This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Moscona, R. A. Articles by Fodor, L. Search for Related Content PubMed PubMed Citation Articles by Moscona, R. A. Articles by Fodor, L.

Patient Satisfaction and Aesthetic Results After Pedicled Transverse Rectus Abdominis Muscle Flap for Breast Reconstruction

Department of Plastic and Reconstructive Surgery, Rambam Medical Center, 8 Ha’Aliya Street, Haifa 31096, Israel

Correspondence: Address correspondence and reprint requests to: Rony A. Moscona, MD; E-mail: rmoscona{at}zahav.net.il

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Background: The transverse rectus abdominis muscle (TRAM) flap is one of the most widely used procedures for breast reconstruction. Our aim was to evaluate the patient satisfaction and aesthetic results after pedicled TRAM flap.

Methods: One hundred thirty-three pedicled TRAM procedures were performed between 1993 and 2000. A questionnaire was filled out by 101 patients, and they represented the study group. We investigated variables of general background, those related to the operation, and those connected with satisfaction.

Results: A total of 75% of women were satisfied with the operation, 73% declared high satisfaction, and only 12% were dissatisfied with the results. A total of 86% were highly satisfied with their appearance in clothes, but only 48% were satisfied with their nude appearance. The lowest grade was given to breast sensation. A total of 82% noted high satisfaction of the spouse, compared with only 7% who stated a lack of satisfaction. Ninety percent claimed that there was no change in sexual attraction, 81% stated there was no change in sexual intercourse, and 79% noted no change in spousal attitude. Younger women reported better symmetry of breasts and a better sexual relationship with the spouse after the procedure. Women who did not undergo radiotherapy were more satisfied with all the aesthetic factors.

Conclusions: Satisfaction is affected by many factors; both objective surgical factors and mental and psychological parameters vary among women. From this point of view, the pedicled TRAM flap can be considered a good option for women desiring breast reconstruction. Those who had immediate breast reconstruction were more satisfied with all measures.

Key Words: Breast reconstruction • TRAM • Satisfaction • Aesthetic results

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
The transverse rectus abdominis muscle (TRAM) procedure was first developed by Hartrampf et al.¹ It is now one of the most widely used techniques for breast reconstruction. The advantages of the TRAM procedure include the ability to use a large amount of autologous tissue instead of foreign bodies.^2–4 Among the aesthetic advantages of this procedure are the following:

1. A natural appearance and consistency of the breast, with better symmetry.
   
2. Good results in overweight women with large breasts and bilateral reconstruction.⁵
   
3. The ability to correct thoracic wall defects caused by the mastectomy (scars and other deformities) or to replace radiated skin if the reconstruction was performed at a later stage.
   
4. Abdominal lift, a secondary gain from the procedure.⁶
   
5. Fewer secondary procedures after TRAM than after other procedures.⁷
   

The disadvantages of TRAM reconstruction are mainly due to the complexity of the procedure, which requires an experienced surgical team and a longer hospitalization and healing period when compared with other methods. The most frequent complications in TRAM procedures are abdominal wall weakness and development of bulge or hernia.⁸ In one study, 85% of patients reported a diminished ability to exercise.⁹ The muscle-splitting technique, fascia sparing, and abdominal reinforcement with mesh were reported as possibilities to avoid abdominal weakness after muscle harvesting. Although the complications associated with this procedure are not negligible, the pedicled TRAM flap remains one of the most used techniques for breast reconstruction and has a high success rate. Other techniques that use the rectus abdominis muscle for reconstruction, such as free TRAM or perforator-based TRAM, are recommended to be performed in centers that have a high success rate with microsurgical procedures.

