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Postoperative graft and flap care: What clinical nurses need to know.

Patients who undergo any type of reconstructive, plastic, orthopedic, or dermatologic surgery are at risk for compromised grafts and flaps. Clinical nurses should be knowledgeable about critical assessment, devices, treatments, and techniques available to care effectively for patients following graft and flap placement.

Grafts and flaps have been identified interchangeably in nursing literature. Although extensively related, these methods are quite different from each other in terms of their intrinsic properties and the surgical techniques involved. Undeniably, with any procedure or surgery performed, complications may occur. Patients who undergo any type of reconstructive, plastic, orthopedic, or dermatologic surgery are at risk for compromised grafts and flaps, mainly due to hypoxia caused by multifactorial issues, such as thrombosis, diabetes, and infection.

Clinical nurses play a critical role in early detection of graft and flap failure. To treat and potentially salvage these surgical complications, nurses must be knowledgeable concerning accurate, meticulous physical examination of grafts and flaps; current modalities (acoustic Doppler sonography, implantable Doppler, laser Doppler flowmetry) used to identify impending vascular problems; and appropriate therapies (leech therapy, antithrombotic therapy, hyperbaric oxygen therapy).

For non-healing wounds, infection-related skin loss, massive burns, skin cancer, diabetic ulcers, and mastectomy, tissue transplantation often offers a favorable solution for aesthetic and wound coverage. Use of grafts and flaps has expanded the ability to perform challenging reconstructive surgery, and improved health outcomes and quality of life for patients with trauma, burns, and cancer (Morris, 2016). Through free flap transplantation, wound healing has improved, and most ablative defects of the head and neck can be reconstructed immediately (Wax, 2014). Experienced surgeons now achieve a success rate of 95%-99% with these procedures (Nahabedian, 2014).

While all flaps have inherent blood supply, grafts are avascular tissues dependent on the quality of the recipient's wound bed for survival and revascularization (Baynosa & Zamboni, 2012). For surgically created wounds, no special wound bed preparation is needed; they are designed to be left with a well-vascularized bed. Often, a healthy bed is expected from an acute traumatic wound once injured and devascularized tissue is removed. For more chronic wounds, promotion of neovascularization requires a period of dressing changes. Complete absence of necrotic or ischemic tissue, cellulitis, purulent drainage, and significant edema in the wound bed is needed for healing. Blood or fluid accumulation beneath the graft, a common cause of graft failure, must be prevented by meticulous hemostasis (Morris, 2016). Thus, careful assessment of the recipient's wound bed is imperative to avoid compromised grafts. Causes of compromised flaps may include random ischemia, venous congestion or occlusion, and arterial occlusion (Baynosa & Zamboni, 2012).

Because successful tissue transplantation depends on sufficient capillary perfusion and micro-vascularization, immediate recognition of signs of inadequate tissue perfusion is critical. Compromised surgical grafts and flaps remain a postoperative concern. Patients with diabetes, vasculopathy from another etiology, and irradiation complications are particularly susceptible to graft or flap failures (Latham, 2013). However, the salvage rate is 75% if compromised flaps are recognized within 6 hours (Nahabedian, 2014). Because nurses provide patient care around-the-clock, they hold a key role in preventing compromised grafts and flaps. An overview of the difference between grafts and flaps, postoperative management, noninvasive monitoring, issues regarding graft and flap failure, and various treatments for compromised grafts and flaps are discussed.

Differences Between Grafts and Flaps

Though related in some ways, grafts and flaps differ in their intrinsic properties and surgical techniques. Both are used for reconstruction and, on occasion, can be made of the same tissue type (skin, fat, tendon, bone, nerve). However, because grafts do not have their own blood supply, they require a sufficient vascular bed with edges for the graft site to remain viable. Flaps carry their own blood supply and, thus, are not dependent on the recipient bed to revascularize the tissue. Additionally, flaps have more versatility; they can be used to fill large defects or recreate structures (e.g., breast) and provide better coverage over joints (Morris, 2016).

