45. Plastic and Reconstructive Care

CHAPTER 45. Plastic and Reconstructive Care

Theresa L. Clifford

OBJECTIVES

At the conclusion of this chapter, the reader will be able to:

1. Describe the clinical management of burn injuries.

2. Describe the anatomy of skin.

3. Describe the physiology of wound healing.

4. Describe preoperative preparation of the plastic surgery patient.

5. Describe common plastic and reconstructive surgeries.

6. Describe common medical conditions affecting surgical outcomes.

7. Identify anesthesia administration concerns for the plastic surgery patient.

8. List psychological factors that affect the plastic surgery patient.

9. Identify nursing care for individual surgical procedures.

10. Evaluate postoperative management and patient education concerns for the plastic surgery patient.

I. OVERVIEW

A. Plastic and reconstructive surgery may be performed for a variety of reasons.

1. Physical appearance

2. Emotional well-being

3. Body image

B. Plastic surgery may be:

1. Elective

2. Cosmetic

3. Reconstructive

a. Correcting congenital or acquired abnormalities

b. Restore normal function and appearance.

C. Anesthetic needs vary on the basis of the complexity of the procedure.

1. Local anesthesia for simple lesion removal

2. Prolonged general anesthesia for complex reconstruction

D. Perioperative needs of the plastic surgery and burn patient.

1. Purpose

2. Procedure

3. Perianesthesia nursing care management

4. Patient education for specific surgical interventions

II. OVERVIEW OF BURNS

A. Determining severity of burn injury

1. Initial area of burn should be reassessed frequently after admission.

2. Size of percent of body surface involved (total body surface area [TBSA])

a. Rule of 9s (Figure 45-1)

(1) Body areas divided into equal multiples of 9

(2) Head and each arm equal 9%.

(3) Chest, back, and leg equal 18% each.

(4) Perineum equals 1%.

FIGURE 45-1 ▪

The rule of 9s.

b. Berkow’s method, or Lund and Browder chart

(1) Used for children

(2) Adjusts for differences in body part sizes between adults and children

(a) Head in child younger than 2 years equals 18%.

(b) Each leg in child younger than 2 years equals 13%.

c. One percent method

(1) Used for quick assessment

(2) Palmar surface of patient’s hand equals approximately 1% TBSA.

(3) Not useful for large-area burns

d. Major burn injury

(1) Adults

(a) Greater than 25% TBSA: partial-thickness burn, age <40 years

(b) Greater than 20% TBSA: partial-thickness burn, age >40 years

(2) Children

(a) Greater than 20% TBSA: partial-thickness burn

(b) Greater than 10% TBSA: full-thickness burn

(3) Other factors

(a) Burns of face, eyes, ears, hands, feet, and perineum

(b) Electrical burns

(d) Patients’ preexisting diseases may impact recovery (e.g., diabetes, congestive heart failure).

B. Depth of injury

1. Superficial injury (first degree)

a. Affects epidermis only

b. Appearance: skin intact, red, blanches

c. Painful

d. Healing time: 2 to 10 days

e. Causes: flash burns, sunburn

2. Partial-thickness injury (second degree)

a. Affects epidermis and part of dermis, leaving skin appendages intact

b. Levels

(1) Superficial partial-thickness: affects upper layers of dermis

(2) Deep partial-thickness

(a) Affects lower layers of dermis

(b) May convert to full-thickness injury

c. Appearance

(1) Superficial partial-thickness: red, moist, blistered, blanches

(2) Deep partial-thickness: deep red, moist, areas of white or yellow tissue, delayed capillary refill

d. Very painful

e. Healing time

(1) If affecting outer layers of dermis, 5 to 21 days

(2) If affecting deeper layers of dermis, 21 to 35 days

(a) May convert to full-thickness burn in first few days after burn

(b) May require skin grafting

f. Causes: scald, flame, chemicals

3. Full-thickness injury (third degree)

a. Affects epidermis and entire dermis and may extend to subcutaneous tissue, muscle, or bone

