As with other surgical patients in the postoperative period, the plastic surgery patient requires close monitoring of vital signs including temperature, heart rate, blood pressure, and oxygen saturation. Although postoperative fever is common, persistent or progressive temperature elevation may indicate infection that requires further evaluation and treatment. Heart rate should be monitored, because tachycardia may result from uncontrolled pain, hypovolemia, arrhythmia, or anemia. Blood pressure must remain normotensive. Elevations in blood pressure may result in bleeding that requires exploration and reoperation. Postoperative hematoma caused by hypertension is well-described after rhytidectomy, especially in male patients, but may also occur after breast surgery or abdominoplasty. Monitoring both oxygen
saturation and respiratory rate is important for those on patient-controlled analgesia (PCA) or high levels of opiates. Unexplained tachypnea, decreased oxygen saturation, with tachycardia merit workup for pulmonary embolism.

As many plastic surgery operations are elective in nature, adequate pain control is of high importance. Various institutional regimens exist with regard to pain control. A common protocol uses PCA with morphine or hydromorphone in those who must remain NPO during the postoperative period. When oral intake is tolerated by the patient, a PO regimen is used, commonly oxycodone at 5 mg for mild pain, 10 mg for moderate pain, and 15 mg for severe pain in standard intervals of 4 hours. These values may be increased in the opiate-tolerant patient, typically with 5-mg increments. Intravenous morphine or hydromorphone is used for breakthrough pain. In addition, adjunctive medications such as acetaminophen, intravenous or PO, are dosed separately and given at 6-hour intervals. Staggered dosing of these medications (given 2 to 3 hours between administration of opiate medication) improves patient pain management. Of note, oxycodone and acetaminophen are given separately, rather than through a combination pill (such as Percocet). This allows uptitration of oxycodone, should pain control necessitate higher dosing, while avoiding higher doses of acetaminophen.

Postoperative nausea, although common, can affect a patient’s entire perception of the operative experience. Most nausea is a direct consequence of general anesthesia or postoperative pain control with opiates. Patients are treated with ondansetron, metoclopramide, or prochlorperazine and other medications such as scopolamine patch or corticosteroids. Though the specific postoperative regimen varies, the awareness of nausea as a significant factor in the postoperative quality of care merits its timely attention and treatment by the health care team. Retching and vomiting associated with nausea, though less common, may obviously cause significant discomfort. Such forced and spasmodic abdominothoracic movement against a closed glottis raises intrathoracic pressure and has untoward results after facial, cosmetic, and reconstructive surgery.

Standard prophylactic antibiotics are used in plastic surgery to prevent surgical site infections (SSIs). These include the first-generation cephalosporin cefazolin in coverage of Staphylococcus and Streptococcus species, with some coverage against Gram-negative bacteria. In patients with cephalosporin allergy or contraindication, clindamycin is used for its effectiveness against Staphylococcus and Streptococcus species. Clindamycin has additional coverage for anaerobic Gram-negative rods. In patients with known methicillin-resistant Staphylococcus aureus, vancomycin is often used.

Postoperative guidelines for antibiotic use (antibiotic choice and duration) are not established and practices vary by surgeon preference. In the majority of cases, breast surgery using tissue expander or implant-based reconstruction has continued antibiotic therapy in the postoperative period. The duration varies, with some surgeons discontinuing antibiotics after 24 hours and others continuing antibiotics for 1 to 2 weeks while drains are in place. Because of the heterogeneity of published results, definitive evidence-based recommendations cannot be made, and antibiotic treatment in the postoperative period remains surgeon-dependent.

Wound management after plastic surgery ranges from simple inspection to negative pressure wound therapy (NPWT) that requires complex dressing
changes. General principles are to leave operative dressings intact until 48 hours postoperatively, at which time wound edges have epithelialized. Dressings are applied to be secure but not overly constrictive to cause pressure necrosis of skin flaps. Dressings should allow the surgeon to examine the wound/surgical site for postoperative hematoma or tissue ischemia that requires immediate attention.

The timing and frequency for postoperative wound care and dressing changes is surgeon dependent. Dressings should remain clean and without saturation with blood or drain fluid. The majority of surgical dressings are changed or removed at 48 hours. Some surgeons use minimal or no dressings. This is often the case when an adhesive is applied along the surgical incision at the end of the operation, to create an impermeable seal. Adhesives commonly used include dermabond topical (2-octyl cyanoacrylate), dermabond prineo, and histoacryl (n-butyl-2 cyanoacrylate).

Binders or ACE wraps may be used to add compression to large surface areas, such as after abdominoplasty or liposuction. They must not be too tight to compromise blood flow. Hand surgery patients have splints that immobilize and protect the operative site after fracture or tendon repair. Cosmetic face and neck lift patients often have elastic or ACE wraps that provide gentle compression in an appropriate vector to prevent seroma/hematoma.

Various dressings may be used after skin grafting. Options for recipient sites include bolsters that are applied intraoperatively and are left in place without manipulation to avoid shear force on the graft. Bolsters are typically fastened with silk sutures, which are removed on postoperative days 5 to 7. Other common dressings for skin graft recipient sites are NPWT using the wound VAC. They are typically removed on postoperative days 5 to 7.

Donor sites have various options for management. Tegaderm, a nonocclusive transparent dressing, is commonly used as a donor site dressing. As fluid accumulates below the dressing, a small incision can be made postoperatively to allow egress of fluid with application of a smaller Tegaderm over the incision site. Xeroform can be applied on donor sites and allowed to stay in place until the skin surface reepithelializes. Other dressings for donor sites include use of Mepilex Ag foam dressings that may be removed in 5 to 7 days postoperatively.

Drains are used to allow removal of serous fluid and blood from tissue spaces, promoting tissue adherence and wound healing. Postoperative drain care depends on the type of drain used. Two general categories of drains are closed suction and passive systems.

Closed suction drains may be TLS (test tube-type device), Hemovac type, or bulb-suction types such as Blake and Jackson-Pratt. TLS drains are used in small enclosed spaces, such as an auricular pocket created during microtia repair or other similar spaces created with craniofacial procedures. TLS drains require frequent change of the collecting test tube, which has negative pressure to allow suction of small quantities of fluid. Drain care requires attention to the proper functioning of the drainage system. A plastic clamp is used to close the tubing system, while the old test tube is removed and a new test tube is secured in place. The plastic clamp is then removed to allow proper drainage. The quantity of fluid in the old test tube may be measured and recorded.

Bulb-suction-type drains have an array of sizes, with smaller ones used for drainage of the scalp or a tissue flap on the face after rhytidectomy. Larger bulb-suction drains are used to evacuate fluid from larger potential spaces. Examples include the abdominal wall after abdominoplasty or deep inferior epigastric artery perforator (DIEP) breast reconstruction or drainage of the posterior back after use of the latissimus dorsi muscle for free tissue or pedicle-based reconstructions. Bulb-suction drains are also used in
recipient sites such as the breast or upper or lower extremity after free tissue transfer. The quality and quantity of fluid must be examined postoperatively. High-output sanguineous drainage or the presence of clotted blood in the drain tubing or collecting bulb may indicate hemorrhage, which may necessitate exploration. High serous output often indicates the need for continued drainage. An increase in drain output after expander/implant-based breast reconstruction may indicate a latent infection that requires further evaluation. A change in the quality of drained fluid, such as odor or purulence, may indicate infection and warrants evaluation.