Care of patient with

reconstructive surgery

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Introduction

 The term "plastic surgery" originates from the Greek

word "plastikos," which means to mold or shape.

 The field of Plastic Surgery can be broken down into

two main categories – reconstructive
procedures and cosmetic procedures

 Both are generally considered sub-specialties of plastic

surgery.

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Categories

Cosmetic
Surgery
Plastic Surgery
Reconstructive
Surgery
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Cosmetic surgery
 Cosmetic surgery is performed to enhance overall
cosmetic appearance by reshaping and adjusting
normal anatomy to make it visually more appealing.

 Unlike reconstructive surgery, cosmetic surgery is not

considered medically necessary.

 Breast augmentation, breast

lift, liposuction, abdominoplasty (tummy tuck)
and facelift are popular examples of cosmetic surgery
procedures.

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What is Reconstructive Surgery?
 Definition
 Reconstructive surgery is all about
repairing people and restoring function.

 It is performed to repair and reshape

bodily structures affected by birth defects,
developmental abnormalities,
trauma/injuries, infections, tumors and
disease.

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Examples include

 Cleft lip and palate repair

 Breast reconstruction following a lumpectomy or
mastectomy for breast cancer,
 Reconstructive surgery after burn injuries.

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Who all do Reconstructive
surgery?
 Plasticsurgeons,maxillo-facial
surgeons and otolaryngologists do reconstructive surgery
on faces after trauma and to reconstruct the head and
neck after cancer

 Reconstructive surgery represents a small but critical

component of the comprehensive care of cancer patients.

 Its primary role in the treatment of cancer patients is to

extend the ability of onco surgeons and specialists to
more radically treat cancer, offering patients the best
opportunity for cure 7
Who all do Reconstructive
surgery?

 Other branches of surgery

 General surgery
 Gynecological surgery,
 Pediatric surgery
 Podiatric surgery
 also perform some reconstructive procedures.
 The common feature is that the operation attempts
to restore the anatomy or the function of the body
part to normal

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Indications of reconstructive
surgery

CONGENITAL
INDICATIONS
ACQUIRED
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 Congenital
 Cleft lip and palate
Using local flaps and grafts, surgeons can repair the incompletely fused
area of the lip and palate.
 Vascular anomalies
Arteriovenous malformations (AVM) and certain haemangiomas.

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Congenital
 Prominent ears, constricted ears and microtia

Reconstructive surgery is used to correct all manner of ear defects;

techniques include otoplasty for prominent or constricted ears
and ‘autogenous ear reconstruction’ for the treatment of
microtia.

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Congenital
 Hypospadias
Soft tissue reconstruction is used to correct this defect of the
urethra in baby boys.

 Craniofacial conditions
Reconstructive surgery is used to correct a wide range of cranial
and facial deformations, such as craniosynostosis

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Congenital
 Hand deformities
Plastic surgeons can also correct birth defects of the
hand – e.g. where a child has been born with too many
or too few digits.

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B.Acquired

 Acquired conditions are those that develop or occur after

birth.

 They can involve disease and infection, or they can

involve accident and injury.

 Acquired conditions that are treated with reconstructive

surgery include as follows

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Cancer
 Plastic surgeons and Onco surgeons spend a great deal of time
operating on cancer patients.

 Reconstructive surgery, mainly excision, closure and flap

reconstruction, is used to treat a range of cancer conditions,
especially cancer of the skin, breast, head and
neck and sarcoma

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  Reconstructive surgical techniques
are crucial in the treatment of
trauma and injury.
Trauma
 These injuries most commonly
involve the hand – in fact, 50% of the
work carried out in many plastic
surgery units is concerned with hand
trauma.

 The treatment of open fractures of

the lower limb is also common, as is
surgery to repair soft tissue injuries
of the face.

mathewvmaths@yahoo.co.in 16
Acquired cont…
 Infection

 Reconstructive surgery is used to remove dead tissue

following severe infections and to repair the surrounding
area.

 Burns

 Plastic surgeons are the primary clinicians involved in the

resuscitation, surgical treatment and reconstruction of
patients who have suffered burns.

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Reconstructive Surgery
techniques
 A. Skin grafts

 A skin graft involves taking a healthy patch of skin from one area
of the body, known as the donor site, and using it to cover
another area where skin is missing or damaged.

 The piece of skin that is moved is entirely disconnected, and

requires blood vessels to grow into it when placed in the
‘recipient site.

