Q&A: Recovery

This is the final post in the three part Q&A series with my oral & maxillofacial surgeon, Dr P.

I have a pre-op consultation today with my plastic & reconstructive surgeon, Dr A.  I also have a pre-op consultation tentatively scheduled with Dr P on 30 July, the day before my likely admission to hospital.

Q&A: RECOVERY

In hospital

What tubes etc will I wake up with?  Are there any I might not be aware of?

  • Arterial lines
  • Venous lines
  • Tracheostomy tube
  • Urinary Catheter line
  • Neck drains
  • Leg drains

We reserve the right to place any other lines necesary for your health and monitoring

What will you look for to determine I am able to move from ICU to my own hospital room?

Flap viability, respiratory status, general medical condition

What will you look for to determine I can have the tracheostomy removed?  How long is it usually left in?

Flap viability, respiratory status, general medical condition. Generally left in for 1-2 weeks

How is the tracheostomy removed?

The tracheostomy is removed in the ward by myself or another doctor. You will have tests done before to make sure you can breathe when we remove it. [Excellent idea.]

What will you look for to determine I can have the nasal feeding tube removed?  How long is it usually left in?

Flap viability. We will remove in 1 week if able to tolerate oral feeding.

How is the NG tube removed?

The NG tube is removed by simple back pressure on the tube. Similar to the Urinary catheter.

When will I be able to get out of bed?

We encourage ambulation to minimise complications. If you have a skin graft we also like a period of immobility of 4-8 days so the graft can become adherent to the underlying tissue. Generally bed for 4-7 days, sitting out of bed thereafter, weight bearing slowly with a frame then assisted walking over 2-4 weeks.

What will you look for to determine I am able to be discharged from hospital?

Flap viability, tissue health, general medical condition

What blood tests will I need after surgery?  What is their purpose?  How often?

Daily blood tests to determine your status of recovery or illness. Similar with ECG or chest x ray.

I have a needle phobia.  A PICC line was suggested.  What are the pros and cons?  What would I need to do to organise?

We will place the major lines while you are asleep. Pro’s are less smaller needles and the ability to hydrate you with blood or fluid as necessary. You do not need to organise anything.

UPDATE: To clear up the confusion, he means the needles will be fewer in number and smaller in size.  He has also said that the IV line they use requires a lot less injections.

At home

When will I have follow up consultations with my surgeons?   When?  What will they be looking for?

Weekly follow up for 6 weeks. We are looking for infection, non union of the jaw, mal union of the jaw. Thereafter monthly/ 3 monthly visits

Will I have follow up tests?  Which tests?  When?  What will they be looking for?

Follow up radiographs, OPG, CT. We are reviewing integration of the flap.

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Q&A: Surgery

This is the second in the three part Q&A series with my oral & maxillofacial surgeon, Dr P.

I have excluded the questions about costs and invoices.  In case anyone wonders about my ability to count to 45.

Q&A: SURGERY*

Surgery preparation

Will I need more tests or scans before admission to hospital?

It would be required to meet Dr L (Physician) to establish baseline Respiratory and Cardiac Function. The Anaesthetist will be advised of your admission and will view your results. Generally you will,have daily blood tests, ECG and Chest x ray in ICU. Thereafter daily or 2nd daily blood tests on the ward. [Yippee]

When will the blood tests, chest x-ray and ECG noted in my hospital admission paperwork take place? Before or after surgery?

The pre op tests will be done approximately 1 week before in the University Preadmission clinic.

Is there anything else I should be doing to prepare for surgery?

Refrain from Smoking, Alcohol, The use of blood thinning agents like anti inflammatories and Aspirin. Advise the medical staff if you have any unusual medical conditions, taking drugs or pills and any allergies. Exercise prior to surgery is OK. Do not chew hard food lest the mandible fracture and get infected.

How will my surgery be affected if I lose too much more weight?

It is not unusual to be catabolic after surgery. We would suggest pre operatively to put on weight by a high caloric diet.

