3.1.1. Adoption of Primary Nursing and Case Management Model

On the day of admission, after the primary nurse received the patient, key information was shared in the WeChat work group for focused attention. Each nurse in the ward performed their respective duties: the psychological liaison nurse immediately provided psychological intervention; the nutrition specialist liaison nurse developed an individualized nutrition plan; the pressure injury liaison nurse monitored the patient’s skin condition; and the primary nurse conducted close observation and documentation of the patient’s condition, with timely updates posted in the WeChat group.

3.1.2. The Primary Nurse Completed the Admission Procedures and Introduced the Ward Environment to the Patient and Family Members

Preoperative preparations were carried out according to medical orders, and successful cases of patients who had undergone the same procedure in the ward were shared to enhance the confidence of the patient and family. Educational videos titled “Preoperative Instructions”, “Pressure Injury Prevention After Flap Transplantation”, and “Ankle Pump Exercises” were played on the ward television to reinforce understanding and help the patient prepare. Family members were also guided to prepare necessary postoperative items, such as lemons, a writing board, and tissues.

3.1.3. Initial Psychological Assessment by the Psychological Liaison Nurse

The psychological liaison nurse conducted the first psychological assessment using medical records, direct communication with the patient and family, and standardized scales. Expert consensus indicates that depression and anxiety are the most common psychiatric comorbidities in cancer patients [7]. For patients with tumors who develop psychological distress, the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scales are recommended to evaluate depressive and anxiety symptoms. The Body Image Scale (BIS) was used to assess the patient’s perception of self-image over the past week [8]. The patient’s scores were PHQ-9: 11 (moderate depression), GAD-7: 12 (moderate anxiety), and BIS: 28 (elevated), all indicating significant psychological burden consistent with his clinical presentation. The primary cause was body-image disturbance due to the visible facial mass, which triggered anticipatory social anxiety and behavioral avoidance, ultimately forming a vicious cycle of depression and anxiety. When the primary nurse first encountered the patient wrapped in a scarf covering his face and learned from the family that he avoided speaking because of the large mass, the psychological liaison nurse was immediately consulted. The liaison nurse escorted the patient and family to a private treatment room, allowed the patient to relax before conducting the interview, and worked to establish initial trust. During the conversation, the patient appeared calm but emotionally flat, with a blank expression and avoidance of eye contact. The nurse encouraged him to express his inner thoughts, listened patiently, validated his feelings, and taught him a simple breathing relaxation technique from mindfulness-based stress reduction, which was appropriate for his current state and helped mildly alleviate his anxiety.

3.2.1. Flap Observation and Nursing, with Vigilance for Vascular Crisis

Expert consensus [5] indicates that the first 72 hours postoperatively represent the period of highest risk for vascular crisis in perforator flaps. Tao Xian-yao et al. [9] demonstrated that flap color, temperature, degree of swelling, capillary refill time, and progression of ecchymosis are the five key parameters for monitoring flap microcirculation. Accurate documentation of the timing of vascular compromise and the appearance of ecchymosis enables early identification of arterial or venous crisis and improves flap survival rates.

Upon the patient’s return to the ward, the right facial flap appeared slightly pale, closely matching the color of the donor thigh skin, with moderate swelling and capillary refill of 1 - 2 seconds. From postoperative day 3 onward, the flap gradually became pinker, swelling slowly subsided, and tissue elasticity remained good.

Specific nursing measures included:

(1) Implementation of the “Flap Circulation Observation Chart” with close monitoring of perfusion. Monitoring methods included infrared thermometry for temperature, cotton-swab compression test for capillary refill, and, when necessary, a 7-gauge needle prick test to assess bleeding. Monitoring frequency was adjusted according to the patient’s condition: hourly for the first 24 hours, every 2 hours from 24 - 72 hours, and every 4 - 6 hours thereafter once stability was confirmed.

(2) Positioning and environmental management: During the immobilization period, the head was kept slightly turned to the right or in neutral position to avoid twisting or compression of the vascular pedicle. Room temperature was maintained at 20˚C - 22˚C to prevent vasospasm.

(3) Circulatory volume management: Effective circulating blood volume was maintained and blood pressure supported. Alprostadil and low-molecular-weight dextran were administered as ordered. Hemostatic agents were avoided unless an emergency arose, to prevent impairment of flap perfusion.

(4) Secure fixation of drainage tubes around the flap to avoid compression of the vascular pedicle.

The patient’s free flap remained pink and soft, with rapid capillary refill (<1.5 seconds), good elasticity, and temperature comparable to the contralateral side, indicating excellent microcirculatory perfusion.

