This information will help you learn about your reconstruction using free tissue transfer and microvascular surgery and how to care for yourself after it.
About Your Surgery
Microvascular reconstruction surgery using tissue transfer is a surgery done to repair the space left in the body after cancer has been removed by transferring tissue from one part of your body (donor site) to the area that needs to be reconstructed or repaired (recipient site). There are different types of this surgery. Some of the information in this resource may not apply to you. Be sure to ask your surgeon or nurse if you have any questions.
Your surgery will be done by both your primary surgeon and your reconstructive surgeon. Your primary surgeon will remove the tumor, bone, and soft tissue. Your reconstructive surgeon will take a free flap (block of tissue) from the donor site and will attach it at to the recipient site. He or she will use a microscope to see and connect the tiny blood vessels in the free flap with the blood vessels at the recipient site. Very thin stitches are used to join the blood vessels together.
Sometimes, a vein is needed to connect the free flap to the recipient site. In that case, your reconstructive surgeon will make a small incision and take a vein from your arm or leg.
You may also need a skin graft to cover the donor or recipient site. This is skin that is taken usually from the buttock or thigh.
Before Your 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 may have with surgery
- A test to evaluate your heart and lungs.
- An angiogram to evaluate the blood vessels in your legs.
- Other tests such as a computed tomography (CT) scan, magnetic resonance imaging (MRI), and x-rays.
- If you will be having head and neck surgery, you will need a consultation with a dentist from our Dental Service. 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 electrocardiogram (EKG).
Try to stop drinking alcohol once your surgery is planned. If you develop a headache, nausea, increased anxiety, or cannot sleep after you stop drinking, tell your doctor right away. These are early signs of alcohol withdrawal and can be treated.
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 free flap receives. This can affect the success of your surgery. There are many resources here at Memorial Sloan Kettering Cancer Center 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 resource Getting Ready for Surgery. It tells you what you need to do to prepare for your surgery. Your nurse will also give you any other resources that you may need.
After Your Surgery
You will wake up in the Post Anesthesia Care Unit (PACU). You will stay in the PACU overnight so that the free flap can be closely monitored. Your family will be able to visit you in the PACU. Your nurse will contact them as soon as your condition is stable.
You will also have:
- Drains (small tubes) at the surgical sites. These drains collect the fluid that can build up under your skin 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.
- A Foley® catheter (thin, flexible tube) that will be placed through your urethra into your bladder in the operating room. It drains your urine while you are bed-bound.. The catheter is usually removed in 3 to 4 days.
- An intravenous (IV) line in a vein in your arm. You will get fluids, antibiotics, pain medication, and if needed, blood thinners through it. Blood thinners prevent your body from forming blood clots in the area of the surgery.
- Compression boots on one or both legs to help circulate blood to help prevent blood clots. If your surgery was on one of your legs, that leg will not have a boot on it.
The nursing staff will care for your surgical sites. As you begin to feel better, they will teach you how to perform some of this care yourself. Please read any resources they give you. They will help you learn to care for your surgical sites.
What to Expect With Specific Types of Reconstruction
Reconstruction in the head and neck area
- After your surgery, it is common to have:
- Difficulty with breathing
- Trouble swallowing
- You may have a tube in your neck to help you breathe. This 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. Your nurses will ask you “yes” and “no” questions about how you feel and whether you have any pain. You will be able to nod your head or write on a pad of paper if you need or want something. The tube 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.
- Your nurses will suction the tracheostomy tube to keep it clear of secretions. Over time, they may teach you how to do this.
- Your surgeon may insert a feeding tube through your nose into your stomach. This will allow you to receive the right amount of nutrients. The tube will stay in until the swelling from the surgery goes down. You will receive high-protein liquid feedings and your medication 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 surgeon 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 to prevent the surgical site from moving. It is usually removed or changed 5 to 7 days after surgery.
- There will be some limitations on your physical activities. Your surgeon or nurse will discuss this with you.
- You must keep your arm or leg elevated at all times. Your surgeon or nurse will tell you when you can stop.