Grafting is relatively easy to perform. The initial survival of skin grafts depends on plasmatic imbibition, a process in which nutrients are diffused from the graft bed during the first 24-48 hours. This is followed by inosculation, a 4-7 day process in which the donor and recipient end capillaries are aligned with vascular network and neovascularization in the third and final phase (Wood, 2015). Adequacy of the donor area and vascularity of the recipient area must be considered. In contrast, performance of flaps is more complex; they range from basic advancements of skin to composites of many types of tissue (Chrysopoulo, 2015). Donor site morbidity, aesthetics, and functionality must be considered. Defect location and size, functional requirements, and exposure of any crucial structures also must be addressed. Finally, the wound bed must be evaluated to determine if a flap is a better option (Morris, 2016) (see Figure 1).

Indications for Grafts and Flaps

Skin grafts and flaps are used for critical wounds (e.g., burns; skin loss due to infection; non-healing large wounds; venous, pressure, or diabetic ulcers) as well as following amputation or mastectomy (Heller, 2014). No practice guidelines exist for management of wounds that cannot be reconstructed with simple primary closure, secondary-intention wound healing (SIH), split-thickness skin grafting (STSG), or full-thickness skin grafting (FTSG) (see Table 1). Local flaps may be treatment alternatives in these situations (Oganesyan, Jarell, Srivastava, & Jiang, 2013). Specifically, flaps (e.g., muscle and myocutaneous flaps) are indicated for large and/or deep anatomic defects, such as surgically planned deficiency (e.g., postmastectomy wound) or the result of trauma or chronic infection (Hsien-tsung Liu, 2015).

Postoperative Care of Grafts and Flaps

Graft and flap complications include infection, dehiscence, vascular insufficiency due to mechanical tension, kinking, compression, hematoma and seroma, and failure and necrosis. For treatment, Krishna and Sahu (2013) emphasized antibiotics, wound care, pain management, suture removal at 5-7 days, and revision if required in 6 months. Specifically, adequate pain management is critical; pain activates the sympathetic nervous system and thus decreases blood flow through the pedicle.

Patient education regarding graft and flap care should be introduced during admission, and reinforced during the recovery phase and upon discharge (see Table 2). Specific teaching also should include postoperative expectations regarding the presence of two scars: site of skin graft application and donor site (Havill, n.d.). Keloid or hypertrophic scarring may appear in people with abnormal response to skin healing. Finally, the nurse should emphasize skin grafts may not look normal for weeks to months (Grande & Mezebish, 2015).

Various methods are used to assess perfusion and oxygenation of flaps for immediate detection of impending flap failure. A combination of internal monitoring with an implantable Doppler probe and clinical monitoring to assess flap viability has been the recent technique of choice (Wax, 2014). Additional medical devices monitor microvascular anastomoses (color duplex ultrasonography, flow coupler, implantable Doppler) or provide assessment through the external surface of the flap (acoustic Doppler ultrasonography, laser Doppler flowmetry, near-infrared and visible light spectroscopy) (Wax, 2014). This manuscript focuses on the three most popular and frequently used devices: acoustic Doppler sonography, implantable Doppler, and laser Doppler flowmetry, all of which are useful in early identification of vascular problems and offer the possibility of more timely intervention before occurrence of complications such as flap thrombosis (Meier et al., 2012).

Graft and Flap Failures

Although enhanced microvascular techniques have led to surgical success rates above 95%, graft and flap revision rate remains at 10%12% (Wax, 2014). Repair of lower extremity and wound defects can be challenging given the high risk for poor healing and infection due to poor vascularization (Oganesyan et al., 2013), especially among older adults. Primary closure of the defects is not sufficient; their limited options for repair include SIH, STSG, FTSG, and local flaps.

