section epub:type=”chapter” id=”c0220″ role=”doc-chapter”> Joni M. Brady; Matthew D. Byrne The field of plastic surgery encompasses cosmetic and reconstructive surgical procedures. Consumer demand for cosmetic surgical procedures has steadily increased over time, with notable improvements observed in the techniques used to achieve optimal esthetic reconstructive surgical outcomes. Plastic and reconstructive surgery techniques include excision of skin lesions, closure of skin wounds, and placement of skin grafts, skin flaps, and bone grafts. Skin grafting is the most common method for covering open areas resulting from incomplete wound healing, trauma, burns, or large surgical incisions. Microvascular tissue transfer and free flaps involve newly positioned tissue requiring constant observation for skin color changes at the operative site, regardless of the type of flap used. Breast reconstruction procedures using autologous grafting include transverse rectus abdominis musculocutaneous, deep inferior epigastric artery perforator, and latissimus dorsi flap techniques. The most serious postsurgical flap complication is hypoxia leading to tissue necrosis. Reconstructive bone grafting is used to correct defects and congenital anomalies, such as cleft lip and palate. A variety of elective outpatient cosmetic surgery procedures are performed, with the type of anesthetic used dependent on the selected procedure. Knowledge of the procedure types performed in the facility where employed is required. Nursing assessments and nursing care should be adjusted to the type of procedure and anesthesia administered for each patient. Postoperative nursing care primarily involves close observation of the surgical site, comfort promotion, and individualized patient care interventions. cosmetic surgery; postoperative care; reconstructive surgery; skin flaps; skin grafts The field of plastic surgery encompasses cosmetic and reconstructive surgery, and related procedures and techniques have continuously evolved over time. The discipline is growing as consumer demand for cosmetic surgical procedures increases1 and the ability to achieve esthetic reconstructive surgical outcomes improves. Plastic surgery derives its name from the Greek word plastikos, which means to mold or give shape. The first successful tissue transfers are said to have originated in India more than 2500 years ago. Modern grafting techniques were explored in the 19th century in Germany.2 Today, reconstructive procedures involve much more than the correction of acquired and congenital deformities. They are also performed to correct defects related to tumors, trauma, infection, burns and postburn contractures, pressure ulcers, or disease.3 Ideally, assessment of the anatomical concern, procedure complexity, risk, and the patient’s personal concerns represents interconnected therapy that strives to restore normal function and enhance appearance to maintain or improve body image and self-esteem.4 Few absolutes exist in plastic and reconstructive surgical techniques or in the associated preoperative or postoperative care. Perianesthesia nurses may encounter a wide variety of surgical techniques, from simple to complex, depending on the type of facility in which the procedures are performed. Only the basic aspects of postoperative plastic surgery patient care are presented in this discussion. Elements of nursing care related to the specific treatment of a specific body area affected during plastic or reconstructive surgical procedures are discussed in other chapters. The reader is advised to refer to the appropriate related chapter for more details. Definitions Abdominoplasty Surgical removal of abdominal fat and skin. Augmentation Mammoplasty Surgical procedure performed to enhance the size and shape of a breast. Blepharoplasty Procedure done to correct deformities of the upper or lower eyelid with excision of redundant skin or protruding fat. Dermabrasion Surgical planing of the skin with removal of the epidermis and portions of the superficial dermis for elimination of high spots or other irregularities in an uneven skin surface. Deep Inferior Epigastric Artery Perforator (DIEP) Flap Autologous breast reconstruction performed using an abdominal wall flap. Less abdominal wall damage is incurred using this technique. Gynecomastia Benign hypertrophy of the breast tissue in males. Inosculation Vessel anastomosis from host to graft that allows for graft revascularization. Latissimus Dorsi (LD) Flap Reconstructive procedure involving donor site muscle, adipose tissue, and skin blood supply left connected and then tunneled to the mastectomy site. Lipectomy Surgical removal of fatty tissue. Otoplasty Surgical procedure done to reduce prominence of the ears. Pedicle Flap A preferred flap for wound tissue that is somewhat avascular, such as cartilage, bone, and tendon, or in the presence of avascular scar tissue and radiation-affected tissue. This type of flap is used to provide soft tissue closure while allowing blood vessels to remain intact. Reduction Mammoplasty Surgical removal of the glandular tissue, fat, and