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REVIEW ARTICLE – RECONSTRUCTIVE ONCOLOGY
Systematic Review: Aesthetic Assessment of Breast
Reconstruction Outcomes by Healthcare Professionals
Saskia W. M. C. Maass, MD
1,2
, Shaghayegh Bagher, MSc
1,2
, Stefan O. P. Hofer, MD, PhD
1,2,5
, Nancy N. Baxter,
MD, PhD
3,4,5
, and Toni Zhong, MD, MHS
1,2,5
1
Division of Plastic & Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network,
Toronto, ON, Canada;
2
Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada;
3
Departments of Surgery and Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada;
4
The Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON, Canada;
5
Department of Surgery, University of Toronto, Toronto, ON, Canada
ABSTRACT
Background. Achieving an aesthetic outcome following
postmastectomy breast reconstruction is both an important
goal for the patient and plastic surgeon. However, there is
currently an absence of a widely accepted, standardized,
and validated professional aesthetic assessment scale fol-
lowing postmastectomy breast reconstruction.
Methods. A systematic review was performed to identify all
articles that provided professional assessment of the aesthetic
outcome following postmastectomy, implant- or autologous
tissue-based breast reconstruction. A modified version of the
Scientific Advisory Committee’s Medical Outcomes Trust
(MOT) criteria was used to evaluate all professional aesthetic
assessment scales identified by our systematic review. The
criteria included conceptual framework formation, reliability,
validity, responsiveness, interpretability, burden, and corre-
lation with patient-reported outcomes.
Results. A total of 120 articles were identified: 52 de-
scribed autologous breast reconstruction, 37 implant-based
reconstruction, and 29 both. Of the 12 different profes-
sional aesthetic assessment scales that exist in the
literature, the most commonly used scale was the four-
point professional aesthetic assessment scale. The highest
score on the modified MOT criteria was assigned to the
ten-point professional aesthetic assessment scale. However,
this scale has limited clinical usefulness due to its poor
responsiveness to change, lack of interpretability, and wide
range of intra- and inter-rater agreements (Veiga et al. in
Ann Plast Surg 48(5):515–520,
2002
).
Conclusions. A ‘‘gold standard’’ professional aesthetic
assessment scale needs to be developed to enhance the
comparability of breast reconstruction results across tech-
niques, surgeons, and studies to aid with the selection of
procedures that produce the best aesthetic results from both
the perspectives of the surgeon and patients.
Breast reconstruction has become an important part of the
surgical care for breast cancer patients.
1
Breast reconstruction
with a satisfactory aesthetic outcome can have a positive effect
on the psychological recovery of the patient following mas-
tectomy.
2,3
A standardized measure of aesthetic outcome after
reconstruction would enable comparisons of breast recon-
struction outcomes for clinical and research purposes. A
previous review by Potter et al. failed to identify a well-ac-
cepted, standardized, and validated aesthetic assessment scale
following postmastectomy breast reconstruction.
4
Numerous
criteria have been proposed for what constitutes the ideal
professional aesthetic assessment scale for breast reconstruc-
tion.
5–8
Munshi et al. noted that the ideal professional aesthetic
assessment scale should be based on quantitative measures that
are easy to understand, reproducible, and have a good corre-
lation with the patient-reported outcome (PRO).
6
Potter et al.
proposed that the core outcomes for assessing aesthetics in-
volve a multidisciplinary approach, and that in addition to
meeting the minimal validity and reliability criteria applied to
other measurement systems, there would be an additional PRO
domain to capture the perspective of the patient.
4
Because a large number of professional aesthetic
assessment scales currently exist for breast reconstruction,
ÓSociety of Surgical Oncology 2015
First Received: 12 September 2014
T. Zhong, MD, MHS
e-mail: toni.zhong@uhn.ca
Ann Surg Oncol
DOI 10.1245/s10434-015-4434-2
and there is no one ideal measurement tool, choosing the
optimal professional aesthetic scale is challenging. A pro-
fessional aesthetic assessment scale was defined as a scale
to evaluate the aesthetic result by a healthcare profes-
sional.
4
The goal of this paper, therefore, was to review
systematically all of the existing aesthetic assessment
scales by healthcare professionals for breast reconstruction.
In addition, we are the first group to evaluate all the pro-
fessional aesthetic assessment scales using well-established
quality criteria for measurement properties.
METHODS
Search and Selection Process
A computerized bibliographic search was performed in
AMED, CINAHL, Cochrane, EMBASE, MEDLINE, Psy-
chINFO, and PubMed in February of 2013. Search items
were: (breast reconstruction OR mammoplasty) AND
(aesthetic OR esthetic OR cosme*), and the search was
limited to English articles published in 1990 or after. Du-
plicates were removed and two independent reviewers
included articles evaluating patients undergoing postmas-
tectomy breast reconstruction, both implant-based, and
autologous reconstruction based on title and abstract. The
two independent reviewers were Saskia Maass (first author)
and Toni Zhong (senior author). Excluded were articles
with no primary data, expert opinions, letters to the editor,
and conference reports. For the second selection, articles
were evaluated based on their full-text and were excluded
when they did not contain a professional aesthetic assess-
ment scale or only contained a patient-reported aesthetic
assessment. Discrepancies between review authors were
solved by reaching consensus. References of the articles
were hand-searched to identify additional relevant papers.
Data Extraction
Included papers were reviewed for the following data:
(1) study population, (2) type of reconstruction, (3) pro-
fession of the observer, (4) method of evaluation, and (5)
the characteristics of the assessment scale. If insufficient
information about the professional aesthetic assessment
scale was provided, then the cited references were
evaluated for additional information.
Medical Outcomes Trust Criteria to Evaluate each
Professional Aesthetic Assessment Scale
To determine the methodological quality of each aes-
thetic assessment tool, both reviewers evaluated each
aesthetic assessment scale using the Medical Outcomes
Trust (MOT) criteria developed by the Scientific Advisory
Committee (SAC).
9–15
All methodological information was
obtained directly from papers that first described the scales
as well as from the papers that subsequently used and
evaluated the scales. Each professional aesthetic assess-
ment scale was graded according to the seven MOT
criteria. One point was assigned when the aesthetic
assessment scale fulfilled the criterion, half a point was
given when most of the criterion was met, and zero points
were assigned when the scale did not meet the criterion.
Six out of the 7 criteria were based on the original MOT
criteria and these included: (1) the underlying conceptual
framework, (2) reliability, (3) validity, (4) responsiveness,
(5) interpretability, and (6) burden for the professional and
the patient. The conceptual framework criterion reflects the
process of development of the scale. One point was as-
signed if this was clearly developed for patients undergoing
postmastectomy breast reconstruction. Reliability refers to
the degree to which scores reflect the underlying phe-
nomenon. Both the intraclass correlation coefficient (ICC),
which determines the degree of concordance between test
and retest, and the internal consistency measured by the
Cronbach’s alpha are common statistics for reliability.
16
For research purposes, a measure should achieve a re-
liability coefficient of at least 0.70.
17
One point was
assigned for a kappa higher than 0.40 or a coefficient above
0.70. Validity is the degree to which an instrument mea-
sures what it is purported to measure. An aesthetic
assessment scale with a Spearman q[0.70 was assigned 1
point. Responsiveness is the ability of an instrument to
distinguish clinically important changes from measurement
error over time even if these changes are small, and this is
measured by the responsiveness ratio (RR).
10,18
When the
RR was at minimum 1.96, this criterion was assigned a
point. Interpretability is defined as the degree to which one
can assign qualitative meaning to quantitative scores.
