return to: Nursing Protocols

I. Purpose of flap:

a. Reconstruction after tumor excision, trauma, post-osteoradial necrosis.

b. Protection of the greater vessels.

c. Correction of congenital defect.

II. Types of flap:

a. Pedicle: one end of the flap remains attached to the original site and the other end is moved to cover existing defect.

1.  Example: pectoralis, latisimus

See: Pedicled Flaps Protocols: Latissimus Free Flap and Pedicled Flap; Pedicled nasoseptal flap (Hadad-Bassagasteguy flap) protocol

b. Free flap: area of tissue is removed from one part of the body and surgically placed over another. Vascular supply for the new area, or "flap," is obtained via anastamosis with vessels at new site.

2. Example: fibula, radial, scapular, latisimus, abdominal, and thigh

III. Airway assessment of the patient with a flap:

a. If patient has a tracheostomy, make sure to suction, change inner cannula, and check cuff pressure upon admission.

b.  Checking cuff pressure:

1. Always have two nurses at the bedside.

2. 4 way stop cock must be attached to sphygmomanmeter in order to remover and replace air into trach cuff.

3. After measuring pressure, replace air in cuff to about 20 mm Hg.

c. A cuffed shiley tracheostomy and obturator that same size as the patient's should always be at the head of the bed in case of airway complications.

d. Patient should have humidified oxygen or room air at all times, but the flap area should ever have cool mist blowing on it.

IV. Checking circulation of the flap:

a. Assess color of flap:

1. Dusky? Blue? Pink? Pale?

b. Free flaps are to be marked and doppled Q1 hour for 48 hrs including time spent on the SICU, prior to arrival on 3JPW.

c. Assess flap for changes in size and swelling:

1. Key indicators for possible hematoma or other complications include sutures over the flap pulling apart and palpable crepitus beneath the skin.

V. Assessing drain status:

a. Patient may have jackson pratt (JP) drains:

1. JPs are to be stripped Q2 hrs for 48 hrs to prevent clotting.

b. Patient may have Penrose drains:

1. Penroses are to be rolled Q2 hrs for 48 hrs to express fluid out and prevent swelling.

c. Patient may have and NG tube:

1. Make sure the NG tube is secured to the nare (suture, tegaderm).

2. Note and chart where the NG stops at the nare in case of future displacement.

VI. Assess split thickness skin graft site (STSG) if present:

a. Dry and intact? Leaking ?

b. Red and beefy vs. pale with clots?

c. The STSG dressing is not to be removed until at least post opertaive day 7 to 10. It is nursing's responsibility, however, to drain fluid off from underneath the dressing: 

1. First, wipe the lower part of the tegaderm over STSG.

2. Next place a 22g needle on a 5ml-10ml syringe and carefully pierce the tegaderm dressing.

3.  Aspirate back on syringe to remove fluid from underneath dressing.

4. Patch with fresh dressing to prevent leakage from needle insertion site.

d. If bolster is present over STSG site, this is not to be removed until the patient discharges from the hospital and returns for follow up appointment at the clinic.

See: Split Thickness Skin Graft

VII. Tips to remember and things to report to physician:

a. Flap patient are never to have a pillow behind their heads at any time.

b. The donor extremity site must be elevated at all times.

c. No weight bearing or toe touch weight bearing for fibula flaps until approved by the physician.

d. Call physician immediately for and change in color, dopple sounds, or increased swelling/firmness at the related flap or donor site.

1. Normal flap color is similar to that of the recipient site.

2. Normal capillary refill of flap site is 1-2 seconds.

3. Be concerned if flap begins to appear pale relative to the donor site or becomes cool to touch.

4. Color and appearance of a congested flap varies, depending on whether the congestion is mild or severe and ranges from a pinkish color to a dark bluish purple color.

e. Confirm that all flap patients have a blood thinner ordered to assist with perfusion to flap area.

All information on this page courtesy of 3 JPW Staff Nurse Orientation Guide