Hypoxia is the primary cause of graft and flap compromise. Particularly, skin grafts are more prone to failure because they do not have their own blood supply. Common etiologies for oxygen insufficiency include previous radiation to the wound site, diabetes, and vascular graft infections. In addition, age, nutritional status, and smoking can affect vascularity of the skin. Other reasons for thrombosis include kink, twist, compression, or tension of the pedicle vessels of the flap, poor flap design, injury during harvest, infection, hypercoagulability, and vasospasm (Hanasono, 2013). The most common result of throm bosis at the microvascular anastomosis, vascular anastomotic failure is a devastating complication that can lead to total failure. However, if recognized early, successful revascularization can be performed in 70%-80% of cases (Wax, 2014).

Therapies for Graft and Flap Failures

For any graft and flap procedures, the goal is to ensure optimization of graft and flap viability toward complete healing. However, due to many hypoxic-related factors, grafts and flaps may fail. Hence, there are modalities that can be applied to salvage failed flaps. These modalities include leech therapy, pharmacological intervention (anticoagulation or antithrombotic therapy), and use of hyperbaric oxygen therapy (HBOT). Of course, early return to the operating room with the surgeon's knowledge of the correct underlying etiology of the compromised grafts and flaps is of utmost significance toward successful graft and flap salvage.

Leech Therapy Leech therapy may be used by plastic surgeons to salvage flaps, particularly if venous congestion occurs. The focus remains on postoperative treatment of the local, pedicled, or microsurgical flap to treat hemodynamic imbalance or venous insufficiency (Houschyar et al., 2015). When assisting with leech therapy, clinical nurses should be able to distinguish between arterial insufficiency and venous congestion. In arterial insufficiency, tissues are pale, turgid, and cool to touch, and capillary refill has slowed (longer than 2 seconds) or is absent. In venous insufficiency, tissues are purplish, engorged, taut, and warm to touch; capillary refill is brisk (less than 1 second). Nurses also should know the patient's medication history, specifically use of any over-the-counter vitamins and herbals. Some of these substances can increase risk of excessive bleeding. For example, use of vitamin E (also suppresses the immune system), dong quai, garlic, ginger, Ginkgo biloba, and ginseng may contribute to vascular complications. Use of aspirin and nonsteroidal anti-inflammatory drugs available over the counter also may be a concern (Spear, 2016).

Pharmacological Treatments

The best antithrombotic therapy in microsurgery is thorough preoperative risk assessment and surgical planning, meticulous intraoperative microvascular technique, and careful postoperative monitoring to enable early detection and intervention (Froemel et al., 2013). Ordinarily, aspirin, dextran, low-molecular-weight (LMWH) or unfractionated heparin (UFH), and hydroxyethyl starch are the mainstay treatments to prevent flap thrombosis (Jokuszies, Herold, Niederbichler, & Vogt, 2012). Use of such agents as prophylaxis is based on the patient's risk factors for thrombosis or coagulopathy, or the surgeon's personal preference and experience. Management goals include optimizing flap survival, monitoring laboratory values, and continuously assessing for adverse effects, especially bleeding. The German Language Working Group for Microsurgery of the Peripheral Nerves and Vessels indicated heparin as the first choice for thrombosis prophylaxis (Froemel et al., 2013). Specifically, subcutaneous LMWH (enoxaparin [Lovenox[R]], dalteparin [Fragmin[R]], and tinzaparin [Innohep[R]]) is considered better than intravenous, continuous UFH; the latter is preferred only in patients with complicating factors such as renal insufficiency.

No clear guidelines and algorithms for thrombosis prophylaxis in microsurgery are available in the literature (Jokuszies et al., 2012). Due to lack of large, well-controlled clinical trials to compare multiple treatments used in microsurgery, antithrombotic treatment and prophylaxis vary greatly from surgeon to surgeon and from institution to institution (Froemel et al., 2013). Without these trials, treatment options will continue to vary and best practice guidelines cannot be identified.