skin from the breasts to achieve lighter, smaller, and firmer breast proportions. Rhinoplasty Reshaping or reconstruction of the nose when its shape has been altered as a result of trauma or when the patient is unhappy with its form. Rhytidectomy Surgical tightening of facial and neck muscles with removal of excess skin; commonly called a facelift procedure. Superficial Inferior Epigastric Artery (SIEA) Flap A microsurgical technique using a reconstructive abdominal flap performed without incising the abdominal wall fascia or dissecting through the rectus muscle. Tissue Expansion Insertion and positioning of a temporary inflatable balloon or implant device under the skin, which is periodically increased in size through instillation of normal saline solution to promote expansion of the skin for reconstructive purposes. Transverse Rectus Abdominis Myocutaneous (TRAM) Flap This procedure is performed after a mastectomy and involves reconstruction of the breast with autografting of lower abdominal muscle, skin, and adipose tissue. A pedicle TRAM flap uses the entire rectus abdominal muscle, whereas the free flap technique only partially involves this muscle. Tumescent Liposuction A dilute solution of lidocaine, used in combination with epinephrine, is injected into the adipose tissue layer to facilitate the vacuum removal of fat cells via a small cannula. Preanesthetic concerns for the patient undergoing skin grafting, flap repair, or any type of tissue grafting should include evaluation of smoking status and smoking cessation education; assessment for vascular concerns that may threaten the healing process, such as diabetes; identification of peripheral vascular disease or hypertension; nutritional assessment of the patient; and patient education regarding the postoperative need for wound site immobilization, effective pain management, intensive care monitoring if necessary, and avoidance of straining or strenuous activities that may cause shearing of new grafts or increase the risk for hematoma development. Basic plastic and reconstructive surgery techniques include excision of skin lesions, closure of skin wounds, and placement of skin grafts and skin flaps. Many minor plastic surgical procedures are performed with local anesthesia and require minimal postoperative nursing care that primarily involves close observation of the surgical site. When the patient receives general or regional anesthesia, postoperative nursing care includes all of the appropriate considerations discussed for general care of the postoperative patient in addition to careful surgical site observation. Preoperative vital signs provide an important baseline for assessing possible postoperative complications. Skin grafting is the most common method for covering open areas resulting from incomplete wound healing, trauma, burns, or large surgical incisions. Grafting involves the removal of a skin layer of varying thickness that is then transplanted to a host site. Transplanted skin layers can originate from the individual, be synthetic in origin, or be an expanded portion of the host’s own skin. The lower abdomen supplies a good source for the full-thickness skin graft.5 The major types of skin grafts are outlined in Box 44.1. Revascularization generally takes 3 to 5 days and requires growth of vessels from the host or the recipient tissue via a process called inosculation. For cosmetically pleasing results, the color, texture, thickness, and hair-bearing nature of the skin used for grafting should be chosen to match the recipient site.5 As a rule, the closer the donor skin is located to the recipient area, the better the match. Factors that influence graft survival include: adherence to the recipient tissue to promote oxygen and nutrient transfer and prevent shearing; adequate vascularity at the site, evidenced by color and capillary refill of the site; close monitoring of graft tissue for early identification of complications; and strict management of oxygenation, hemodynamic stability, thermoregulation, pain control, and positioning.6 Postoperative monitoring and assessment for serum or blood in the graft site are important during the first 24 hours. Seroma or hematoma fluid collection can cause the graft to lift from its bed and must be removed through aspiration technique. The donor site should be kept clean, and it heals by forming a new layer of skin.7 Many variations exist in the type of wound dressing used, use of pressure dressings, required positioning of the patient, use of ice or antibiotic ointments, and handling of donor sites. Every effort should be made to keep the patient calm and still and to prevent touching, removing, or shifting of dressings. Some dressings, such as the bolster dressing shown in Fig. 44.1, may actually be sutured in place to apply constant equal pressure on the wound bed and prevent seroma or hematoma formation.7 Negative pressure wound therapy may be used to bolster skin grafts for an assortment of wounds, including the burn population.8 Devices that may be used to monitor microvascular anastomosis include an implantable Doppler and duplex