Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Breast reconstruction: Preoperative assessment

INTRODUCTION

Breast reconstruction is an option for patients following a unilateral or bilateral mastectomy, or after breast conservation therapy (BCT) with a less than ideal cosmetic result. Breast reconstruction provides psychological, social, emotional, and functional improvements, including improved psychological health, self-esteem [1-4], sexuality, and body image [1-9]. Patients who choose breast reconstruction are presented with complex decisions, including the type and timing of reconstruction.

This topic review will discuss the preoperative assessment and evaluation of candidates for immediate or delayed breast reconstruction, special clinical settings (contralateral mastectomies, radiation therapy), and physical and psychologic outcomes. The approaches for reconstruction, including autologous tissue reconstruction and prosthetic devices (implants), are reviewed separately. (See "Breast reconstruction: Autologous tissue" and "Breast reconstruction: Prosthetic devices".)

UTILIZATION AND PATTERNS OF CARE

Outcomes research on quality of life (QOL) improvements and psychosocial benefits associated with breast reconstruction served as the driving force for the 1998 Women's Health and Cancer Rights Act, which mandated healthcare payer coverage for breast and nipple reconstruction, contralateral procedures to achieve symmetry, and treatment for the sequelae of mastectomy [10]. This was followed in 2001 by additional legislation imposing penalties on noncompliant insurers. Whether passage of these laws has contributed to changes in clinical practice is unclear.

Although the rate of breast reconstruction has increased, the number of women who undergo reconstruction after mastectomy remains low [11,12]. Data collected from the American Society of Plastic Surgeons showed that the number of breast reconstructions performed annually increased from 78,832 in 2000 to 95,589 in 2013 [11-13]. The low rates of breast reconstruction are in part due to a low referral rate to plastic surgeons. A survey of attending general surgeons from a population-based sample of 1844 women diagnosed with breast cancer in 2002 showed that only 24 percent of surgeons referred more than 75 percent of their mastectomy patients to plastic surgeons prior to surgery [14]. A survey of patients diagnosed with breast cancer reported that the desire to avoid additional surgery was the most common reason given for not pursuing reconstruction [15]. Inadequate education about reconstructive options also plays a role. In a study of 84 women treated with mastectomy, participants were able to answer only 38 percent of questions about reconstruction options correctly [16].

Approximately 40 percent of all patients undergoing a mastectomy undergo breast reconstruction, and immediate breast reconstruction is increasing by approximately 5 percent per year [17]. Implant-based reconstruction has been increasing at a rate of 11 percent per year, while the rate of autologous reconstruction has remained unchanged. Additional studies have demonstrated that unilateral mastectomy rates are decreasing by 2 percent per year, whereas contralateral and bilateral prophylactic mastectomies are increasing at the rate of 15 percent and 12 percent per year, respectively [18].

