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Reconstruction Using Free Tissue Transfer and Microvascular Surgery: A Guide to Care

Introduction

You will be having reconstructive surgery. It is done to repair the space left after cancer has been removed. Your surgeon will use a “free flap” and microsurgery. This booklet describes the surgery and tells you what to expect.

Some of the information in the booklet will not apply to you. Be sure to ask your reconstructive surgeon or nurse about the details of your surgery.

Definition of Reconstruction with Free Flap and Microsurgical Technique

A free flap takes a block of tissue from one part of your body (called the donor site) and moves it to the site that needs reconstruction (called the recipient site). The surgeon uses a microscope to connect the small blood vessels that feed the tissue that is being transferred with blood vessels at the site that needs reconstruction. These blood vessels are smaller than a matchstick. The stitches used to join them are finer than a human hair. Sometimes, a longer vessel is needed. In that case, the surgeon will take a vein from your arm or leg. It is removed through a small incision. Connecting the blood vessels allows the free flap to live in its new spot. This is called microsurgery.

Possible Outcomes

If your cancer surgery results in a defect that must be repaired with a free flap, you can expect that some things will be different. These changes may be permanent or temporary. For example, you may have permanent changes in your:

  • Appearance (scars at the donor and recipient sites, skin color changes). Your free flap may be a different color than the surrounding skin.
  • Lifestyle (not being able to do all of the things you could do before the surgery). It depends on the location of the flap. For example, a flap from your leg may prevent you from doing some of the exercises that you were able to do before your surgery.
  • Ability to swallow.
  • Ability to eat some types of foods.
  • Ability to speak, if your surgery is on your tongue or voice box (larynx).
  • Sensation on the skin at your surgical sites. You may have numbness or tingling at the sites. These improve over time but they will always feel number than normal skin.

You are likely to have strong feelings about any permanent changes. You may be angry, scared, self-conscious, or sad. Many people are available to talk about your feelings with you. Your surgeons, nurses, and social worker can all help by telling you how others have coped. You can also talk with a psychiatrists or psychologist. Adjusting to changes takes time. Having a professional to listen and guide you may make it easier. Take part in your care and ask questions. Tell your doctor, nurse, or other member of your health care team about your concerns.

You will also have temporary changes. These include swelling after surgery. You may not be able to do some physical activities, such as sitting and walking. These changes may take weeks or months to resolve. The time varies from person to person. It also depends on the extent of the surgery.

Before Surgery

After the consultation with your reconstructive surgeon, he or she may decide that you should have:

  • A medical clearance visit. Your safety is our top concern. This visit will help your surgeon plan your care to lower any risks you might have with surgery. This visit is likely to make your operation safer.
  • A test to evaluate your heart and lungs.
  • An angiogram to evaluate the blood vessels in your legs.
  • Other tests such as a CT scan, MRI, and x-rays.
  • A consultation with a dentist from our Dental Service if you will have had head and neck surgery. You may have a dental x-ray and dental impressions. Nasal or ear molds may be made before your surgery. These molds will be used later to make the appropriate prosthesis for you. A prosthesis is something that replaces a body part.

You will then have pre-surgical testing (PST). It is the final step before your surgery. Testing may include blood work, a chest x-ray, and an EKG (electrocardiogram). You may see an anesthesiologist. This is the doctor who gives you medicine to make you sleep through the surgery.

Let your doctor know if giving up alcohol before surgery will be a problem for you. You can get medicine to help prevent withdrawal symptoms. If not treated, alcohol withdrawal syndrome can lead to serious complications

We strongly encourage smokers to stop smoking. Nicotine found in cigarettes, cigars, chewing tobacco, and nicotine patches constricts blood flow. It can decrease the amount of blood that the flap receives. This can affect the success of the operation. There are many resources here at MSKCC to help you quit. Ask your doctor or nurse for information. You can also call the Tobacco Treatment Program at (212) 583-3015.

Your nurse will give you the booklet “Getting Ready for Surgery.” It tells you what you need to do to prepare for your operation. Your nurses will give you other booklets, self-care cards, exercises, and instructions you may need.