9
One
point was assigned if information was given on the means
and standard deviation of the population. The burden for
professional and patient evaluates the overall time burden.
One point was assigned when burden was deemed to be
low from the professional and patient. A seventh criterion
is to assess the relationship between the professional aes-
thetic assessment scale and PRO as advocated by Potter
et al., and 1 point was assigned when the correlation was
[0.71.
4
Because all the aesthetic outcome scales were
described in English only, and we are only evaluating those
scales intended for professional assessment, the two addi-
tional criteria of the MOT ‘‘alternatives modes of
administration’’ and ‘‘cultural and language adaptations or
translations’’ were found not to be applicable in our review.
Table 1provides a summary of the seven modified MOT
criteria used.
S. W. M. C. Maass et al.
RESULTS
Search Results
A total of 5,845 citations were generated from the data-
base search, and of these 3,214 duplicates were excluded,
leaving a number of 2,631 articles. Based on the titles and
abstracts, articles that did not evaluate patients undergoing
postmastectomy breast reconstruction were excluded. Also
excluded were records with no primary data, expert opinions,
letters to the editor, and conference reports; this totaled 1,753
citations. The full-text of 878 articles was reviewed and 763
articles were excluded, because they did not use a profes-
sional aesthetic assessment scale. An additional 5 articles
were found after reviewing the full text and references. A
total number of 120 articles were included in the review. The
search and selection process is summarized in Fig. 1.
Study Characteristics
(1) Study population: From the 120 articles selected, 95
described outcomes exclusively following breast recon-
struction, 13 included only outcomes following breast-
conserving therapy (BCT), and 12 contained both breast
reconstruction and BCT.
(2) Type of reconstruction: Fifty-two articles included
only patients following autologous breast reconstruction,
37 included implant-based reconstructions, 29 included
both autologous and implant-based reconstruction, and 2
articles did not specify the reconstruction method.
(3) Observer: The aesthetic assessment was performed
exclusively by plastic surgeons in 65 studies, whereas an-
other 39 studies contained assessments by other medical
professionals, such as nurses, residents, fellows, and other
house-staff. Fifteen of the reviewed articles used a com-
bination of professionals and nonprofessionals to perform
the aesthetic assessments. The profession of the observer
was unknown in 19 articles.
(4) Professional aesthetic assessment scale: For 67 ar-
ticles, the aesthetic assessment was performed by means of
photographs, 9 were based on clinical assessments, 8 were
based on both clinical and photographic assessments, and
36 studies failed to state details. Table 2presents an
overview of the current professional aesthetic assessment
scales used in each study, organized from most to least
commonly used.
19
TABLE 1 Simplified summary of the 7 modified Medical Outcomes Trust criteria for evaluating professional aesthetic assessment
scales
4,9,10,16–18,47
Characteristic Definition Criteria for scoring
Development of
conceptual
framework
The scale includes a process that involves qualitative interviews
with patients, item generation and preliminary scale formation,
and several iterations of redraft based on feedback from patients
and surgeons
1=Patients undergoing post-mastectomy breast
reconstruction
0=Cosmetic augmentation, breast conserving
therapy or other
Reliability The degree to which scores reflect the underlying phenomenon and
not measurement error. A reliable measure is also reproducible.
The most appropriate statistics to determine test-retest
concordance is the intraclass correlation coefficient. A good
measure to test the internal consistency is Cronbach’s alpha
1=jof 0.40–0.75 fair to good agreement and
j[0.75 excellent agreement
Cronbach a[0.71
0=j\0.40 indicates poor agreement
Cronbach aB0.70
Validity The degree to which an instrument measures what it is purported to
measure. To demonstrate construct validity, research findings
need to support the proposed hypothesis
1=Spearman q[0.71
0=Spearman qB0.70
Responsiveness The ability of an instrument to distinguish clinically important
changes from measurement error over time, even if these changes
are small
1=Responsiveness ratio C1.96
0=Responsiveness ratio \1.96
Interpretability Information on the means and standard deviations (SD) in patient
subpopulations and an anchor-based approach that uses an
external criterion to operationalize a minimally important change
(MIC) are important elements of an interpretable scale
1=if means or SD in the groups or reference
population have been calculated or if MIC have
been calculated for the scale
0=if means or SD in the reference population is
unknown, or if MIC is unknown
Burden for
professional
and patient
This criteria evaluates the overall time burden required for the
professional and patient to complete the professional aesthetic
assessment scale
1=Burden low
0=Burden high
Patient reported
outcome
The correlation between the patient and the professional evaluation
of the aesthetic result
1=high positive correlation, [0.71
0=minimal correlation, B0.70
Aesthetic Assessment Breast Reconstruction
(5) Specific characteristics of the professional aesthetic
assessment scales: The number of properties per scale
varied from 1 to 12 items, with a median of 4 properties for
all the reviewed articles. These specific properties includ-
ed: shape, overall aesthetics, symmetry, volume, scars,
inframammary fold, nipple-areola complex, contour, posi-
tion, areola, color, consistency, ptosis, mobility, and
rippling. Of all the articles that we reviewed, a total of 48
articles included a measure of patient satisfaction with the
professional aesthetic assessment scale (Fig. 2).
MOT Criteria
Table 3presents the summary of our evaluation of the
12 professional aesthetic assessment scales as prescribed
by the MOT and the score that we assigned to each of the 7
modified MOT criteria. The four-point professional aes-
thetic assessment scale is the most commonly used method
of aesthetic evaluation. The ten-point scoring scale fulfills
over four of the seven criteria ascribed by the MOT. Below
is a more detailed description of each of the 12 professional
aesthetic assessment scales with respect to its adherence to
the modified MOT criteria.
Four-Point Scale This scale has not been validated in the
breast reconstruction population.
20
The reliability of the
four-point scale was modest, with an inter-rater agreement
jof 0.55.
21
Its validity has not been proven, and the
Spearman coefficient for the postoperative scoring has
been found to be 0.57.
22
The weighted kappa to calculate
the intraobserver agreement was 0.70 according to Vrieling
et al.
21
The correlation with the patient’s assessment was
analyzed by Schuster et al. and found to be good.
23
A score
of 3 out of 7 was assigned.
Five-Point Scale The reliability measured with the inter-
rater agreement was good, the validation of the scale was
fair, and the questionnaire burden is low.
24
The total score
was 2 out of 7.
Garbay/Lowery Scale The Garbay assessment scale has
been analyzed in detail by Lowery and often is referred to
as the Lowery scale.
8,25
Lowery et al. assessed the
reliability and found kappa values from 0.19 to 0.63.
21
The intra-rater agreement kappa values were from 0.21 to
0.67 for the subscales. Carlson et al. found inter-rater
agreement kappa values from 0.31 to 0.72.
26
The total was
2 out of 7 points.
Three-Point Scale The reliability, validity, responsiveness,
and correlation with the patients’ assessment have not been
tested. One point out of 7 was assigned for low questionnaire
burden.