b. Appearance: hard, dry, leathery; color may be black, tan, white; nonblanching

c. Minimal to no pain

d. Healing time: requires excision and skin grafting

e. Causes: flame, scald, chemicals, electrical, contact with hot surfaces

C. Part of body involved

1. Specific areas of body have significant impact on healing, cosmetic appearance, and function.

2. Head, face, and chest burns significantly related to respiratory function

3. Hand, face, and feet burns significantly related to cosmetics and function

4. Perineal burns significantly related to infection

5. Circumferential burns significant because of compromised circulation

D. Burning agent

1. Scald

a. Most common type of burn, especially in children

b. Caused by immersion, splash, or steam

2. Flame and flash burns

a. Second most common type of burn

b. Commonly associated with smoke inhalation

c. Frequently full thickness in nature

d. From house fires, kerosene or gasoline ignition

3. Contact burns

a. Area burned is well defined in appearance in shape of item contacted.

b. May occur from hot metal, asphalt, or sand

4. Chemical burns

a. Less than 10% of all injuries

b. Acid or alkali

c. May be topical or ingested

d. More commonly from industrial accidents

5. Electrical

a. Least common

b. May cause significant internal or external damage

c. Direct current or alternating current

d. Alternating current more dangerous than direct current because of increased risk for cardiopulmonary arrest

e. Cataracts may occur 1 to 2 days to 3 years after burn.

f. May require extensive reconstructive surgery (e.g., myocutaneous flaps)

E. Age of burn patient

1. Higher mortality in patients younger than 2 years or older than 60 years

2. Thinness of skin in very young and very old makes injury more likely.

3. Changes in immune status alter ability to heal.

F. Preexisting medical conditions that impair healing process

1. Cardiovascular disease

2. Diabetes

3. Pulmonary disease: asthma, chronic obstructive pulmonary diseases

G. Other associated injuries at time of burn that might affect healing

1. Smoke inhalation

2. Traumatic injury (e.g., fractures, closed head injury)

3. Need for tracheostomy significantly increases mortality risk.

III. ANATOMY AND PHYSIOLOGY

A. Function of skin

1. Largest organ of the body

2. First line of defense against trauma and infection

3. Retention of body fluids

4. Regulation of body temperature

a. Vasoconstriction and vasodilation

b. Evaporation of water

5. Secretion and excretion

a. Secretion of oil from sebaceous glands to lubricate skin, preventing cracks and organism invasion

b. Excretion of water, sodium chloride, cholesterol, and urea from sweat glands

6. Metabolizes and produces vitamin D

7. Sensation and communication

a. Pressure, pain, touch, temperature

b. Reaction to environmental stimuli

8. Generates new skin

a. Contributes to self-image

B. Anatomy of skin

1. Properties of the skin

a. Accounts for one sixth of total body weight

b. Receives one third of resting cardiac output

2. Structure of skin

a. Epidermis

(1) Outermost layer—often tough and leathery

(a) Made up of five layers of keratinocytes

(i) Stratum corneum

[a] Layers of dead keratinized cells

[b] Layers

[1] Provide vapor barrier

[2] Protect body from microorganisms and chemical irritants

[c] A localized build-up of dead cells is a callus.

(ii) Stratum lucidum

(iii) Stratum granulosum

(iv) Stratum spinosum

(v) Stratum basale

[a] Regenerates epithelial covering

[b] Necessary for spontaneous healing

[c] Journey from stratum basale to stratum corneum takes 14 to 21 days.

(b) Surface and deepest layers most important in burn care

(d) Epidermis lines skin appendages

(i) Sebaceous glands

(ii) Sweat glands

(iii) Hair follicles

(e) New skin can be generated from lining of skin appendages even if epidermis is destroyed.

(f) Varies in thickness from 0.05 to 1.5 mm.

