44 Care of the plastic and reconstructive surgical patient
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.
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 the reconstruction of a 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.
The field of plastic surgery encompasses cosmetic and reconstructive surgery, and related procedures and techniques have continuously evolved over time. This discipline is growing as consumer demand for cosmetic surgical procedures increases1 and the ability to achieve aesthetic 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 nineteenth-century Germany. 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.2,3 Ideally, these procedures represent interconnected therapy4 that strives to restore normal function and enhance appearance to maintain or improve body image and self-esteem.5
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.
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, primarily involving close observation of the surgical site. When the patient receives general or regional anesthesia, postoperative nursing care includes all 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 that result 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.6
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. As a rule, the closer the donor skin is located to the recipient area, the better the match.
Box 44-1 Major Types of Skin Grafts
• A full-thickness graft includes all underlying dermis and epidermis and a small amount of subcutaneous tissue. These grafts, used to cover areas such as the nasal tip, dorsum, ala, and sidewall of the lower eyelid and ear, are more prone to necrosis.
• A split-thickness graft includes a portion of the underlying dermis and the entire epidermis. This graft is the least durable. It can be thin, medium, or thick, depending on the amount of dermis included.
• A free cartilage graft involves a portion of cartilage that is harvested and reimplanted to provide structure and support to the site. One example is the use of rib cartilage to create an ear structure in a patient with microtia.
Factors that influence graft survival include: adherence to the recipient tissue; adequate vascularity signs, which include color and capillary refill of site; close monitoring of graft tissue for early identification of complications; and strict management of oxygenation, hemodynamic stability, thermoregulation, pain control, and positioning. Postoperative monitoring and assessment for serum or blood in the graft site is important during the first 24 hours. Excess fluid can cause the graft to lift from its bed and must be removed. The donor site should be kept clean, and 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. 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 cold packs to reduce metabolic requirements of the graft and enhance its chances of survival. 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 original vascular site.
Pedicle flaps are the preferred surgical treatment method for covering of wounds with: inadequate vascularity to support a skin graft; 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 reestablishment of vasculature. Regardless of the type of flap used, the newly positioned tissue is kept under constant observation by perianesthesia nursing personnel. 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 tissue necrosis. 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 antiinflammatory drugs or corticosteroids.8
Venous thrombosis is more commonly encountered, but it 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 or monitoring findings that indicates 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.9 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.