Baker Scale The Baker scale was intended to assess
capsular contractures for patients after augmentation
Database search: AMED, CINAHL, Cochrane, EMBASE, MEDLINE, PsychlNFO, Pubmed
Search terms: (Breast reconstruction or mammaplasty) AND (aesthetic or esthetic or cosme*)
Limits: English, published after 1990
Records Excluded:
Total Number of Records Screened:
n=2631
Full Text Articles Assessed for Eligibility:
n=878
Hand-searching of article references n=5
Articles included:
n=120
Inclusion Eligibility Screening Identification
Records Excluded by reading Title,Abstract:
Records Excluded by reading Full Text
Duplicates
- No evidence of implant or autologous breast
reconstruction
- No description of or reference to a
professional aesthetic assessment scale
- Only patient-reported aesthetic assessment
- No primary data, expert opinions, letters to
the edtior and conference reports
n=5845
n=3214
n=1753
n=763
FIG. 1 Flow diagram of article selection process
S. W. M. C. Maass et al.
TABLE 2 Summary of the different professional aesthetic assessment scales in the literature and their frequency of occurrence
Aesthetic scale Author of
scale
Grading scale Aesthetic
characteristics
Frequency of
citation in
literature
References
Four-point Vrielings et al. 0. excellent result
1. good
result
2. fair result
3. poor result
1. scar
2. size
3. shape
4. nipple position
5. shape of areola
6. skin color
7. global cosmetic result of the reconstructed
breast
in comparison to the other breast
42 23,46,48–87
Five-point Thomson et al. 1. very poor result
2. poor result
3. satisfactory result
4. good result
5. very good result
1. overall cosmetics
2. symmetry
3. shape
4. size
5. skin color
6. visible scars
18 24,31,49,88–102
Garbay/lowery
Scale
8,25
Garbay et al. 1. poor result
2. mild or fair result
3. natural or good result
1. volume
2. shape and placement of the breast mound
3. inframammary fold
4. breast mound scars
16 1,8,25,26,70,103–113
Three-point Berrino et al. 1. good/excellent
2. satisfactory
3. unsatisfactory
1. overall aesthetic outcome
14 49,56,86,114–124
Baker/Spear
27,28
Spear and Baker
et al.
1a. breast absolutely
natural
1b. soft, but implant
detectable
2. mildly firm
3. moderate firm
4. severe contracture
1. capsular contractures
13 23,29,49,90,94,95,101,116,125–129
Ten-point Visser et al. N/A 1. overall aesthetic outcome
2. volume
3. shape
4. symmetry
5. scarring
6. nipple-areola complex
11 1,3,29,31,32,127,129–133
Harvard/Harris
Scale
34–36
Rose et al. 1. none
2. slight
3. moderate
4. severe
1. fibrosis and retraction of the breast
2. skin changes
3. matchline effect of the radiated skin
837,103,126,134–138
Linear Numeric
Analogue
Score
Song et al. N/A 1. overall aesthetic outcome
2. volume
3. symmetry
4. contour
5. nipple-areola complex
6. inframammary fold
7. symmetry
8. scar quality
9. skin paddle quality and appearance
breast position
733,38,40,139–142
Two-point Chawla et al. 1. good-excellent
2. fair-poor
1. aesthetic assessment
541,121–123,143
Aesthetic Assessment Breast Reconstruction
mammoplasty.
27
Spear and Baker et al. modified the
capsular contracture scale in 1995 for patients who had
implant-based breast reconstruction.
28
Spearman
correlation coefficient was calculated to evaluate the
correlation between the professional’s and patient’s
scores, which was 0.40 and considered low.
29,30
The
scale was assigned 1 out of 7 points for low questionnaire
burden.
Ten-Point Scale Visser et al. showed an inter-rater
agreement for the ten-point scale of 0.848.
31
Validity
tested using the Spearman coefficient ranged from
0.70–0.83. Veiga found an inter-rater agreement from
0.17 to 1.00; the intra-rater agreement ranged from 0.06 to
0.80.
1
Five articles described a significant or close
correlation between the patient aesthetic assessment
scores and the evaluation by professionals.
3,29,31–33
The
total score was 4.5 out of 7.
Harris Scale This professional aesthetic assessment scale
also is referred to as the Rose or Harvard scale.
34–36
It was
developed to monitor the effects or radiotherapy on the
aesthetic outcome in BCT patients, and not for
postmastectomy breast reconstruction. The inter-rater
agreement was 0.66 as found by Preuss et al.
37
The total
score was 2 out of 7 for low burden and good correlation
with PRO.
Linear Numeric Analogue Score Song et al. evaluated the
0–100 linear numeric analogue scale.
38
The inter-rater
agreement ranged from 0.23 to 0.38, the Cronbach awas
0.89, and the intra-rater agreement was 0.81.
38,39
Salgarello
et al. found a close correlation between the patients’ and
professional assessment of the aesthetic outcome.
40
The
score was 4 out of 7.
Two-Point Scale A two-point scale was used by Chawla
et al. to score the aesthetic assessment either as good-
excellent or fair-poor.
41
The total score was 1 out of 7
points for low burden.
Six-Point Scale A six-point scale scored 1 point for low
burden of use.
Cohen Scale Cohen et al. developed and statistically
analyzed the Cohen Scale.
7
The inter-rater agreement was
j0.0–0.39, the Cronbach was a0.92, and the intra-rater
agreement was j0.25 to 0.66.
21,42
There was a moderate
correlation with the patient assessment; the Spearman
coefficient was 0.36–0.53.
22
The total score was 3 out of 7.
Seven-Point Scale The inter-rater agreement of a seven-
point scale with 6 subscales had a jthat ranged from 0.36
to 0.56.
43
The total score was 1 out of 7.
DISCUSSION
Our systematic review of 120 published articles identi-
fied 12 different aesthetic assessment scales by
professionals for breast reconstruction. The common
TABLE 2 continued
Aesthetic scale Author of
scale
Grading scale Aesthetic
characteristics
Frequency of
citation in
literature
References
Six-point Eriksen et al. 1. very bad
to
6. very good
1. shape
2. size
3. scars
4. nipple-areola complex
5. symmetry
6. overall aesthetic result
3 144–146
Cohen Scale
147
Cohen et al. N/A 1. position
2. defects
3. projection
4. inframammary fold
5. median contour
6. overall appearance
27,147
Seven-point Gahm et al. 1. not at all
to
7. absolutely
1. appearance of upper pole
2. projection
3. inframammary fold
4. natural look
5. implant edges
6. shape
243,148
S. W. M. C. Maass et al.
deficiencies shared by all the existing professional aesthetic
assessment scales include their limited responsiveness and
interpretability. Both of these attributes are important re-
quirements in a clinically useful measurement tool. In other
words, for the aesthetic assessment to be clinically rele-
vant, it needs to be responsive to detect possible changes in
the breast reconstruction aesthetic outcome over time.
Furthermore, the numerical grading from the professional
aesthetic assessment scale should lend qualitative meaning
and provide information on what change in score would be
considered clinically meaningful. In addition, the lack of an
existing criterion standard for a subjective phenomenon,
such as aesthetic outcome makes assessment of validity
challenging. Of the 12 different professional aesthetic
assessment scales that we evaluated, the ten-point profes-
sional aesthetic assessment scale was found to have the
most rigorous measurement properties.
9
The strengths are
the significant correlation with the patient aesthetic
evaluation, and the scale’s validity demonstrated by a high
Spearman coefficient of 0.70–0.83.
3,29,31–33
The primary
weaknesses associated with this scale are the wide range of
inter-rater agreements (0.17–1.0) and intra-rater agree-
ments (0.06–0.80).
1
Ideal Professional Aesthetic Assessment Scale
It is important to have a single reliable and responsive
professional aesthetic assessment scale to measure aes-
thetic outcomes following breast reconstruction that is
validated in this population, and supported by PRO. The
development of this ideal aesthetic assessment tool would
enhance the comparability of breast reconstruction results
across techniques, surgeons, and studies to aid with the
selection of procedures that produce the best aesthetic re-
sults. The ideal aesthetic assessment scale or ‘‘gold
standard’’ for the professional aesthetic evaluation after
breast reconstruction should ideally adhere to all seven of
the modified MOT criteria.
