๐ ็ธฝ็ฎ้ ๏ฝ ๐ ่ฑๆๅๆ๏ผๆฌ็ฏ๏ผ ๏ฝ ๐ ๅฎๆด็ฟป่ญฏ ๏ฝ โญ ็ฒพ่ฏ็ญ่จ
POSTOPERATIVE CARE
Postoperative care after flap surgery varies from practice to practice. Some surgeons have the patient change the bandage once to several times a day, cleansing the wound at each bandage change. Others apply a bandage for a day or two and leave the sutured wounds open to air thereafter. Still others apply a single bandage at the time of the surgery and leave it undisturbed for up to a week. Regardless of how the postoperative care is accomplished, there are common goals to achieve during the postoperative period.
One of these common goals is to prevent postoperative bleeding. The first 48โhours is the time period during which bleeding and hematomas most commonly occur. Efforts to reduce these complications include meticulous intraoperative hemostasis and the postoperative application of pressure to the wound. Pressure can be applied by using taping techniques, pressure wraps, or specialized pressure garments. Normally, pressure becomes less important after 24 to 48โhours. In the patient at higher risk for bleeding, it may be necessary to maintain pressure for a more prolonged period of time. In some patients with a very high risk of postoperative bleeding, it may be helpful to use a tie-over bolster dressing directly over the wound to ensure constant firm pressure throughout the postoperative period.
Another common goal in the postoperative care of flaps is to reduce the risk of infection. All forms of infection can complicate the postoperative course and affect the cosmetic and functional results. Prevention of postoperative infections is covered in Chapter 151. However, good surgical technique and observance of sterile technique during reconstruction is paramount. One novel approach, particularly well-suited for cutaneous reconstructions, is the direct infiltration of the unclosed wound preoperatively with local anesthesia containing antibiotics. The benefit of intralesional nafcillin and clindamycin has been studied and this procedure is used routinely in some practices prior to reconstruction.
An additional important goal in the postoperative care of flap reconstruction is protection of the flap tissue from all environmental insults, including contamination, physical injury, temperature extremes, excessive movement and stretching of the sutured skin during the early postoperative period, and ultraviolet radiation. This is best accomplished by occlusive bandaging techniques and thorough education of the patient.
Presented here are the details of postoperative flap care as routinely implemented in one surgical practice. After the completion of flap reconstruction, a light bandage consisting of hypoallergenic tape over Steri-Stripsโข is placed directly over the incision lines. The tape completely covers the sutured skin resulting in complete occlusion of the wound. A โbulkyโ secondary bandage is then applied on top of this thin primary bandage. The bulky bandage consists of rolled or fluffed absorbent gauze, which is affixed with hypoallergenic paper tape, using a technique of taping which applies downward pressure. This is accomplished by the placement of one end of the tape on the skin of one side of the wound and stretching it over the top of the bulky gauze and then attaching the other end to the opposite side of the flap under tension. This is repeated numerous times with thin, 1-cm-wide strips of tape until the bulky gauze is entirely covered and firmly affixed by the tape. The patient is instructed to remove the bulky secondary bandage 24 to 48โhours after surgery, leaving the thin, flat primary bandage in place. This bandage is left undisturbed and kept dry for the remainder of the week.
The patient returns to the office after 1 week for bandage removal, suture removal, and evaluation of the wound. Any evidence of hematoma, infection, or other complication is addressed. The skin is cleansed and another thin bandage consisting of Steri-Stripsโข and hypoallergenic tape is applied for one more week. The patient is instructed again to keep this bandage dry and to remove it in 1 week (i.e. 2 weeks after the surgery). The patient is encouraged to contact the physician during the postoperative period if there are any problems and to return in 3 months for a final evaluation of the wound healing process. Minor revisions may be made at that time to optimize the aesthetic and functional results.