types of reconstruction
What is involved in an implant reconstruction?
Implant reconstructions can be done using a silicone gel implant or a saline implant. To make room for the implant in the tissue, the skin needs to expand. This is done using a tissue expander.
What are some prophylactic post-operative actions that a nurse may implement to prevent adverse post-operative complications.
- flap monitoring and assessment
- deep breathing and coughing
- moon boots
- monitor vitals
- encourage ambulation
What are the advantages and disadvantages of silicone gel implants?
Silicone gel implants feel more natural than saline implants and do not require injury to other parts of the body, as in autologous implants. However, silicone implants have the potential for microscopic leaks, and have the potential for infection. The implants are meant to last for forever, however this is not always the case.
Define prophylactic
something intended to prevent harm
Do patients have to pay for their own breast reconstruction?
No, Ontario Health Insurance Plan (OHIP) covers the cost for these surgeries as long as a patient has a valid OHIP number.
Explain how tissue expanders work
A tissue expander is put under the skin to expand the surrounding tissue. The expander is like a flat balloon, which is slowly filled with fluid over several months at the doctor's office visits. Once the expander is slightly larger than the implant, the expander is removed and replaced with a silicone or saline implant.
Upon assessment, you notice discolouration of the breast flap. This may indicate.
A. decreased arterial flow
B. venous outflow obstruction
C. poor venous return
D. a normal postoperative finding
Answer: A
Why might saline implants be a less popular choice?
Saline implants have a much less natural feel than silicone implants or autologous transplants. Additionally, saline implants have the potential to rupture or deflate.
What does autologous mean?
Using someone's own tissue from elsewhere on the body to form a breast.
What if only one breast needs to be reconstructed? What happens if they don't look alike?
What is a LAT flap?
The Latissimus Dorsi muscle in the back, responsible for the twisting motions of your back, is harvested and placed where the breast would be.
You notice your patient is complaining of a sore calf. The leg appears red and is warm to the touch. What do you expect is occurring? What will your action be? What would you continue to monitor for?
Potential Deep Vein Thrombosis. Notify MRP STAT. Continue to monitor for pulmonary embolism or stroke.
Why is a DIEP reconstruction flap the gold standard in autologous reconstructions?
What is capsullar contracture?
Capsullar contracture is a potential complication of breast implant surgery. This can cause your reconstructed breast to shift, change shape, or feel harder. A capsule around the implant contracts or thickens, causing pain, shifting, distortion, and hardening of the reconstructed breast.
The patient asks about when they can go back to their job that includes heavy lifting. What is your response?
For the first month or month and a half you should not lift or push anything heavier than 5 lbs. Avoid bending forward or flexing, and get plenty of rest. Walking is a great idea for exercise.
What is a DIEP flap?
Tissue is completely disconnected from the abdomen and then reconnected to the chest. This type of flap does not include taking muscle from the abdomen. It needs microsurgery and takes longer to do.
Your patient is post-op day 1. You notice on your kardex that you are required to do a flaps assessment q4H. Describe a flaps assessment.
- monitor flaps perfusion by assessing cap refill, which may be normal (1-3 seconds), slow (more than 3 seconds), or slow (more than 3 seconds)
- monitor flaps perfusion using a Doppler to listen for perfusion, heard like the sound of a pulse.
- assess colour as pink, cyanotic, or white
- compare the reconstructed breast with the unaffected breast if applicable.
Why might a TRAM flap be chosen?
A TRAM flap might be chosen because the surgery takes less time and allows tissue to remain connected to its original site.
What does DIEP mean?
Deep Inferior Epigastric Procedure. A type of breast flap surgery.
Name 5 potential risks for having a reconstruction surgery.
- pain
- deep vein thrombosis
- pulmonary embolism
- bleeding
- loss of sensation
- delation of implants
- dissatisfaction with results
- implant may move, resulting in a change of appearance
- microleaks of silicone gel implants
- implant breaks through muscle wall and skin
- infection
What is a TRAM flap reconstruction?
the tissue of the abdomen is swung up into the chest, a piece of the tissue remains connected to the abdomen
What criteria should be fulfilled before being discharged?
- lack of urinary retention, more than 30ml/hr.
- patient can demonstrate management of drains or drains are removed
- adequate pain management
- adequate intake
- management of nausea and vomiting
- flaps assessments have been good.
Why would a LAT surgery be chosen over a DIEP surgery?
A LAT surgery may be chosen if the patient is thin and does not have much abdominal tissue. Additionally, a LAT surgery would be chosen if a surgeon is not trained in microsurgery.
What does the term TRAM mean?
Transverse Rectus Abdominus Myocutaneous flap
How does previous radiation affect breast reconstruction?
Radiation causes permanent damage to the chest wall tissues, resulting in dissatisfaction with the appearance of the reconstructed breast and increased risk of infection. Autologous breast reconstruction is preferred in patients who have had radiation, however implant reconstruction may also be successful.