Medical Oncologist
CION Cancer Clinics
Primary closure, skin graft, local flap or free flap: how they differ | CION Cancer Clinics
A skin graft is a thin layer of skin moved on its own, so it needs a healthy wound bed to survive. A flap moves thicker tissue with its own blood supply, so it can cover bone or skin damaged by radiation. Stitching the edges is simplest, and a free flap is the most complex. Your team matches the option to the wound and to you. 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 the difference between a graft and a flap?
- How do a skin graft and a flap compare?
- Who does each option usually suit, and who does it not?
- How does your team choose between them?
- What do families often assume that is not quite right?
- What should you ask about the closure plan?
- What can a comparison page not tell you?
- Common questions about grafts and flaps
The short answer
What is the difference between a graft and a flap?
A skin graft is a thin layer of skin moved on its own, with no blood supply, so it has to pick up blood vessels from the wound it is laid on. A flap is thicker tissue moved together with its own blood supply, so it can cover places a graft cannot, such as bare bone.
Where stitching the wound fits in
The simplest option of all is to bring the edges of the wound together and stitch them. This is called primary closure, and it is how most cancer operations end. It only works when the skin around the wound is loose enough to stretch across without pulling on an eyelid, a lip or a joint.
Local flap and free flap
A local flap uses tissue right beside the wound. It stays attached on one side and is turned or slid into place. A free flap is taken from a distant part of the body, cut completely free, and its tiny artery and vein are joined to vessels near the wound under a microscope. That joining is what makes a free flap a much longer operation.
These are four options your surgeon chooses between. This page explains them. It cannot tell you which one your wound needs.Side by side
How do a skin graft and a flap compare?
Skin graft
Flap
Thin skin only, with no blood supply of its own
Skin, fat and sometimes muscle or bone, with its own blood supply
Needs a healthy, well-supplied wound bed to take
Can cover bone, tendon, plates and skin damaged by radiation
Shorter operation and usually a shorter stay
Longer operation, especially for a free flap
Often looks thinner or a different shade from the skin around it
Fills depth and bulk, but may look bulkier at first
Leaves a shallow, graze-like donor area
Leaves a longer scar where the tissue was taken
The four options
Who does each option usually suit, and who does it not?
Each one fits some wounds well and others poorly. The notes below are typical patterns, not rules for your case.
Primary closure
Suits small or narrow wounds where the nearby skin is loose, such as many operations on the trunk or the breast.
Does not suit
- Wide gaps that would pull tight
- Areas near the eye, lip or a joint
Skin graft
Suits shallow wounds with a healthy base, such as some scalp, limb or surface skin cancers.
Does not suit
- Bare bone, tendon or metal
- Skin already treated with radiation
Local flap
Suits small to moderate wounds on the face, nose or hands, where nearby skin gives a close colour and texture match.
Does not suit
- Large gaps
- Skin nearby that is scarred or irradiated
Free flap
Suits large or complex gaps, such as after removing part of the jaw, tongue or chest wall, or where bone must be rebuilt.
May not suit
- People who cannot manage a long anaesthetic
- Badly damaged vessels near the wound
Not sure whether this applies to you?
Ask an oncologistBehind the decision
How does your team choose between them?
The cancer comes first
The first aim is to remove the cancer with a clear margin, a rim of healthy tissue around it. The size of the gap is only known properly once that is planned.
What lies underneath
If bone, tendon, a large vessel or a metal plate will be left bare, a graft is usually off the table and a flap comes in.
Radiation and past surgery
Skin that has had radiation, or will have it soon, heals poorly. The team may choose tissue with its own blood supply for that reason alone.
You as a whole
Your heart, lungs, sugar control, smoking and what you need the area to do all shape how far up the options it is safe and sensible to go.
Commonly believed
What do families often assume that is not quite right?
"A free flap is the most advanced, so it must give
the nicest result."
Not always. A local flap on the face often matches colour and texture more closely than tissue brought from the thigh. The right option is the one that fits the wound, not the most complex one.
"A graft is quick, so we should ask for that
instead."
A graft placed where it cannot take will fail and leave an open wound, sometimes delaying radiation or other treatment. Ask the team why a graft is or is not suitable before asking for one.
"Once the wound is closed, the look is final."
Grafts and flaps change for many months. Swelling settles, colour fades and bulk shrinks. Some people have a smaller second operation later to thin or reshape a flap.