Surgeons

Is there anyone else on my medical team that I could/should meet before my surgery?

I think he missed this one.

Who will be involved in the surgery other than Dr P (oral & maxillofacial surgeon) and Dr A (plastic & reconstructive surgeon)?  What is their role?

Dr XX may be involved in the surgery. He is a Head and Neck Surgeon and I will advise you of his availability. Dr XX is the Advanced Fellow in Surgery. Dr XX and Dr XX are members of The University Cosmetic and Plastic Surgery Unit and may be involved. Our roles are multi disciplinary in that we all look after you in respect of your surgery and progress.

Who does the tracheostomy?

Dr XX, myself or Dr XX will do the tracheostomy. All the surgeons above can also do the tracheostomy as required.

Fibulectomy and fibula flap

What do you learn from my doppler ultrasounds on the artery and vein in my legs?

The Dopplers and Ultrasound are done to exclude that the Peroneal artery is separate and stand alone from the Posterior Tibial Artery.

Do you take the whole fibula?  What happens to the joints or bone parts that remain?  Do you take muscle with the fibula?

We take the whole fibula but preserve the distal 10 cm’s otherwise you could develop an unstable ankle joint. We take muscle with the fibula.

How will you know if the fibula flap is failing?

If the fibula flap is failing we see a change in colour of the flap, associated blood indcators like elevated white cell count, high temperature ad tachycardia. You will be unwell if infection sets in. We may organise a Technecium 99 Bone scan 3-4 days after surgery to confirm blood flow to the flap.

How much will I be able to move with my jaw wired?

We wire the jaw for 3-4 weeks for assistance with the healing process. Following this we place elastic bands for 2-4 weeks for partial assistance with mastication and occlusion. You will be fed by a Naso gastric tube for 1-2 weeks. Thereafter a full fluid diet, then a soft diet.

Mandibulectomy

How will you know if you have removed all the tumour?

We would suggest a repeat MRI 1 week before the surgery to give maximum information regarding bony infitration of the tumour. MRI’s do not produce radiation but give exact localisation of the tumour. [This doesn’t quite answer my question.]

What will you do if you can’t remove all the tumour?

Your preliminary findings suggest we can remove all the tumour. If the “final” pathology margins suggest we are not clear then we will advise you of a wider clearance needed as a separate surgery.

How much of my soft tissue will you remove?  What will be the effect on my face?

Soft tissue includes,

  • Free and attached mucosa (Gum)
  • Periosteum
  • Buccinator muscle (part)
  • Mylohyoid muscle (part)
  • Associated nerves, blood vessels.
  • Important nerves include Inferior Alveolar Nerve, Possible facial nerve branches including Marginal Mandibular and Buccal nerve

You will have scarring, fullness or depression of facial aesthetic units, alteration of symmetry of face, compromised jaw opening, sensation or movement of the face.

We over correct the deformity and aim to give more fullness than depression of tissue. We may need to undertake repair/revision/reconstruction of tissue or jaw/teeth at a later date.

When will you get the results of the pathology on the removed tumour and mandible?  What will you do if you find malignancy?  What will you do if the tumour is not clearly benign?

The pathology will take about 1-2 weeks before the jawbone is “decalcified” to enable the patholoist to advise on margin clearance. We reserve the right to advise you on this and also the need for wider excision.

Will you do follow up checks with me in hospital?  Will other doctors do follow up checks?  For what and how often?

We will do daily follow up checks on you, this includes myself, Dr A, Dr XX, Intensive Care Specialists, Dr L (Consultant Physician) and other Doctors.

Nursing, Dietitian, Speech pathology, Physiotherapy also.

*Disclaimer: He did not have access to my files and his answers are indicative only.

Homeward bound

I will be discharged from hospital by lunch time.  Dr P just popped in to see his patients in the ward.

He took three samples, just like in my first biopsy.  The worrisome extension of the tumour into the soft tissue was glistening and white, he said. In the soft tissue, there were signs of infection and efforts to protect against the expanding tumour.  Of course, as I have heard many times now, only the pathologists will be able to determine if the tumour is cancerous by examining the samples under a microscope.

