Serletti, J. M. (2006). DIEP and pedicled TRAM flaps: A comparison of outcomes. Plastic and Reconstructive Surgery, 117(6), 1720-1721.
ABSTRACT. This article was a commentary written in response to an outcome analysis article comparing the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap to the deep inferior epigastric perforator (DIEP) flap in patients presenting for unlilateral autogenous breast reconstruction. The author critiqued the article and gave his opinions on the types of flaps. His brief comments on proper patient selection criteria being an important component in providing a safe and reliable procedure sparked our interest in discussing the importance of patient selection criteria for the elective, reconstruction patient as well as the aesthetic patient.
COMMENTS. Having worked extensively with breast reconstruction patients perioperatively and as a support group facilitator for several years, I value the importance of patient selection criteria and proper patient education and preparation for women undergoing any type of breast reconstruction procedure.
It is crucial to begin with a thorough patient consultation. In many practices (as was the case with ours), the nurse may be the first to get this information. Important components would include patients' breast cancer diagnosis history/previous surgeries and treatments, assessment of how they are coping with the diagnosis (particularly for immediate reconstruction), knowledge regarding breast reconstruction options, support systems available, lifestyle issues (smoking history, activity level, work demands), and any fears or anxiety about potential surgery and recovery.
How physically and psychologically prepared is the patient for the surgical experience that may lie ahead? Has the surgical team addressed the body image adjustments that she will need to cope with? Is there any psychological support or screening available to the patient through a psychologist, support group, and patient-to-patient referral network?
In my experiences with women undergoing potential immediate reconstruction in particular, I would "red flag" those who needed further psychological support by our team psychologist prior to undergoing surgery. Some of these women had not yet been able to accept their diagnosis and "loss" and needed to do so prior to having a successful reconstructive outcome. If this is not done, regardless of how wonderful the surgical results are, the patient may not be able to see or accept the change. I recall one patient who met with the psychologist twice for preoperative evaluation at the recommendation of the both the general and plastic surgeons. She "convinced" the surgical team that she was able to handle her immediate free TRAM flap breast reconstruction surgery and recovery despite all of the red flags raised. For over a year following amazing reconstruction results, this patient was angry and upset with "how her breast looked" and the "disfigurement" she perceived.
The plastic surgical nurse is in a unique position to screen for proper patient selection and preparation for breast reconstructive surgery. A savvy surgeon will recognize what he or she can offer to help ensure a positive outcome for women faced with many decisions on a journey they never wanted to take.
DPS
Section Description
The Journal Club provides commentaries on topical studies relevant to plastic surgical nursing practice. Anyone with a suggestion for a particular topic may contact the Section Editors, Dawn Sagrillo, BSN, RN, CPSN, at [email protected], or Sue Kunz, BS, RN, CPSN, at [email protected].