9
1. Conceptual framework formation: The professional
aesthetic assessment scale should be at least analyzed for
patients undergoing breast reconstruction after
mastectomy.
2 and 4. Reliability and responsiveness: Both the inter-
rater and intra-rater agreement of the scale should at least
have a fair to good agreement. Fortin et al. recommends a
panel of three evaluators for the evaluation of the aesthetic
outcome.
44
3. Validity: The validity of the ideal professional aes-
thetic assessment scale should be analyzed and have good
correlation for all criteria.
5. Interpretability: The quantitative value on the
assessment scale should have qualitative meaning, and the
developers of the scale should provide information about
what change scores should be considered clinically
meaningful.
45
6. Burden: The scale should pose a low burden on both
the patient and the professional.
6
Shape Overall Symmetry
Infra-mammary fold
Position
Ptosis
Patients’ Satisfaction
Scar
Contour
Consistency
Rippling
Volume
Nipple-areola-complex
Color
Mobility
68 67 66
47 47 48
39
27 25 22 18 15
762
FIG. 2 Specific properties addressed by the professional aesthetic
assessment scales
TABLE 3 Summary of the 12 professional aesthetic assessment scales and the score that we assigned to each of the 7 modified Medical
Outcomes Trust criteria
Professional aesthetic
assessment scale
Four-
point
Five-
point
Lowery Three-
point
Baker Ten-
point
Harris Linear numeric
analogue score
Two-
point
Six-
point
Cohen Seven-
point
Conceptual and
measurement model
001 0 0101 0010
Reliability 1 1 0 0 0 01 0 0 1 0
Validity 0 0 0 0 0 1 0 0 0 0 0 0
Responsiveness 0 0 0 0 0 0 0 0 0 0 0 0
Interpretability 0 0 0 0 0 0 0 0 0 0 0 0
Burden 1 1 1 1 1 1 1 1 1 1 1 1
PRO 1 0 0 0 0 1 1 1 0 0 0 0
Total score (out of 7) 3 2 2 1 1 4.5 2 4 1 1 3 1
Aesthetic Assessment Breast Reconstruction
7. Patient assessment: The scale should have a good
agreement with the patient assessment of the aesthetic
outcome.
7
Limitation
To improve inter-rater agreement, all assessment scales
should ideally be performed by healthcare professionals
with the same level of expertise. However, as demonstrated
by our review, healthcare professional is a widely used
term, from an unknown observer with unknown experi-
ence, to an experienced plastic surgeon. This has shown to
lead to different results.
46
Furthermore, in some studies the
assessor was the operating surgeon, which could lead to
significant bias. Another significant limitation of our re-
view was that only 18 of the 120 articles that we reviewed
actually provided methodological information on the aes-
thetic assessment scales that were used.
CONCLUSIONS
Of the 12 different professional aesthetic assessment
scales, the ten-point professional aesthetic assessment scale
was found to have the highest quality as evaluated by the
modified version of the MOT criteria set by SAC.
9
How-
ever, this scale has limited clinical usefulness due to its
poor responsiveness to change, lack of interpretability, and
wide range of intra- and inter-rater agreements.
1
A ‘‘gold
standard’’ professional aesthetic assessment scale needs to
be developed to enhance the comparability of breast re-
construction results across techniques, surgeons, and
studies to aid with the selection of procedures that produce
the best aesthetic results from both the perspectives of the
surgeon and patients.
REFERENCES
1. Veiga DF, Neto MS, Garcia EB, et al. Evaluations of the aes-
thetic results and patient satisfaction with the late pedicled
TRAM flap breast reconstruction. Ann Plast Surg.
2002;48(5):515–20.
2. Eltahir Y, Werners LL, Dreise MM, et al. Quality-of-life out-
comes between mastectomy alone and breast reconstruction:
comparison of patient-reported BREAST-Q and other health-
related quality-of-life measures. Plast Reconstr Surg.
2013;132(2):201e–9e.
3. Haekens CM, Enajat M, Keymeulen K, Van der Hulst RR. Self-
esteem and patients’ satisfaction after deep inferior epigastric
perforator flap breast reconstruction. Plast Surg Nurs.
2011;31(4):160–6.
4. Potter S, Harcourt D, Cawthorn S, et al. Assessment of cosmesis
after breast reconstruction surgery: a systematic review. Ann
Surg Oncol. 2011;18(3):813–23.
5. Kim MS, Sbalchiero JC, Reece GP, Miller MJ, Beahm EK,
Markey MK. Assessment of breast aesthetics. Plast Reconstr
Surg. 2008;121(4):186e–94e.
6. Munshi A, Kakkar S, Bhutani R, Jalali R, Budrukkar A, Din-
shaw KA. Factors influencing cosmetic outcome in breast
conservation. Clin Oncol (R Coll Radiol). 2009;21(4):285–93.
7. Cohen M, Evanoff B, George LT, Brandt KE. A subjective
rating scale for evaluating the appearance outcome of au-
tologous breast reconstruction. Plast Reconstr Surg. 2005;
116(2):440–9.
8. Lowery JC, Wilkins EG, Kuzon WM, Davis JA. Evaluations of
aesthetic results in breast reconstruction: an analysis of re-
liability. Ann Plast Surg. 1996;36(6):601–6; discussion 607.
9. Lohr KN, Aaronson NK, Alonso J, et al. Evaluating quality-of-
life and health status instruments: development of scientific re-
view criteria. Clin Ther. 1996;18(5):979–92.
10. Terwee CB, Bot SD, de Boer MR, et al. Quality criteria were
proposed for measurement properties of health status question-
naires. J Clin Epidemiol. 2007;60(1):34–42.
11. Aaronson N, Alonso J, Burnam A, et al. Assessing health status
and quality-of-life instruments: attributes and review criteria.
Qual Life Res. 2002;11(3):193–205.
12. Andresen EM. Criteria for assessing the tools of disability out-
comes research. Arch Phys Med Rehabil. 2000;81(12 Suppl
2):S15–20.
13. McDowell I. Measuring health: a guide to rating scales and
questionnaires. Oxford: Oxford University Press; 2006.
14. Lundberg M, Grimby-Ekman A, Verbunt J, Simmonds MJ.
Pain-related fear: a critical review of the related measures. Pain
Res Treat. 2011;2011:494196.
15. Cano SJ, Browne JP, Lamping DL, Roberts AH, McGrouther
DA, Black NA. The Patient Outcomes of Surgery-Head/Neck
(POS-head/neck): a new patient-based outcome measure. J Plast
Reconstr Aesthet Surg. 2006;59(1):65–73.
16. Streiner DL, Norman GR. Health measurement scales: a prac-
tical guide to their development and use. Oxford: Oxford
University Press; 2008.
17. Nunnally J, Bernstein I. Psychometric theory, 3rd edn. New
York: McGraw-Hill; 1994.
18. Guyatt GH, Deyo RA, Charlson M, Levine MN, Mitchell A.
Responsiveness and validity in health status measurement: a
clarification. J Clin Epidemiol. 1989;42(5):403–8.
19. Baxter NN, Rothenberger DA, Lowry AC. Measuring fecal in-
continence. Dis Colon Rectum. 2003;46(12):1591–605.
20. Vrieling C, Collette L, Bartelink E, et al. Validation of the
methods of cosmetic assessment after breast-conserving therapy
in the EORTC ‘‘boost versus no boost’’ trial. EORTC Radio-
therapy and Breast Cancer Cooperative Groups. European
Organization for Research and Treatment of Cancer. Int J Radiat
Oncol Biol Phys. 1999;45(3):667–76.