                         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Oct 2014. | This topic last updated: Aug 19, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Rowland JH, Desmond KA, Meyerowitz BE, et al. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 2000; 92:1422.
  2. Dean C, Chetty U, Forrest AP. Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet 1983; 1:459.
  3. Slavin SA, Love SM, Goldwyn RM. Recurrent breast cancer following immediate reconstruction with myocutaneous flaps. Plast Reconstr Surg 1994; 93:1191.
  4. Macadam SA, Ho AL, Lennox PA, Pusic AL. Patient-reported satisfaction and health-related quality of life following breast reconstruction: a comparison of shaped cohesive gel and round cohesive gel implant recipients. Plast Reconstr Surg 2013; 131:431.
  5. Teimourian B, Adham MN. Survey of patients' responses to breast reconstruction. Ann Plast Surg 1982; 9:321.
  6. 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.
  7. 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.
  8. Stevens LA, McGrath MH, Druss RG, et al. The psychological impact of immediate breast reconstruction for women with early breast cancer. Plast Reconstr Surg 1984; 73:619.
  9. Schain WS. Breast reconstruction. Update of psychosocial and pragmatic concerns. Cancer 1991; 68:1170.
  10. 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.
  11. Data from the American Society of Plastic Surgeons (ASPS) National Plastic Surgery Statistics Clearinghouse www.plasticsurgery.org/media/statistics/index.cfm (Accessed on September 10, 2007).
  12. Alderman AK, Wei Y, Birkmeyer JD. Use of breast reconstruction after mastectomy following the Women's Health and Cancer Rights Act. JAMA 2006; 295:387.
  13. American Society of Plastic Surgeons. 2013 Plastic Surgery Statistics Report. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. http://www.plasticsurgery.org/Documents/news-resources/statistics/2013-statistics/plastic-surgery-statistics-full-report-2013.pdf.
  14. Alderman AK, Hawley ST, Waljee J, et al. Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer 2007; 109:1715.
  15. Morrow M, Mujahid M, Lantz PM, et al. Correlates of breast reconstruction: results from a population-based study. Cancer 2005; 104:2340.
  16. Lee CN, Belkora J, Chang Y, et al. Are patients making high-quality decisions about breast reconstruction after mastectomy? [outcomes article]. Plast Reconstr Surg 2011; 127:18.
  17. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plast Reconstr Surg 2013; 131:15.
  18. Cemal Y, Albornoz CR, Disa JJ, et al. A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg 2013; 131:320e.
  19. Meretoja T, Suominen E. Demand for plastic surgical operations after primary breast cancer surgery. Scand J Surg 2005; 94:211.
  20. Joslyn SA. Patterns of care for immediate and early delayed breast reconstruction following mastectomy. Plast Reconstr Surg 2005; 115:1289.
  21. Alderman AK, McMahon L Jr, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg 2003; 111:695.
  22. Chung KC, Hamill JB, Kim HM, et al. Predictors of patient satisfaction in an outpatient plastic surgery clinic. Ann Plast Surg 1999; 42:56.
  23. Losken A, Burke R, Elliott LF 2nd, Carlson GW. Infonomics and breast reconstruction: are patients using the internet? Ann Plast Surg 2005; 54:247.
  24. Lin KY, Johns FR, Gibson J, et al. An outcome study of breast reconstruction: presurgical identification of risk factors for complications. Ann Surg Oncol 2001; 8:586.
  25. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg 2000; 105:2374.
  26. Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking on flap and donor-site complications in pedicled TRAM breast reconstruction. Plast Reconstr Surg 2005; 116:1873.
  27. Goodwin SJ, McCarthy CM, Pusic AL, et al. Complications in smokers after postmastectomy tissue expander/implant breast reconstruction. Ann Plast Surg 2005; 55:16.
  28. Hopwood P, Maguire GP. Body image problems in cancer patients. Br J Psychiatry Suppl 1988; :47.
  29. Kroll SS, Netscher DT. Complications of TRAM flap breast reconstruction in obese patients. Plast Reconstr Surg 1989; 84:886.
  30. Spear SL, Ducic I, Cuoco F, Taylor N. Effect of obesity on flap and donor-site complications in pedicled TRAM flap breast reconstruction. Plast Reconstr Surg 2007; 119:788.
  31. Paige KT, Bostwick J 3rd, Bried JT, Jones G. A comparison of morbidity from bilateral, unipedicled and unilateral, unipedicled TRAM flap breast reconstructions. Plast Reconstr Surg 1998; 101:1819.
  32. Beahm EK, Walton RL, Chang DW. Breast reconstruction in the obese patient. Plast Reconstr Surg 2006; 118:15.
  33. Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2002; 109:2265.
  34. Atisha DM, Alderman AK, Kuhn LE, Wilkins EG. The impact of obesity on patient satisfaction with breast reconstruction. Plast Reconstr Surg 2008; 121:1893.
  35. Greco JA 3rd, Castaldo ET, Nanney LB, et al. Autologous breast reconstruction: the Vanderbilt experience (1998 to 2005) of independent predictors of displeasing outcomes. J Am Coll Surg 2008; 207:49.
