Surgical options in wound healing.

This article addresses methods of reconstruction for major acquired and traumatic soft-tissue defects in adults. The reconstructive ladder is used as a basis for discussing the various options for surgical closure. Conditions such as facial trauma, head and neck cancer, median sternotomy, sternal osteomyelitis, bronchopleural fistula, necrotizing fascitis, pressure ulcers, and degloving injuries are used as examples of reconstruction. Nursing aspects, including postoperative flap monitoring, are reviewed. Outcomes of reconstruction, including flap failure, are addressed.

The TRAM flap in breast reconstruction.

With the TRAM flap, the surgeon can restore the woman's breast using her own tissue while simultaneously giving her a flatter abdomen (Noguchi et al., 1992). Monitoring of the flap begins in the recovery room. Nurses monitor the flap by assessing the Doppler signal, color, temperature, and capillary refill every 15 minutes. Before the patient goes home, she is instructed in wound and drain care, and the nurses outline encouraged activities and activity restrictions.

Using the latissimus dorsi flap for breast reconstruction.

The preferred method for breast reconstruction is the simplest type that can meet the patient's needs and expectations (Bostwick, 1989). Several breast reconstruction procedures are presented in this issue. In this article, only breast reconstruction using the latissimus dorsi flap is discussed.

Creating a realistic breast: the nipple-areola reconstruction.

Breast reconstruction is a multi-stage process, leaving many patients overwhelmed by the surgeries they have had to endure by the time they reach the final stages. Patients, however, are encouraged to complete their new breast by undergoing nipple and areolar reconstruction. These last two procedures improve the aesthetic result by transforming the surgically created breast mount into a more natural-appearing breast. This final touch enhances body image, restoring the patient's feeling of wholeness. These procedures are mostly done in the office under local or no anesthesia, depending on the sensation present in the reconstructed breast.

Microsurgical transfer of vascularized tissue to close problem wounds.

Interventions to achieve optimal wound healing challenge the skills of all health care professionals. Although most wounds are best managed by appropriate nursing intervention outside the OR, some complex wounds require more expeditious closure to ensure maximum preservation of vital structures and their functions. Microsurgical transfer of vascularized tissue (ie, flaps) often is the only method of achieving immediate wound coverage. Perioperative team members who treat such wounds must be aware of the distinct attributes and potential morbidity associated with flap procedures.

Methods of reconstruction.

This article discusses methods of reconstruction, ranging from simple free-hand skin grafts to microvascular tissue transfer. The simplest reconstructive option must be chosen to suit the defect and to achieve the least possible donor morbidity. The most suitable reconstructive choices are discussed for each of the following situations: to provide a large surface area, to provide hair-bearing tissue, to fill "dead space," to restore motor function, or to provide composite bone and soft-tissue structures.

Current concepts in breast reconstruction.

Breast cancer is the leading malignancy in women in the United States. Breast reconstruction is an important aspect in the treatment regime for breast cancer. Reconstruction now is a daily occurrence, providing women with a life-enhancing opportunity. Women contemplating reconstruction may choose from a broad menu of options allowing for tailored care.

Surgical management of pressure ulcers.

This article describes how debridement and dressings are used to clean wounds prior to closure with myocutaneous flaps. Post-operative care focuses on promoting flap perfusion, especially by reducing pressure on the flap and by promoting wound drainage. Rehabilitation of the patient is imperative to reduce recidivism.

Skin flaps in plastic surgery: an overview.

Once the exclusive preserve of the plastic surgery unit, skin flaps are now being seen by nurses in a variety of surgical specialties. The author describes what the different kinds of flaps are, then explains the vital observations and interventions nurses must perform to keep the patient's skin flap viable.

Breast reconstruction using an innovative flap procedure.

Most patients consider breast reconstruction an essential part of total breast cancer management. In the wake of the silicone-gel implant controversy, more women are considering breast reconstruction using their own tissue. Since 1982, the transverse rectus abdominis myocutaneous (TRAM) flap has become a well-established and popular method of reconstruction. For many women, TRAM flap reconstruction is the surgery of choice following mastectomy. It offers victims of breast cancer the potential for soft, natural-appearing breast mounds without the risks associated with other types of flaps or manufactured implants. A description of autogenous tissue grafting using the TRAM flap for breast reconstruction is provided with associated perioperative nursing care guidelines and potential complications.

Free flap breast reconstruction.

New advances in breast reconstruction are now an integral part of the surgical treatment of breast cancer. Microvascular free flap breast reconstruction is a complex surgical procedure requiring advanced nursing care both intra- and post-operatively in order to achieve maximum aesthetic results and facilitate the recovery process.

The care and feeding of microvascular flaps: how nurses can help prevent flap loss.

Free flaps are used to reconstruct defects that cannot be repaired by traditional methods using local adjacent tissue. Advantages include a single operation, decreased immobility, increased vascular supply to tissues for healing, minimal risk of flap loss, and primary closure of the donor site. Disadvantages are a long operation, two surgical sites, need for surgery if vascular compromise occurs, donor site morbidity, and expense. Preoperative care focuses on readiness for surgery and avoidance of medications (nicotine, caffeine) and situations (cold exposure) that cause vasospasm. Intraoperative nursing care includes positioning, range of motion, and pneumatic compression devices for the long case. The operating microscope requires special care and instruments. After surgery, blood flow to the flap is closely monitored. Laser flow Doppler can be used with data recorded on a flow sheet. Common postoperative problems include temperature instability, pain, blood pressure fluctuations, and oliguria. Dismissal teaching includes avoidance of vasoconstrictive medications and dressing changes.

General principles of flap reconstruction: goals for aesthetic and functional outcome.

Plastic surgeons are often requested to reconstruct defects following traumatic injury or after tumor ablation. These defects most commonly occur in the head and neck region and in the extremities. Reconstructions must balance the aesthetic and functional goals against morbidity of the donor site. This article provides a better understanding of reconstructive flaps through application of general principles. Flaps are classified according to type. Characteristics of both the donor site and the reconstructive recipient site are then explored. Case examples serve to illustrate the general principles enumerated.