The samples have been whisked away to a pathologist at the Royal Prince Alfred.  She will likely consult with the pathologist from the first biopsy.  If necessary, the radiation oncologist from Macquarie University Hospital will also have a look.  Dr P now seems to think he may hear by the end of the week.

I will have a consultation with him next week to discuss the pathology results.  Unless the results are nasty.  Nasty means clearing their schedules.  Nasty means resection and reconstruction surgery either this coming Saturday or the next.

Time to root for a late July surgery date.

Biopsy two down

I have oxygen pumping gently in my nose.  An IV drip in my arm. No feeling on the outside of my left jaw. Raw throat from breathing tubes through my nose down my throat during surgery. The facial swelling has started.  And the pain inside my mouth at the biopsy site is beginning to stir.

But I am awake.  I even feel in much better shape this time.  I asked for and ate my dinner: mashed potato, soft pizza, steamed veg, bread and butter pudding, custard and apple juice. Not too shabby in this hotel, as Darren kept accidentally calling it as we filled out the admission forms.

Do you mind hanging on there a tick while I find Kevin, my nurse tonight?

They are on their pain meds round, the little assistant tells me.  Pain out of ten?  Oh five, maybe six.

I can wait. I’ve had practice at that today.  I waited about four hours before I heard the dulcet tones of Dr P strolling along the hallway.  Relief.  I was overwhelmed with relief.  He will take it all in hand now.

Ruth and the porter took me down to theatre.  Dr P wandered by with coffees for the operating team.  Good to know they are taking a break and will be ready to go again.  The anaesthetist Kirsten (good sign) and operating nurse Bev were lovely about my needle phobia and followed the worst bit quickly with a dose of the good stuff.

Helen, the nurse in the intensive care unit, called Darren for me as soon as I asked and I could speak to him.  By about 4pm, maybe a bit later, I was back in my room and on the cockpit phone to Mum when they waltzed in chirpily reading her new book from today’s mothers group combined first birthday party.

Alannah wasn’t super keen to get close and burst into distressed tears.  Then moments later she was enthusiastically shoving in one mandarin, then a second, and high-fiving me from the armchair. Tiredness overtook her after not too long. She is a trooper, my little girl.  Virus, long day, much change already from the rhythm she knew and loved.

Time for pain meds. I can hear Kevin now.

Waiting

I have showered with chlorhexidine antiseptic wash. Ruth, my nurse, has dressed me in my hospital gown.  She has put on my funky leg stockings and red surgical hat.  She got me emla patches to desensitise my elbow crease and hand.  I cry like a baby from fear of needles. I am labelled all over.  I checked, right name, right doctor.

There is a cockpit, as they call it, on a large mechanical arm over my bed.  Internet, telephone, games, television, the works.  Touch screen and keyboard.

I have read some of your emails and comments this morning.  I have played sudoku.  I have watched some bad television.  I called Dad to try out the phone (and say hi, of course).

I am nervous.  Scared perhaps.  Yes, scared.  It seems a much bigger deal this time.  This hospital is modern, imposing, serious.

Darren has gone home.  Alannah has a last-minute doctor’s appointment and a party today.  The combined first birthday party of our mothers group boys and girls.  No one is actually one yet, not until 29 June, but they will all come in a rush soon.  I am happy that Alannah isn’t missing out.  It will all be over by the time I wake up.  I wonder how much I will miss out on as this runs its course.

Lalalalalala.

Sometimes I can distract myself.  More often than not.  Other times it feels like time stands still. I was in the bath for half an hour on Thursday night.  Lying still and staring at my orange toe nails.  Seeing them and not seeing them.

I am feeling calmer now.  It comes in waves.

Three hours of waiting will do that.

Ruth knows I am waiting and nervous.  Bless her cottons socks.  She just called to say they are caught up in surgery and she will be in soon.  I shall seek out some more distraction until then.

Second biopsy -18 June 2011