recipients and in patients receiving long-term immunosuppressants, cover skin wounds.

such as azathioprine, cyclosporine, or corticosteroids (e.g.,

prednisone). Skin Grafts
occurs in people with AIDS. This form Skin grafting is a technique in which a section of skin is detached from its
of KS is characterized by local skin lesions and disseminated visceral own blood supply and transferred as free tissue to a distant (recipient) site.
and mucocutaneous diseases. This is a more aggressive tumor type Skin grafting can be used to repair almost any type of wound and is the
than other forms of KS (Radu & Pantanowitz, 2013). More most common form of reconstructive surgery.
information on AIDS-related KS can be found in Chapter 36. Skin grafts are commonly used to repair surgical defects such as those
that result from excision of skin tumors, to cover areas denuded of skin
PLASTIC, RECONSTRUCTIVE, AND (e.g., burns), and to cover wounds in which insufficient skin is available to
permit wound closure. They are also used when primary closure of the
COSMETIC PROCEDURES wound increases the risk of complications or when primary wound closure
would interfere with function.
The word comes from a Greek word meaning “to form.” Plastic or Skin grafts may be classified as autografts, homografts, or xenografts.
reconstructive procedures are performed to reconstruct or alter congenital An autograft is tissue obtained from the patient’s own skin. A homograft is
or acquired defects to restore or improve the body’s form and function. tissue obtained from a donor of the same species. These grafts are also
Often the terms and are used interchangeably. This referred to as allogeneic or allografts. A xenograft or heterograft is tissue
type of surgery includes closure of wounds, removal of skin tumors, repair obtained from another species. A common xenograft for human skin is the
of soft tissue injuries or burns, correction of deformities, and repair of pig.
cosmetic defects. Plastic surgery can be used to repair many parts of the Grafts are also referred to by their thickness. A skin graft may be a split-
body and numerous structures, such as bone, cartilage, fat, fascia, mucous thickness (i.e., thin, intermediate, or thick) or a full-thickness graft,
membrane, muscle, nerve, and cutaneous structures. Bone inlays and depending on the amount of dermis included in the specimen. A split-
transplants for deformities and nonunion can be performed, muscle can be thickness graft can be cut at various thicknesses and is commonly used to
transferred, nerves can be reconstructed and spliced, and cartilage can be cover large wounds or defects for which a full-thickness graft or flap is
replaced. As important as any of these measures is the reconstruction of impractical (see Fig. 61-7). A full-thickness graft consists of epidermis and
the cutaneous tissues around the neck and the face; this is usually referred the entire dermis without the underlying fat. It is used to cover wounds that
to as aesthetic or cosmetic surgery. are too large to be closed directly (Urden, Stacy, & Lough, 2014).
Cosmetic procedures are generally considered to be ones that correct
defects that are not life threatening or caused by disease. An example Site Selection
would be removal of a benign mole or sebaceous cyst from the face. Most The site where the intact skin is harvested is called the
health insurance plans do not cover procedures deemed to be cosmetic, and Selection of the donor site is made to match the color and texture of skin at
these procedures can be expensive. Procedures that are performed to the surgical site and to leave as little scarring as possible.
correct a surgical defect, such as removal of a skin cancer or correction of
a significant congenital defect such as a cleft lip, are generally covered by
insurance.

Wound Coverage: Grafts and Flaps

Various surgical techniques, including skin grafts and flaps, are used to

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 reattachment of a skin graft to a recipient site bed is referred to as a “take.”
After a skin graft is put in place, it may be left exposed (in areas that are
impossible to immobilize) or covered with a light dressing or a pressure
dressing, depending on the area of the body (Urden et al., 2014).

Nursing Management
The nurse must ensure that both the surgical and the donor sites receive
proper postoperative care. The surgical site is covered by the harvested
skin, and the donor site heals by re-epithelization of the raw, exposed
dermis. Both sites are protected by dressings as they heal. Prevention of
infection is essential, as it is with all surgical sites. Both sites can be kept
soft and pliable with cream (e.g., lanolin).

