Pre-operative considerations

Authors: Liv Schöllhammer, MD, Frederik Gulmark Hansen, med.stud. and Magnus Balslev Avnstorp, MD

To evaluate a surgical concern regarding the use of a local skin flap, a sufficient physical examination of the patient is crucial. The most important steps are briefly discussed in this next section. If you want to know more about preoperative assessment, click the link below and read our chapter on the subject.

Danish model of pre-operative assessment

Patient Presentation and history

• Trauma mechanism: Is it an excised tumor or a traumatic lesion
• Tumor excised radically:  The tumor needs to radically excised, verified by a pathologist, before a skin flap is considered
• General patient condition: uncontrolled diabetes mellitus, extensive smoking history or bleeding disorders can be contraindications
• Age and gender
• Medical treatment: Diabetes mellitus, hypertension, bleeding disorders, blood thinning medicine must be paused or bridged with klexane/fragmin etc.

Physical examination

• Skin quality
• Size and depth of defect
• Distance to important facial anatomic structures such as the eyelids, lip or nerves.
• Quality of the donor site and the size of a potential flap

Pre-OP Considerations

• To pause blood thinning medicine and all natural, herbal medicine including omega-3 fish oil, which has a blood thinning effect
• If the patient has skin cancer, do you have pathology verified free margins of the excision before proceeding with the skin flap?
• Is the patient fit for surgery in general anesthesia? If not, can the procedure be done in local anesthesia?

Pre-operative Information

It is always important to inform about the risk of infection, bleeding, pain and scars – including keloid.  Depending on the location there’s a risk of facial nerve damage, stretching (deformation) of important structures i.e. eyelid ectropion or visible scarring.  Furthermore, the greatest risk of flap failure is vascular insufficiency, which may result in yet another surgery.

Post-Operative Care

In case of a larger facial flap it may be relevant with follow-up in the outpatient clinic 3 months post-operative.
In case of an uncomplicated facial flap the patient may have follow-up at the general practitioner.
In case of a melanoma and deep infiltrating skin cancer in risk areas near eyes, nose, lip, the follow-up is essential.

Follow the link listed below for further details on the follow-up in the chapter malignant melanoma.