Only a few studies have addressed patient satisfaction and aesthetic aspects after breast reconstruction.^2,10,11 A number of comparative studies have been performed to evaluate which procedure gives the best surgical results. A study by Kroll and Baldwin¹¹ indicated that patient satisfaction with the TRAM procedure was significantly higher than that with other reconstructive methods, with one drawback of larger scars. Bostwick and Jones⁶ examined the aesthetic advantages of the TRAM procedure compared with other reconstructive procedures. Cederna et al.¹² found that satisfaction with implants or TRAM reconstruction was similar.

Kroll et al.¹³ reported that immediate reconstruction is more successful and that radiation before reconstruction damages the aesthetic outcome. According to Alderman et al.,¹⁴ the TRAM procedure (free and pedicled) yielded higher satisfaction; however, when pedicled TRAM and free TRAM were compared, the pedicled flap yielded higher aesthetic satisfaction. The bias of the study is the fact that 23 different surgeons with different techniques performed the operations. Other authors found that satisfaction was higher after free TRAM than after pedicled TRAM.^15,16 Brandberg et al.¹⁷ examined the effects of a number of late reconstructive procedures on women’s quality of life and their effects on sexual relations, with an emphasis on general and aesthetic satisfaction. Most women reported improvement in quality of life after latissimus dorsi and TRAM reconstruction, with no distinction between the radiated and nonradiated groups.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
One hundred thirty-three pedicled TRAM procedures were performed between July 1, 1993, and July 1, 2000, by the senior author (R.A.M.). Five women died during this period, eight could not be contacted, and six refused to participate in the study. The medical records of 101 patients who completed the questionnaire were reviewed, and they represented the study group.

Research Variables
General variables included marital status, number of offspring, educational level, age, weight, body build, smoking habits, and breast size. Variables regarding the patient’s disease and operation included the side of reconstruction (right, left, or bilateral), radiotherapy (yes/no), chemotherapy (yes/no), time elapsed since reconstruction, time between mastectomy and reconstruction, time group between mastectomy and reconstruction (immediate/late), nipple reconstruction (yes/no/plans for future reconstruction), operation on the opposite breast (yes/no), purpose of operation on the opposite breast (cosmetic/medical), and second procedure on the reconstructed breast (yes/no). Variables regarding satisfaction from the procedure were grouped as follows: general satisfaction, specific aspects of satisfaction and surgical outcome, and effects of the operation on the spousal relationship (Table 1).

Answers to the questions were classified according to a five-point Likert scale.¹⁸ An answer of 4 or 5 was categorized as pleased, and an answer of 1 or 2 was categorized as not pleased. The purpose of this dichotomous categorization was to enable comparison of our results to the results of prior studies that either used a dichotomous scale¹⁹ or converted the study’s findings into a dichotomous scale.^14,17

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
This study included 101 women aged 26 to 64 years, with an average age of 49 years. Eighty patients were married, 10 were divorced, 4 were single, and 7 were widowed. Sixty-one percent were university graduates, 11.88% had bilateral procedures, 65% had immediate reconstruction and 35% had delayed reconstruction within an average of 55 months, and 48 women underwent nipple reconstruction.

General Satisfaction with Outcome
General satisfaction was rated from 1 (low) to 5 (high) by using a five-point Likert scale.¹⁸ Seventy-five percent of the women were satisfied with the surgical outcome, with 55% reporting absolute satisfaction. Twelve percent of the women were not satisfied with the surgical outcome, and 13% stated fair satisfaction. General satisfaction with the surgical outcome was 4.08, with a standard deviation of 1.27. The main reasons for dissatisfaction were a lack of satisfaction with the nude appearance and lack of satisfaction with scars and breast sensation (Tables 2 and 3). Sixty-seven percent would be ready to repeat the operation, and 80% stated that they would recommend the operation to a friend. Sixty-three percent had no difficulty with daily activities, whereas 10% did have difficulties. Fifty-five percent stated that they had no difficulty in performing strenuous activities.