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Skin grafts
 There are three basic types of skin graft. These are:

 Split thickness skin graft

 Full-thickness skin graft’
 Composite graft

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techniques

 B. Tissue expansion

Tissue expansion is a procedure that enables the body to ‘grow’

extra skin by stretching surrounding tissue.

 A balloon-like device called an expander is inserted under the

skin near the area to be repaired, and is then gradually filled
with salt water, causing the skin to stretch and grow.

 The time involved in tissue expansion depends on the individual

case and the size of the area to be repaired.

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C.Flap surgery

Flap reconstruction involves the transfer of a living piece of

tissue from one part of the body to another, along with
the blood vessel that keeps it alive.

 Unlike a skin graft, flaps carry their own blood supply, so

can be used to repair more complex defects.

 Flap surgery can restore form and function to areas of

the body that have lost skin, fat, muscle movement,
and/or skeletal support.
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types of flap

 There are three main types of flap.

1. Local flap

 Uses a piece of skin and underlying tissue

that lie near to the wound.
 The flap remains attached at one end so
that it continues to be nourished by its
original blood supply and is repositioned
over the wounded area.

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 In above diagram case - a skin cancer has been removed from the
nose leaving a defect that cannot simply be stitched up. A local
flap, called a bilobed flap is used to close the defect. The flap
consists of skin along with the underling soft tissue and its blood
supply. A local flap like this relies on the fact that the skin has
some natural elasticity and uses the lax skin in the bridge of the
nose to close a defect near the tip of the nose where the skin is
naturally tight. 24
Regional flap
 It uses a section of tissue that is attached by a specific blood vessel.
 When the flap is lifted, it needs only a very narrow attachment to the original
site to receive its nourishing blood supply from the artery and vein.

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Regional flap

 This pictures shows muscle from the calf being

transferred, keeping its blood supply intact to cover
an open fracture below the knee.

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3- Free flap/microsurgery
 Free flap reconstruction also involves the transfer of
living tissue from one part of the body to another,
along with the blood vessel that keeps it alive.

 A free flap is a further modification of flap

transfer where the flap is entirely disconnected from
its original blood supply and then reconnected using
microsurgery in the recipient site.

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 In above image, the patient has an open fracture of his right lower leg. A
muscle is taken from his inner left thigh and transferred to his right leg.
The blood vessels that keep this muscle alive are dissected out of his left
thigh along with the flap, divided, and then joined up micro surgically to
blood vessels in his right leg. This keeps the flap alive in its new position.
To complete the reconstruction a split skin graft is taken from the left
thigh and laid over the free muscle flap. This is called a free gracilis
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muscle flap
 Common Types of
reconstructive surgeries
 Breast reconstruction surgery

 The goal of breast reconstruction is to reform or reshape one

or both breasts after a mastectomy or lumpectomy.

 This reconstruction process can help a person find their self-

confidence again and feel better during
their cancer recovery

 Although many factors can help determine the most suitable

type of breast reconstruction, there are three main options
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Breast reconstruction surgery

 Implants or prosthetics:
This type of surgery uses silicone or saline
implants.
 Autologous or skin flap surgery:
This method uses tissue from another part of
the body.
 Combined
In some cases, a surgeon might use a combination of both techniques
to create a more natural reconstruction of the breast

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Implants
 When reconstructing a breast with implants, a surgeon will
insert silicone or saline implants underneath the skin or muscle,
in the place of the previous breast tissue.
 For most people, this is a two stage procedure. During the first
stage, a surgeon places a tissue expander underneath the
remaining breast skin, or pectoralis muscles. The expander
serves as a temporary saline implant that gradually stretches
the remaining tissue.
 After the person has fully healed following surgery, surgeon will
inject sterile saline or salt water through the skin into the
tissue expander on a weekly basis. This balloon gradually grows,
stretching the overlaying skin and muscle until the breast
reaches a size with which the person is comfortable.

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Implants

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Implants
 When the chest tissues heal and the surgeon has added enough
saline to the tissue expander in preparation for the implants,
they will perform the second procedure to insert the implants.

 The surgeon removes the tissue expanders and replaces them

with either a silicone or saline implant. They will usually reopen
the original scar. This often means that the procedure leaves no
new scars on the chest.

 In some cases, a surgeon may place a permanent saline or

silicone implant at the time of the mastectomy, without use of a
tissue expander.
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Implants

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Skin flap surgery
 With skin flap surgery, the surgeon takes tissue from another part
of the body and moves it to the chest to rebuild the breast.

 The surgeon usually removes this tissue from the abdomen.

However, it may come from other places on the body, including the
buttock, back, or thigh.

