 4pm.

You can email photographs of the wound to the plastic specialist nurses for remote assessment by emailing salford.plastics.nurses@nca.nhs.uk

Over the weekends or out of hours, please attend Salford Royal Accident & Emergency services.

We hope this information has been useful, please do not hesitate to contact your nursing and medical team with any questions.