(i) Thickest at soles of feet, palms, scapula

(ii) Thinnest at eyelids

b. Additional epidermal cells

(1) Melanocytes

(a) Produce melanin, a pigment protecting skin from ultraviolet radiation

(b) Give skin its color depending on quantities of melanin

(2) Merkel cells

(a) Mechanoreceptors providing information on light touch sensation

(3) Langerhans’ cells

(a) Help fight infection by engulfing foreign material

c. Epidermal appendages

(1) Hair

(a) Traps air between hair and skin to regulate body temperature

(2) Nails

(a) Protect the distal end of digits

(3) Sweat and sebaceous glands

(a) Help to cool the body as well as reduce infections

d. Dermis—the layer of skin lying immediately under the epidermis; the true skin.

(1) Five main functions of the dermis

(a) Support and nourish the epidermis

(b) Accommodate epidermal appendages

(d) Support thermoregulation

(e) Provide sensation

(2) Two layers

(a) Papillary layer

(i) Composed of fibrous connective tissue made of collagen and elastin

(ii) Contains numerous capillaries, lymphatics, and nerve endings

(b) Reticular layer

(i) Densely arranged connective tissue increasing structural support for the skin

(3) Hypodermis—subcutaneous tissue

(a) Functions to:

(i) Store fat for energy

(ii) Cushion

(iii) Insulate

(b) Contains fascia to facilitate structural movement

e. Deeper tissues

(1) Muscles

(2) Tendons

(3) Ligaments

(4) Bones

C. Physiology of wound healing

1. An alteration in the integrity and function of tissues in the body

2. Intentional wounds from surgical procedure

3. Unintentional wounds include accidental trauma such as a motor vehicle crash or by persistent forces such as that which causes pressure ulcers

4. Terms describing wounds include:

a. Abrasion

b. Avulsion

c. Contusion

d. Laceration

e. Puncture

D. Process of wound healing

1. Inflammation

a. Vascular response—hemostasis for bleeding control

(1) Injury causes blood cells to enter wound and release coagulation factors to promote platelet aggregation and seal the vessel walls.

(2) Thromboplastin is released from injured cells, activating the clotting cascade.

(3) Platelets release growth factors required for tissue development during the subsequent phases of healing.

b. Cellular response—combating infectious processes

(1) Histamines are released from mast cells to cause vasodilation and increased capillary permeability to bring needed nutrients, chemical, and white blood cells (WBCs) to the injured area.

(2) Epithelialization occurs; WBCs cleanse wound (phagocytosis).

(3) Stage of exudate and wound drainage

(4) Stage lasts from time of initial injury up to 4 days.

2. Proliferation

a. Four major events occur.

(1) Neovascularization (angiogenesis)

(a) Formation of new blood vessels in order to reestablish perfusion

(2) Epithelialization

(a) Migration of epithelial cells across the wound

(3) Collagen formation

(a) Collagen fibers add strength to the healing wound.

(4) Granulation tissue formation and contracture

(a) Temporary network of connective tissue formed to fill in wounds

(b) Wound margins begin to move towards the center of the wound.

b. Begins several days after an injury and lasts several weeks

3. Remodeling and maturation

a. Collagen fibers are remodeled, and scar matures.

(1) Becomes flat, thin, silver in color

(2) Stage lasts 1 to 2 years.

E. Comorbidities affecting wound healing

1. Local factors

a. Healing affected by vascularity, tissue tension and motion relative to wound location

b. Dimensions of wound (shape, size, depth)

c. Temperature of wound (normothermic wounds heal better)

d. Desiccation or dehydration of wound

e. Presence of necrotic tissue, foreign bodies, or infection

f. Incontinence or other chronic skin irritants

g. Mechanical trauma such as prolonged or excessive pressure or friction to surface of wound

h. Use of cytotoxic products near wound

i. Dead space—accumulation of air or fluid slows healing, promotes infection.

2. Age

a. Children heal rapidly.

b. Geriatric patients heal slower because of:

(1) Decreased circulation

(2) Higher incidence of chronic illnesses

3. Activity limitations

a. Increase risk of skin breakdown and delayed repair

4. Nutrition

a. Malnutrition, dehydration, and vitamin deficiency slow healing process.

b. Large healing demands require large nutritional reserves.