3.2.2. Observation and Documentation of Wound Condition to Prevent Infection

Zhou Yang et al. [10] reported that wound care is an essential component of postoperative flap nursing. Appropriate dressing selection and meticulous wound cleaning promote healing and reduce complications.

Specific measures included:

(1) On the first postoperative day, the suture line of the facial flap was covered with blood crusts. The wound was cleaned daily with normal saline, followed by disinfection with povidone-iodine to keep the area dry and clean.

(2) Because the flap bridged the facial skin and oral cavity, oral hygiene was suboptimal, with noticeable odor and moderate sputum production occasionally mixed with blood. Thorough oral care and observation of sputum characteristics were therefore critical. During the immobilization period, the oral cavity was wiped twice daily with gauze-wrapped hemostatic forceps. After immobilization was discontinued, an oral irrigator was used for cleaning, with frequency adjusted according to the degree of oral soiling.

(3) Body temperature was monitored and recorded regularly on the temperature chart, while laboratory results (complete blood count and inflammatory markers) were reviewed dynamically.

On postoperative day 1, laboratory results showed a white blood cell count of 13.4 × 10⁹/L, C-reactive protein (CRP) of 82.7 g/L, and procalcitonin of 0.73 ng/mL. The patient’s highest body temperature reached 38.7˚C. Given the absence of purulent wound discharge or clear signs of localized infection at the time, the condition was considered a postoperative inflammatory response, with possible infection not excluded. The clinical rationale for antibiotic use was based on fever and elevated inflammatory markers; however, there was no definitive microbiological or localized evidence of infection. Antibiotics were administered as ordered. During hospitalization, the inflammatory markers gradually declined. On the day before discharge, the white blood cell count had decreased to 7.65 × 10⁹/L, CRP to 37.1 g/L, and procalcitonin to 0.05 ng/mL. The wound remained normal, oral hygiene had improved, there was no foul odor, and no signs of infection developed.

3.2.3. Monitoring the Patient’s Nutritional Intake and Developing an Individualized Nutrition Plan

Because the surgical wound was located in the oral and maxillofacial region, the large wound surface and flap transplantation resulted in increased intraoperative and postoperative exudation and bleeding, leading to greater nutrient loss. Postoperative tissue repair also significantly increased the demand for nutrients. In addition, the hypermetabolic state associated with malignancy elevates resting energy expenditure [11], making malnutrition more likely. Therefore, close monitoring of nutritional status and timely nutritional supplementation are essential in patients undergoing flap transplantation to reduce the incidence of malnutrition [12].

Upon admission, the primary nurse immediately performed Nutritional Risk Screening 2002 (NRS-2002), yielding a score of 4, indicating nutritional risk. The score remained 5 on the first postoperative day and on the day of discharge, confirming ongoing nutritional risk. The nutrition specialist liaison nurse applied the “five-step ladder” nutritional therapy model and used the body-weight formula method to estimate the patient’s energy and protein targets [13]: 1625 - 1950 kcal/day for energy and 65 - 130 g/day for protein. An individualized nutrition plan was then formulated based on the patient’s specific condition.

Table 1. Personalized postoperative diet plan and actual total energy intake versus target.

On the day of admission, the primary nurse and nutrition specialist liaison nurse inquired about the patient’s dietary habits and appetite, informed the attending physician, and the physician prescribed a complete enteral nutrition formula (Neng Quansu) together with intravenous nutritional support. From the first postoperative day onward, nutrition was provided via nasogastric tube feeding combined with parenteral nutrition, with intravenous support used as a supplement. The dietary regimen was dynamically adjusted according to the patient’s postoperative progress. During postoperative days 1 - 3, while the patient remained immobilized and bedridden, gastrointestinal function gradually adapted to nasogastric feeding, and the feeding volume was increased progressively (details shown in Table 1).

During hospitalization, the patient’s nutritional intake gradually increased. On postoperative day 1, hemoglobin was 76 g/L and albumin was 28.6 g/L. On the day before discharge, hemoglobin had risen to 92 g/L and albumin to 39.2 g/L. The patient’s body weight remained stable, and nutritional intake met the target requirements. However, hemoglobin and albumin levels did not show significant improvement compared with the values at admission.

3.2.4. Prevention and Management of Postoperative Complications

Zhu Gaifang et al. [14] emphasized that complication prevention is a critical aspect of perioperative nursing for patients undergoing oral-maxillofacial flap reconstruction. Because these procedures involve extensive resection, prolonged operative time, and extended postoperative immobilization in the supine position, pressure injuries and deep-vein thrombosis are common complications [15]-[17]. The patient’s preoperative BMI was 17.0 (underweight), the operation lasted approximately 5 hours, and he required strict head immobilization and bed rest for 3 days.

