Expect to wake with dressings, drains and a small window left over the flap so the team can look at it, and expect that flap to be checked very frequently, often hourly at first, day and night. You will be kept warm and well hydrated, and told to keep pressure off the flap and off the joined vessels. Most people begin sitting up and moving within the first day or two. The intensity of the first week has one reason behind it: the transferred tissue depends on two small stitched vessels, and problems with them are treatable when they are caught early.
Why are the checks so frequent?
The artery and vein joined under the microscope are the entire blood supply of the flap. If a clot forms in either, circulation stops, and the tissue can only survive for a limited time without it. Nurses check the colour, warmth, swelling and refill of the flap, sometimes with a small probe, and record it each time. Most difficulties declare themselves in the first two or three days, which is why the checks are heaviest then and are spaced out afterwards.
If a problem is found, an urgent return to the operating theatre may be advised to explore and reopen the vessels. Being taken back to theatre is unwelcome news but it is not a failure of the operation. It is the reason the monitoring exists, and early exploration is what saves flaps.
Where will you be nursed?
Most people spend the first day or two in an intensive care or high dependency setting, then move to a ward. The room is kept warm, because cold makes small vessels narrow. You will be encouraged to drink or will receive fluids, since low blood pressure and dehydration are unhelpful for a flap. Depending on the site, a position may be prescribed for you, such as keeping a leg elevated, avoiding turning the neck, or not lying on a particular side.
How much pain should you expect?
There are two areas that hurt, and many people find the donor site the sorer of the two. The reconstructed area is often numb rather than painful, because nerves were divided there. Pain relief is given regularly rather than on demand, and it is worth telling the nurses early when it is inadequate instead of waiting. Uncontrolled pain raises blood pressure and stress hormones, neither of which helps healing, so asking for more is sensible rather than weak.
What are the drains, tubes and dressings for?
- Drains remove fluid and blood from the operated areas and are removed as the output falls.
- A urinary catheter is often used at first while you are on strict bed rest and fluid monitoring.
- The flap dressing usually leaves part of the flap visible for observation, so do not cover it yourself.
- A feeding tube may be used for a few days after reconstruction inside the mouth or throat.
- Splints or a supportive boot may be applied when a limb has been reconstructed.
What does the donor site feel like?
The donor area is a real wound with its own recovery, and it should be given its own attention. Expect soreness, tightness, bruising and swelling there, and expect its own dressing, sometimes with a skin graft covering it. If tissue was taken from the thigh, walking may feel awkward at first. From the abdomen, sitting up and coughing are uncomfortable. From the forearm or lower leg, movement of the nearby joint may be restricted for a while. The donor scar is usually longer than people expect, and asking to see it explained before surgery is entirely reasonable.
When do you start moving?
Earlier than most people assume. Physiotherapy usually begins within the first day or two with breathing exercises and sitting up, then progresses to standing and short walks as the team allows. Lower limb flaps have their own protocol for how long the leg stays elevated and when it may be lowered and weight taken, and this is decided by your surgeon rather than by a general rule. Early movement reduces the chance of chest infection and clots in the legs, and it also makes the second and third week considerably easier than it would otherwise be.
What should you avoid in this week?
Do not smoke, and do not use tobacco in any form, as nicotine narrows the small vessels the flap depends on. Do not let anything press on the flap, including tight clothing, a strap, a bandage applied by someone unfamiliar with the case, or lying on it. Do not adjust the dressing over the flap. Keep the room warm. Follow the fluid instructions rather than restricting drinking because of the catheter.
What warning signs matter?
Tell the nurses immediately if the flap looks pale, white, blue, dusky or very swollen, if the dressing is soaking through with blood, if you develop fever with shaking chills, if breathing becomes difficult, or if calf pain or chest pain begins. In hospital these are reported at once to the team. After discharge, the same signs mean going to an emergency department now rather than waiting for the next appointment.
When can you go home?
Discharge depends on the flap being stable, pain being controlled, drains being out or manageable, and you being able to move safely. Many people are in hospital for around a week or somewhat longer, and reconstructions of the mouth, jaw or lower limb often take longer than that. Before you leave you should have written instructions, a review date, and a number to contact. Enquiries at this clinic go to WhatsApp, so a photograph can be sent quickly if something looks different.
The first week is demanding, and it is the week that decides most of what follows. Almost everything asked of you in it exists to protect the blood supply of the flap. It helps to have one family member who understands the instructions properly, because they will be the person noticing a change in the flap at home and deciding whether to send a photograph or head straight to hospital.