Figure 61-7 • Layers of skin appropriate Flaps

for split- and full-thickness graft.
Another form of wound coverage is provided by flaps. A flap is a segment
of tissue that remains attached at one end (i.e., a base or pedicle) while the
Graft Application other end is moved to a recipient area. Its survival depends on functioning
The skin graft is taken from the donor or host site and applied to the arterial and venous blood supplies and lymphatic drainage in its pedicle or
desired site, called the or base (Clark, Wang, & Terris, 2015). A flap differs from a graft in that a
For a graft to survive and be effective, certain conditions must be met: portion of the tissue is attached to its original site and retains its blood
The recipient site must have an adequate blood supply so that normal supply. An exception is the free flap, which is described later.
physiologic function can resume. Flaps may consist of skin, mucosa, muscle, adipose tissue, omentum,
The graft must be in close contact with its bed to avoid accumulation and bone. They are used for wound coverage and provide bulk, especially
of blood or fluid between the graft and the recipient site. when bone, tendon, blood vessels, or nerve tissue is exposed. Flaps are
The graft must be fixed firmly (immobilized) so that it remains in used to repair defects caused by congenital deformity, trauma, or tumor
place on the recipient site. ablation (removal, usually by excision) in an adjacent part of the body
The area must be free of infection. (Clark et al., 2015).
The graft, when applied to the recipient site, may be sutured in place; Flaps offer an aesthetic solution because a flap retains the color and
alternatively, it may be slit and spread apart to cover a greater area. The texture of the donor area; is more likely to survive than a graft; and can be
process of revascularization (establishing the blood supply) and used to cover nerves, tendons, and blood vessels. However, several

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surgical procedures are usually required to advance a flap. The major to cause a cutaneous herpes eruption. Tretinoin cream (Renova) may be
complication is necrosis of the pedicle or base as a result of failure of the prescribed with instructions to apply it 2 to 3 weeks preoperatively; this is
blood supply. associated with accelerating re-epithelialization post dermabrasion.
A striking advance in reconstructive surgery is the use of free flaps or Patients must be educated preprocedurally about the postprocedural
free tissue transfer achieved by microvascular techniques. A free flap is dressing regimen and when to return to the primary provider to have
completely severed from the body and transferred to another site. A free dressing changes performed (Wong, Arnold, & Boeckman, 2016).
flap receives early vascular supply from microvascular anastomosis with
vessels at the recipient site. The procedure usually is completed in one Facial Reconstructive Surgery
step, eliminating the need for a series of surgical procedures to move the Reconstructive procedures on the face are individualized to the patient’s
flap. Microvascular surgery allows surgeons to use a variety of donor sites needs and desired outcomes. They are performed to repair deformities or
for tissue reconstruction (Clark et al., 2015). restore normal function. They may vary from closure of small defects to
complicated procedures involving implantation of prosthetic devices to
Cosmetic Procedures conceal a large defect or reconstruct a lost part of the face (e.g., nose, ear,
jaw). Each surgical procedure is customized and involves a variety of
Chemical Face Peeling incisions, flaps, and grafts. Multiple surgical procedures may be required.
The process of facial reconstruction is often slow and tedious. Because a
Chemical face peeling involves application of a chemical mixture to the
person’s facial appearance affects self-esteem so greatly, this type of
face for superficial destruction of the epidermis and the upper layers of the
reconstruction is often a very emotional experience for the patient.
dermis to treat fine wrinkles, keratoses, and pigment problems. It is
especially useful for wrinkles at the upper and lower lip, forehead, and Face-Lift
periorbital areas. The type of chemical used depends on the planned depth
of the peel. The patient who is conscious feels a burning sensation that Rhytidectomy (face-lift) is a surgical procedure that removes soft tissue
continues for 12 to 24 hours. Frequent small doses of analgesic and folds and minimizes cutaneous wrinkles on the face. It is performed to
tranquilizing agents are prescribed to keep the patient comfortable. The create a more youthful appearance. Psychological preparation requires that
most common complications include discoloration of the skin, infection of the patient recognize the limitations of surgery and the fact that miraculous
the burned area, persistent sensory changes or itching, and occasionally rejuvenation will not occur. The patient is informed that the face may
permanent scarring of the skin (Arif, 2015). appear bruised and swollen after the dressings are removed and that
several weeks may pass before the edema subsides. Corticosteroids (e.g.,
Dermabrasion methylprednisolone) and vitamin C are prescribed postoperatively to
minimize edema. Prophylactic antibiotic agents such as cephalexin
Dermabrasion is a form of skin abrasion used to treat acne scarring, aging,
(Keflex) may also be prescribed postoperatively (Warren & Neligan,
and sun-damaged skin. A special instrument (e.g., motor-driven wire
2013).
brush, diamond-impregnated disc) is used. The epidermis and some
superficial dermis are removed by a sanding-type action, and enough of
the dermis is preserved to allow re-epithelization of the treated areas. Laser Treatment of Cutaneous Lesions
Results are best in the face because it is rich in intradermal epithelial Lasers are devices that amplify or generate highly specialized light energy.
elements (Hession & Graber, 2015). They can mobilize immense heat and power when focused at close range
Patients with a history of herpes simplex viral infection are typically and are valuable tools in providing dermatologic abrasion therapy. The
prescribed prophylactic antiviral medications (e.g., valacyclovir [Valtrex]) laser modalities used for this purpose today include scanned carbon
preprocedurally so that the physiologic stress of the procedure is less likely