- If your free flap or skin graft is on your legs or feet, your surgeon or nurse will tell you when you can dangle your legs or walk. This may not be for 1 to 3 weeks or more after surgery.
Reconstruction of your lower back and buttock or vagina
- A loose surgical binder may be put on you in the operating room to hold the dressings in place.
- You may be placed on a bed that has a special air mattress. This prevents direct pressure on the surgical sites and the incision.
- You may be told to lie on your sides or on the side opposite the incision. This is to prevent direct pressure on the incision.
- You may be allowed to walk starting 2 or 3 days after surgery.
- You may not be able to sit until several weeks after surgery. This is so that no tension is put on the incision.
Monitoring the free flap
For the first week after your surgery, doctors and nurses will monitor the blood supply to your reconstructed site and nearby tissues often. To do this, they will use a machine called a Doppler®. It is noisy, but painless. They may also check the temperature and the color of the flap. These exams are very important, since free flaps can be repaired if problems are found early.
Caring for the donor site
The care of your donor site will depend on how the wound was closed. It may have been closed:
- By bringing the edges of the skin together. This will look like a line of stitches.
- With a skin graft. If a skin graft was used, it will have a large dressing on it. The dressing is usually removed 5 to 7 days after surgery. Your nurse will explain how to care for it and will also give you the resource Split Thickness Skin Graft.
No matter how the donor site is closed, avoid tension or pulling on the site.
If your donor site is on your abdomen, elevate your knees in bed, by placing a pillow below your knees. When you are out of bed, sit with your feet on a stool. Your physical therapists will help you position your body after surgery. You may also be given binders that place gentle pressure against your abdomen, which makes it easier to move around.
If your donor site is on your upper back, do not raise your arms above your shoulders for 10 to 15 days.
Removing the stitches
Your stitches will likely be removed 7 to 10 days after your surgery.
Some people have radiation to the surgical sites. In this case, the stitches may stay in place for 2 to 3 weeks or longer.
Limits on physical activity
After your surgery, you will need to temporarily avoid certain exercises and movements. This is to make sure you do not create any tension on the newly reattached blood vessels. These limits depend on the location and the type of free flap you have had. Your doctors and nurses will give you specific instructions.
Most people can eat a regular diet when they go home. If your surgery was in your mouth, you will most likely go home on a full liquid or puréed diet. A puréed diet is one in which all the food is processed in a blender. Your dietitian or nurse will review this with you.
When you leave the hospital, wear comfortable and loose-fitting clothing. Do not wear anything that directly presses on your free flap. This can interfere with the blood supply to the free flap.
If you want to cover the surgical area of the free flap, try a scarf, hat, or shawl. Your nurse will help you choose clothing that is best for the type of surgery you had.
If a car seat belt falls across your incisions, place a small pillow or folded towel under the seat belt on top of the incision.
Caring for your surgical sites at home
- 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 may be numb and you can easily hurt yourself without knowing it. This includes hot water bottles, heating pads, and ice packs. Avoid staying in saunas and in steam rooms longer than 5 minutes at a time.
- Do not use makeup on your incisions 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.
- Do not shave over your incisions while your stitches are still in place. When your stitches are removed, use an electric razor on and around the free flap or reconstructed area.
- Do not put anything on your incisions until they are completely healed, including:
- Perfume and cologne
- Avoid Jacuzzis and swimming pools until your incisions are completely healed.
- Avoid sun exposure to your surgical sites. After the incisions have completely healed, use a PABA-free sunscreen with an SPF of 30 or higher.
- Check with your doctor or nurse before doing any strenuous exercise, such as running, jogging, and lifting weights
Dealing With Permanent Changes
After your surgery, you may have temporary or permanent changes in the areas of your surgery. For example, you may have permanent changes in your:
- Appearance (e.g., scars at the donor and recipient sites, skin color changes). Your free flap may be a different color than your surrounding skin.
- Lifestyle (not being able to do all of the things you could do before the surgery). This 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 psychiatrist 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 healthcare team about your concerns.
Both of your surgeons will need to see you after you leave the hospital. 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.