Reconstructive surgery

Management of patient with Reconstructive surgery- Plastic surgery- Cleft lip and cleft plate, Breast reconstruction.....

1. Management of patient with reconstructive surgery MATHEW VARGHESE V MSN(RAK),FHNP (CMC Vellore),CPEPC Nursing officer AIIMS Delhi 1 [email protected]

2. 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 [email protected]

3. Categories 3 [email protected]

4. 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 [email protected]

5. 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 [email protected]

6. Examples include Cleft lip and palate repair Breast reconstruction following a lumpectomy or mastectomy for breast cancer, Reconstructive surgery after burn injuries. 6 [email protected]

7. 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 [email protected]

8. 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 [email protected]

9. Indications of reconstructive surgery 9 [email protected]

10. 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 [email protected]

11. 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 [email protected]

12. 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 [email protected]

13. 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 [email protected]

14. 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 [email protected]

15. 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 [email protected]

16. 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 [email protected]

17. 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 [email protected]

18. Hand surgery Plastic surgeons are involved in the management of a wide range of conditions that affect the hand including Nerve compression Paralysis Arthritis Dupuytren’s Contracture 18 [email protected]

19. 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 [email protected]

20. Skin grafts There are three basic types of skin graft. These are: Split thickness skin graft Full-thickness skin graft ’ Composite graft 20 [email protected]

21. 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 [email protected]

22. 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 [email protected]

23. 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 [email protected]

24. 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 [email protected]

25. 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 [email protected]

26. 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 [email protected]

27. 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 [email protected]

28. 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 [email protected]

29. 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 [email protected]

30. 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 [email protected]

31. 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 [email protected]

32. Implants 32 [email protected]

33. 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 [email protected]

34. Implants 34 [email protected]

35. 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 [email protected]

36. 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 [email protected]

37. 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 [email protected]

38. 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 [email protected]

39. 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 [email protected]

40. 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 [email protected]

41. 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 [email protected]

42. Cleft Lip and Palate Repair 42 [email protected]

43. Symptoms Difficulty with feedings Difficulty swallowing, with potential for liquids or foods to come out the nose Nasal speaking voice Chronic ear infections 43 [email protected]

44. 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 [email protected]

45. 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 [email protected]

46. Complications Difficulty feeding.   Ear infections and hearing loss.   Dental problems.   Speech difficulties.   Challenges of coping with a medical condition.   46 [email protected]

47. Prevention Consider genetic counseling.   Take prenatal vitamins.   Don't use tobacco or alcohol. 47 [email protected]

48. 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 [email protected]

49. 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 [email protected]

50. 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 [email protected]

51. 51 [email protected]

52. 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 [email protected]

53. 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 [email protected]

54. 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 [email protected]

55. 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 [email protected]

56. Nursing Role 56 [email protected]

57. 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 [email protected]

58. 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 [email protected]

59. 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 [email protected]

60. 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 [email protected]

61. drain 61 [email protected]

62. Penrose drain 62 [email protected]

63. 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 [email protected]

64. bolster 64 [email protected]

65. 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 [email protected]

66. 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 [email protected]

67. 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 [email protected]

68. 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 [email protected]

69. 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 [email protected]

70. 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 [email protected]

71. 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 [email protected] Plot No 3, LSC, Sector C​ Pocket 6/7 Vasant Kunj New Delhi 110070 1800 103 8301 [phone]