"Stitching it shut means no reconstruction was
needed, so the cancer was small."
How a wound is closed depends on where it is and how loose the skin is. It says nothing reliable about how serious the cancer was. That comes from the pathology report.
Before you sign
What should you ask about the closure plan?
- Which option is planned, and why not the one below it
- What the back-up is if it does not work on the day
- Where any donor site will be and what it leaves
- Whether radiation afterwards changes the choice
- Who checks the graft or flap on the ward
- Whether a later touch-up operation is likely
Being straight with you
What can a comparison page not tell you?
A table can show what each option usually does. It cannot see your wound, your scans or your health. Two people with cancers in the same place can be offered different closures for sound reasons, and neither team is wrong.
Plans can change during the operation
The final size of the gap is sometimes only clear once the cancer is out and the margins have been checked. Surgeons often plan a first choice and a back-up, and move between them on the table. It helps to know both before you go in, so a change does not come as a shock.
The decision is not yours to carry alone
You bring what matters to you: speaking clearly, eating, looking like yourself, getting back to work or keeping the operation short. The team brings what is safe and likely to heal. The plan should come from both. If it does not feel that way, ask for it to be explained again, or ask for a second opinion.
Questions we are asked
Common questions about grafts and flaps
Which heals faster, a graft or a flap?
A graft usually means a shorter operation, but it needs the area kept still while it takes, and the donor area can be sore. A flap is a bigger operation with a longer stay. How quickly you recover depends as much on the cancer surgery as on the closure.
What does it mean if a graft does not take?
Part or all of the graft has not picked up a blood supply and does not survive. Small patches often heal with dressings. Larger losses may need a new graft or a flap. Your team will check it at the first dressing change and tell you what they see.
Is a local flap the same as plastic surgery?
It is one kind of reconstructive plastic surgery. It may be done by a head and neck surgeon, a skin cancer surgeon or a plastic surgeon, depending on the site. What matters is that the surgeon does this kind of repair regularly. Ask who will do it.
Can a flap be done after radiation?
Yes, and flaps are often chosen for exactly that reason, because they bring in healthy tissue with its own blood supply. Radiation can make the nearby vessels harder to work with, so the team may look for vessels further away. Mention every past radiation course at the first visit.
Will the grafted skin grow hair or sweat?
It carries the features of the place it was taken from. Skin from a hairy area may grow hair, and a thin graft often sweats less. Feeling in the area is usually reduced, at least at first. Ask your surgeon what to expect from the site chosen for you.
Why was I told a free flap was needed for a small cancer?
Because the position can matter more than the size. Removing a small cancer from the jaw or floor of the mouth may leave bone bare or affect eating and speech. Ask the surgeon to show you what will be removed and why a simpler closure would not work there.
Should I get a second opinion on the closure plan?
You are always free to. It can help most when the suggested operation is long, affects your face or speech, or when you are unsure why one option was chosen over another. Take all your scans and biopsy reports so the second team sees the same picture.
Does the type of closure change what we pay?
A longer operation with more theatre time and a longer stay usually costs more. How much of that you pay yourself depends on your cover. Aarogyasri, CGHS, ECHS, EHS and cashless insurers each have their own rules. Call the helpline to check your cover against the plan.
Meet the Specialists
17+ senior cancer specialists. One panel for your case.
Trained at AIIMS, Tata Memorial, and leading international centres. Combined 150+ years of experience. Every complex case is reviewed by 3+ of them — together.
Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
Medical Oncologist
Medical Oncologist
Surgical Oncologist
Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
Surgical Oncologist
Surgical Oncologist
Surgical Oncologist
Dr. Vinay Mamidala
MBBS, MS(General Surgery), M.Ch(Surgical Oncology), FMAS, FARIS(Ongoing)
Surgical Oncologist
Radiation Oncologist
Radiation Oncologist
Radiation Oncologist
Hematologist
Surgical Oncologist
Dr. Vajja Sandeep Kumar
MBBS, MS (General Surgery), DrNB (Surgical Oncology), FALS Oncology
Surgical Oncologist
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Sources
- National Cancer Institute — Surgery to Treat Cancer
- NHS — Skin graft
- Cancer.Net — What to Expect When Having Surgery
- Macmillan Cancer Support — Cancer information and support
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.
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