  36. Jandali S, Nelson JA, Sonnad SS, et al. Breast reconstruction with free tissue transfer from the abdomen in the morbidly obese. Plast Reconstr Surg 2011; 127:2206.
  37. Sullivan SR, Fletcher DR, Isom CD, Isik FF. True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg 2008; 122:19.
  38. Khoo A, Kroll SS, Reece GP, et al. A comparison of resource costs of immediate and delayed breast reconstruction. Plast Reconstr Surg 1998; 101:964.
  39. Al-Ghazal SK, Sully L, Fallowfield L, Blamey RW. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol 2000; 26:17.
  40. Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2000; 106:1014.
  41. Al-Ghazal SK, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer 2000; 36:1938.
  42. Fung KW, Lau Y, Fielding R, et al. The impact of mastectomy, breast-conserving treatment and immediate breast reconstruction on the quality of life of Chinese women. ANZ J Surg 2001; 71:202.
  43. Mock V. Body image in women treated for breast cancer. Nurs Res 1993; 42:153.
  44. Pusic A, Thompson TA, Kerrigan CL, et al. Surgical options for the early-stage breast cancer: factors associated with patient choice and postoperative quality of life. Plast Reconstr Surg 1999; 104:1325.
  45. Nano MT, Gill PG, Kollias J, et al. Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ J Surg 2005; 75:940.
  46. Chawla AK, Kachnic LA, Taghian AG, et al. Radiotherapy and breast reconstruction: complications and cosmesis with TRAM versus tissue expander/implant. Int J Radiat Oncol Biol Phys 2002; 54:520.
  47. Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg 1998; 102:49.
  48. 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; 99:686.
  49. Kronowitz SJ, Kuerer HM. Advances and surgical decision-making for breast reconstruction. Cancer 2006; 107:893.
  50. Namnoun JD. Options for the contralateral breast in breast reconstruction. In: Surgery of the Breast: Principles and Art, Spear SL (Ed), Lippincott, Williams and Wilkins, Philadelphia 2006. p.888.
  51. Nahabedian MY. Managing the opposite breast: contralateral symmetry procedures. Cancer J 2008; 14:258.
  52. Patel KM, Nahabedian MY. Nipple Reconstruction. In: Plastic Surgery, Peter Neligan. (Ed), Elsevier, London 2012.
  53. Khansa I, Boehmler JH 4th. Aesthetic outcomes in women undergoing breast-conserving therapy followed by mastectomy and microsurgical reconstruction. Microsurgery 2014.
  54. Kim MS, Sbalchiero JC, Reece GP, et al. Assessment of breast aesthetics. Plast Reconstr Surg 2008; 121:186e.
  55. Cochrane RA, Valasiadou P, Wilson AR, et al. Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. Br J Surg 2003; 90:1505.
  56. Wang HT, Barone CM, Steigelman MB, et al. Aesthetic outcomes in breast conservation therapy. Aesthet Surg J 2008; 28:165.
  57. Heil J, Czink E, Golatta M, et al. Change of aesthetic and functional outcome over time and their relationship to quality of life after breast conserving therapy. Eur J Surg Oncol 2011; 37:116.
  58. Pérez-Cano R, Vranckx JJ, Lasso JM, et al. Prospective trial of adipose-derived regenerative cell (ADRC)-enriched fat grafting for partial mastectomy defects: the RESTORE-2 trial. Eur J Surg Oncol 2012; 38:382.
  59. Spear SL, Rao SS, Patel KM, Nahabedian MY. Reduction mammaplasty and mastopexy in previously irradiated breasts. Aesthet Surg J 2014; 34:74.
  60. Pomahac B, Recht A, May JW, et al. New trends in breast cancer management: is the era of immediate breast reconstruction changing? Ann Surg 2006; 244:282.
  61. Motwani SB, Strom EA, Schechter NR, et al. The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys 2006; 66:76.
  62. Schechter NR, Strom EA, Perkins GH, et al. Immediate breast reconstruction can impact postmastectomy irradiation. Am J Clin Oncol 2005; 28:485.
  63. Buchholz TA, Kronowitz SJ, Kuerer HM. Immediate breast reconstruction after skin-sparing mastectomy for the treatment of advanced breast cancer: radiation oncology considerations. Ann Surg Oncol 2002; 9:820.
  64. Nahabedian MY, Momen B. The impact of breast reconstruction on the oncologic efficacy of radiation therapy: a retrospective analysis. Ann Plast Surg 2008; 60:244.
  65. Wright JL, Cordeiro PG, Ben-Porat L, et al. Mastectomy with immediate expander-implant reconstruction, adjuvant chemotherapy, and radiation for stage II-III breast cancer: treatment intervals and clinical outcomes. Int J Radiat Oncol Biol Phys 2008; 70:43.
  66. Albornoz CR, Matros E, McCarthy CM, et al. Implant breast reconstruction and radiation: a multicenter analysis of long-term health-related quality of life and satisfaction. Ann Surg Oncol 2014; 21:2159.
  67. Classen J, Nitzsche S, Wallwiener D, et al. Fibrotic changes after postmastectomy radiotherapy and reconstructive surgery in breast cancer. A retrospective analysis in 109 patients. Strahlenther Onkol 2010; 186:630.
  68. Adesiyun TA, Lee BT, Yueh JH, et al. Impact of sequencing of postmastectomy radiotherapy and breast reconstruction on timing and rate of complications and patient satisfaction. Int J Radiat Oncol Biol Phys 2011; 80:392.
  69. Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg 2000; 105:930.