Approximately 60% of the women were pleased with the breast and abdominal scar appearance. Fifty-five percent indicated appropriate symmetry between the breasts after the procedure, whereas 22% were not satisfied from this point of view. The variable of breast feeling in the reconstructed breast received the lowest score. Only 40% were satisfied with this parameter, whereas 31% were not satisfied. The average of general aesthetic satisfaction was 3.54, with a standard deviation of .98.

Effects of the Reconstructive Surgery on Spousal Relationships
Eighty-two percent of the women declared high satisfaction of the spouse, compared with only 7% who described lack of satisfaction. Ninety percent of the women claimed that there was no change in sexual attraction. Six percent reported improvement in the sexual relationship, 13% women reported deterioration, and 81% had no change in sexual intercourse. There was high correlation between aesthetic satisfaction and sexual relationship with the spouse (P < .003; Rp (relative potency) = .32).

Differences Between Women Who Would Repeat the Surgery and Those Who Would Not
We compared the women who were satisfied with the procedure and those who were not to determine the differences between the two groups. The average satisfaction among women who would repeat the procedure was much higher than among those who would not (4.42 and 3.36, respectively). The difference in satisfaction between the two groups was statistically significant regarding to the aesthetic parameters (symmetry, scars, sensation, and appearance clothed and nude). There was no significant relationship between the two groups regarding sexual relationship with the spouse.

Relationship Between Background Parameters and Satisfaction Parameters
Education Level
There was a significantly low negative correlation between level of education and body perception. Higher levels of education implied more drastic changes in body perception. The higher the woman’s level of education, the more she reported lower satisfaction of the spouse.

Age
Younger women were more satisfied with the procedure and would recommend it more. Younger women reported better symmetry of breasts and a better sexual relationship with the spouse after the procedure.

Breast Size
Women with larger breasts were less satisfied with their appearance in clothes compared with woman with smaller breasts. There was no statistical correlation between size of breasts and satisfaction with nude appearance or any other factor. No significant statistical correlation was found between satisfaction and marital status and weight.

Variables Related to the Procedure
Unilateral or Bilateral Reconstruction
Bilateral reconstruction had a higher grading than unilateral reconstruction in every aspect except for the bare appearance of the reconstructed breast.

Radiation
Women who were not treated with radiotherapy were significantly more satisfied with all aesthetic factors, especially the touch sensation of the reconstructed breast.

Chemotherapy
There was no significant statistical difference in general and aesthetic satisfaction among women who received chemotherapy compared with those who did not.

Time From Mastectomy to Reconstruction
A prolonged period of time between mastectomy and reconstruction had a negative effect on all parameters of general and aesthetic satisfaction.

Time Since Reconstruction
The longer the time after the reconstruction, the more satisfied women were with the touch sensation of the reconstructed breast.

Nipple Reconstruction
Women who underwent nipple reconstruction tended to recommend the procedure to friends.

Operation on the Reconstructed/Opposite Breast
There was no statistical significance in the relationship between undergoing another breast operation (for any reason) and satisfaction.

Predictors of Satisfaction
When all the parameters were taken into consideration, two statistically significant predictors for general and aesthetic satisfaction were noted:

1. Time between mastectomy and reconstruction: the longer the time between mastectomy and reconstruction, the less satisfied the women.
   
2. Radiotherapy treatment: women who were treated with radiotherapy were less satisfied with the reconstruction.
   

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Factors affecting the satisfaction of women with TRAM breast reconstruction were studied retrospectively to create an informative tool for women who are about to undergo this procedure. The characters of the research population were no different from those in the literature^{2,12,14,19,20} regarding patient age, marital status, division into unilateral and bilateral reconstruction, and division to early versus late reconstruction.

General Satisfaction
It is difficult to compare these findings with those in the literature because other reports refer to general satisfaction with a number of reconstruction types and do not isolate satisfaction with the TRAM procedure. Satisfaction^19,21,22 with immediate breast reconstruction varied widely, from 50% to 88.8%. The general satisfaction rate in our study was 75%, similar to that reported in the literature.