21. Fleiss JL. Statistical methods for rates and proportions. 2nd edn.
New York: Wiley; 1981.
22. Siegel S, Castellan NJ. Nonparametric statistics for the behav-
ioral sciences. New York: McGraw-Hill; 1988.
23. Schuster RH, Kuske RR, Young VL, Fineberg B. Breast re-
construction in women treated with radiation therapy for breast
cancer: cosmesis, complications, and tumor control. Plast Re-
constr Surg. 1992;90(3):445-52; discussion 453–4.
24. Thomson HJ, Potter S, Greenwood RJ, et al. A prospective
longitudinal study of cosmetic outcome in immediate latissimus
dorsi breast reconstruction and the influence of radiotherapy.
Ann Surg Oncol. 2008;15(4):1081–91.
25. Garbay JR, Rietjens M, Petit JY. Esthetic results of breast re-
construction after amputation for cancer. 323 cases. J Gynecol
Obstet Biol Reprod (Paris). 1992;21(4):405–12.
26. Carlson GW, Losken A, Moore B, et al. Results of immediate
breast reconstruction after skin-sparing mastectomy. Ann Plast
Surg. 2001;46(3):222–8.
S. W. M. C. Maass et al.
27. Baker DG, Leith JT. Protection of the skin of mice against
irradiation with cyclotron-accelerated helium ions by 2-mer-
captoethylamine. Acta Radiol Ther Phys Biol.
1975;14(6):561–71.
28. Spear SL, Baker JL, Jr. Classification of capsular contracture
after prosthetic breast reconstruction. Plast Reconstr Surg.
1995;96(5):1119–23; discussion 1124.
29. Ramon Y, Ullmann Y, Moscona R, et al. Aesthetic results and
patient satisfaction with immediate breast reconstruction using
tissue expansion: a follow-up study. Plast Reconstr Surg.
1997;99(3):686–91.
30. Mukaka MM. Statistics corner: A guide to appropriate use of
correlation coefficient in medical research. Malawi Med J.
2012;24(3):69–71.
31. Visser NJ, Damen TH, Timman R, Hofer SO, Mureau MA.
Surgical results, aesthetic outcome, and patient satisfaction after
microsurgical autologous breast reconstruction following failed
implant reconstruction. Plast Reconstr Surg.
2010;126(1):26–36.
32. Gui GP, Tan SM, Faliakou EC, Choy C, A’Hern R, Ward A.
Immediate breast reconstruction using biodimensional anato-
mical permanent expander implants: a prospective analysis of
outcome and patient satisfaction. Plast Reconstr Surg.
2003;111(1):125–38; discussion 139–40.
33. Nicholson RM, Leinster S, Sassoon EM. A comparison of the
cosmetic and psychological outcome of breast reconstruction,
breast conserving surgery and mastectomy without reconstruc-
tion. Breast. 2007;16(4):396–410.
34. Rose MA, Olivotto I, Cady B, et al. Conservative surgery and
radiation therapy for early breast cancer. Long-term cosmetic
results. Arch Surg. 1989;124(2):153–7.
35. Harris JR, Levene MB, Svensson G, Hellman S. Analysis of
cosmetic results following primary radiation therapy for stages I
and II carcinoma of the breast. Int J Radiat Oncol Biol Phys.
1979;5(2):257–61.
36. Harris JR. Breast-conserving therapy as a model for creating
new knowledge in clinical oncology. Int J Radiat Oncol Biol
Phys. 1996;35(4):641–8.
37. Preuss J, Lester L, Saunders C. BCCT.core—can a computer
program be used for the assessment of aesthetic outcome after
breast reconstructive surgery? Breast. 2012;21(4):597–600.
38. Song AY, Fernstrom MH, Scott JA, Ren DX, Rubin JP, Shestak
KC. Assessment of TRAM aesthetics: the importance of subunit
integration. Plast Reconstr Surg. 2006;117(1):15–24.
39. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing
rater reliability. Psychol Bull. 1979;86(2):420–8.
40. Salgarello M, Farallo E. Immediate breast reconstruction with
definitive anatomical implants after skin-sparing mastectomy.
Br J Plast Surg. 2005;58(2):216–22.
41. Chawla AK, Kachnic LA, Taghian AG, Niemierko A, Zapton
DT, Powell SN. Radiotherapy and breast reconstruction: com-
plications and cosmesis with TRAM versus tissue expander/
implant. Int J Radiat Oncol Biol Phys. 2002;54(2):520–6.
42. Cronbach LJ. Coefficient alpha and the internal structure of
tests. Psychometrika. 1951;16(3):297–334.
43. Gahm J, Edsander-Nord A, Jurell G, Wickman M. No differ-
ences in aesthetic outcome or patient satisfaction between
anatomically shaped and round expandable implants in bilateral
breast reconstructions: a randomized study. Plast Reconstr Surg.
2010;126(5):1419–27.
44. Fortin AJ, Cheang M, Latosinsky S. Cosmetic outcomes fol-
lowing breast conservation therapy: in search of a reliable scale.
Breast Cancer Res Treat. 2006;100(1):65–70.
45. Jaeschke R, Singer J, Guyatt GH. Measurement of health status.
Ascertaining the minimal clinically important difference. Con-
trol Clin Trials. 1989;10(4):407–15.
46. Munhoz AM, Montag E, Arruda EG, et al. The role of the lateral
thoracodorsal fasciocutaneous flap in immediate conservative
breast surgery reconstruction. Plast Reconstr Surg.
2006;117(6):1699–710.
47. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ.
Development of a new patient-reported outcome measure for
breast surgery: the BREAST-Q. Plast Reconstr Surg.
2009;124(2):345–53.
48. Al-Ghazal SK, Blamey RW. Subcutaneous mastectomy with
implant reconstruction: cosmetic outcome and patient satisfac-
tion. Eur J Surg Oncol. 2000;26(2):137–41.
49. Bacilious N, Cordeiro PG, Disa JJ, Hidalgo DA. Breast recon-
struction using tissue expanders and implants in Hodgkin’s
patients with prior mantle irradiation. Plast Reconstr Surg.
2002;109(1):102–7.
50. Bassiouny MM, Maamoun SI, El-Shazly Sel D, Youssef OZ.
TRAM flap for immediate post mastectomy reconstruction:
comparison between pedicled and free transfer. J Egypt Natl
Canc Inst. 2005;17(4):231–8.
51. Crisera CA, Chang EI, Da Lio AL, Festekjian JH, Mehrara BJ.
Immediate free flap reconstruction for advanced-stage breast
cancer: is it safe? Plast Reconstr Surg. 2011;128(1):32–41.
52. Delay E, Gratadour AC, Jorquera F, Zlatoff P, Bremond A.
Immediate autologous latissimus breast reconstruction after skin
sparing mastectomy. Eur J Plast Surg. 1999;22(2/3):111–8.
53. Delay E, Jorquera F, Pasi P, Gratadour AC. Autologous latis-
simus breast reconstruction in association with the abdominal
advancement flap: a new refinement in breast reconstruction.
Ann Plast Surg. 1999;42(1):67–75.
54. Denewer A, Setit A, Farouk O. Outcome of pectoralis major
myomammary flap for post-mastectomy breast reconstruction:
extended experience. World J Surg. 2007;31(7):1382–6.
55. Disa JJ, McCarthy CM, Mehrara BJ, Pusic AL, Cordeiro PG.
Immediate latissimus dorsi/prosthetic breast reconstruction fol-
lowing salvage mastectomy after failed lumpectomy/irradiation.