 Skin flap surgery highly complex, as it involves transferring tissue

from one area of the body to another.

 Two methods are available for this surgery:

 Free flap surgery

 Pedicle flap surgery

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free flap surgery

 In free flap surgery, a surgeon completely removes the

tissue and the blood vessels that provide it with
circulation for placement in the breast.

 They stitch the blood vessels into other blood vessels in

the chest at the intended site of placement. These
blood vessels are very small, so the surgeon will use a
microscope to sew them together in a procedure called
microsurgery.

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pedicle flap surgery,
 In pedicle flap surgery, a surgeon will not entirely remove
the transplanted tissue from its blood vessels. Instead, the
tissue remains attached to the body, and the surgeon
usually rotates this into the chest to form the breast.
 A surgeon usually uses tissue from the abdomen or back for
pedicle flap surgery.

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Risks and complications
 Bleeding or blood clots
 Infection
 Potential complications with anesthesia
 Fluid
buildup in the breast or at the
donor site (for skin flap surgery)
 Extreme fatigue
 Slow or disrupted wound healing
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Complications…..
 Tissue death, or necrosis, which may develop
in the skin, fat, or tissue flap
 Loss of muscle strength at the donor site (for
skin flap surgery)
 Changes in breast or nipple sensation
 Need for more surgical procedures if
complications occur
 Uneven breasts
 Problems with the implant, such as movement,
rupture, leakage, or scar tissue
 Need to have the implants removed
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Breast Reduction surgery
 Also called reduction mammaplasty, breast reduction is a procedure
that removes excess breast fat, tissue and skin to reach a breast size
that’s more in proportion with the body.

 It can also be to relieve discomfort from overly large breasts.

 Men can also undergo breast reduction.

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Cleft Lip and Palate Repair
 Cleft lip and cleft palate are some of the most
common birth defects.

 This type of plastic surgery is designed to correct this

abnormal development and restore a more normal
appearance.

 Cleft lip and cleft palate are openings or splits in the

upper lip, the roof of the mouth (palate) or both.

 Cleft lip and cleft palate result when facial structures

that are developing in an unborn baby don't close
completely.
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Cleft Lip and Palate Repair

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Symptoms
 Difficulty with feedings
 Difficulty swallowing, with potential for liquids or
foods to come out the nose
 Nasal speaking voice
 Chronic ear infections

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Causes

 Researchers believe that most cases of cleft lip and

cleft palate are caused by an interaction of genetic
and environmental factors.

 In many babies, a definite cause isn't discovered.

 The mother or the father can pass on genes that

cause clefting, either alone or as part of a genetic
syndrome that includes a cleft lip or cleft palate as
one of its signs

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Risk factors
 Family history.

 Exposure to certain substances during pregnancy.

Cleft lip and cleft palate may be more likely to occur in pregnant
women who smoke cigarettes, drink alcohol or take certain
medications.

 Having diabetes.

 Being obese during pregnancy.

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Complications
 Difficulty feeding.

 Ear infections and hearing loss.

 Dental problems.

 Speech difficulties.

 Challenges of coping with a medical condition.

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Prevention
 Consider genetic counseling.
 Take prenatal vitamins.
 Don't use tobacco or alcohol.

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Treatment
 The goals of treatment for cleft lip and cleft palate are to
improve the child's ability to eat, speak and hear normally and
to achieve a normal facial appearance.
 Care for children with cleft lip and cleft palate often involves a
team of doctors and experts, including:
 Plastic Surgeons, ENT specialists, Pediatricians
 Pediatric dentists,Orthodontists,
 Nurses
 Auditory or hearing specialists
 Speech therapists
 Genetic counselors
 Social workers
 Psychologists

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Surgery schedule
 Cleft lip repair — within the first 3 to 6 months of
age
 Cleft palate repair — by the age of 12 months, or
earlier if possible
 Follow-up surgeries — between age 2 and late teen
years
 Surgery can significantly improve your child's
appearance, quality of life, and ability to eat, breathe
and talk.
 Possible risks of surgery include bleeding, infection,
poor healing, widening or elevation of scars, and
temporary or permanent damage to nerves, blood
vessels or other structures. 49
Hand or Foot Surgery
 Hand surgery can improve conditions that impair the hand,
including carpal tunnel syndrome, rheumatoid arthritis and
Dupuytren’s contracture

 These surgeries can treat diseases that cause pain and impair
strength, function and flexibility in the wrists and fingers.

 They can also correct some abnormalities that may have been
present at birth.

 Foot surgeries may also be available for people affected by tumors,

or by webbed or extra toes.