It is known that this procedure weakens the strength of the abdomen, especially during strenuous exercise, but, according to the literature, it does not damage the ability to perform everyday tasks.^8,9,23 Our study showed the same tendency: everyday function was not altered. The results of our study match the results in the literature regarding difficulty in strenuous exercise.

It seems that the decrease in abdominal wall strength, a known side effect of this procedure, is not significant regarding the degree of satisfaction with the final outcome of the reconstruction. Simon et al.²⁴ reported decreased abdominal muscle strength in the bipedicled group, and this was the main reason for dissatisfaction.

General satisfaction, approximately 75%, is very high when compared with that from other aesthetic procedures²⁵ and can be compared with satisfaction with augmentation mammoplasty, considered to be the procedure with the highest satisfaction rate^25–27 (approximately 90%). Therefore, the satisfaction rate with the TRAM procedure is high, especially considering that it is a complex procedure.

Aesthetic Satisfaction
There was high satisfaction (86%) with appearance in clothing and lower satisfaction (48%) with nude appearance. The gap between satisfaction with appearance in clothes as compared with the nude body is predictable because it is obvious that a breast that has been operated on and has scars will not look as good in a nude state as its appearance in clothes. This gap was described in the literature by Eberlein et al.¹⁰ All the women in his study gave statistically significantly higher grades to their appearance in clothes for every breast reconstruction method.

It seems that the relatively large scars on the abdomen and breast after this procedure do not affect the women’s aesthetic satisfaction. This is in correlation with Kroll and Baldwin,¹¹ who found that satisfaction with the scars was 2.5 on a scale of 1 to 4 (where 1 is the highest score). They also found that the grade of symmetry in TRAM reconstruction was 2.1 on a scale of 1 to 4 (where 1 is the highest score). Our study showed a grade of 3.48 on a scale of 1 to 5 (where 5 is the highest score). Despite the use of different scales, it seems that the symmetry in our study received a higher grade. Cederna et al.¹² found that 50% of women were very pleased with breast symmetry, 12.5% were pleased, and 37.5% were somewhat pleased. Our results showed that the most disturbing issue, which received the lowest grading regarding the aesthetic aspects of the procedure, was touch sensation. In the literature, this parameter is the most problematic of all the aesthetic parameters.

The Effect of the Operation on the Spousal Relationship
Approximately one fourth of the patients answered "not relevant" when asked questions regarding the spousal relationship. These women might not be in a spousal relationship or separate their personal trauma and the procedure they underwent from the spousal relationship.

Satisfaction of the spouse (82%) with the operation was higher than the satisfaction of the women themselves (75%). This may be because a high percentage of women chose not to answer this question, but the trend was clear.

The only significant change for the worse seemed to be in the parameter of sexual relationships, with 13% reporting a change for the worse. This is in correlation with Brandberg et al.,¹⁷ who stated that one of the problematic issues after reconstruction is intimate situations and sexual relationships. We found an improvement in the attitude of the spouses toward the patients, and this is explained by the fact that difficult circumstances bring couples together, especially when one of the partners suffers. This was not documented in the literature.

There is vast documentation in the literature regarding difficulties in sexual relationships in breast cancer patients; some even view this problem as a long-term side effect of the disease.^28–30 According to the literature on sexual relationships after mastectomy,³¹ 90% of women remain sexually active, but there was a drastic decline in the quality of sexual relationships for various reasons in 42% of these women.

Differences Between Women Who Would and Would Not Undergo the Procedure Again
Women who state they would undergo the operation again were more pleased with all aesthetic parameters. We found differences between the two groups regarding the issues of strenuous exercise, body image, and spousal satisfaction with the procedure. These parameters received low grading in the group that would not repeat the procedure, but this tendency had only marginal statistical significance. We can conclude that these parameters also affect satisfaction, but they are not as significant as the aesthetic aspect.

