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 composite graft comprises two or more tissue components and often includes skin and subcutaneous tissue, cartilage, or mucosa that can be used to reconstruct a patient’s ear, nose, or eyelid.

• 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.

• An autograft indicates that the donor and the recipient are the same person.

• An isograft signifies that the donor and the recipient are genetically identical.

• Allograft or homograft means that the donor and the recipient are of the same species; this procedure may entail the use of cadaver tissue.

• A xenograft indicates that the donor and the recipient are of different species (e.g., porcine or bovine sources).

• Bioengineered skin and skin substitutes contain cells that may be animal, human, or host hybrids which acclimatize to the wound and accelerate healing. The mechanism of action is unknown.

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.

FIG. 44-1 Sutured bolster dressing.

(From Adams DC, Ramsey ML: Grafts in dermatologic surgery: review and update on full- and split-thickness skin grafts, free cartilage grafts, and composite grafts, Dermatol Surg 31:1055−1067, 2005.)

Flaps

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 and free flaps

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.

Breast reconstruction flap techniques

Breast cancer affects millions of women across the world each year, and reconstruction after mastectomy has become a routine part of breast cancer treatment. Breast reconstruction using autologous grafting is commonly accomplished in several ways, does not adversely affect cancer survival rates, and can serve to enhance the patient’s psychologic state. The transverse rectus abdominis musculocutaneous (TRAM) flap procedure involves the reconstruction of a 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 deep inferior epigastric artery perforator (DIEP) flap. All these flap procedures use a segment of abdominal muscle mass to achieve the breast graft. This muscle resection has frequently resulted in an abdominal bulge, abdominal hernia, and some degree of permanent loss of the patient’s abdominal strength. These findings occur at a lower incidence rate in the DIEP patient population. Surgeons performing the TRAM technique may choose to implant propylene mesh at the time of resection to better support the abdominal wall.¹⁰

FIG. 44-2 Transverse rectus abdominis myocutaneous (TRAM) flap. A, After mastectomy of the involved breast, (B) a breast is reconstructed using the lower abdominal skin and fatty tissue. In a pedicled TRAM, the tissue’s own blood supply remains attached, and the lower abdominal tissue is rotated into position on the chest. The tissue is tunneled under the skin to the chest area, where it is brought through the mastectomy incision. The reconstructed tissue is shaped to form a matching breast and placed in the mastectomy skin pocket. A free TRAM flap refers to using skin and tissue that are completely disconnected from their blood supply, moved from the abdomen to the new site, and reconnected to different blood vessels. A nipple and areola can be tattooed on later after healing has taken place.

(From Goodman CC, Fuller KS: Pathology: implications for the physical therapist, ed 3, St. Louis, 2009, Saunders.)

Another procedure available for use in autologous breast reconstruction is the latissimus dorsi flap (LD) technique. The LD flap procedure is especially useful in the low body mass index patient who lacks the abdominal tissue reserves needed for flap harvest.¹¹ Although a functional option, this procedure has been associated with less overall patient satisfaction than with the abdominal graft options.¹⁰ As with all postoperative flap procedures, nursing care of the postoperative breast reconstruction patient centers on observation of the graft site in addition to general perianesthetic breast surgery patient care (see Chapter 43).

Evidence-Based Practice

A comparison study evaluated patient satisfaction with four breast reconstruction techniques: transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric artery perforator (DIEP), latissimus dorsi (LD) flap, and implants. A validated questionnaire was sent to 583 postreconstructive breast surgery patients with a 75% response rate obtained (119 pedicle TRAM, 117 DIEP, 116 LD, 87 tissue expander). Conclusive findings showed that the abdominal TRAM flap group had significantly greater aesthetic and general satisfaction with this procedure’s results than did the LD flap population.

Implications for practice

Patients may have several options for the type of reconstructive breast flap procedure performed. Preoperative discussions surrounding the available breast surgery techniques and related patient satisfaction outcomes may better assist a patient in making an informed decision about the course of treatment pursued.

Source: Yeuh JH, et al: Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques, Plast Reconstr Surg 125:1585−1595, 2010.

Bone grafts

After bone grafting has been performed, the graft site must be immobilized, and excessive movement of the patient should be avoided. The donor site is generally the greater source of postoperative discomfort over the graft site.⁹ Pain should be anticipated and aggressively managed with opioid analgesics. If split-rib grafts are used, the patient should be placed in a low Fowler position. Respiratory status should be frequently assessed, and any signs of possible pneumothorax, such as tachycardia and tachypnea, should be reported immediately to the surgeon. Ice often is applied for reduction of swelling and pain management, and the graft site may necessitate elevation.

Surgical repair of facial bone injuries

The facial bones often are fractured during motor vehicle crashes, falls, fights, and sporting events because of their protrusion and prominence. Fractures differ in location and complexity, and repair can vary from closed reduction to internal fixation with plates and screws, interosseous wiring, and bone grafting. Repair of facial bones often requires general anesthesia. If the damage is extensive and airway obstruction or concomitant cranial or intrathoracic injury is present, a tracheostomy must be performed. All patients who have facial, jaw, or neck surgery need the placement of a tracheostomy tray at the postanesthesia care unit (PACU) bedside in the event an airway emergency should occur. When the patient is admitted, this equipment must also be available for immediate use on the inpatient nursing unit.

