- Email: [email protected]
Nurse-led preassessment breast reduction clinic
694
Short reports and correspondence
a benign condition! As the deformity increased his function deteriorated and no surgical advances seemed available to improve matters. At the present time, the only theoretical possibility that comes to mind would be a controversial one, as yet not performed in the UK e a homograft hand transplant. This however has both ethical and immunological issues which to date have not been fully resolved.
Table 1
Outcome of patients seen in nurse-led clinic
Number of patients BMI < 27 Average BMI Potential clinic time saved (h)
Eligible
Not eligible
39 (36%) 39 23.7 6.5
70 (64%) 0 30.7 23.3
References 1. Wada H, Jinnai K, Urabe H. Hypoplasty of the breast due to x-ray irradiation. Aesthetic Plast Surg 1986;10:137e41. 2. Culley M. Beatson Cancer Clinic admits to overdose errors. Scottish Daily Mail; 13 May 2006:7. 3. Leake C. Damning new evidence that could finally win justice for 1,000 Nuclear Bomb Test Veterans of Christmas Island. The Mail on Sunday 7 May 2006:44.
J.C. McGregor Department of Plastic Surgery, St John’s Hospital, Livingston, West Lothian EH54 6PP, UK E-mail address: [email protected] ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.09.002
Nurse-led preassessment breast reduction clinic Cosmetic surgery is one of the few areas of healthcare that has been restricted within the National Health Service (NHS).1 The offer of surgery has to be based on clinical need. In Scotland an exceptional referral pathway has been devised for aesthetic procedures. For breast reduction, patients must fulfil the following criteria, ‘hypertrophy/gigantomastia e massive disproportion to body size in a patient up to a body mass index of 27 and physical symptoms e.g. back/neck pain and/or intertrigo ..’.2 Nurse-led clinics play an increasing role in many surgical specialties. They have been shown to be effective for the preoperative assessment of patients undergoing routine elective surgery.3 In our unit we have employed a trained nurse practitioner as part of the Action on Plastic Surgery programme, to assess all patients seeking reduction mammaplasty. Our aims were threefold: (1) to reduce the overall waiting time (for patients to be seen) and the time to operation if appropriate; (2) to free up time in outpatient clinics for ‘higher priority’ patients; and (3) to allow patients more time for assessment and explanation for the surgery involved. One hundred and twenty-seven new patients were offered an appointment for the nurse-led breast reduction clinic over a 12 month period between January 2005 and January 2006. These patients would otherwise have been placed on the outpatient waiting list of two consultant plastic surgeons. Eighteen patients failed to attend their appointment. A full medical history was taken and reasons for seeking breast reduction were
explored. Factors such as smoking, current symptoms, bra size, weight and height were recorded. Of the 109 patients seen only 39 (36%) were referred on to see a consultant. Three of these patients initially had a body mass index (BMI) greater than 27 and made a further appointment to see the nurse practitioner. At the second appointment they had lost the required weight and were therefore referred on to see a consultant. The remaining 67 (64%) patients did not meet referral criteria as they had a BMI greater than 27. All patients eligible for referral were keen to be seen by a consultant once they had found out what the surgery entailed. It should be noted that the role of the nurse practitioner was not to exclude patients from referral on medical grounds. Table 1 summarises the outcomes of patients seen in the nurse-led clinic. Mean waiting time to be seen was 5.3 months for the nurse-led clinic and a further 2.6 months for the consultant clinic. Of the 39 patients referred on to see a consultant only 22 were placed on the waiting list for reduction mammaplasty. Reasons for not proceeding to surgery are summarised in Table 2. Seeing a new patient in the outpatient department for consideration of reduction mammaplasty requires adequate time to assess and explain in full the procedure to the patient. A fair estimate of time required for such assessment is about 20 min. We have found that patients who have been preassessed only require about 10 min for adequate assessment and explanation. We estimate that around 30 h of consultant clinic time has been saved over the 12 month period by only seeing patients who fulfil the referral criteria based on BMI. We accept that in many departments it is the responsibility of the general practitioner to select patients in which case they would not pose an extra commitment on outpatient time. However, such practice denies the patient the opportunity to find out what the procedure, benefits and disadvantages of
Table 2 Outcome of patients referred on to see a consultant Patients referred to see a consultant Waiting list/operation Weight gain/fluctuation Patients not willing to proceed Failure to attend Incorrect indication (e.g. mastopexy) Medical contra-indication
39 22 5 4 4 3 1
Short reports and correspondence reduction mammaplasty involve. We propose that a nurseled clinic can fulfil this role.
References 1. Timmons MJ. Rationing of surgery in the National Health Service: the plastic surgery model. Ann R Coll Surg Engl (Suppl.) 2000;82:332e3. 2. www.pathways.scot.nhs.uk/plasticsurgery.htm. 3. Casey D, Ormrod G. The effectiveness of nurse-led surgical preassessment clinics. Prof Nurse 2003;12:685e7.