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dioxide laser, pulsed carbon dioxide laser, pulsed erbium/yttrium-
aluminum-garnet (Er:YAG) laser, fractional Er:YAG laser resurfacing,
combination carbon dioxide and Er:YAG lasers, and fractionated
photothermolysis (Husain & Alster, 2016).
Each of these lasers is a precise surgical instrument that vaporizes and
excises water-containing tissues with minimal damage. Because the beams
used can seal blood and lymphatic vessels, they create a dry surgical field
that makes many procedures easier and quicker. Therefore, these lasers are
generally safe to use on patients with bleeding disorders or those receiving
anticoagulant therapy. They are primarily used to improve the appearance
of facial wrinkles, although they are also useful in removing epidermal
nevi, tattoos, certain warts, skin cancer, ingrown toenails, and keloids.
Incisions made with the laser beam heal and scar much like those made by
a scalpel. Patients with a history of herpes simplex viral infection typically
receive preprocedural antiviral prophylaxis (Husain & Alster, 2016).
CRITICAL THINKING EXERCISES
Nursing Management 1 You are caring for an 18-year-old female college student with chronic, cystic acne. She has
been prescribed oral isotretinoin. What side effects should you review with this patient? What
The majority of dermatologic and reconstructive procedures are performed type of screening should be done before she is started on the isotretinoin? What are some self-
care strategies you could recommend?
in the physician’s office or in an outpatient surgical department; therefore,
2 You work in a dermatology clinic. A 46-year-old woman presents to the clinic with a
most care takes place in the home. Most procedures, except very extensive new onset of silvery plaques and is diagnosed with moderate psoriasis. The dermatologist has
reconstruction, are performed under local anesthesia or moderate sedation, prescribed methotrexate therapy. The patient says to you “My daughter takes that drug for her
therefore requiring a very short recovery time. Unless there are Crohn’s disease. How can this also work for treating what I have?” How you would answer the
patient? What is the strength of the evidence that methotrexate is effective in treating moderate
complications, the patient does not need hospitalization. The nurse must to severe psoriasis? Describe components of your plan to educate this woman on how to best
prepare both the patient and family for what to expect during the self-manage her disease.
postoperative recovery time. Table 61-6 lists a few of the nursing 3 A 44-year-old construction worker presenting to the family practice clinic where you
work states that his father had melanoma and that now he is concerned about several pigmented
considerations that must be reviewed in educating the patient and family. lesions on his arms and neck. He also has red, scaly, nonhealing lesions on his scalp and face.
Describe your focused priority assessments and interventions. What are the priorities for
TABLE 61-6 Nursing Considerations in Cosmetic Procedures education that you should provide to this patient about preventing melanoma and performing
self-examination of the skin?

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