The operation will take several hours and you will stay in the recovery room until you are ready to return to the ward.

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1 This booklet is designed to give you information about having a free flap following a lower limb injury. We hope it will answer some of the questions that you, or those who care for you, may have at this time. This booklet is not meant to replace the consultation between you and your healthcare team, but aims to help you understand more about what is discussed. A free flap is the movement of tissue from one site on the body to another. The tissue, along with its blood supply, is detached from the original location and then transferred to another location. There are various areas on the body that this tissue can be moved from and your surgeon will discuss with you which is the best option for you. You may need a free flap if you have had an injury that has left an open wound that can not be stitched back together. The operation will protect the wound from further trauma, enable you to move your limb normally again and improve the appearance of it. You may have several trips to theatre before you are ready for a free flap. This is to ensure the wound is free of infection and to apply a special vacuum dressing, which helps prepare the wound for the free flap. Samples will also be sent from the wound to ensure you are getting the correct antibiotics. The orthopaedic team may also be involved and make a plan for how they will repair any broken bones. You may also need blood tests and a tracing of your heart (ECG) as well as any other tests that examine the blood supply to the limb. Your surgeon will discuss this with you. p1

2 Your surgeon will discuss the procedure and any alternatives with you. An anaesthetic doctor will see you to discuss the anaesthetic with you. Following this, you will need to sign a consent form and your surgeon will go through this with you and explain what the operation involves. This is an opportunity to ask any questions you may have. The night before the operation, you will need to keep warm as this will help your blood flow more easily. You will be given fluids through a drip so that you do not get dehydrated. You will not be allowed anything to eat or drink before the operation, including sweets and chewing gum. Your nurse will advise you on when to stop eating and drinking. You will be given a general anaesthetic which will put you to sleep throughout the whole operation. The surgeon will detach the tissue from the donor site and reconnect it where your wound is and then the surgeon will use microsurgery to reconnect the blood supply, so that blood can flow in and out of the flap. The operation will take several hours and you will stay in the recovery room until you are ready to return to the ward. You may feel very drowsy due to the effects of the anaesthetic. The nurses on the ward will closely monitor your flap to ensure the blood is flowing through it, using a machine called a Doppler, which helps monitor the blood flow. You may have dressings around the flap and to the donor site. You will also have your blood pressure, pulse and temperature checked regularly and you will be given fluids through a drip. It is important that you are kept warm for the first 48 hours and you will have a special warming blanket to help with this. You will have a catheter inserted into your bladder so that the nurses can monitor the amount of urine you are passing. Once you feel well enough, you will be able to eat and drink again. For the first few days, you will need to stay in bed with your limb elevated to reduce swelling and encourage the blood to flow through the limb. You may be able to get out of bed and sit in a chair but you must ensure your leg is elevated at all times. Your surgeon will advise you when you are able to do this. On the fifth day after the operation you will start to dangle the limb for short periods. This is when you lower the leg over the side of the bed, which the nurses/physiotherapist will explain to you. On the sixth day after the operation, you will begin to mobilise with the help of the physiotherapist. Once the physiotherapist is happy that you are safely walking you will be able to go home. You will be assessed as to whether you need antibiotics through your vein at home. If you do, you will need to stay in hospital until a special line is put into your arm. District nurses will then visit you at home to give the antibiotics to you. p2

