Plastics reconstruction and repair

Recommendations

Identify and Treat the Cause
1 Develop a detailed approach for patient assessment and reconstructive surgery planning to reduce the risk of postoperative complications. Level of Evidence
Not Assessed
2 Conduct a inspection. Level of Evidence
Not Assessed


Address Patient-Centered Concerns
3 Provide individualized patient education. Level of Evidence
5


Provide Local Wound Care
4 Manage wound complications by addressing systemic and local factors, bacterial balance and infection, and patient-centred concerns. Level of Evidence
Not Assessed
5 Optimize wound healing environment. Level of Evidence
Not Assessed


Provide Organizational Support
6 Establish and empower an interprofessional team to provide post-operative care. Level of Evidence
5


Background

Reconstructive plastic surgery may be used to correct facial and other abnormalities occurring as a result of birth defects, trauma, infection or disease. The goal of reconstructive surgery may be to improve function, appearance or both. Reconstructive surgery is usually carefully planned and often carried out in stages.

Large skin defects often require the use of grafts, tissue expansion or flaps. Local, regional, musculocutaneous, fasciocutaneous, bone/soft tissue or microvascular free flaps may be used to fill defects. For some time now, microsurgery has allowed reattachment of severed limbs.

Complications of reconstructive surgery include delayed healing, bleeding and hematoma formation, dehiscence, graft failure, scar formation and contracture, failure of vessel anastamoses, and infection. Patient factors increasing the risk of complications are smoking, history of radiation, connective tissue diseases, poor perfusion, malnutrition, and immunocompromise. Surgical factors affecting complications include inadequate hemostasis, poor suturing technique, inadequate vascularity of graft sites, and excessive manipulation of graft sites, interfering with graft take.

A study of risk factors for complications after breast reconstructive surgery found obesity, smoking and radiation significantly to influence development of complications, including wound-healing complications, infection and reoperation.

Preoperative analysis of individual surgical needs and risk factors for complication development can help determine candidacy for reconstructive surgery, optimal preoperative management approaches to reduce the risk of complications, the best procedures or techniques to achieve the desired result, and the optimal timing of the procedure. Detailed planning can minimize the development of postoperative complications.

Management of wound complications follows the principles of wound healing: addressing systemic and local factors, bacterial balance and infection, and patient-centred concerns.

References

Essential Publications
1 Fibrin glue – Face lifts Quality Indicator
 Type: RCT
Marchac D, Greensmith AL. Early postoperative efficacy of fibrin glue in face lifts: A prospective randomized trial. Plast. Reconstr. Surg. 2005;115(3):911-916.
The purpose of this study was to determine the efficacy of the use of fibrin glue in face lifts. The use of glue significantly reduced wound drainage compared to no glue (p = 0.037), but this difference was not deemed surgically significant. There was no significant difference in grades of hematomas, ecchymosis, and edema. On the basis of this study, the authors have reduced their use of fibrin glue for this purpose.
2 Preoperative showering - Antiseptics Quality Indicator
 Type: RCT
Kalantar-Hormozi AJ, Davami B. No need for preoperative antiseptics in elective outpatient plastic surgical operations: A prospective study. Plast. Reconstr. Surg. 2005;116(2):529-531.
The purpose of this study was to determine the efficacy of preoperative showering with antiseptics in preventing wound infections in elective outpatient plastic surgery. 1810 patients were evenly divided into two groups (using a randomization procedure regarded as not appropriate), one showering with normal saline solution and the other showering with the antiseptics Chlorhexidine or Betadine. No surgical site infections occurred in either group. This indicates that preoperative showering with antiseptics does not significantly reduce levels of infection.
3 Preoperative showering – Povidone-iodine Quality Indicator
 Type: RCT
Veiga DF, Damasceno CAV, Filho JV, Silva Jr RV, Cordeiro DL, Vieira AM, Andrade CHV, Ferreira LM. Influence of povidone-iodine preoperative showers on skin colonization in elective plastic surgery procedures. Plast. Reconstr. Surg. 2008;121(1):115-118.
The researchers examined the effect of preoperative showering with povidone-iodine on skin colonization in elective plastic surgery in this study. Showering with povidone-iodine significantly reduced levels of staphylococcal skin colonization compared to showering without povidone-iodine, but the difference for fungi and enterobacteria colonies was non-significant.


Enablers for practice

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