Association Between Background and Satisfaction Parameters
Women who are more educated tend to have deterioration of body perception and report lower satisfaction of the spouse. These findings have not been reported in the literature and are difficult to explain. Perhaps more educated women are perfectionists and are harder on themselves.

Younger women were generally more satisfied with the procedure, and they reported better symmetry (statistically significant) and better sexual relationships with the spouse and recommended the procedure to friends more readily. Alderman et al.¹⁴ found that older women tended to be less pleased. No correlation between age and aesthetic outcomes was found in several studies.^11,13,19,32 Other authors^33,34 found that young women tend to be less satisfied. Schover et al.³⁵ explained the finding that young women are less satisfied by claiming that most had no psychological adjustment with the handicap caused by the mastectomy.

Women with larger breasts were less satisfied with their appearance in clothes after the reconstruction. The literature’s reference to the effect of the size of the breast is minimal and is limited to mentioning that TRAM reconstruction is more successful than other types of reconstruction for large breasts because of its ability to create ptosis and inframammary lines, but it does not discuss the relationship between patient satisfaction and breast size.⁶

Influence of Parameters Pertaining to the Procedure
Location of the Reconstruction
Women who had bilateral reconstruction were more satisfied with all the aesthetic parameters except for nude appearance, which corresponds to Kroll and colleagues’ findings^11,13 that bilateral reconstruction is more aesthetically pleasing. This can be explained by the fact that bilateral reconstruction has better symmetry, so appearance in clothes is better. Andrade et al.¹⁹ did not find a statistically significant difference in satisfaction of unilateral compared with bilateral reconstruction.

Radiotherapy
Women who had radiation were less pleased. Although postradiation tissue injuries were well documented in the past,³⁶ autologous reconstruction is still a preferred option for patients who need to undergo radiotherapy³⁷ because reconstruction with implants leads to a higher rate of implant removal and increased capsule contractures.

Chemotherapy
There was no relation between chemotherapy treatment and satisfaction with TRAM reconstruction in our study.

Time Between Mastectomy and Reconstruction (Immediate/Late Reconstruction)
Women who had immediate reconstruction were significantly more satisfied with all general and aesthetic parameters. Most of the literature regarding this issue supports this finding. This is probably due to the surgical technique of skin-sparing mastectomy.^28,38 Immediate reconstruction also has psychological advantages.^3,20

Time From Reconstruction
The longer the time from reconstruction, the more satisfied women were with the outcome. Andrade et al.¹⁹ reported that a longer time from reconstruction made the subject less prominent in the women’s lives, as evidenced by the fact that the women accepted the result of the procedure.

Nipple Reconstruction
Women who had nipple reconstruction were not more satisfied than women who did not have nipple reconstruction. Andrade et al.¹⁹ supported this finding, showing no correlation between nipple reconstruction and satisfaction. In contrast, other authors^2,11,13 reported that women who had nipple reconstruction reported higher aesthetic grades.

Satisfaction is affected by many factors: both objective surgical factors and mental and psychological parameters vary among women. Satisfaction with the TRAM procedure in the literature^{2,6,10,11,14,19} is higher compared with other types of reconstruction, although women who have late reconstruction or undergo radiotherapy are not satisfied. However, young women who undergo immediate reconstruction tend to have higher satisfaction.

Received for publication May 22, 2006. Accepted for publication May 23, 2006.

