Post operative
Authors: Mette Hørberg, consultant in oral and maxillofacial surgery, Frederik Gulmark Hansen, med.stud., Magnus Balslev Avnstorp MD and Jytte Buhl, consultant in oral and maxillofacial surgery
Post-operative information
Hospitalization for 7-10 days.
Post-operative calm regime, elevated headboard – a minimum of 30 degrees, no pressure to the neck and anastomosis.
Regular clinical examination of the flap is key to assessing for adequate vascularity. Checking colour, turgor, temperature, capillary response as well as doppler (sound and color scale) every half an hour the first 24 hours, every hour the second day after surgery, and every 2nd hour the third day after surgery, and the following days twice a day till discharge. Monitoring of blood supply and blood flow in free flaps with a doppler can either be through an implantable doppler which is placed around the artery or the vein or both, or can be performed externally with a hand held doppler.
Neck drains should be left in place until drainage is minimal. Removal of drain not earlier than when producing less than 20 ml serous fluid.
Thrombosis prophylaxis (Fragmin and Intermittent Pneumatic Compression Socks, IPC-socks) should be commenced on day 1 post-operatively.
A naso-gastric tube or a Percutaneous endoscopic gastrostomy, PEG feeding tube, is applied as the patient is not allowed to have any oral intake, water included, for the first week. Feeding can be initiated immediately after surgery with the PEG feeding tube, starting at 40 mL/hour and full dose after the 1st post-operative day.
Further post-operative oral incompetence, liquid diet for 6 weeks, and the need for prosthetic rehabilitation.
The leg should be elevated after surgery and the drain discontinued when producing less than 30 ml/day.
We commence mobilisation on day 1 with support if necessary.
The dressing is removed on day 5 to assess the the split thickness graft and to give air to the wound twice a day for adequate healing of the wound. Compression socks are applied when mobilised.
Due to the tracheostomy, speaking is not possible until decannulation.
Follow-up
Orthopantomographic x-ray is performed to secure correct placement of the transplant and implants before discharge (figure 1 and 2).
The patient is seen by the Plastic Surgeon a week after discharge, and then again 3 months after surgery.
The histology is assessed after 3 weeks and the answer is given by the Head and Neck Surgeon. At this point radiation therapy will also be discussed if necessary.
Radiation therapy will be initiated 4-6 weeks after surgery.
The patient is seen by the Maxillofacial Surgeon after 1-2 weeks after surgery.
Dental rehabilitation will be performed after surgery and radiation therapy.