Determinants of aesthetic satisfaction following TRAM and implant breast reconstruction

INTRODUCTION: Several studies have evaluated patient satisfaction following breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap and tissue expander/implant. However, the specific aesthetic determinants of patient satisfaction have not been determined. METHODS: Patients who had undergone tissue expander/implant or TRAM flap reconstruction were retrospectively polled on their age, type and timing of reconstruction, mastectomy type, laterality of reconstruction, adjuvant therapy, and symmetrizing and nipple-areolar procedures. Aesthetic satisfaction based on breast shape, symmetry of breast shape, breast size, symmetry of breast size, breast scarring, and breast sensation was assessed using a 5-point scale. RESULTS: Two hundred eleven patients with 105 TRAM flaps and 160 expander/implants responded. Unilateral TRAM recipients rated their breast shape, symmetry of breast shape, and symmetry of breast volume significantly higher than did implant patients. When bilateral reconstruction patients were evaluated, no significant differences were seen. The presence of nipple-areolar reconstruction positively influenced every parameter except breast sensation. Immediate reconstruction, skin-sparing mastectomy, and age >60 years at the time of reconstruction were also associated with higher scores, while postoperative radiation therapy resulted in lower satisfaction. Free flap reconstruction produced higher satisfaction in breast shape and breast scarring when compared with pedicle flap reconstruction. CONCLUSIONS: Aesthetic satisfaction after breast reconstruction is highly influenced by the presence of nipple-areolar reconstruction and less so by age, timing of reconstruction, adjuvant therapy, or free flap procedures. The type of reconstructive procedure is a significant variable only in unilateral reconstruction.