	REFERENCES

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 

1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69:216–25.[Medline]
2. Trabulsy PP, Anthony JP, Mathes SJ. Changing trends in postmastectomy breast reconstruction: a 13-year experience. Plast Reconstr Surg 1994; 93:1418–27.[CrossRef][Medline]
3. Elliott LF, Eskenazi L, Beegle PH Jr, et al. Immediate TRAM flap breast reconstruction: 128 consecutive cases. Plast Reconstr Surg 1993; 92:217–27.[Medline]
4. Rosen PB, Jabs AD, Kister SJ, Hugo NE. Clinical experience with immediate breast reconstruction using tissue expansion or transverse rectus abdominis musculocutaneous flaps. Ann Plast Surg 1990; 25:249–57.[Medline]
5. Wilkins EG, August DA, Chang AD, Smith DJ Jr. Immediate, bilateral transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction after mastectomy. Am Surg 1993; 59:519–22 discussion 522–4.[Medline]
6. Bostwick J III, Jones G. Why I choose autogenous tissue in breast reconstruction. Clin Plast Surg 1994; 21:165–75.[Medline]
7. McCraw JB, Horton CE, Grossman JA, et al. An early appraisal of the methods of tissue expansion and the transverse rectus abdominis musculocutaneous flap in reconstruction of the breast following mastectomy. Ann Plast Surg 1987; 18:93–113.[CrossRef][Medline]
8. Hartrampf CR Jr. Abdominal wall competence in transverse abdominal island flap operations. Ann Plast Surg 1984; 12:139–46.[CrossRef][Medline]
9. Mizgala CL, Hartrampf CR Jr, Bennett GK. Assessment of the abdominal wall after pedicled TRAM flap surgery: 5- to 7-year follow-up of 150 consecutive patients. Plast Reconstr Surg 1994; 93:988–1002; discussion 1003–4.[Medline]
10. Eberlein TJ, Crespo LD, Smith BL, et al. Prospective evaluation of immediate reconstruction after mastectomy. Ann Surg 1993; 218:29–36.[Medline]
11. Kroll SS, Baldwin B. A comparison of outcomes using three different methods of breast reconstruction. Plast Reconstr Surg 1992; 90:455–62.[Medline]
12. Cederna PS, Yates WR, Chang P, et al. Postmastectomy reconstruction: comparative analysis of the psychosocial, functional, and cosmetic effects of transverse rectus abdominis musculocutaneous flap versus breast implant reconstruction. Ann Plast Surg 1995; 35:458–68.[CrossRef][Medline]
13. Kroll SS, Coffey JA Jr, Winn RJ, Schusterman MA. A comparison of factors affecting aesthetic outcomes of TRAM flap breast reconstructions. Plast Reconstr Surg 1995; 96:860–4.[Medline]
14. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg 2000; 106:769–76.[CrossRef][Medline]
15. Edsander-Nord A, Brandberg Y, Wickman M. Quality of life, patients’ satisfaction, and aesthetic outcome after pedicled or free TRAM flap breast surgery. Plast Reconstr Surg 2001; 107:1142–53; discussion 1154–5.[CrossRef][Medline]
16. Kovacs L, Papadopulos NA, Ammar SA, et al. Clinical outcome and patients’ satisfaction after simultaneous bilateral breast reconstruction with free transverse rectus abdominis muscle (TRAM) flap. Ann Plast Surg 2004; 53:199–204.[CrossRef][Medline]
17. Brandberg Y, Malm M, Blomqvist L. A prospective and randomized study, "SVEA," comparing effects of three methods for delayed breast reconstruction on quality of life, patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg 2000; 105:66–74; discussion 75–6.[Medline]
18. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966; 44(Suppl):166–206.
19. Andrade WN, Baxter N, Semple JL. Clinical determinants of patient satisfaction with breast reconstruction. Plast Reconstr Surg 2001; 107:46–54.[CrossRef][Medline]
20. Franchelli S, Leone MS, Berrino P, et al. Psychological evaluation of patients undergoing breast reconstruction using two different methods: autologous tissues versus prostheses. Plast Reconstr Surg 1995; 95:1213–8; discussion 1219–20.[Medline]
