Composite graft advice

For paediatric pre-operative\post-operative day surgery patients.

What is a composite graft?

A composite graft is where the amputated piece of skin is stitched back onto the fingertip. This is to help to cover any exposed bone at the tip of the finger and to also preserve the length of the finger.

What are the alternatives to a composite graft?

Depending on how much tissue has been amputated it may be possible to encourage the area to heal with dressings (conservative treatment).

Before the operation

You will receive a call from the plastic surgery coordinator with a date and time for your child to come in for surgery. They may arrange for your child to either be seen face to face or have a telephone pre-assessment. This is to check your child is fit and well for the anesthetic and to refer to an anesthetist for further input if needed prior to the day of surgery. You will also be given fasting times for the day of surgery; no food for 6 hours prior to admission time, no breast milk 4 hours prior to admission time and no clear fluids 2 hours prior to admission time.

Please make sure that you have a supply of paracetamol and ibuprofen (if your child can take these) at home to give after the operation. These are not routinely given for you to take home after the operation.

If your child is unwell from the time of being listed for surgery on the day of admission, please contact the plastics coordinator to inform them, as surgery may need to be postponed due to the increased risk of anesthetic.

On the day of surgery

When your child arrives on the ward

Please arrive on the ward on the correct date and admission time of your child’s planned surgery. Please make sure fasting instructions have been followed, if these have not been followed the procedure may not be able to go ahead.

The time of admission is not the time that your child will go down to theatre, the order of the operating list is organised by children’s age and clinical need.

A nurse will admit your child to the ward, this includes checking your child’s details, if they have any allergies and checking your child’s temperature, pulse and blood pressure. Numbing cream may be applied to your child’s hands depending on their age, if they are going to be asleep during the operation.

You will see the surgical team who will gain written permission (consent) to say you are happy for the procedure to go ahead, prior to signing this the surgical team will discuss what the procedure will include and the risks and benefits of carrying out the surgery. You also can ask any questions that you may have about the procedure. They will also mark the area to be operated on with surgical pen.

The anaesthetist will also see your child prior to going to theatre. They will check your child is medically fit for the procedure and general anaesthetic (if your child is having this). They will also discuss the different ways the anaesthetic can be given, and which method would be best for your child.

In theatre

If your child did not have a cannula inserted in their hand in the anaesthetic room, they will have one inserted once they are asleep, this is so medications can be given during the operation and also after surgery if required.

The amputated skin from the top of the finger is cleaned and the tip of the finger is cleaned, any foreign bodies are removed. If there is any exposed bone, this is normally made slightly shorter to ensure that the skin at the end of the finger fully covers the bone.

Dissolvable sutures are then usually used to secure the amputated skin to the fingertip. A non-adhesive dressing is then applied, gauze and bandage are applied over the top of this.

After the operation

You will be contacted by the children’s recovery team to inform you that your child is in recovery.

After the surgery your child may feel drowsy or sleep, they may be restless and upset after waking from the surgery (this normally settles on its own).

Your child can eat and drink as they feel able to after the procedure.

There may be swelling and bruising to the area. This will go down with elevation of the limb and should settle over the following days/weeks.

You may go home once your child has eaten, drank and passed urine. We will also make ensure that your child is comfortable after the procedure, before you go home.

After you go home

Paracetamol and ibuprofen should be given regularly for the first couple of days.

The dressing needs to be kept dry.

Keep the limb elevated as much as possible, this is to reduce swelling to the finger and can also help to alleviate pain.

It is normal for there to be some oozing. If at home, there is fresh blood visible please contact the children’s plastics CNS 07729 107964 or attend A&E.

You will have an appointment in 7-10 days in the children’s plastic dressing clinic. Here the dressing will be removed, and the wounds will be checked, and another dressing is applied, this is normally smaller than the dressing applied in theatre. It is normal for a composite graft not to survive and turn black, if this happens the graft is usually kept on the fingertip to act as a natural dressing (biological dressing). The graft will eventually start to lift off from the fingertip as the skin heals underneath.

It is important to encourage your child to move and use their finger so that it does not become stiff and sore.

Signs of infection

• Redness around wound or spreading away from the wound.
• Increased pain to wound that is out of proportion to the surgery carried out.
• Hot to touch, when compared with the temperature of the surrounding skin.
• There is a foul smell coming from the wound.
• There is pus or excessive ooze from the wound.
• Your child has a temperature and feels unwell

If any of these signs appear please contact your GP, but if your child is very ill take them straight to A&E.

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches) and a current repeat prescription from your GP.

Please tell the ward staff about all of the medicines you use. During your stay If you wish to take your medication yourself (self-medicate) please speak with your nurse. Pharmacists visit the wards regularly and can help with any medicine queries.

MyChart

We would encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device

If you are interested in this please let us know and we can provide information, or look on our website: MyChart

Contacts/further information

Paediatric Plastic Surgery CNS: 07729 107964

Email the paediatric plastics department

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one to one care is required.