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Quality of Life and Patient-Reported Outcomes in Breast Cancer Survivors

A Multicenter Comparison of Four Abdominally Based Autologous Reconstruction Methods

Macadam, Sheina A. M.D., M.H.S.; Zhong, Toni M.D., M.H.S.; Weichman, Katie M.D.; Papsdorf, Michael M.D.; Lennox, Peter A. M.D.; Hazen, Alexes M.D.; Matros, Evan M.D.; Disa, Joseph M.D.; Mehrara, Babak M.D.; Pusic, Andrea L. M.D., M.H.S.

Plastic and Reconstructive Surgery: March 2016 - Volume 137 - Issue 3 - p 758–771
doi: 10.1097/01.prs.0000479932.11170.8f
Breast: Original Articles
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Background: Approximately 20 percent of women select autologous tissue for postmastectomy breast reconstruction, and most commonly choose the abdomen as the donor site. An increasing proportion of women are seeking muscle-sparing procedures, but the benefit remains controversial. It is therefore important to determine whether better outcomes are associated with these techniques, thereby justifying longer operative times and increased costs.

Methods: Patients from five North American centers were eligible if they underwent reconstruction by means of the deep inferior epigastric artery perforator (DIEP) flap, muscle-sparing free transverse abdominis myocutaneous (TRAM) flap, free TRAM flap, or the pedicled TRAM flap. Patients were sent the BREAST-Q. Demographics and complications were collected.

Results: The authors analyzed 1790 charts representing 670 DIEP, 293 muscle-sparing free TRAM, 683 pedicled TRAM, and 144 free TRAM patients with an average follow-up of 5.5 years. Flap loss did not differ by flap type. Partial flap loss was higher in pedicled TRAM compared with DIEP (p = 0.002). Fat necrosis was higher in pedicled TRAM compared with DIEP and muscle-sparing free TRAM (p < 0.001). Hernia/bulge was highest in pedicled TRAM (p < 0.001). Physical well-being (abdomen) scores were higher in DIEP compared with pedicled TRAM controlling for confounders.

Conclusions: Complications and patient-reported outcomes differ when comparing abdominally based breast reconstruction techniques. The results of this study show that the DIEP flap was associated with the highest abdominal well-being and the lowest abdominal morbidity compared with the pedicled TRAM flap, but did not differ from muscle-sparing free TRAM and free TRAM flaps.


Vancouver, British Columbia, and Toronto, Ontario, Canada; and New York, N.Y.

From the Department of Surgery, Division of Plastic and Reconstructive Surgery, the Department of Psychology, University of British Columbia; the Division of Plastic and Reconstructive Surgery, University Health Network, University of Toronto; the Department of Surgery, Division of Plastic and Reconstructive Surgery Montefiore Medical Center; New York Medical Center, New York University; and the Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center.

Received for publication July 2, 2015; accepted October 27, 2015.

Presented at the 69th Annual Canadian Society of Plastic Surgeons Meeting, in Victoria, British Columbia, Canada, June 2 through 6, 2015, and at the 2015 American Society of Plastic Surgeons Meeting, in Boston, Massachusetts, October 16 through 20, 2015.

Disclosure:Dr. Pusic is a co-developer of the BREAST-Q which is owned by Memorial Sloan Kettering Cancer Center and the University of British Columbia. When the BREAST-Q is used in for-profit clinical trials, Dr. Pusic receives a share of any license revenues based on the inventor sharing policies of these two institutions. The other authors have no financial interest to declare in relation to the content of this article.

A “Hot Topic Video” by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to and click on “Plastic Surgery Hot Topics” in the “Videos” tab to watch.” On the iPad, tap on the Hot Topics icon

Sheina A. Macadam, M.D., M.H.S., Plastic and Reconstructive Surgery, University of British Columbia, Suite 1000, 777 West Broadway, Vancouver, British Columbia V5Z 4J7, Canada,

©2016American Society of Plastic Surgeons