21. Noguchi M, Kitagawa H, Kinoshita K, et al. Psychologic and cosmetic self-assessments of breast conserving therapy compared with mastectomy and immediate breast reconstruction. J Surg Oncol 1993; 54:260–6.[Medline]
22. Berry MG, al-Mufti RA, Jenkinson AD, et al. An audit of outcome including patient satisfaction with immediate breast reconstruction performed by breast surgeons. Ann R Coll Surg Engl 1998; 80:173–7.
23. Mizgala CL, Hartrampf CR Jr, Bennett GK. Abdominal function after pedicled TRAM flap surgery. Clin Plast Surg 1994; 21:255–72.[Medline]
24. Simon AM, Bouwense CL, McMillan S, et al. Comparison of unipedicled and bipedicled TRAM flap breast reconstructions: assessment of physical function and patient satisfaction. Plast Reconstr Surg 2004; 113:136–40.[Medline]
25. Freiberg A, Giguere D, Ross DC, et al. Are patients satisfied with results from residents performing aesthetic surgery? Plast Reconstr Surg 1997; 100:1824–31; discussion 1832–3.[Medline]
26. Fiala TG, Lee WP, May JW Jr. Augmentation mammoplasty: results of a patient survey. Ann Plast Surg 1993; 30:503–9.[Medline]
27. Hetter GP. Improved patient satisfaction with augmentation mammoplasty: the transaxillary subpectoral approach. Aesthetic Plast Surg 1991; 15:123–7.[CrossRef][Medline]
28. Thors CL, Broeckel JA, Jacobsen PB. Sexual functioning in breast cancer survivors. Cancer Control 2001; 8:442–8.[Medline]
29. Lim J, Hoe AL, Wong CY, Soo KC. Sexuality of women after mastectomy. Ann Acad Med Singapore 1995; 24:659–63.[Medline]
30. Wilmoth MC, Townsend J. A comparison of the effects of lumpectomy versus mastectomy on sexual behaviors. Cancer Pract 1995; 3:279–85.[Medline]
31. Barni S, Mondin R. Sexual dysfunction in treated breast cancer patients. Ann Oncol 1997; 8:149–53.[Abstract/Free Full Text]
32. Clough KB, O’Donoghue JM, Fitoussi AD, et al. Prospective evaluation of late cosmetic results following breast reconstruction: I. Implant reconstruction. Plast Reconstr Surg 2001; 107:1702–9.[CrossRef][Medline]
33. Anderson SG, Rodin J, Ariyan S. Treatment considerations in postmastectomy reconstruction: their relative importance and relationship to patient satisfaction. Ann Plast Surg 1994; 33:263–70; discussion 270–1.[CrossRef][Medline]
34. Baker RR. The management of breast cancer with immediate or delayed reconstruction. Adv Surg 1992; 25:51–64.[Medline]
35. Schover LR, Yetman RJ, Tuason LJ, et al. Partial mastectomy and breast reconstruction. A comparison of their effects on psychosocial adjustment, body image, and sexuality. Cancer 1995; 75:54–64.[CrossRef][Medline]
36. Hopewell JW, Calvo W, Jaenke R, et al. Microvasculature and radiation damage. Recent Results Cancer Res 1993; 130:1–16.[Medline]
37. Schuster RH, Kuske RR, Young VL, Fineberg B. Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis, complications, and tumor control. Plast Reconstr Surg 1992; 90:445–52; discussion 453–4.[Medline]
38. Kroll SS, Ames F, Singletary SE, Schusterman MA. The oncologic risks of skin preservation at mastectomy when combined with immediate reconstruction of the breast. Surg Gynecol Obstet 1991; 172:17–20.[Medline]

This article has been cited by other articles:

				J. Fernandez-Delgado, M. J. Lopez-Pedraza, J. A. Blasco, E. Andradas-Aragones, J. I. Sanchez-Mendez, G. Sordo-Miralles, and M. M. Reza Satisfaction with and psychological impact of immediate and deferred breast reconstruction Ann. Onc., August 1, 2008; 19(8): 1430 - 1434. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Moscona, R. A. Articles by Fodor, L. Search for Related Content PubMed PubMed Citation Articles by Moscona, R. A. Articles by Fodor, L.