An established and essential part of microsurgery is represented by pharmacologic prevention of and surgical intervention for thromboembolic events. Currently, the promising success rates of micro-vascular free tissue transfer can be attributed to appropriate patient selection, excellent microsurgical technique, tissue transfer to adequate recipient vessels, and early anastomotic revision in case of thrombosis. The choice of antithrombotic agents as a contributing factor of success in tissue transfer transplantation continues to be unclear (Jokuszies et al., 2012). Antithrombotic therapy alone would not guarantee prevention and treatment of compromised grafts and flaps. Optimizing clinical outcomes and increasing multicentric and international comparability of postoperative results and complications are essential in developing consistent standards and algorithms in reconstructive surgery.

Hyperbaric Oxygen Therapy

HBOT can maximize the viability of compromised tissue, reducing the need for regrafting or repeating flap procedures (Baynosa & Zamboni, 2012). Absolute contraindications include untreated pneumothorax; and use of bleomycin, cisplatin, disulfiram, and doxorubicin. Relative contraindications include asthma, seizure, chronic obstructive pulmonary disease, high fever, and upper respiratory infection. Twice-daily treatment is the standard regimen for HBOT until the appearance of a viable graft and flap occurs. Then once-daily treatment continues until the compromised graft or flap is healed completely. If benefit is not seen after 20 treatments, the need to continue the therapy must be evaluated (Latham, 2013).


Advances in postoperative graft and flap care, flap monitoring techniques, and treatments to salvage compromised grafts and flaps continue to occur. The best antithrombotic regimen in microsurgery involves a multimodal approach emphasizing risk-adapted monitor ing and interventions (Froemel et al., 2013). Also, good microsurgical technique and quality training are imperative. Clinical nurses should be knowledgeable about critical assessment, devices, treatments, and techniques available to care effectively for patients following graft and flap placement. Frequent updates and access to current literature, studies, and clinical trials will guide them to evidence-based practice in graft and flap care.

Instructions For Continuing Nursing Education Contact Hours

Postoperative Graft and Flap Care: What Clinical Nurses Need to Know

Deadline for Submission: June 30, 2019

To Obtain CNE Contact Hours MSNJ 1708

1. For those wishing to obtain CNE contact hours, you must read the article and complete the evaluation through the AMSN Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to

2. Evaluations must be completed online by June 30, 2019. Upon completion of the evaluation, a certificate for 1.2 contact hours may be printed.

Learning Outcome

After completing this learning activity, the learner will be able to describe critical nursing considerations related to postoperative graft and flap care.

Learning Engagement Activity

Compare the patient education information in Table 2, "Patient Education: Flap and Graft Sites," with the patient education information available in your organization on this topic. Is there any opportunity to update that patient education material?

The author(s), editor, editorial board, content reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.

This educational activity is jointly provided by Anthony J. Jannetti, Inc. and the Academy of Medical-Surgical Nurses (AMSN).

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP 5387. Licensees in the state of California must retain this certificate for four years after the CNE activity is completed.

This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director.


Acosta, A.E., Aasi, S.Z., MacNeal, R.J., Messingham, M.J., & Arpey, C.J. (2015). Skin grafting. In J.K. Robinson, C.W. Hanke, D.M. Siegel, A. Fratila, A.C. Bhatia, & T.E. Rhorer (Eds.), Surgery of the skin: Procedural dermatology (3rd ed.). Philadelphia, PA: Elsevier.

Baynosa, R.C., & Zamboni, W.A. (2012). The effect of hyperbaric oxygen on compromised grafts and flaps. Undersea and Hyperbaric Medicine, 39(4), 857-865. Chrysopoulo, M.T. (2015). Tissue flap classification. Medscape Drugs & Disease. Retrieved from

Deune, G.E., & Cohan, T (n.d.). Skin graft wound care. Retrieved from http:// patient-forms-guides/EGDSkinGraftWoundCare.pdf

Froemel, D., Fitzsimons, S.J., Frank, J., Sauerbier, M., Meurer, A., & Barker, J.H. (2013). A review of thrombosis and antithrombotic therapy in microvascular surgery. European Surgical Research, 50(1), 32-43. doi :10.1159/000347182