Plast Reconstr Surg. 2008;121(4):159e–64e.
56. Drucker-Zertuche M, Robles-Vidal C. A 7 year experience with
immediate breast reconstruction after skin sparing mastectomy
for cancer. Eur J Surg Oncol. 2007;33(2):140–6.
57. Drucker-Zertuche M, Bargallo-Rocha E, Zamora-Del RR. Ra-
diotherapy and immediate expander/implant breast reconstruction:
should reconstruction be delayed? Breast J. 2011;17(4):365–70.
58. Fan LJ, Jiang J, Yang XH, et al. A prospective study comparing
endoscopic subcutaneous mastectomy plus immediate recon-
struction with implants and breast conserving surgery for breast
cancer. Chin Med J (Engl). 2009;122(24):2945–50.
59. Fayman MS, Potgieter E, Becker PJ. The pedicle tram flap: a
focus on improved aesthetic outcome. Aesthetic Plast Surg.
2006;30(3):301–8.
60. Fersis N, Hoenig A, Relakis K, Pinis S, Wallwiener D. Skin-
sparing mastectomy and immediate breast reconstruction: inci-
dence of recurrence in patients with invasive breast cancer.
Breast. 2004;13(6):488–93.
61. Hidalgo DA. Aesthetic refinement in breast reconstruction:
complete skin-sparing mastectomy with autogenous tissue
transfer. Plast Reconstr Surg. 1998;102(1):63–70; discussion
71–2.
62. Ho AL, Tyldesley S, Macadam SA, Lennox PA. Skin-sparing
mastectomy and immediate autologous breast reconstruction in
locally advanced breast cancer patients: a UBC perspective. Ann
Surg Oncol. 2012;19(3):892–900.
63. Kroll SS, Baldwin B. A comparison of outcomes using three
different methods of breast reconstruction. Plast Reconstr Surg.
1992;90(3):455–62.
64. Kroll SS, Schusterman MA, Reece GP, Miller MJ, Smith B.
Breast reconstruction with myocutaneous flaps in previously
Aesthetic Assessment Breast Reconstruction
irradiated patients. Plast Reconstr Surg. 1994;93(3):460–9;
discussion 470–1.
65. Kroll SS, Coffey JA, Jr., Winn RJ, Schusterman MA. A com-
parison of factors affecting aesthetic outcomes of TRAM flap
breast reconstructions. Plast Reconstr Surg. 1995;96(4):860–4.
66. Kronowitz SJ, Robb GL, Youssef A, et al. Optimizing au-
tologous breast reconstruction in thin patients. Plast Reconstr
Surg. 2003;112(7):1768–78.
67. Kronowitz SJ, Feledy JA, Hunt KK, et al. Determining the op-
timal approach to breast reconstruction after partial mastectomy.
Plast Reconstr Surg. 2006;117(1):1–11; discussion 12–4.
68. Kuske RR, Schuster R, Klein E, Young L, Perez CA, Fineberg
B. Radiotherapy and breast reconstruction: clinical results and
dosimetry. Int J Radiat Oncol Biol Phys. 1991;21(2):339–46.
69. Mosahebi A, Ramakrishnan V, Gittos M, Collier DS. Envelope
mastectomy and immediate reconstruction (EMIR), improving
outcome without oncological compromise. J Plast Reconstr
Aesthet Surg. 2006;59(10):1025–30.
70. Mosahebi A, Ramakrishnan V, Gittos M, Collier J. Aesthetic
outcome of different techniques of reconstruction following
nipple-areola-preserving envelope mastectomy with immediate
reconstruction. Plast Reconstr Surg. 2007;119(3):796–803.
71. Munhoz AM, Aldrighi C, Montag E, et al. Optimizing the nip-
ple-areola sparing mastectomy with double concentric
periareolar incision and biodimensional expander-implant re-
construction: aesthetic and technical refinements. Breast.
2009;18(6):356–67.
72. Munhoz AM, Aldrighi C, Montag E, et al. Periareolar skin-
sparing mastectomy and latissimus dorsi flap with biodimen-
sional expander implant reconstruction: surgical planning,
outcome, and complications. Plast Reconstr Surg.
2007;119(6):1637–49; discussion 1650–2.
73. Noguchi M, Saito Y, Mizukami Y, et al. Breast deformity, its
correction, and assessment of breast conserving surgery. Breast
Cancer Res Treat. 1991;18(2):111–8.
74. Noguchi M, Saito Y, Taniya T, et al. Wide resection with
latissimus dorsi muscle transposition in breast conserving sur-
gery. Surg Oncol. 1992;1(3):231–6.
75. Noguchi M, Earashi M, Ohta N, et al. Mastectomy with and
without immediate breast reconstruction using a musculocuta-
neous flap. Am J Surg. 1993;166(3):279–83.
76. Noguchi M, Minami M, Earashi M, et al. Oncologic and cos-
metic outcome in patients with breast cancer treated with wide
excision, transposition of adipose tissue with latissimus dorsi
muscle, and axillary dissection followed by radiotherapy. Breast
Cancer Res Treat. 1995;35(2):163–71.
77. Papp C, Wechselberger G, Schoeller T. Autologous breast re-
construction after breast-conserving cancer surgery. Plast
Reconstr Surg. 1998;102(6):1932–6; discussion 1937–8.
78. Roostaeian J, Pavone L, Da Lio A, Lipa J, Festekjian J, Crisera
C. Immediate placement of implants in breast reconstruction:
patient selection and outcomes. Plast Reconstr Surg.
2011;127(4):1407–16.
79. Roostaeian J, Sanchez I, Vardanian A, et al. Comparison of
immediate implant placement versus the staged tissue expander
technique in breast reconstruction. Plast Reconstr Surg.
2012;129(6):909e–18e.
80. Spear SL, Onyewu C. Staged breast reconstruction with saline-
filled implants in the irradiated breast: recent trends and
therapeutic implications. Plast Reconstr Surg.
2000;105(3):930–42.
81. Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on
pedicled TRAM flap breast reconstruction: outcomes and im-
plications. Plast Reconstr Surg. 2005;115(1):84–95.
82. Spear SL, Newman MK, Bedford MS, Schwartz KA, Cohen M,
Schwartz JS. A retrospective analysis of outcomes using three
common methods for immediate breast reconstruction. Plast
Reconstr Surg. 2008;122(2):340–7.
83. Spear SL, Schwarz KA, Venturi ML, Barbosa T, Al-Attar A.
Prophylactic mastectomy and reconstruction: clinical outcomes
and patient satisfaction. Plast Reconstr Surg. 2008;122(1):1–9.
84. Spear SL, Slack C, Howard MA. Postmastectomy reconstruction
of the previously augmented breast: diagnosis, staging, method-
ology, and outcome. Plast Reconstr Surg. 2001;107(5):1167–76.
85. Tallet AV, Salem N, Moutardier V, et al. Radiotherapy and
immediate two-stage breast reconstruction with a tissue ex-
pander and implant: complications and esthetic results. Int J
Radiat Oncol Biol Phys. 2003;57(1):136–42.
86. Tzafetta K, Ahmed O, Bahia H, Jerwood D, Ramakrishnan V.
Evaluation of the factors related to postmastectomy breast re-
construction. Plast Reconstr Surg. 2001;107(7):1694–701.
87. Vrieling C, Collette L, Fourquet A, et al. The influence of pa-
tient, tumor and treatment factors on the cosmetic results after
breast-conserving therapy in the EORTC ‘boost vs. no boost’
trial. EORTC Radiotherapy and Breast Cancer Cooperative
Groups. Radiother Oncol. 2000;55(3):219–32.
