Reconstructive surgery

MANAGEMENT OF PATIENT
WITH RECONSTRUCTIVE
SURGERY
MATHEW VARGHESE V
MSN(RAK),FHNP (CMC Vellore),CPEPC
Nursing officer
AIIMS Delhi
1
mathewvmaths@yahoo.co.in

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.
2

CATEGORIES
Plastic
Surgery
Cosmetic
Surgery
Reconstructive
Surgery
3

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.
4

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.
5

EXAMPLES INCLUDE
 Cleft lip and palate repair
 Breast reconstruction following a lumpectomy or
mastectomy for breast cancer,
 Reconstructive surgery after burn injuries.
6

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
8

INDICATIONS OF RECONSTRUCTIVE SURGERY
INDICATIONS
CONGENITAL
ACQUIRED
9

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.
10

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.
11

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

12

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.
13

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
14

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
15

TRAUMA
 Reconstructive surgical techniques are crucial in
the treatment of trauma and injury.
 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.
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.
17

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.
19

SKIN GRAFTS
 There are three basic types of skin graft. These are:
 Split thickness skin graft
 Full-thickness skin graft’
 Composite graft
20

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. 21

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.
22

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.
23

 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.
25

REGIONAL FLAP
 This pictures shows muscle from the calf being
transferred, keeping its blood supply intact to cover
an open fracture below the knee.
26

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.
27

 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 muscle flap
28

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
29

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 or breas
30

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.
31

IMPLANTS
32

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. 33

IMPLANTS
34

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
35

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.
36

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.
37

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
38

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 39

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.
40

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.
41

CLEFT LIP AND PALATE REPAIR
42

SYMPTOMS
 Difficulty with feedings
 Difficulty swallowing, with potential for liquids or
foods to come out the nose
 Nasal speaking voice
 Chronic ear infections
43

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
44

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. 45

COMPLICATIONS
 Difficulty feeding.
 Ear infections and hearing loss.
 Dental problems.
 Speech difficulties.
 Challenges of coping with a medical condition.
46

PREVENTION
 Consider genetic counseling.
 Take prenatal vitamins.
 Don't use tobacco or alcohol.
47

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 48

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.
50

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.
52

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.
53

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.
54

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.
55

NURSING ROLE
56

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
57

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.
58

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
59

ASSESSING DRAIN STATUS:
 Patient may have jackson pratt (JP) drains:
 JPs are 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. 60

DRAIN
61

PENROSE DRAIN
62

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 opertaive 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.
63

BOLSTER
64

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.
65

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.
66

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

RESEARCH ARTICLE (CANADIAN NURSING STUDY)
CARR, T. L., GROOT, G., COCHRAN, D., VANCOUGHNETT, M., & HOLTSLANDER, L. (2019).
EXPLORING WOMEN'S SUPPORT NEEDS AFTER BREAST RECONSTRUCTION SURGERY: A
QUALITATIVE STUDY. CANCER NURSING, 42(2), E1–E9.
HTTPS://DOI.ORG/10.1097/NCC.0000000000000600
 Title : A Qualitative Studyon Exploring Women’s
Support Needs After Breast Reconstruction Surgery
 Background
 The procedures for breast reconstruction (BR) after
mastectomy frequently initiate a difficult recovery
period. A better understanding of women’s support
needs after surgery would improve patient care.
 Objective
 The aim of this study was to identify patients’
support needs after BR.
68

 Methods
 In a retrospective study design, 21 participants described
their support experiences after BR, including their sources
of support and the impact of support on their recovery in a
semistructured interview. Transcriptions of the interviews
were analyzed using thematic analysis.
 Results
 Four support needs were identified and were composed of
elements of instrumental, emotional, and informational
support. These needs were addressed to varying degrees
by healthcare providers, family members, and other women
who had BR experience.
 Conclusion
 Women’s experience of BR and their ability to cope are
markedly better when their support needs are effectively
addressed. Greater attention to their needs for support has
the potential to improve patient care.
69

REFERENCE
 Macionis V. Definition of plastic surgery: A historical perspective.
Journal of Plastic, Reconstructive & Aesthetic Surgery.
2017;70:132-133.
 Hasen K.V., Few J.W., Fine N.A., (2002), Plastic surgery: a
component in the comprehensive care of cancer
patients. Oncology 16(12). p. 1685-98. PMID 12520643.
 Gilmartin, J. (2011). "A critical literature review: the impact of
reconstructive surgery following massive weight loss on patient
quality of life". Journal of Nursing and Healthcare of Chronic
Illnesses. 3 (3): 209–221. doi:10.1111/j.1752-
9824.2011.01100.x.
 https://medicine.uiowa.edu/iowaprotocols/post-operative-care-
flap-patient-nursing-protocol
 https://www.cancer.net/navigating-cancer-care/how-cancer-
treated/surgery/reconstructive-surgery
 https://www.webmd.com/a-to-z-guides/reconstructive-surgery
 https://www.plasticsurgery.org/reconstructive-procedures
70

 Smile Train is a nonprofit organization and charity
providing corrective surgery for children with cleft
lips and palates
 Headquartered in New York City and founded in
1999, Smile Train provides free corrective cleft
surgery in 87 countries, training local doctors and
providing hospital funding for the procedures.
71
Plot No 3, LSC, Sector C
Pocket 6/7
Vasant Kunj
New Delhi 110070
1800 103 8301
+91 11 47856300

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