Medical Oncologist
CION Cancer Clinics
Flap closure of the perineal wound after APR | CION Cancer Clinics
Flap closure fills the hollow left after the rectum and anus are removed with a piece of your own healthy muscle and skin, moved in from the tummy wall, the buttock or the inner thigh. It is offered when simple stitching is unlikely to hold, most often after radiotherapy. This page explains which flaps are used, what changes for you, and what the decision cannot promise. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed September 2026, next review due September 2027
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On this page
- What is flap closure, and why might you need it?
- Which flaps are commonly used, and where does the tissue come from?
- What actually happens when a flap is part of the plan?
- How do simple closure and flap closure compare?
- Who does a flap not suit, and what can this page not tell you?
- Three things families ask about flaps, and what is actually true
- Common questions about flap closure after APR
The short answer
What is flap closure, and why might you need it?
Flap closure means the surgeon fills the space left after the rectum and anus are removed with a piece of your own healthy muscle and skin, moved in from the tummy wall, the buttock or the inner thigh. It is offered when ordinary stitching is unlikely to hold.
Why the ordinary stitch-up sometimes fails
An abdominoperineal resection (APR) takes out the lowest part of the bowel and the anus, leaving a deep hollow between the buttocks. If the skin edges are simply pulled together over it, fluid collects underneath, the edges pull apart, and the wound can stay open for months. Radiotherapy beforehand makes this more likely, because treated skin has a poorer blood supply.
What a flap changes
A flap brings tissue that has not been treated with radiation, with its own blood supply still attached. It fills the hollow so there is no space for fluid to gather, and gives the wound a healthy base to heal on. It adds time to the operation and a second wound where the tissue was taken from. Your team weighs those costs against the chance of a wound that will not close on its own.
Not every centre has a plastic surgeon on the team. Ask who will be doing the flap and how often they do it.The options
Which flaps are commonly used, and where does the tissue come from?
The name on your consent form tells you where the tissue is being moved from.
Tummy wall flap (VRAM)
A strip of the long muscle down one side of the tummy, with the skin over it, is turned down through the pelvis to fill the hollow. It is the most used flap after APR because the tissue is large and its blood supply is reliable.
Worth knowing
- Taken from the side opposite the stoma
- Leaves a long vertical scar on the tummy
- Can weaken the tummy wall on that side
Buttock flap (gluteal)
Skin and fat, sometimes with part of the buttock muscle, are swung inwards from one or both sides. The tummy is untouched, which matters if it has been operated on before or a stoma needs the space.
Sitting is restricted for longer afterwards.Inner thigh flap (gracilis)
A slim muscle from the inside of the thigh is tunnelled up into the pelvis. It is smaller than a tummy flap, so it suits a smaller hollow. Walking is not usually affected, because other thigh muscles take over its job.
Mesh instead of a flap
Some surgeons rebuild the floor of the pelvis with a sheet of biological mesh rather than moving tissue. It avoids a second wound but does not fill the hollow, so it is generally used for smaller defects where the skin itself is healthy.
Not sure whether this applies to you?
Ask an oncologistAround the operation
What actually happens when a flap is part of the plan?
Planning with two surgeons
The cancer surgeon and the plastic surgeon look at the scans, at earlier scars, and at where your stoma will be marked, because the flap and the stoma cannot share the same side of the tummy. Ask them to draw the scars on paper for you.
The operation itself
The cancer part is done first. The flap is raised, moved and stitched in at the end, which adds time under anaesthetic. Expect a longer day than a standard APR, and tell the family to plan for a long wait.
The first days
Nurses check the colour and warmth of the flap skin often, because the moved tissue depends on a single blood supply. You will be positioned to keep pressure off it. Drains stay until the fluid has settled.
Going home
You leave with two wounds to care for, a stoma to learn, and instructions on how to lie, sit and wash. A family member should be shown the wound before discharge.
Side by side
How do simple closure and flap closure compare?
Simple closure
Flap closure
The skin edges are stitched together over the hollow
The hollow is filled with living tissue, then the skin is closed over it
One wound, in the perineum
Two wounds: the perineum and the place the flap came from
Usually chosen where the wound is small and untreated by radiation
Usually chosen after radiotherapy, after an extralevator APR, or when a previous wound failed
Higher chance the wound opens and needs months of dressings
Lower chance of an open wound, but a small chance the flap itself fails
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One thing that cannot wait
A flap that turns dark, dusky purple or pale white, or that becomes cold compared with the skin next to it, is a flap losing its blood supply. So is sudden heavy bleeding or a wound that swells tightly within hours. Ring the ward or the helpline straight away and say the words "flap surgery". Do not wait for the next dressing change.