88. Clough KB, Cuminet J, Fitoussi A, Nos C, Mosseri V. Cosmetic
sequelae after conservative treatment for breast cancer: classi-
fication and results of surgical correction. Ann Plast Surg.
1998;41(5):471–81.
89. Clough KB, O’Donoghue JM, Fitoussi AD, Vlastos G, Falcou
MC. Prospective evaluation of late cosmetic results following
breast reconstruction: II. Tram flap reconstruction. Plast Re-
constr Surg. 2001;107(7):1710–6.
90. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year expe-
rience with tissue expander/implant breast reconstruction: part
II. An analysis of long-term complications, aesthetic outcomes,
and patient satisfaction. Plast Reconstr Surg.
2006;118(4):832–9.
91. Elton C, Jones SE, Jones PA. Initial experience of intramam-
mary prostheses in breast conservation surgery. Eur J Surg
Oncol. 1999;25(2):138–41.
92. Evans AA, Straker VF, Rainsbury RM. Breast reconstruction at
a district general hospital. J R Soc Med. 1993;86(11):630–3.
93. Hayes AJ, Jenkins MP, Sandhu SS, Baum M. Subpectoral breast
reconstruction using the biodimensional system. Ann R Coll
Surg Engl. 1997;79(5):355–60.
94. Lossing C, Elander A, Gewalli F, Holmstrom H. The lateral
thoracodorsal flap in breast reconstruction: a long-term follow
up study. Scand J Plast Reconstr Surg Hand Surg.
2001;35(2):183–92.
95. McCarthy CM, Pusic AL, Disa JJ, McCormick BL, Mont-
gomery LL, Cordeiro PG. Unilateral postoperative chest wall
radiotherapy in bilateral tissue expander/implant reconstruction
patients: a prospective outcomes analysis. Plast Reconstr Surg.
2005;116(6):1642–7.
96. McKeown DJ, Hogg FJ, Brown IM, Walker MJ, Scott JR,
Weiler-Mithoff EM. The timing of autologous latissimus dorsi
breast reconstruction and effect of radiotherapy on outcome. J
Plast Reconstr Aesthet Surg. 2009;62(4):488–93.
97. Moran SL, Nava G, Behnam AB, Serletti JM. An outcome
analysis comparing the thoracodorsal and internal mammary
vessels as recipient sites for microvascular breast reconstruction:
a prospective study of 100 patients. Plast Reconstr Surg.
2003;111(6):1876–82.
98. Nano MT, Gill PG, Kollias J, Bochner MA. Breast volume re-
placement using the latissimus dorsi miniflap. ANZ J Surg.
2004;74(3):98–104.
99. Nano MT, Gill PG, Kollias J, Bochner MA, Malycha P, Wine-
field HR. Psychological impact and cosmetic outcome of
surgical breast cancer strategies. ANZ J Surg.
2005;75(11):940–7.
S. W. M. C. Maass et al.
100. Raja MA, Straker VF, Rainsbury RM. Extending the role of
breast-conserving surgery by immediate volume replacement.
Br J Surg. 1997;84(1):101–5.
101. Ringberg A, Tengrup I, Aspegren K, Palmer B. Immediate
breast reconstruction after mastectomy for cancer. Eur J Surg
Oncol. 1999;25(5):470–6.
102. Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-
assisted breast reconstruction. Aesthetic Plast Surg.
2008;32(3):418–25.
103. Carlson GW, Page AL, Peters K, Ashinoff R, Schaefer T,
Losken A. Effects of radiation therapy on pedicled transverse
rectus abdominis myocutaneous flap breast reconstruction. Ann
Plast Surg. 2008;60(5):568–72.
104. Denewer A, Setit A, Hussein O, Farouk O. Skin-sparing mas-
tectomy with immediate breast reconstruction by a new
modification of extended latissimus dorsi myocutaneous flap.
World J Surg. 2008;32(12):2586–92.
105. Denewer A, Farouk O. Can nipple-sparing mastectomy and
immediate breast reconstruction with modified extended latis-
simus dorsi muscular flap improve the cosmetic and functional
outcome among patients with breast carcinoma? World J Surg.
2007;31(6):1169–77.
106. Gerber B, Krause A, Dieterich M, Kundt G, Reimer T. The
oncological safety of skin sparing mastectomy with conservation
of the nipple-areola complex and autologous reconstruction: an
extended follow-up study. Ann Surg. 2009;249(3):461–8.
107. Gerber B, Krause A, Reimer T, et al. Skin-sparing mastectomy
with conservation of the nipple-areola complex and autologous
reconstruction is an oncologically safe procedure. Ann Surg.
2003;238(1):120–7.
108. Giacalone PL, Rathat G, Daures JP, Benos P, Azria D, Rouleau
C. New concept for immediate breast reconstruction for invasive
cancers: feasibility, oncological safety and esthetic outcome of
post-neoadjuvant therapy immediate breast reconstruction ver-
sus delayed breast reconstruction: a prospective pilot study.
Breast Cancer Res Treat. 2010;122(2):439–51.
109. Li FC, Jiang HC, Li J. Immediate breast reconstruction with
implants after skin-sparing mastectomy: a report of 96 cases.
Aesthetic Plast Surg. 2010;34(6):705–10.
110. Mori H, Umeda T, Osanai T, Hata Y. Esthetic evaluation of
immediate breast reconstruction after nipple-sparing or skin-s-
paring mastectomy. Breast Cancer. 2005;12(4):299–303.
111. Omranipour R, Bobin JY, Esouyeh M. Skin-sparing mastectomy
and immediate breast reconstruction (SSMIR) for early breast
cancer: eight years single institution experience. World J Surg
Oncol. 2008;6:43.
112. Salgarello M, Visconti G, Barone-Adesi L. Nipple-sparing
mastectomy with immediate implant reconstruction: cosmetic
outcomes and technical refinements. Plast Reconstr Surg.
2010;126(5):1460–71.
113. Yueh JH, Houlihan MJ, Slavin SA, Lee BT, Pories SE, Morris
DJ. Nipple-sparing mastectomy: evaluation of patient satisfac-
tion, aesthetic results, and sensation. Ann Plast Surg.
2009;62(5):586–90.
114. Berrino P, Campora E, Leone S, Zappi L, Nicosia F, Santi P.
The transverse rectus abdominis musculocutaneous flap for
breast reconstruction in obese patients. Ann Plast Surg.
1991;27(3):221–31.
115. Bogetti P, Cravero L, Spagnoli G, et al. Aesthetic role of the
surgically rebuilt inframammary fold for implant-based breast
reconstruction after mastectomy. J Plast Reconstr Aesthet Surg.
2007;60(11):1225–32.
116. Cordeiro PG, Pusic AL, Disa JJ, McCormick B, VanZee K.
Irradiation after immediate tissue expander/implant breast re-
construction: outcomes, complications, aesthetic results, and
satisfaction among 156 patients. Plast Reconstr Surg.
2004;113(3):877–81.
117. Di G-H, Yu K-D, Wu J, et al. Immediate breast reconstruction
with latissimus dorsi musculocutaneous flap: A suitable option
for Chinese women after mastectomy. Chin J Cancer Res. 2006
2006;18(2):5.
118. Dian D, Schwenn K, Mylonas I, Janni W, Jaenicke F, Friese K.
Aesthetic result among breast cancer patients undergoing au-
tologous breast reconstruction versus breast conserving therapy.
