SurgSpace / Specialties / Plastic & Reconstructive Surgery
Plastic & Reconstructive Surgery
Soft-tissue reconstruction organised as a ladder: direct closure, graft, local flap, free tissue, always the simplest rung that works. Hand surgery where millimetres are function, and burns, where the skin's failure becomes the whole body's problem.
Backdrop: A split-thickness skin graft donor site · User:Kevin308 · Public domain
After, and when it goes wrong
Post-op & Emergencies
The expected course, the ward reads, and the calls that cannot wait.
The expected course and the ward reads, then the complications and the calls that cannot wait.
On the ward
Three boards, three reads
POD 0, hour 14 · free flap
Flap darker than the 12:00 photo
Refill under 1 second
Dark ooze on pinprick
Doppler signal present
The Doppler is fine, so is the flap fine?
The read
No: this is the venous failure picture, congestion, brisk refill and dark ooze, and a venous problem often keeps an arterial Doppler signal while the flap drowns. The clinical triad outranks the probe. The correct action happened the moment concern formed: the flap team is called now, because pedicle salvage is a race the ward can only lose by watching.
POD 5 · split-skin graft, first dressing take-down
Graft pink and adherent centrally
One edge lifted over a small haematoma
Donor site: healing, painful
Patient keen to mobilise
How is a graft judged, and what threatens it now?
The read
Percentage take, honestly estimated and documented: adherent pink graft has plumbed into the bed, while the lifted edge over haematoma is lost territory (blood is a graft's commonest assassin, shear its second). Small losses granulate or get regrafted; the plan now is protecting the take, dressing the donor site (often the sorer wound), and mobilisation per protocol rather than enthusiasm, since shear undoes plumbing.
Hour 10 · 30% TBSA burn resuscitation
Urine 0.3 mL/kg/hr for 2 hours
Formula volume running as calculated
HR 118
Lactate 2.9
The formula is being followed, so why is the urine falling?
The read
Because the formula is a starting estimate, not a prescription: this patient is under-resuscitated on the numbers that matter (urine, heart rate, lactate), and the rate is titrated up accordingly. The equal and opposite error, drowning patients in reflex boluses, causes its own compartment syndromes; the discipline is hourly titration to urine output, escalating to the burn team when the trajectory does not answer.
Emergencies
The calls that cannot wait
Necrotising soft-tissue infection
Recognise: Pain out of proportion to visible signs, spreading induration, dusky or blistering skin, crepitus, and a patient far sicker than the surface: the infection is running along fascia beneath innocent-looking skin.
First move: Broad antibiotics and radical surgical debridement within hours: imaging must never delay theatre, and the first operation is rarely the last.
The failing free flap
Recognise: A flap changing against its baseline: congested and dark or pale and silent, with the hours-old photograph as the witness.
First move: Call the flap team immediately: the treatment is re-exploration of the pedicle, and salvage is a function of minutes-to-theatre, not cleverness at the bedside.
The airway burn
Recognise: Facial burns, soot in the mouth, hoarseness, stridor, enclosed-space fire: the airway that is about to swell shut.
First move: Intubate early on prediction: the anatomy worsens hourly, and the intubation refused at hour one becomes the surgical airway of hour four.
Flexor sheath infection
Recognise: Kanavel's four: fusiform swelling, a finger held flexed, pain on passive extension, tenderness along the sheath. Pus is in a tunnel that destroys gliding.
First move: Elevation, intravenous antibiotics and urgent hand-surgery review: established sheath pus is washed out in theatre, and the finger's function pays for every day of 'seeing how it goes'.
Hub shaped by the Surgical Specialties Lead with the Plastic surgery reviewer (open seat). Images and videos carry their source; educational use for supervised learning, not clinical guidance.