Omar Quaba Rhona McIvor Michaela Davies John D. Holmes Department of Plastic Surgery, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK E-mail address: [email protected] ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.07.007
BOOK REVIEW Body Contouring after Massive Weight Loss, Al S. Aly (Ed.), Quality Medical Publishing, St Louis, 2006, ISBN 1-57626-211-1, Price £235.50. A recent government report has predicted that the incidence of obesity within the UK is set to rise. If the current trends continue then it is estimated that more than 12 million adults and one million children will be obese by 2010. Bariatric surgery is a relatively new and effective method for dealing with morbid obesity producing long term rapid weight loss. The number of bariatric procedures performed within the UK is forecast to rise and this will generate a population of patients who will require body contouring surgery. Body Contouring after Massive Weight Loss is a very comprehensive text encompassing all aspects of managing
695 the massive weight loss patient. The book is edited by Dr Al S. Aly, well known for his contributions to this area of plastic surgery. He is the author of several chapters, other contributors include Peter Rubin and the late Ted Lockwood. The first part of this book is concerned with the fundamentals of obesity. The opening chapter covers the prevalence of obesity both within the USA and worldwide. There is a good descriptive chapter on the basics of bariatric surgical techniques including both restrictive and malabsorptive procedures. Physiological changes and potential complications arising from bariatric surgery are discussed with emphasis on how this may affect subsequent plastic surgical correction. A further chapter is dedicated to physical and psychological patient evaluation highlighting preoperative psychological preparation and postoperative expectations. The second part of this book covers contouring procedures in each anatomic region. Each chapter opens with a description of aesthetic concepts, goals and relevant anatomy. Preoperative marking up is particularly well covered with numerous high quality colour illustrations helping to clarify these various concepts. An abundance of clinical photographs and diagrams take the reader through the individual stage of the operative sequences addressing important topics such as patient positioning and order of skin flap excision. There are numerous postoperative colour photographs to demonstrate points of technique. Each chapter ends with a discussion on potential pitfalls and complications with useful advice on how these are best managed. As an additional benefit, two DVD’s are included with this book that gives edited video coverage of the preoperative marking and surgical stages involved in brachyoplasty, upper body lift and belt lipectomy. In summary, this book is essential reading for anyone intending to treat this patient group. It would however be a useful reference to anyone offering a more conventional body contouring practice. N.D. Rhodes E-mail address: [email protected] doi:10.1016/j.bjps.2007.01.008
Short reports and correspondence
a benign condition! As the deformity increased his function deteriorated and no surgical advances seemed available to improve matters. At the present time, the only theoretical possibility that comes to mind would be a controversial one, as yet not performed in the UK e a homograft hand transplant. This however has both ethical and immunological issues which to date have not been fully resolved.
Table 1
Outcome of patients seen in nurse-led clinic
Number of patients BMI < 27 Average BMI Potential clinic time saved (h)
Eligible
Not eligible
39 (36%) 39 23.7 6.5
70 (64%) 0 30.7 23.3
References 1. Wada H, Jinnai K, Urabe H. Hypoplasty of the breast due to x-ray irradiation. Aesthetic Plast Surg 1986;10:137e41. 2. Culley M. Beatson Cancer Clinic admits to overdose errors. Scottish Daily Mail; 13 May 2006:7. 3. Leake C. Damning new evidence that could finally win justice for 1,000 Nuclear Bomb Test Veterans of Christmas Island. The Mail on Sunday 7 May 2006:44.