3 Failure of the flap The most significant problem specific to this operation is failure of the flap due to loss of blood supply. Occasionally the blood flow to the flap is blocked, causing some or all of the skin, fat and muscle to become discoloured and die. If this happens, further surgery may be needed. Bleeding Sometimes a collection of blood (haematoma) can form under the wound resulting in bleeding. Infection No matter how much care is taken, there is always the possibility of getting an infection. Should this happen, infections can be treated successfully with antibiotics. Scars from healing There will be scars from the operation where the wounds recover and heal. When the scars have healed it is advisable to massage them gently with a moisturising cream to soften the scar tissue. Numbness and loss of feeling This is due to damage to the nerves during the operation. It may gradually fade over time, but may last up to a year after surgery and can sometimes be permanent. You will need to take things easy at first and keep your limb elevated when possible to reduce the swelling. You will have been given instructions on how to look after your wounds or a district nurse may have been arranged. You will be given an appointment to be seen by the nurses in the Plastic Dressing Clinic or with your consultant. You may be given medicines to go home with such as painkillers or antibiotics, which the ward nurses will explain how you should take before you leave. If necessary, please take your painkillers at least 45 minutes before your clinic appointment or visit from the community nurse, to help your pain relief during a change of dressing. If you are given antibiotics make sure you complete the course. You should stop smoking. If you continue to smoke, you are much more likely to suffer: a higher rate of infection wound breakdown skin death flap failure. If you need help giving up smoking, visit for advice and support. p3

4 The operation may leave your flaps with some of the following features: Bulky, and sticking out from the surrounding skin. Variations in skin tone, hairiness and direction of hair growth depending on the donor site. For flaps where muscle has had a skin graft over the top, there will be no fat layer under the skin so the skin layer will be thinner and the darker pigmentation of the flap will be visible. For flaps where the donor-site skin is different from the skin surrounding the recipient site, there will be some colour changes. The initial bulkiness of the muscle flaps reduces over time as the swelling reduces and the muscle shrinks. Try not to be too concerned if your flap looks bulky and bulges out slightly. It takes a good months for everything to settle and mature, and part of this phase means that the scars and tissue will shrink down and protrude less. In cases where it remains elevated and bulky, additional steps can be taken to improve the way it looks, including pressure bandaging and liposuction. Please remember that the way you look when you leave hospital, is not the way you will always look. Much of the redness, swelling and scarring will fade, reduce and flatten, leaving less obvious scaring. Due to the severe nature of your injured limb it is likely to always be swollen, especially if a circular frame has been applied. This can be reduced by elevation when resting and compression once the soft tissues have healed and any external fixation has been removed. If you have been given exercises to perform by a physiotherapist, it is very important that you continue to do the exercises you were shown. If you have been given a splint to wear by the occupational therapist, it is very important that you continue wearing it. Please contact us if you have any queries or concerns, or if you experience: redness, swelling or pain around your wounds, flap or skin graft green/brown smelly discharge coming through your dressing a high temperature or fever general feelings of being unwell bleeding that will not stop after applying gentle pressure dressings falling off or becoming wet. p4

5 The plastic surgery clinical nurse specialist Monday to Friday (except bank holidays) between and Also contactable via pager - dial and ask for page Plastic Surgery Dressing Clinic Monday to Friday (except bank holidays) between and Outside these times, or if you are unable to reach the plastic surgery clinical nurse specialist or Plastic Surgery Dressing Clinic, please contact the ward from which you were discharged and ask to speak to the nurse in charge. If you feel you need to be seen urgently please contact your GP or attend the accident and emergency department at the hospital where you had your operation. If you wish to make or change an appointment please call We aim to provide the best possible service and staff will be happy to answer any of the questions you may have. If you have any suggestions or comments about your visit, please either speak to a member of staff or contact the patient advice and liaison service (PALS) on (Charing Cross, Hammersmith and Queen Charlotte s & Chelsea hospitals), or (St Mary s and Western Eye hospitals). The PALS team are able to listen to your concerns, suggestions or queries and are often able to help sort out problems on behalf of patients. Visit for more information. Alternatively, you may wish to express your concerns in writing to: The chief executive s office Imperial College Healthcare NHS Trust Trust Headquarters The Bays, South Wharf Road London W2 1NY This leaflet can be provided on request in large print, as a sound recording, in Braille, or in alternative languages. Please contact the communications team on Reconstructive and plastic surgery Published: October 2013 Review date: October 2016 Reference no: 2393T Imperial College Healthcare NHS Trust p5