5. Behavioral risk taking

a. Nicotine—causes poor healing because of:

(1) Oxygen deprivation

(2) Peripheral vasoconstriction

(3) Increased platelet aggregation leading to “tough” clots

b. Alcohol abuse can lead to poor nutrition.

6. Psychological stress

a. Corticosteroids decrease inflammatory response.

b. Catecholamines suppress microcirculation.

7. Medications

a. Chronic use of:

(1) Aspirin-containing products

(2) Steroids

(3) Nonsteroidal anti-inflammatory drugs (NSAIDs)

b. Chemotherapy and other immunosuppressive drugs

8. Immunosuppression

a. History of cancer, human immunodeficiency virus, hypothyroidism, etc.

9. Comorbidities

a. Diabetes

(1) Peripheral macrovascular and microvascular changes

(2) Poor glycemic control

(3) Loss of sensation and neuropathies

(a) Impaired ability to recognize continued tissue damage

(4) Impaired oxygenation and perfusion

(5) Slowed epithelialization and wound contraction

(6) Impaired phagocytosis

b. Peripheral vascular disease

(1) Impaired blood flow such as in venous stasis or anemia

c. Pulmonary disease

(1) Hypoxemia causes tissue hypoxia, which will divert necessary oxygen and nutrients from tissues.

d. Obesity (>20% ideal body weight)

(1) Increased incidence of wound dehiscence and infection

(2) Poorly vascularized adipose increases risk of ischemia.

e. History of bleeding disorders

F. Physiologic changes after burn injury

1. Burn shock

a. Massive fluid and protein shifts from intravascular space to interstitium

(1) Vasodilation, increased capillary permeability, and altered cell membrane at injury site

(2) Hypovolemic shock occurs because of volume loss.

(3) Edema of tissues occurs from increased capillary permeability.

b. Hypovolemia stage lasts for first 48 hours after injury.

c. Sodium and protein lost from intravascular space into interstitium

2. Hypothermia

a. Loss of water and heat by evaporation

b. Loss of skin’s ability to vasoconstrict or vasodilate in response to environmental temperature

3. Cardiovascular

a. Decreased cardiac output related to hypothermia, uncompensated hypovolemia, and release of myocardial depressant factor

b. Catecholamine release from stress response causes vasoconstriction and increases systemic vascular resistance.

c. Potential for decreased organ perfusion exists.

4. Pulmonary

a. Potential airway obstruction from edema of face and neck

b. Decreased chest wall compliance if chest expansion is impaired by chest burns

c. Bronchopulmonary mucosal damage from smoke inhalation

5. Metabolic

a. Hypermetabolic state occurs as result of stress response.

b. Patient develops catabolic state.

6. Immunologic

a. Postburn immunosuppression occurs from changes in humoral and cell-mediated immunity.

b. Loss of skin as first line of defense

7. Hematologic

a. Potential red blood cell hemolysis from thermal injury

b. Decreased coagulation ability from loss of clotting factors into interstitium

8. Gastrointestinal

a. Development of paralytic ileus

b. Prone to stress ulcer development

9. Renal failure

a. Related to inadequate fluid resuscitation

b. Related to myoglobinuria from muscle damage in electrical and severe flame burns

IV. ASSESSMENT

A. Local procedures

1. Complete blood cell count

2. Prothrombin time (PT)/partial thromboplastin time (PTT) with a history of bleeding or easy bruising

3. Additional tests as appropriate depending on the patient’s medical history and physical exam

B. General anesthesia

1. Complete blood cell count

2. Chemistry profile

3. Electrocardiogram (ECG) in adults older than 45 years or with known cardiac condition

4. Pulmonary function testing if necessary

5. Chest x-ray film (in adults or in children with pulmonary pathologic findings)

6. Bleeding profile:

a. PT

b. PTT

c. International normalized ratio (INR)

7. Pregnancy testing as indicated or desired

C. Psychological considerations

1. Body image—the mental picture we possess of our own body

a. Body image is a changing dynamic entity influenced by internal and external factors.

b. Body image is a component of how we feel about ourselves.

c. Most patients undergo elective cosmetic surgery because of body image dissatisfaction.