Grande, D., & Mezebish, D.J. (2015). Skin grafting treatment and management. Retrieved from article/1129479-treatment#d 12

Hanasono, M.M. (2013). Prevention and treatment of free flap thrombosis (and what to do after the flap fails). [PowerPoint slides]. Retrieved from www.signup4. net/Upload/KAIS13A/PHYE325E/Hanas ono_Prevention%20and%20Treatment %20of%20Free%20FlapThrombosis.pdf

Havill, S. (n.d.). Skin grafting. Retrieved from Heller, J.L. (2014). Skin flaps and grafts?self-care. Retrieved from 000743.htm

Houschyar, K.S., Momeni, A., Maan, Z.N., Pyles, M.N., Jew, O.S., Strathe, M., & Michalsen, A. (2015). Medical leech therapy in plastic reconstructive surgery. Wiener Medizinische Wochenschrift, 165(19-20), 419-425. doi:10.1007/s10354-015-0382-5

Hsieh, S.T. (2015). Free tissue transfer flaps. Retrieved from

Hsien-tsung Liu, P. (2015). Muscle and musculocutaneous flaps. Retrieved from 1284776-overview#a6

Jokuszies, A., Herold, C., Niederbichler, A.D., & Vogt, P.M. (2012). Anticoagulative strategies in reconstructive surgery clinical significance and applicability.

German Medical Science, 10, Doc01. doi:10.3205/000152

Krishna, D., & Sahu, S.A. (2013). Principles of local flaps in plastic surgery. [PowerPoint slides]. Retrieved from http://www.

Latham, E. (2013). Hyperbaric oxygen therapy. Retrieved from

McGrath, M.H., & Pomerantz, J. (2012). Plastic surgery. In C.M. Townsend, R.D. Beauchamp, B.M. Evers, & Mattox, K. L. (Eds.), Sabiston textbook of surgery (19th ed.). Philadelphia, PA: Elsevier Saunders.

Meier, J. K., Prantl, L., Muller, S., Moralis, A., Liebsch, G., & Gosau, M. (2012). Simple, fast and reliable perfusion monitoring of microvascular flaps. Clinical Hemorheology and Microcirculation, 50(1-2), 1324. doi:10.3233/CH-2011 -1439

Morris, D. (2016). Principles of grafts and flaps for reconstructive surgery. Retrieved from principles-of-grafts-and-flaps-for-recon structive-surgery

Nahabedian, M.Y (2014). Free tissue transfer flaps. Retrieved from http://emedicine.

Oganesyan, G., Jarell, A.D., Srivastava, M., & Jiang, B. (2013). Efficacy and complication rates of full-thickness skin graft repair of lower extremity wounds after Mohs micrographic surgery. Dermatologic Surgery, 39(9), 1334-1339. doi:10.1111/dsu.12254

Scherer-Pietramaggiori, S.S., Pietramaggiori, G., & Orgill, D.P. (2013). Skin graft. In PC. Neligan (Ed.), Plastic surgery (3rd ed). Philadelphia, PA: Elsevier.

Spear, M. (2016). Medicinal leech therapy: Friend or foe. Plastic Surgical Nursing, 36(3), 121-125. doi:10.1097/PSN.00000 00000000152

Wax, M.K. (2014). The role of the implantable Doppler probe in free flap surgery. The Laryngoscope, 124(S1), S1-S12. doi:10. 1002/lary.24569

Wood, B.C. (2015). Skin grafts and biologic skin substitutes. Retrieved from http:// 1295109-overview#a3

Chessa del Rosario, MSN, RN, AGACNP, is Cardiovascular-Thoracic Intensive Care Unit (CVTICU) Nurse, Keck Hospital, University of Southern California, Los Angeles, CA.

Thomas W. Barkley, Jr., PhD, ACNP-BC, ANP, FAANP, is President, Barkley & Associates, Inc., and Professor Emeritus, School of Nursing, California State University, Los Angeles, CA.