Arch Gynecol Obstet. 2007;275(6):445–50.
119. Enajat M, Rozen WM, Whitaker IS, Smit JM, Van Der Hulst
RR, Acosta R. The deep inferior epigastric artery perforator flap
for autologous reconstruction of large partial mastectomy de-
fects. Microsurgery. 2011;31(1):12–7.
120. Lee JW, Chang TW. Extended latissimus dorsi musculocuta-
neous flap for breast reconstruction: experience in Oriental
patients. Br J Plast Surg. 1999;52(5):365–72.
121. Tomita K, Yano K, Matsuda K, Takada A, Hosokawa K. Es-
thetic outcome of immediate reconstruction with latissimus
dorsi myocutaneous flap after breast-conservative surgery and
skin-sparing mastectomy. Ann Plast Surg. 2008;61(1):19–23.
122. Ueda S, Tamaki Y, Yano K, et al. Cosmetic outcome and patient
satisfaction after skin-sparing mastectomy for breast cancer with
immediate reconstruction of the breast. Surgery.
2008;143(3):414–25.
123. Ziswiler-Gietz J, Makrodimou M, Harder Y, Banic A, Erni D.
Outcome analysis of breast reconstruction with free transverse
rectus abdominis musculocutaneous (TRAM) flaps. Swiss Med
Wkly. 2008;138(7-8):114–20.
124. Gendy RK, Able JA, Rainsbury RM. Impact of skin-sparing
mastectomy with immediate reconstruction and breast-sparing
reconstruction with miniflaps on the outcomes of oncoplastic
breast surgery. Br J Surg. 2003;90(4):433–9.
125. Adams WP, Jr., Rios JL, Smith SJ. Enhancing patient outcomes
in aesthetic and reconstructive breast surgery using triple an-
tibiotic breast irrigation: six-year prospective clinical study.
Plast Reconstr Surg. 2006;117(1):30–6.
126. Aristei C, Falcinelli L, Bini V, et al. Expander/implant breast
reconstruction before radiotherapy: outcomes in a single-insti-
tute cohort. Strahlenther Onkol. 2012;188(12):1074–9.
127. Behranwala KA, Dua RS, Ross GM, Ward A, A’Hern R, Gui
GP. The influence of radiotherapy on capsule formation and
aesthetic outcome after immediate breast reconstruction using
biodimensional anatomical expander implants. J Plast Reconstr
Aesthet Surg. 2006;59(10):1043–51.
128. De Lorenzi F, Lohsiriwat V, Barbieri B, et al. Immediate breast
reconstruction with prostheses after conservative treatment plus
intraoperative radiotherapy. long term esthetic and oncological
outcomes. Breast. 2012;21(3):374–9.
129. Rietjens M, De Lorenzi F, Venturino M, Petit JY. The suspen-
sion technique to avoid the use of tissue expanders in breast
reconstruction. Ann Plast Surg. 2005;54(5):467–70.
130. Castello JR, Garro L, Najera A, Mirelis E, Sanchez-Olaso A,
Barros J. Immediate breast reconstruction in two stages using
anatomical tissue expansion. Scand J Plast Reconstr Surg Hand
Surg. 2000;34(2):167–71.
131. Cocquyt VF, Blondeel PN, Depypere HT, et al. Better cosmetic
results and comparable quality of life after skin-sparing mas-
tectomy and immediate autologous breast reconstruction
compared to breast conservative treatment. Br J Plast Surg.
2003;56(5):462–70.
132. Hayes AJ, Garner JP, Nicholas W, Laidlaw IJ. A comparative
study of envelope mastectomy and immediate reconstruction
(EMIR) with standard latissimus dorsi immediate breast recon-
struction. Eur J Surg Oncol. 2004;30(7):744–9.
Aesthetic Assessment Breast Reconstruction
133. Hernanz F, Regano S, Redondo-Figuero C, Orallo V, Erasun F,
Gomez-Fleitas M. Oncoplastic breast-conserving surgery: ana-
lysis of quadrantectomy and immediate reconstruction with
latissimus dorsi flap. World J Surg. 2007;31(10):1934–40.
134. Anderson PR, Hanlon AL, Fowble BL, McNeeley SW, Freed-
man GM. Low complication rates are achievable after
postmastectomy breast reconstruction and radiation therapy. Int
J Radiat Oncol Biol Phys. 2004;59(4):1080–7.
135. Baschnagel AM, Shah C, Wilkinson JB, Dekhne N, Arthur DW,
Vicini FA. Failure rate and cosmesis of immediate tissue ex-
pander/implant breast reconstruction after postmastectomy
irradiation. Clin Breast Cancer. 2012;12(6):428–32.
136. Bassiouny M, El-Marakby HH, Saber N, Zayed SB, Shokry A.
Quadrantectomy and nipple saving mastectomy in treatment of
early breast cancer: feasibility and aesthetic results of adjunctive
latissmus dorsi breast reconstruction. J Egypt Natl Canc Inst.
2005;17(3):149–57.
137. Cassileth L, Kohanzadeh S, Amersi F. One-stage immediate
breast reconstruction with implants: a new option for immediate
reconstruction. Ann Plast Surg. 2012;69(2):134–8.
138. Zaha H, Onomura M, Nomura H, Umekawa K, Oki M, Asato H.
Free omental flap for partial breast reconstruction after breast-
conserving surgery. Plast Reconstr Surg. 2012;129(3):583–7.
139. Fernandez Delgado JM, Martinez-Mendez JR, de Santiago J,
Hernandez-Cortes G, Casado C. Immediate breast reconstruc-
tion (IBR) with direct, anatomic, extra-projection prosthesis:
102 cases. Ann Plast Surg. 2007;58(1):99–104.
140. Hudson DA, Skoll PJ. Single-stage, autologous breast restora-
tion. Plast Reconstr Surg. 2001;108(5):1163–71; discussion
1172–3.
141. Margulies AG, Hochberg J, Kepple J, Henry-Tillman RS,
Westbrook K, Klimberg VS. Total skin-sparing mastectomy
without preservation of the nipple-areola complex. Am J Surg.
2005;190(6):907–12.
142. Sacchini V, Pinotti JA, Barros AC, et al. Nipple-sparing mas-
tectomy for breast cancer and risk reduction: oncologic or
technical problem? J Am Coll Surg. 2006;203(5):704–14.
143. Spear SL, Davison SP. Aesthetic subunits of the breast. Plast
Reconstr Surg. 2003;112(2):440–7.
144. Eriksen C, Lindgren EN, Frisell J, Stark B. A prospective ran-
domized study comparing two different expander approaches in
implant-based breast reconstruction: one stage versus two
stages. Plast Reconstr Surg. 2012;130(2):254e–64e.
145. 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(5):1142–53; discussion 1154–5.
146. Gahm J, Jurell G, Edsander-Nord A, Wickman M. Patient sat-
isfaction with aesthetic outcome after bilateral prophylactic
mastectomy and immediate reconstruction with implants. J Plast
Reconstr Aesthet Surg. 2010;63(2):332–8.
147. Cohen BE, Casso D, Whetstone M. Analysis of risks and aes-
thetics in a consecutive series of tissue expansion breast
reconstructions. Plast Reconstr Surg. 1992;89(5):840–3; dis-
cussion 844–5.
148. Lindegren A, Halle M, Docherty Skogh AC, Edsander-Nord A.
Postmastectomy breast reconstruction in the irradiated breast: a
comparative study of DIEP and latissimus dorsi flap outcome.
Plast Reconstr Surg. 2012;130(1):10–8.
S. W. M. C. Maass et al.