2. Motivation for plastic surgery

a. Internal motivation—surgery to change physical appearance of oneself

b. External motivation—surgery to change physical appearance at recommendation of others

c. Patients who are internally motivated are most pleased with surgical outcomes.

d. History of repeated surgeries

e. Patients who are dissatisfied with results may:

(1) Request or undergo repeat procedures

(2) Experience

(a) Depression

(b) Isolation

(d) Self-destructive behaviors

f. Rule out body dysmorphic disorder—preoccupation with an aspect of one’s appearance.

3. Preoperative psychological assessment

a. Determine mental status and mood.

(1) Poor outcomes associated with history of depression and/or anxiety

(2) Patients with personality disorders also have poor postoperative outcomes.

b. Understand patient’s perception of body deformity.

c. Understand patient’s expectation of surgical outcome.

d. Explore significant other’s feelings regarding procedure.

e. Assess postoperative support and coping mechanisms.

4. Integration of surgical changes into body image

a. Patients may progress through the stages of grieving.

b. Changed physical appearance slowly integrates into body image and then self-concept.

c. Some patients never integrate changes into body image; may request more surgery or require counseling.

5. Nursing care related to body image

a. Encourage patient to verbalize feelings.

b. Reassure patient that it is normal to desire physical attractiveness.

c. Support the stages of grieving.

d. Be nonjudgmental with verbal and nonverbal communication.

6. Determine patient’s expectations of surgery.

a. Expectations realistic?

(1) Poor outcomes associated with unrealistic expectations

b. Motivation for surgery?

c. Reinforce that immediate results may not meet patient’s expectations because of swelling, color changes, and suture lines.

d. Family expectations

e. Reinforce that long-term results may not meet expectations.

7. Impact of deformity on patient’s self-perception

a. How does patient view it as changing his or her life?

b. How important is it to be attractive?

c. Effect of others’ reactions on patient

8. Psychological evaluation and/or therapy may be appropriate before procedure.

V. PERIOPERATIVE CONCERNS

A. Preprocedural teaching

1. Preemptive medications should be reviewed with patient.

2. NPO (nothing by mouth) instructions

3. Review any over-the-counter medications and herbal remedies patient uses to determine whether any need to be stopped.

4. Encourage patient to stop smoking before surgery.

5. Encourage to wear loose, button-up clothing with preferably slip-on shoes for comfort.

6. Have patient arrange for a ride and home care support.

B. Procedural concerns

1. Primary goals for plastic surgery procedures

a. Provide cosmetically acceptable results.

b. Restore function.

c. Promote healing with minimal scarring.

d. Prevent infection.

2. Many procedures are carefully planned before surgery using photography, computerized imaging, and so forth.

3. Patient positioning requirements

a. Provide comfortable access to surgical field.

(1) Optimal position on table to allow for repositioning during procedure to evaluate results (e.g., mammoplasty)

b. Prevent nerve compression from improper positioning.

(2) Careful positioning

(3) Padding of pressure points

4. Promote venous drainage.

a. Use of sequential compression devices (SCDs) and thromboembolism deterrent stockings (TEDS), for example

5. Provide for greatest hypotensive advantages (reduction of bleeding) if deliberate hypotensive technique is used.

6. Incision placement

a. Incisions placed so that scar lines lie parallel to existing skin lines or behind hairline

b. Skin lines represent areas with minimal tension.

c. Cosmetic effect better if tension is minimized

d. Frequently found under long axis of muscle

7. Hemostasis

a. Must be obtained and maintained to promote good cosmetic effect

b. Bleeding under skin potentiates:

(1) Inflammation

(2) Infection

(3) Pressure

(4) Dehiscence

c. Achieved with:

(1) Ligation

(2) Electrocautery

(3) Pressure

8. Instrumentation

a. Microinstrumentation for nontraumatic repair

b. Use of operating microscope

(1) Provides three-dimensional view (stereoscopic) that must be clearly seen by surgeon and assistants

(2) Careful movements in vicinity of operating table

(3) May require separate instrument tables for donor and recipient sites

c. Lasers

(1) LASER: acronym for light amplification by stimulated emission of radiation

(2) Carbon dioxide (CO ₂) laser, argon laser, and neodymium:yttrium-aluminum-garnet (Nd:YAG) laser may be used in aesthetic (cosmetic) surgery.