ultrasonography.9 Generally, the grafted area should be elevated and protected from both pressure and motion. The patient should be positioned to prevent any pressure on or other trauma to the graft or the donor site. The surgeon may order intermittent cooling packs to reduce discomfort.10 Dressings over grafts should be observed closely for drainage. The presence of excess drainage should be reported to the physician. The term flap commonly refers to a skin flap; however, with recent advances in reconstructive surgery, flaps are not limited to skin tissue. Flaps are classified by anatomic composition: skin with muscle fascia or bone or both, skin alone, omentum, or a composite of these tissues. The term flap implies maintenance of vascularity from the original location of harvest, unlike transplantation, which implies complete separation from the original vascular site.6 Pedicle flaps are the preferred surgical treatment method for covering wounds having inadequate vascularity to support a skin graft; the reconstruction of full-thickness defects of specialized body parts such as ears, eyelids, nose, and lips; and concealment of gliding tendons. Reconstructions that require tissue bulk, such as decubitus ulcer closure, may also involve skin flap placement. Microvascular tissue transfer represents an important advancement in the field of reconstructive surgery. This technique requires the use of a high-magnification operative microscope for re-establishment of vasculature. Regardless of the type of flap used, the newly positioned tissue is kept under constant observation by perianesthesia nursing personnel.6,10 Postanesthesia nursing management of the patient who has undergone microsurgery is consistent with established care requirements for the specific procedure performed, with emphasis on notation of color changes in the skin at the operative site. The most serious complication in a microvascular tissue transfer procedure is hypoxia leading to tissue necrosis.9 Tissue death occurs when the artery or the vein that supplies the flap develops a thrombus. Arterial thrombosis can result in complete flap failure within 4 hours of onset. Arterial occlusion is characterized by a pale cool flap that does not bleed when stuck with a needle. Hematomas can form at the recipient site and occur more commonly in the patient who preoperatively smokes or uses nonsteroidal anti-inflammatory drugs or corticosteroids.9 Venous thrombosis is more commonly encountered but is not an immediate threat. Thrombosis is characterized by a congested warm mottled flap that continuously oozes dark blood. Objective assessment of the flap is possible with fluorometry, transcutaneous oxygen tension, thermometry, laser Doppler scan, temperature monitoring, buried Doppler probe, or photoplethysmograph disk for monitoring of blood flow. Any change in skin color from the normal baseline assessments that indicate imminent occlusion should be reported to the surgeon immediately. A donor site typically generates more painful stimuli than the transplanted skin graft or flap site.10 Pain management should be individualized and based on the patient’s self-reported pain levels. Nursing care should include administration of analgesics and selected nonopioid adjuvants with attention to comfort measures as needed. Breast cancer affects millions of women around the world each year, and reconstruction after mastectomy has become a routine part of breast cancer treatment. Breast reconstruction using autologous grafting produces a more natural appearance,11 is commonly accomplished in several ways, does not adversely affect cancer survival rates, and can serve to enhance the patient’s psychological state.3 The transverse rectus abdominis myocutaneous (TRAM) flap procedure involves reconstruction of the breast with autografting of lower abdominal muscle, skin, and adipose tissue. The procedure can be performed using a pedicle TRAM flap or a free TRAM flap (Fig. 44.2). The pedicle TRAM procedure was first developed in the early 1980s. Through improved understanding of flap physiology and surgical techniques, common procedural options have evolved to include the use of a free TRAM flap, muscle-sparing free TRAM flap, and DIEP flap. Muscle resection has frequently resulted in an abdominal bulge, abdominal hernia, and some degree of permanent loss of the patient’s abdominal strength. Surgeons performing the TRAM technique may choose to implant propylene mesh at the time of resection to better support the abdominal wall.11,12 The DIEP reconstructive procedure involves a rectus abdominis muscle incision but leaves the muscle completely intact while elevating subcutaneous abdominal fat and skin to achieve the breast graft. The untoward abdominal muscle findings previously described occur at a lower incidence rate in the DIEP patient population.13
44: Care of the Plastic and Reconstructive Surgical Patient
Abstract
Keywords
Perianesthesia nursing care
Skin grafts
Flaps
Microvascular Tissue Transfer and Free Flaps
Breast Reconstruction Flap Techniques
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