Definition of Immediate Reconstructive Surgery

  • Your primary surgeon removes the tumor, bone, and soft tissue. Your reconstructive surgeon takes a free flap from another part of your body and attaches it at the site to be reconstructed or repaired. Ask how long your entire operation may last.
  • On the Head and Neck Service, the two surgeons work together during the operation. On other services, the primary surgeon removes the tumor. Then the reconstructive surgeon repairs the area.
  • You may also need a skin graft. This is a shave of skin usually taken from the buttock or thigh to cover the donor site. The reconstructed site may need more skin than what the doctor could take with the graft. This can be used to cover the donor site or be used in addition to the free flap at the recipient site.

After Surgery

You will feel sleepy when you wake up in the Post-Anesthesia Care Unit (PACU). If your surgery was on your head or neck, you may have a tube in the neck to help you breathe. It is called a tracheostomy tube. It will stay in until the swelling goes down. If you have this tube, you will not be able to speak. The nurses will ask you “yes” and “no” questions about how you feel and whether you have any pain. You will be able to shake or nod your head or write on a tablet of paper if you need or want something.

All patients stay in the PACU overnight. This is so the free flap can be closely monitored. Your family will be able to visit you in the PACU. The nurse will contact them as soon as they have checked everything and your condition is stable.

  • You will have a Foley® catheter (a tube). It is placed through your urethra into your bladder in the operating room. It lets your urine drain while you are asleep. The catheter is usually removed in three to four days. Its removal is usually painless.
  • You may have drains (small tubes) at the surgical sites. These drains will prevent the collection of fluid under the skin. Instead, they let the fluid collect into small containers that are pinned to your hospital gown. These drains do not hurt. They are removed when the drainage is less than 1 ounce (30 mL) in 24 hours. This is usually within the first 4 to 10 days after your surgery.
  • You will have an intravenous (IV) line. You will get fluid, antibiotics, pain medicine, and if needed, blood thinners through it. Blood thinners prevent your body from forming blood clots in the surgical area.
  • You will have Venodyne® compression boots on one or both legs. They help circulate blood through the leg to help prevent blood clots. They are not put on a leg that was operated on.

Free-Flap Check

For the first week after surgery, doctors and nurses will monitor the blood supply to your reconstructed site and nearby tissues. They use a machine called a Doppler®. It is noisy, but painless. They may also check the temperature and the color of your flap. These assessments are very important since free flaps can be saved if problems are detected early. The assessments are done often during the first week.

Care of the Donor Site

The care of your donor site will depend on the method used to close the wound.

  • It may be closed by bringing the edges of the skin together. This will look like a simple suture line. The area is kept clean and dry until you are allowed to shower.
  • Another method to close the donor site is with a skin graft. If a skin graft is used, it will have a large dressing on it. The dressing will typically be removed 5 to 7 days after your surgery. Your nurse will explain the care and will also give you the “Split Thickness Skin Graft” booklet. It has information concerning the care of this area.
  • If a free flap donor site is on your arm or leg, you may have bandages or a splint in place. Your nurse may ask you not to move it or to keep the area elevated. They will tell you how long you should do this.

No matter how the donor site is closed, avoid tension or pulling. If you have abdominal donor sites, elevate your knees in bed. When you are out of bed, sit with your feet on a stool. You may also be given binders if your donor site is on your abdomen. These place gentle pressure against your abdomen making movement easier. Do not raise your arms above your shoulders for 10 to 15 days if your donor site is on your upper back.

Suture Removal

Your stitches will likely be removed 7 to 10 days after your surgery. Some patients have radiation to the surgical sites. In this case, the stitches may stay in place for 2 to 3 weeks or longer.

What to Expect with Specific Procedures

Reconstruction in the Head and Neck Area

  • It is common to have:
    • Swelling.
    • Difficulty with breathing.
    • Trouble swallowing.
  • You may have a tracheostomy tube in your windpipe through your neck. This will assure that swelling does not interfere with your breathing. It is usually removed 7 to 10 days after surgery.
    • You will have a humidifier collar near your tracheostomy tube. It will moisten the air you breathe and prevent drying of the tissues that line your windpipe.
    • The nurse will suction the tracheostomy tube to keep it clear of secretions. Over time, they may teach you how to do it.
  • Your surgeon may insert a feeding tube through your nose into your stomach. This will allow you to receive the right amount of calories, vitamins and minerals. It will stay in until the swelling from the surgery goes down. High-protein liquid feedings and your medicine are given through this tube. Before you are allowed to eat and drink, a specialist may check to make sure it is safe for you to swallow. This is usually 10 to 15 days after your surgery.
  • You may be told to sleep without pillows and with your head elevated. This is to prevent further swelling. Your doctor or nurse will tell you how long you must sleep this way.