J.C. McGregor Department of Plastic Surgery, St John’s Hospital, Livingston, West Lothian EH54 6PP, UK E-mail address: [email protected] ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.09.002
Nurse-led preassessment breast reduction clinic Cosmetic surgery is one of the few areas of healthcare that has been restricted within the National Health Service (NHS).1 The offer of surgery has to be based on clinical need. In Scotland an exceptional referral pathway has been devised for aesthetic procedures. For breast reduction, patients must fulfil the following criteria, ‘hypertrophy/gigantomastia e massive disproportion to body size in a patient up to a body mass index of 27 and physical symptoms e.g. back/neck pain and/or intertrigo ..’.2 Nurse-led clinics play an increasing role in many surgical specialties. They have been shown to be effective for the preoperative assessment of patients undergoing routine elective surgery.3 In our unit we have employed a trained nurse practitioner as part of the Action on Plastic Surgery programme, to assess all patients seeking reduction mammaplasty. Our aims were threefold: (1) to reduce the overall waiting time (for patients to be seen) and the time to operation if appropriate; (2) to free up time in outpatient clinics for ‘higher priority’ patients; and (3) to allow patients more time for assessment and explanation for the surgery involved. One hundred and twenty-seven new patients were offered an appointment for the nurse-led breast reduction clinic over a 12 month period between January 2005 and January 2006. These patients would otherwise have been placed on the outpatient waiting list of two consultant plastic surgeons. Eighteen patients failed to attend their appointment. A full medical history was taken and reasons for seeking breast reduction were
explored. Factors such as smoking, current symptoms, bra size, weight and height were recorded. Of the 109 patients seen only 39 (36%) were referred on to see a consultant. Three of these patients initially had a body mass index (BMI) greater than 27 and made a further appointment to see the nurse practitioner. At the second appointment they had lost the required weight and were therefore referred on to see a consultant. The remaining 67 (64%) patients did not meet referral criteria as they had a BMI greater than 27. All patients eligible for referral were keen to be seen by a consultant once they had found out what the surgery entailed. It should be noted that the role of the nurse practitioner was not to exclude patients from referral on medical grounds. Table 1 summarises the outcomes of patients seen in the nurse-led clinic. Mean waiting time to be seen was 5.3 months for the nurse-led clinic and a further 2.6 months for the consultant clinic. Of the 39 patients referred on to see a consultant only 22 were placed on the waiting list for reduction mammaplasty. Reasons for not proceeding to surgery are summarised in Table 2. Seeing a new patient in the outpatient department for consideration of reduction mammaplasty requires adequate time to assess and explain in full the procedure to the patient. A fair estimate of time required for such assessment is about 20 min. We have found that patients who have been preassessed only require about 10 min for adequate assessment and explanation. We estimate that around 30 h of consultant clinic time has been saved over the 12 month period by only seeing patients who fulfil the referral criteria based on BMI. We accept that in many departments it is the responsibility of the general practitioner to select patients in which case they would not pose an extra commitment on outpatient time. However, such practice denies the patient the opportunity to find out what the procedure, benefits and disadvantages of
Table 2 Outcome of patients referred on to see a consultant Patients referred to see a consultant Waiting list/operation Weight gain/fluctuation Patients not willing to proceed Failure to attend Incorrect indication (e.g. mastopexy) Medical contra-indication
39 22 5 4 4 3 1
Short reports and correspondence reduction mammaplasty involve. We propose that a nurseled clinic can fulfil this role.
References 1. Timmons MJ. Rationing of surgery in the National Health Service: the plastic surgery model. Ann R Coll Surg Engl (Suppl.) 2000;82:332e3. 2. www.pathways.scot.nhs.uk/plasticsurgery.htm. 3. Casey D, Ormrod G. The effectiveness of nurse-led surgical preassessment clinics. Prof Nurse 2003;12:685e7.
Omar Quaba Rhona McIvor Michaela Davies John D. Holmes Department of Plastic Surgery, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK E-mail address: [email protected] ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.07.007
BOOK REVIEW Body Contouring after Massive Weight Loss, Al S. Aly (Ed.), Quality Medical Publishing, St Louis, 2006, ISBN 1-57626-211-1, Price £235.50. A recent government report has predicted that the incidence of obesity within the UK is set to rise. If the current trends continue then it is estimated that more than 12 million adults and one million children will be obese by 2010. Bariatric surgery is a relatively new and effective method for dealing with morbid obesity producing long term rapid weight loss. The number of bariatric procedures performed within the UK is forecast to rise and this will generate a population of patients who will require body contouring surgery. Body Contouring after Massive Weight Loss is a very comprehensive text encompassing all aspects of managing
695 the massive weight loss patient. The book is edited by Dr Al S. Aly, well known for his contributions to this area of plastic surgery. He is the author of several chapters, other contributors include Peter Rubin and the late Ted Lockwood. The first part of this book is concerned with the fundamentals of obesity. The opening chapter covers the prevalence of obesity both within the USA and worldwide. There is a good descriptive chapter on the basics of bariatric surgical techniques including both restrictive and malabsorptive procedures. Physiological changes and potential complications arising from bariatric surgery are discussed with emphasis on how this may affect subsequent plastic surgical correction. A further chapter is dedicated to physical and psychological patient evaluation highlighting preoperative psychological preparation and postoperative expectations. The second part of this book covers contouring procedures in each anatomic region. Each chapter opens with a description of aesthetic concepts, goals and relevant anatomy. Preoperative marking up is particularly well covered with numerous high quality colour illustrations helping to clarify these various concepts. An abundance of clinical photographs and diagrams take the reader through the individual stage of the operative sequences addressing important topics such as patient positioning and order of skin flap excision. There are numerous postoperative colour photographs to demonstrate points of technique. Each chapter ends with a discussion on potential pitfalls and complications with useful advice on how these are best managed. As an additional benefit, two DVD’s are included with this book that gives edited video coverage of the preoperative marking and surgical stages involved in brachyoplasty, upper body lift and belt lipectomy. In summary, this book is essential reading for anyone intending to treat this patient group. It would however be a useful reference to anyone offering a more conventional body contouring practice. N.D. Rhodes E-mail address: [email protected] doi:10.1016/j.bjps.2007.01.008