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Scar Revision
 This is a group of treatments that attempt to minimize the
appearance of a scar and help it blend in more effectively with
the surrounding skin.
 Treatments can range from mild, topical treatments and
minimally invasive procedures to surgical revision.
 Know that while scars can be reduce they cannot be completely
removed.

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Tissue Expansion
 Tissue expansion is a process that allows the body to
grow extra skin in almost any area of the body.

 A silicone balloon expander is inserted under the skin

near the area that needs to be repaired and gradually
filled with salt water over time—this causes the skin to
stretch and grow.

 It’s most commonly used for breast reconstruction

after breast removal, but it can also help in other
areas.
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Advantages and Disadvantages
of Reconstructive Surgery
 Advantages of Reconstructive Surgery

 The main advantage of the Reconstructive Surgery is that it

gives a normal look to the patient.

 This will also have a great effect on the patient's self

esteem and will give her an emotional well being, which is
important in all aspects of life, including the professional
and personal aspects.

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Advantages and Disadvantages
of Reconstructive Surgery
 Disadvantages of Reconstructive Surgery

 The main disadvantage of Reconstructive Surgery may

be the costs involved. Depending on the complexity of
the surgery, the costs may not be within the budget of
many patients.

 Another disadvantage is that choosing an

inexperienced surgeon can result in poor quality work,
which may require a new surgery to fix.
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Nursing Role

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 Assessment of sign & symptoms of
infection at the site of reconstruction

 Fever of Over 101F

 Feeling of Overall Malaise
 Green, Cloudy (Purulent) or Malodorous Drainage
 Increasing or Continual Pain from Wound
 Redness Around Wound
 Swelling of Wounded Area
 Hot Skin Near Wound
 Loss of Function and Movement

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Airway assessment of the
patient with a flap:
 If patient has a tracheostomy, make sure to suction, change
inner cannula, and check cuff pressure upon admission.
 Checking cuff pressure:

 Always have two nurses at the bedside.

 After measuring pressure, replace air in cuff
to about 20 to 30 cm of H20.
 A cuffed shiley tracheostomy and obturator that same size as
the patient's should always be at the head of the bed in case of
airway complications.
 Patient should have humidified oxygen or room air at all times,
but the flap area should ever have cool mist blowing on it.
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Checking circulation of the flap:
 Assess color of flap:

Dusky? Blue? Pink? Pale?

 Free flaps are to be marked and doppled
every hour for 48 hrs

 Assess flap for changes in size and swelling:

 Key indicators for possible hematoma or other

complications include sutures over the flap
pulling apart and palpable crepitus beneath
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Assessing drain status:
 Patient may have jackson pratt (JP) drains:

 JPsare to be stripped Q2 hrs for 48 hrs to

prevent clotting.
 Patient may have Penrose drains:

 Penroses are to be rolled Q2 hrs for 48 hrs

to express fluid out and prevent swelling.
 Patient may have and NG tube:

 Make sure the NG tube is secured to the

nare (suture, tegaderm).
 Note and chart where the NG stops at the
nare in case of future displacement.
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drain

61
Penrose drain

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Assess split thickness skin graft
site (STSG) if present:
 Dry and intact? Leaking ?

 Red and beefy vs. pale with clots?

 The STSG dressing is not to be removed until at least post

operative day 7 to 10.

 It is nursing's responsibility, to drain fluid off from

underneath the dressing:

 If bolster is present over STSG site, this is not to be removed

until the patient discharges from the hospital and returns for
follow up appointment at the clinic.
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bolster

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TIPS to remember and
things to report to physician
 The donor extremity site must be elevated at all times.

 No weight bearing or toe touch weight bearing for fibula

flaps until approved by the physician.

 Call physician immediately for and change in color, dopple

sounds, or increased swelling/firmness at the related flap or
donor site.

 Normal flap color is similar to that of the

recipient site.
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TIPS to remember and
things to report to physician
 Normal capillary refill of flap site is 1-2 seconds.

 Be concerned if flap begins to appear pale relative

to the donor site or becomes cool to touch.

 Color and appearance of a congested flap varies,

depending on whether the congestion is mild or
severe and ranges from a pinkish color to a dark
bluish purple color.
 Confirm that all flap patients have a blood thinner ordered to assist with
perfusion to flap area.

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Conclusions

 Reconstructive surgery represents a small but critical

component of the comprehensive care of cancer

patients.

 Its primary role in the treatment of cancer patients is

to extend the ability of other surgeons and specialists

to more radically treat cancer, offering patients the

best opportunity for cure.

67