Reconstruction on Your Arm or Leg

  • You may be given a cast, splint, or sling. It is used to prevent the surgical site from moving. It is usually removed or changed five to seven days after your surgery.
  • You will be told what physical activities you can and cannot do.
  • You must keep your arm or leg elevated at all times. Your surgeon or nurse will tell you when you can stop.
  • You will be told when you can dangle your legs or walk if your free flap or skin graft is on your legs or feet. This may not be for one to three or more weeks after surgery.

Reconstruction of Your Chest or Breast(s)

  • A loose surgical bra may be put on in the operating room. It is to hold the chest dressing or support the reconstructed breast(s).
  • An abdominal binder may be put on in the operating room. It is to support the abdominal donor site.

Reconstruction of Your Lower Back and Buttock, or Vagina

  • A loose surgical binder may be put on in the operating room. It is to hold the dressings.
  • You may be placed on a bed that has a special air mattress. This prevents direct pressure on the surgical sites and the suture lines.
  • You may be told to lie on your sides or on the side opposite the incision. This is to prevent direct pressure on the suture lines.
  • You may be allowed to walk starting two or three days after surgery. You may be told not to sit until several weeks after surgery. This is so that no tension is put on the donor site incision line.
  • Remember: Do not sit unless your doctor or nurse approves this.

Self-Care

After your operation, the nursing staff will do all of your care. As you begin to feel better, they will teach you how to perform some of this care yourself. Please read any patient education cards and booklets they give you. They will help you learn to care for your surgical sites.

Limits on Physical Activities

After your operation, you will be told to avoid certain exercises and movements. This is to make sure you do not have any tension on the newly reattached blood vessels. These are temporary limits. They depend on the location and the type of free-flap you have had. Your doctors and nurses will give you specific instructions.

Diet

Most patients can eat a regular diet when they go home. If the surgery is in the mouth, you will most likely go home on a full liquid or pureed diet. A pureed diet is one in which all the food is processed in a blender. You may be given a copy of a booklet describing this diet. No matter what type of diet you are on, a dietitian or your nurse will review it with you.

Clothing Hints

When you leave the hospital, wear comfortable and loose-fitting clothing. Do not wear anything that directly presses on your flap. This can interfere with the blood supply to the flap. If you want to cover the area of the free flap to help improve your appearance, try a scarf, hat, or shawl. Your nurse will help you choose clothing that is best suited for the type of surgery you had. Car seat belts may fall across your incisions. If so, place a small pillow or folded towel under the seat belt on top of the incision.

Follow-Up Appointments

Both of your surgeons will need to see you after discharge. Call each surgeon's office to schedule an appointment. It is very important that you go to these follow-up appointments. Write down any questions you and your family may have and bring them with you to your appointments.

Special Points

  • Do not apply direct pressure to the free flap (e.g., tight belt, neck tie, or tight bra).
  • Do not place direct heat or cold on the surgical sites. They are numb and you can easily hurt yourself without knowing it. This includes hot water bottles, heating pads, or ice packs. Also avoid staying in saunas and in steam rooms longer than five minutes at a time.
  • Do not use make-up on the suture lines until they have completely healed. After that, you can use it to hide and improve the appearance of your surgical sites. Your doctor and nurse will let you know when it is safe to do so.
  • If you shave, use an electric razor on and around the free flap or reconstructed area. Do not shave over the suture lines while your sutures are still in place.
  • Do not put anything on the suture lines until they are completely healed. This includes:
    • Perfume and cologne.
    • After-shave.
    • Moisturizer.
  • Avoid Jacuzzis and swimming pools until your suture lines are completely healed.
  • Avoid sun exposure to the surgical sites. Use Sunblock after the suture lines have completely healed. Make sure it is PABA-free and has an SPF of 30 or higher.
  • Check with your doctor or nurse before doing any sport. Examples are running, jogging, and lifting weights.

Conclusion

Patients tell us that their emotions change in the days and weeks after surgery. Talking about your feelings may help you cope. Let your family, friends, doctors, and nurses know how you are feeling. Your social worker may have the name of a patient-to-patient volunteer who has had the same surgery. If you would like, you can request that this volunteer visit you. Please ask a member of your healthcare team if you would like more information about support services or support groups.