Being straight with you
Who does a flap not suit, and what can this page not tell you?
A flap is not the right answer for everyone. It adds hours to the operation, so someone with a weak heart or lungs may be safer with a simpler closure and a longer wound-care plan. Someone whose tummy wall has been cut several times may not have a usable tummy flap. Heavy smoking, poorly controlled diabetes and very low body weight all make a flap more likely to struggle.
The trade-offs your team is weighing
They are balancing the chance of a wound that will not close against a second wound, a longer anaesthetic and a possible weak spot in the tummy wall. Two good surgeons can reasonably choose differently. Ask which of these worries applies to you, and why the balance tipped the way it did.
What this page cannot tell you
It cannot tell you whether you need a flap. That depends on your scans, your radiotherapy, your earlier operations and your general health. It also cannot tell you how your own wound will heal. Most flap wounds settle, some open partly and need dressings, and a small number of flaps fail and need a further operation.
Bring the person who will help with your dressings to the appointment where the flap is explained.Commonly believed
Three things families ask about flaps, and what is actually true
"A flap means the cancer was worse than they told us."
The flap decision is about the wound, not the cancer. It is driven by radiotherapy, the size of the hollow and the health of the skin. The pathology report, not the closure method, tells you about the cancer.
"Once the flap is in, the wound problem is solved."
A flap lowers the chance of a wound that will not close, but it does not remove it. The edges can still separate, and fluid can still collect. What changes is that the base of the wound is healthy tissue, so problems usually settle faster.
"She can sit normally as soon as she is home."
Sitting puts weight directly on the new tissue, and for buttock flaps in particular you will be asked to avoid it for a period your surgeon sets. Lying on your side and standing are the early positions. A cushion helps later, not in the first weeks.
Questions we are asked
Common questions about flap closure after APR
Why did my surgeon say I need a flap when my neighbour did not?
Almost always because of radiotherapy, or because more tissue had to be removed in your case. Radiation makes the skin around the anus heal slowly, and a wider removal leaves a bigger hollow. The closure is chosen for the wound, not the diagnosis.
Will the flap affect where my stoma goes?
Yes, which is why the two are planned together. A tummy wall flap is taken from one side, so the stoma is placed on the other. If the sides clash, the team may choose a buttock or thigh flap instead.
How long does the operation take with a flap?
Longer than a standard APR, because the flap is raised and stitched in after the cancer part is finished. Your surgeon will give you their own estimate, since it depends on which flap is used. Tell the family to expect a long wait and not to read anything into the clock.
What does a healthy flap look like in the first week?
Pink or the same colour as the surrounding skin, warm to the touch, and slightly swollen. Bruising at the edges is common. What the nurses watch for is a change: a flap going dusky, pale or cold. If you notice that at home, ring the same day.
Will I have feeling in the flap skin?
Usually little or none at first, because the nerves to the skin are cut when it is moved. Some feeling returns over months, but the flap often stays numb. You may not feel soreness building when you sit, so check the area with a mirror or ask someone to look.
Can the second wound cause its own problems?
Yes. The tummy wound can develop a bulge or hernia on the weakened side, the thigh wound can collect fluid, and any of them can become infected. It is one reason the choice of flap is made carefully.
Does Aarogyasri or insurance cover the flap part?
The flap is part of the cancer operation, and most schemes and cashless insurers treat it that way when it is written into the surgical plan. Aarogyasri, CGHS, ECHS and EHS are accepted at CION. Ask for a written estimate before you are admitted.
What should I ask before I sign the consent form?
Which flap, from where, and why that one for your wound. Who is raising it and how often they do it. What the scars will look like, drawn on paper. What the sitting and lifting rules will be. And what the plan is if the flap struggles.
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MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
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Dr. Vinay Mamidala
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Sources
- Cancer Research UK — Surgery for bowel cancer
- Macmillan Cancer Support — Bowel cancer
- National Cancer Institute — Rectal Cancer Treatment (PDQ), patient version
- American Cancer Society — Surgery for colorectal cancer
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
The Perineal Wound After APRWhat the wound is, and how it is cared for at homeWhy the Perineal Wound Heals SlowlyThe reason a flap is discussed in the first placeExtralevator APR ExplainedThe wider operation that most often needs a flapSitting, Cushions and Comfort After APRThe daily practicalities once you are homeWound, Stitches and ScarsGeneral wound care that applies to both wounds
Talk to us
Been told you may need a flap?
Send us your scans and the operation note you have been given. A surgical oncologist will explain what has been recommended and why, and help you list the questions to ask. One helpline serves every CION centre.