The first week after lower limb flap cover is almost entirely about protecting the blood supply of the tissue that has just been moved. Expect bed rest with the leg raised, a splint or the existing frame holding the limb still, staff checking the colour and warmth of the flap through the day and the night, one or two drains, regular pain medicines and blood tests. Very little is asked of you in this week except to stay still, stay warm, stay off tobacco and let the team watch. Decisions about sitting up and moving are taken day by day rather than in advance.
What happens on the day of surgery and the first night?
The operation is long, particularly if tissue has been brought from another part of the body and its vessels joined to vessels in the leg under a microscope. You wake with a bulky dressing that has a window cut in it so the flap can be seen, a splint or frame holding the limb, a drain at the flap and often another at the donor area, and a drip running. Some patients spend the first night in an intensive care or high dependency bed simply because monitoring is easier there. You will be kept warm and well hydrated, because cold and a low blood pressure make small vessels narrow, and narrow vessels are exactly what a new flap does not need.
Why is the leg kept raised and completely still?
Raising the limb helps blood drain out of the flap, and swelling is the main enemy of a freshly joined vein. Keeping the limb still protects the join between the vessels, which is very small and needs a few days before it settles. For this reason the hip and knee on that side are usually left alone early on. You may be told not to let the leg hang down at all, not to sit at the edge of the bed, and not to turn without help. It feels restrictive and it is dull, and it is also the single most useful thing you can do for the result.
What are flap checks and why does someone wake you at night?
A nurse or doctor looks through the window in the dressing and notes the colour of the flap, its temperature and how quickly colour comes back after gentle pressure. Sometimes a small probe is used to listen to the vessel. These checks are frequent in the first days and are then spaced out. They continue overnight because a flap that is losing its circulation gives its earliest signs quietly, and the sooner that is picked up, the more likely it is that a return to theatre will help. Being woken repeatedly is a sign that the team is doing its job properly.
What will the pain, the drains and the dressings be like?
Pain is often worse at the donor area than at the flap, especially where muscle has been taken or a graft has been applied. It is managed with regular medicines given by the clock rather than waiting for it to build up. Drains come out once the fluid draining into them settles. The main dressing over the flap is usually left undisturbed early unless there is a reason to open it, while the donor site dressing may be inspected sooner. Tell the nurses if the pain suddenly changes in character, because that is information the team needs, not a complaint.
What about the donor area?
The donor area may be the thigh, the calf, the back or the abdomen, depending on which flap was chosen. If a large area of skin was taken, a thin graft from the thigh may be used to resurface it, and that patch has its own dressing and its own itch as it heals. The donor limb is usually allowed to move early, and gentle movement there prevents stiffness. Ask the team what the donor scar is expected to look like and whether it will affect strength, because this part of the operation is easy to forget until it is done.
What can go wrong in this week?
The problem watched for most closely is a block in the vessels. A flap that turns blue and swollen suggests that blood is not draining out, while one that turns pale and cool suggests that blood is not coming in. Either can lead to a return to theatre, sometimes within hours, and going back quickly is normal practice rather than a disaster. Other events include a collection of blood or fluid under the flap, infection, and small areas along the edge of the flap that do not survive and are later trimmed or dressed. No operation of this size is risk free, and the team will explain what they are seeing rather than leaving you to guess.
What can the family do to help?
More than you would expect. Keep the patient from sitting up or swinging the leg down before the team allows it. Keep the room warm and the leg propped as instructed. Bring protein rich food once eating is allowed, and mention any diabetes so that sugars are watched. Make sure nobody in the family encourages a cigarette, a beedi or tobacco in any form, because these narrow the very vessels the surgery depends on. Know who to call at night, keep the accident and hospital papers in one folder, and let the patient sleep between checks.
When does movement start?
Movement starts in small pieces. Breathing exercises, arm exercises and movement of the other leg usually begin on the first day or two, both to keep you comfortable and to reduce the chance of clots and chest problems. Later in the week, if the flap looks settled, the team may allow you to sit up more, still without letting the operated leg hang down. Letting the leg go downwards in stages, and then standing and walking, belongs to the weeks that follow, and is guided by the flap and the fracture together.