Caption: FIGURE 1. Patterns of Muscle Flap Vascular Anatomy
Comparison: Full-Thickness Skin Grafting vs. Split-Thickness
Skin Grafting

Full-Thickness Skin Grafting        Split-Thickness Skin Grafting
(FTSG)                              (STSG)

Consists of entire epidermis,       Contains epidermis, some amounts
dermis                              of dermis

Usually used for small areas due    Usually used for extensive skin
to minimal donors                   coverage (e.g., cancer
                                    resections, burns)
Produces minimal contraction        Most susceptible to post-graft
Demonstrates greatest resistance    Less resistant to surface trauma
to trauma
Possible aesthetic complication     Easily vascularized, survives
due to skin color mismatch          transplantation more reliably
                                    (thinner than FTSG)
Longer revascularization process    Donor sites heal effectively
compared to STSG due to thickness   based on thickness of STSG.
Scars usually closed in a           Scars consist of superficial,
straight line with stitches         tender grazed area that heals
                                    more slowly (initially under a
                                    special dressing).
Donor site/incision generally at    Donor site/incision at thigh
groin/inguinal area

Sources: Deune & Cohan (n.d.), Havill (n.d.), Morris, 2016.

Patient Education: Flap and Graft Sites

Rest for several days after surgery. Avoid any movement that might
stretch or injure the flap or graft. Avoid hitting or bumping
the area.

Keep dressing and area around it clean and free from dirt or sweat.
Do not let the dressing get wet.

Do not touch the dressing. Leave it in place as long as your doctor
recommends (generally 4-7 days).

Take pain medication or other medication as directed.

If possible, elevate the wound above your heart; you may need to do
this while sitting or lying. Use pillows to elevate the area
and help reduce swelling.

Per physician's order, use an ice pack on the bandage to help with
swelling. Ask how often to apply ice. Keep the bandage
dry during use of ice.

See physician to have dressing changed in 4-7 days. Dressing to the
flap or graft site may be changed by the doctor several
times over 2 to 3 weeks. As the site heals, you may be able to care
for the wound and apply dressings independently.

Do not scratch wound or pick at it when itching occurs.

Ensure SPF 30 or higher sunscreen application to surgical sites for
sun exposure.

Notify physician if the following occurs: (a) Persistent pain does
not improve after taking pain medication; (b) Bleeding persists
after 10 minutes of gentle direct pressure; (c) Dressing loosens;
(d) Graft or flap edges start to come up or appear to
bulge; (e) Signs of infection (e.g., increased drainage [thick, tan,
green, or yellow] or odor from the wound); (f) Oral temperature
>100 [degrees] F (37.8[degrees] C) for more than 4 hours; or (g)
Red streaks leading away from wound.

Keep dressing clean and dry.

See physician to have dressing changed in 4-7 days or ask for
instructions on how to remove it. You may be able to leave the
wound uncovered. However, if it is in an area that is covered by
clothing, you may want to cover the site to protect it.

Do not apply lotions or creams to the wound per physician order. Do
not pick scabs or scratch the wound as it heals.

Sponge baths may be needed for 2-3 weeks in early stages of wound
healing. When the physician permits bathing, showers
are recommended. Soaking causes wound to reopen. Keep the dressing
dry and consider covering wound with a plastic bag.

If bathing is permitted, gently rinse the wound with water. Do not
rub or scrub the wound. Special cleansers may be used per
physician order.

Sources: Acosta, Aasi, MacNeal, Messingham, & Arpey, 2015; Grande
& Mezebish, 2015; Hsieh, 2015; Krishna & Sahu, 2013;
McGrath & Pomerantz, 2012; Scherer-Pietramaggiori, Pietramaggiori,
& Orgill, 2013.
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Title Annotation:CNE SERIES
Author:del Rosario, Chessa; Barkley, Thomas W., Jr.
Publication:MedSurg Nursing
Article Type:Report
Date:May 1, 2017
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