Plastic and Reconstructive Surgery Global Open is an open source journal available for everyone to read. I refer to it frequently. The articles I focus on are those regarding breast reconstruction. The article entitled, “A Standardized Approach to Deep Inferior Epigastric Perforator Flap Marking” was recently brought to my attention by a plastic surgeon, Dr. Roy Kim. I know Dr. Kim via social media and speaking to him at the annual Plastic Surgery conference. I recently had the privilege of meeting two of the authors of the paper, Dr. Edward Reece and Dr. Sebastian Winocour both of Baylor College of Medicine. I think he knew I would find this study fascinating. I decided to write a commentary on this study of marking patients for DIEP flap surgery.
A Patient Advocate’s Thoughts: A Study Marking Patients for DIEP Flap Surgery
I chose DIEP flap as the method of breast reconstruction after my own double mastectomy. After reading the paper carefully I was curious about the author’s proposed method for marking patients for this surgery. I read frequent discussions in social media from plastic surgeons and patients about symmetry and scar placement in the breast area. These discussions make sense since symmetry is an important and final focus of this surgery, rebuilding the breasts.
However, I don’t hear as much discussion about the symmetry and scar placement of the donor site, the abdominal area. The authors point out a standardized approach has not been written about in the literature. This proposed method was introduced in the paper for this reason.
Comments for the Authors of the Study from A Patient Advocate
The technique described in the paper felt very familiar to my initial consult for my DIEP flap surgery. I was in a standing position as the microsurgeon who performed my DIEP flap carefully assessed the entirety of the area he would be using for my surgery. My plastic surgeon carefully used a measurement tool while dictating numbers to the nurse. She recorded them on a laptop building my medical file for this procedure. I will admit being naked from the lower abdomen up and holding the surgical gown open was uncomfortable. No other man had seen me like this since my double mastectomy seven months prior to this consult.
Consideration of this vulnerability in patients was not part of the paper. I understand this but to that point, I would add to the authors, compassion and care must be taken for patients in this setting. I wanted to share this information when instructing trainees in methods of marking a patient for DIEP flap surgery.
What Variabilities Are Considered in Marking Patients for DIEP Flap Surgery?
The standardized methodology proposed in this paper made sense to me on many levels. I looked at the drawing in Figure 1 of the paper. The symmetry in the lines stood out to me when symmetry is so often discussed as it relates to final outcomes in breast reconstruction. However, I am curious how certain variability would make this standardized approach challenging. Here are some of my questions.
- How does intraoperative planning change when the patient is marked in a prone position under anesthesia vs. the standing position at consult?
- Do variations in skin laxity among patients have the potential of making these proposed markings for DIEP flap surgery more challenging? I assume age and those who have had pregnancies impact these measurements.
- Can these proposed measurements be used consistently for patients with variability in BMI?
- How do prior surgical scars change this standardized approach?
- How do any current medical conditions, f. ex. presentation of scoliosis, affect this standardized approach?
In Conclusion
Each patient has unique body habitus when they present for DIEP flap surgery. This becomes the challenge for plastic surgeons. This proposed method was a fascinating study to read from the standpoint of a patient and patient advocate.
I welcome feedback, thoughts and comments from the plastic surgery community and patients regarding this standardized approach on marking patients for DIEP flap surgery. Is it something you have ever used? Maybe you have used something similar. Consistency, efficiency, and symmetry are important techniques to the patient and the plastic surgeon. I applaud the authors of this paper pursuing optimal surgical outcomes for patients in DIEP flap breast reconstruction.