Specific preventive measures included:

(1) Pressure injury prevention: The Waterlow Pressure Ulcer Risk Assessment Scale was used; the score on the day of surgery was 16, indicating high risk. Given the long operative duration, a Mepilex self-adhesive soft silicone foam dressing was applied to the sacral area before the patient was transferred to the operating room to reduce pressure and friction. A hydrogel pad was placed under the sacrum on the hospital bed, and the patient’s position was changed every 2 hours using a turning pillow during the immobilization period. Room temperature was kept appropriate, and nutritional intake was maintained to support skin barrier function.

(2) Deep-vein thrombosis prevention: The Caprini thrombosis risk assessment scale was used. The score was 3 (moderate risk) on admission, rose to 7 (high risk) on the first postoperative day, and remained at 5 (high risk) after immobilization was discontinued and at discharge. The patient and family were taught ankle-pump exercises and straight-leg raises preoperatively. Postoperatively, active exercises (ankle pumps and straight-leg raises, 3 times daily, 10 repetitions each) and passive therapy (low-frequency pulsed electrical stimulation, twice daily for 20 minutes) were implemented. Limb movements were performed within the patient’s pain-free tolerance. Ambulation was encouraged on postoperative days 5–7. With the collaborative efforts of the medical team, nurses, and patient, no pressure injuries or thromboembolic complications occurred during hospitalization.

3.2.5. Comprehensive Perioperative Psychological Support Based on the 5E Care Model

The 5E nursing model refers to Evaluate, Empathy, Ensure, Enable, and Encourage. This model has been studied and applied in the rehabilitation care of patients with chronic diseases and cancer [18]. The responsible nurse and psychological liaison nurse provided humanistic psychological support to the patient in three phases.

Phase 1 (Preoperative phase): On the day of admission, a trusting relationship was established with the patient to help him accept the medical team. A psychosocial assessment was then conducted. The patient’s PHQ-9 score was 11 and GAD-7 score was 12, indicating moderate depression and anxiety. The BIS score was 28, suggesting the presence of body image disturbance. The patient was encouraged to express his inner thoughts, and his emotional needs were actively listened to [19] to help alleviate anxiety. He was also taught breathing techniques, including pursed-lip breathing (2 - 3 times per day, 15 - 20 minutes per session) and diaphragmatic breathing (2 - 3 times per day, 15 - 20 minutes per session).

Phase 2 (Immobilization period): Support was provided to help the patient cope with the most difficult postoperative period. This included alleviating physical discomfort, conducting close monitoring and care of the free flap, wound care, nutritional status monitoring, and prevention of complications. Through frequent ward rounds and communication, family support was mobilized. The patient was guided to practice mindfulness breathing and relaxation techniques, specifically breath control: placing both hands on the chest and abdomen, relaxing the shoulders and arms, inhaling through the nose and exhaling through the mouth, performing three deep, slow breaths, with the final inhalation held for 3 seconds, repeated 3 - 5 times [20].

Phase 3 (Gradual recovery): The patient was encouraged to reintegrate into society. With family support, he was motivated to leave the ward and engage with external stimuli. On the day of discharge, the psychological liaison nurse reassessed his mental status. The patient appeared cheerful, with bright eyes and a slight smile, although he still avoided direct eye contact. His PHQ-9 score was 4 and GAD-7 score was 4, indicating no significant or only minimal symptoms of depression and anxiety. The BIS score had decreased to 15, suggesting that body image concerns persisted but had improved compared with admission.

Relying on the hospital’s self-developed “Internet + Full-Cycle Intelligent Management” platform, the patient was incorporated into a systematic management process. Li Yufei et al. [21] noted in their review that mobile health (mHealth) can effectively support transitional rehabilitation nursing care for patients with oral cancer. The platform regularly pushed standardized video guidance materials on oral function exercises and shoulder-neck rehabilitation training. These materials were simultaneously sent to the patient or family via a WeChat mini-program at discharge, with a check-in function enabled to monitor training adherence. In addition, the platform sent SMS reminders to the patient and family for timely return visits, which is particularly important for dermatofibrosarcoma protuberans (DFSP), especially in high-recurrence areas such as the head and neck. At the two-month postoperative follow-up, the patient’s voice was clear and fluent. The nasogastric tube had been successfully removed, and oral intake had been resumed with good dietary tolerance. Body weight had increased to 55 kg. Mouth opening was currently limited to approximately one finger width, primarily due to local tissue reconstruction and scar formation following buccal flap repair.