(3) Uses

(a) Removal of professional tattoos and traumatic scars

(b) Obliteration of blood vessels

(d) Alternative for skin resurfacing (CO ₂ laser)

(i) Laser blepharoplasty

(4) Precautions

(a) Warning signs should be posted indicating that a laser is being used.

(b) Skin preparation solution may not contain combustible agents.

(d) Proper eye protection for everyone must be provided.

d. Endoscopy

(1) Endoscope requires body cavity for insertion of scope and visualization.

(a) No natural cavities in plastic surgery operative areas

(i) Cavity created by use of umbrella or balloonlike retractor on soft tissues

(b) Uses

(i) Endoscopic forehead lift

(ii) Facelift

(iii) Augmentation or reduction mammoplasty

(iv) Abdominoplasty

C. Anesthesia concerns

1. Selection of anesthetic routes and agent

a. Local anesthesia

(1) Suitable for minor plastic surgical procedures (e.g., skin lesions, rhinoplasty)

(2) Often used for outpatients or office patients

(3) Indicated for procedures that require patient participation (e.g., patients may need to open and close eyes during blepharoplasty)

(4) Selection of agent that lasts 50 to 100 minutes longer than anticipated length of surgery

b. Regional anesthesia

(1) Suitable for procedures localized to extremity

(a) Axillary, plexus blocks for upper extremities

(b) Sciatic block for feet

c. General anesthesia

(1) Suitable for long procedures, pediatrics, and anxious patients

(2) Long plastic procedures generally require lighter general anesthesia.

(3) Selection of inhalation agents

(a) Agents that do not sensitize the heart to catecholamines because of large doses of epinephrine used in plastic procedures (e.g., isoflurane)

(b) Agents that are less likely to precipitate coughing and laryngospasm, particularly in procedures of face and neck

(c) Length of time required for elimination for short procedures (e.g., enflurane is rapidly eliminated if used in procedures that last less than 40 minutes)

(d) Inducing deliberate hypotension

(i) Selection of agents that induce hypotension

[a] Reduces blood loss

[b] Improves visibility at surgical field

(ii) May be accomplished with volatile agents alone or in combination with:

[a] Ganglionic blocking agents

[b] Vasodilators

[c] Alpha-blockers

[d] Beta-blockers

(iii) Used for reconstruction of head and neck

(iv) Hypotension onset and reversal performed slowly to prevent rapid blood pressure fluctuations (e.g., perfusion to organ is maintained)

2. Intraoperative management

a. Airway management

(1) Method of intubation (oral or nasal) depends on access to surgical field.

(a) Nasal intubation for oral procedures

(b) Use of oral or nasal Ring-Adair-Elwyn (RAE) tube for cleft lip and palate repair (endotracheal tubes with sharp curves that promote access to field by surgeon)

(c) Intubation may be difficult and require fiberoptic bronchoscope in patients, particularly children, with maxillofacial deformities.

(2) Ensure vigorous spontaneous breathing before extubation in patients with maxillofacial surgery.

(3) Esophageal or precordial stethoscope to assess ventilation

(4) Monitor oxygenation.

(a) Transcutaneous oxygen measurement

(b) Direct arterial blood gas measurement

(5) Carbon dioxide monitoring; end-tidal carbon dioxide

(a) Elevated carbon dioxide levels result in vasodilation, which increases bleeding and intracranial pressure.

b. Cardiovascular management

(1) ECG monitoring (including ST-segment analysis) for patients at risk for coronary ischemia

(a) From use of epinephrine

(b) As result of deliberate hypotensive technique