On admission to the PACU, the patient who has undergone repair of the facial bones is placed in a low Fowler position as soon as the condition warrants. The elevated position helps to minimize the development of head and neck edema. In the case of a patient with a wired jaw, treatment with antiemetics is essential to prevent vomiting and aspiration. Frequent suctioning of secretions may be necessary in the early postoperative period; therefore the nurse must maintain close airway monitoring with careful performance of oral and endotracheal tube suctioning as needed.

When interdental wire fixation is performed, opening of the jaws may become necessary if an airway emergency develops (see Chapter 32 for care of the patient with interdental fixation). A pair of wire clippers should be clearly visible and affixed to the head of the bed to facilitate rapid opening of the jaws if needed. Good oral hygiene is a priority for these patients, and petrolatum ointment should be applied to the lips to prevent drying and cracking.

Surgical repair of cleft lip and palate

Cleft lips and palates are among the more common congenital defects encountered in the U.S. population.¹² Children born with these defects may have associated problems, including facial growth abnormalities, dental irregularities, speech difficulties, ear diseases, psychological disorders, and cosmetic challenges. The infant with a cleft palate generally encounters difficulty nursing and swallowing. Repair of the cleft lip (Figs. 44-3 and 44-4) is usually accomplished when the “rule of 10” is met: 10 weeks of age, a body weight of at least 10 lbs, and a hemoglobin level of at least 10 g/dL. Repair is accomplished with general anesthesia, with palatal, maxillary regional nerve blocks available for use.¹³^,¹⁴

FIG. 44-3 Preoperative appearance of unilateral cleft lip.

FIG. 44-4 Postoperative appearance of unilateral cleft lip. Incision is covered with antibiotic ointment to prevent crusting.

On PACU admission, the infant is placed in a semiprone position, and the arms should be guided away from the operative site to avoid disruption of the newly repaired lip. Postoperative complications can include acute airway obstruction, laryngospasm, bronchospasm, bleeding, and aspiration of secretions and blood.¹⁵ Hemorrhage, although rare, is a possible complication. Because loss of even a few milliliters of blood in an infant can be significant, any bleeding requires rapid control intervention. Measures should be taken to minimize crying because it puts excessive tension on the newly repaired lip, and the parents should be present at the earliest possible time to facilitate soothing of the child. Depending on the type of anesthesia and intraoperative opioid dosing used, postoperative pain medication or sedation may be needed to comfort the infant. In addition to preventing lip trauma, the most important nursing activity is airway management. Humidified mist should be used to promote general respiratory well being and aid in clearing of secretions. In some cases, a nasal trumpet can be used to maximize oxygenation and may be sutured to the nostril to prevent dislodgement. When the child is fully awake from the anesthesia small sips of clear fluids may be given. Pain status, although difficult to assess in an infant, must be evaluated. Analgesia should be provided when indicated, and oral analgesics such as acetaminophen can be used. Iced normal saline solution–soaked gauze can be applied to the suture areas to reduce swelling and promote comfort.

Cleft palate

Depending on the extent of the palate defect and accompanying lip defect, if present, repair may be completed when the child is 6 to 18 months of age. Optimization of speech and feeding is often a priority. The repair can be phased, requiring multiple procedures that include palatoplasty with bone grafts and orthodontic inserts.¹⁶ Certain procedures, such as nasoseptal reconstructions, can be delayed until the child becomes a teenager. On admission to the PACU, the child is placed in the semiprone or “tonsil” position with careful attention given to airway maintenance. As in cleft lip repair, the child’s arms should be guided away from the surgical site, and crying should be avoided. The head should not be flexed because this position tends to occlude the airway. Suctioning may be necessary but must be performed gently and only if the nurse’s view is unobstructed. The catheter, plastic dental suction tip, or Yankauer suction tip should be passed over the dorsum of the tongue, and only minimal vacuum pressure should be used. A mist tent or cold-mist humidifier should be used to aid in the elimination of secretions. Pain should be assessed and managed with opioids and adjuvants as indicated. Hemorrhage is a possible complication, and any active bleeding requiring control should be reported to the surgeon.

Cosmetic surgery

Men and women seek cosmetic surgery to enhance their physical appearance and emotional well being. Millions of cosmetic surgical procedures are performed each year in the United States, and many of these are performed in an outpatient surgery center or office-based practice setting. Most of these cosmetic procedures are performed on an outpatient basis. The anesthetic course depends on the selected procedure and the individual patient, and can involve straight local, local with sedation, or general anesthesia. Nursing assessments and nursing care should be adjusted to the type of anesthesia administered and then individualized for each patient’s needs.

Blepharoplasty

Blepharoplasty is a procedure to correct deformities of the upper or lower eyelid with excision of redundant skin or protruding fat. The procedure may be performed for a cosmetic benefit or when eyelid drooping impedes vision.¹⁷ The procedure is usually performed with local anesthesia with supplemental intravenous sedation. Iced compresses minimize swelling and bleeding. The patient may resume a regular diet after surgery; however, hot liquids are contraindicated for 24 hours to prevent vasodilation and bleeding. Activities such as bending and heavy lifting should be avoided. Pain should be assessed and managed with appropriate analgesics. Drugs that alter coagulation times should be avoided. Antibiotic ointment may be used for lubrication (see Chapter 33).