  70. Krueger EA, Wilkins EG, Strawderman M, et al. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys 2001; 49:713.
  71. Spear SL, Majidian A. Immediate breast reconstruction in two stages using textured, integrated-valve tissue expanders and breast implants: a retrospective review of 171 consecutive breast reconstructions from 1989 to 1996. Plast Reconstr Surg 1998; 101:53.
  72. Contant CM, van Geel AN, van der Holt B, et al. Morbidity of immediate breast reconstruction (IBR) after mastectomy by a subpectorally placed silicone prosthesis: the adverse effect of radiotherapy. Eur J Surg Oncol 2000; 26:344.
  73. Tallet AV, Salem N, Moutardier V, et al. Radiotherapy and immediate two-stage breast reconstruction with a tissue expander and implant: complications and esthetic results. Int J Radiat Oncol Biol Phys 2003; 57:136.
  74. Ascherman JA, Hanasono MM, Newman MI, Hughes DB. Implant reconstruction in breast cancer patients treated with radiation therapy. Plast Reconstr Surg 2006; 117:359.
  75. Vandeweyer E, Deraemaecker R. Radiation therapy after immediate breast reconstruction with implants. Plast Reconstr Surg 2000; 106:56.
  76. Nava MB, Pennati AE, Lozza L, et al. Outcome of different timings of radiotherapy in implant-based breast reconstructions. Plast Reconstr Surg 2011; 128:353.
  77. Eriksson M, Anveden L, Celebioglu F, et al. Radiotherapy in implant-based immediate breast reconstruction: risk factors, surgical outcomes, and patient-reported outcome measures in a large Swedish multicenter cohort. Breast Cancer Res Treat 2013; 142:591.
  78. Anderson PR, Hanlon AL, Fowble BL, et al. Low complication rates are achievable after postmastectomy breast reconstruction and radiation therapy. Int J Radiat Oncol Biol Phys 2004; 59:1080.
  79. Cordeiro PG, Pusic AL, Disa JJ, et al. Irradiation after immediate tissue expander/implant breast reconstruction: outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg 2004; 113:877.
  80. McCarthy CM, Pusic AL, Disa JJ, et al. Unilateral postoperative chest wall radiotherapy in bilateral tissue expander/implant reconstruction patients: a prospective outcomes analysis. Plast Reconstr Surg 2005; 116:1642.
  81. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on April 01, 2014).
  82. Huang CJ, Hou MF, Lin SD, et al. Comparison of local recurrence and distant metastases between breast cancer patients after postmastectomy radiotherapy with and without immediate TRAM flap reconstruction. Plast Reconstr Surg 2006; 118:1079.
  83. Jhaveri JD, Rush SC, Kostroff K, et al. Clinical outcomes of postmastectomy radiation therapy after immediate breast reconstruction. Int J Radiat Oncol Biol Phys 2008; 72:859.
  84. Williams JK, Carlson GW, Bostwick J 3rd, et al. The effects of radiation treatment after TRAM flap breast reconstruction. Plast Reconstr Surg 1997; 100:1153.
  85. Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg 2002; 109:1919.
  86. Schrenk P, Woelfl S, Bogner S, et al. The use of sentinel node biopsy in breast cancer patients undergoing skin sparing mastectomy and immediate autologous reconstruction. Plast Reconstr Surg 2005; 116:1278.
  87. Kronowitz SJ, Chang DW, Robb GL, et al. Implications of axillary sentinel lymph node biopsy in immediate autologous breast reconstruction. Plast Reconstr Surg 2002; 109:1888.
  88. Chagpar AB, Scoggins CR, Martin RC 2nd, et al. Predicting patients at low probability of requiring postmastectomy radiation therapy. Ann Surg Oncol 2007; 14:670.
  89. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg 2004; 113:1617.
  90. Metcalfe KA, Semple J, Quan ML, et al. Changes in psychosocial functioning 1 year after mastectomy alone, delayed breast reconstruction, or immediate breast reconstruction. Ann Surg Oncol 2012; 19:233.
  91. Elder EE, Brandberg Y, Björklund T, et al. Quality of life and patient satisfaction in breast cancer patients after immediate breast reconstruction: a prospective study. Breast 2005; 14:201.
  92. Atisha D, Alderman AK, Lowery JC, et al. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. Ann Surg 2008; 247:1019.
  93. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg 2000; 106:769.
  94. Alderman AK, Kuhn LE, Lowery JC, Wilkins EG. Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study. J Am Coll Surg 2007; 204:7.
  95. 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.
  96. Chun YS, Sinha I, Turko A, et al. Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 2010; 126:1133.
  97. Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006; 117:737.
  98. Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 2005; 115:436.
  99. Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009; 124:752.
  100. Suominen S, Asko-Seljavaara S, Kinnunen J, et al. Abdominal wall competence after free transverse rectus abdominis musculocutaneous flap harvest: a prospective study. Ann Plast Surg 1997; 39:229.
  101. Kind GM, Rademaker AW, Mustoe TA. Abdominal-wall recovery following TRAM flap: a functional outcome study. Plast Reconstr Surg 1997; 99:417.
  102. Alderman AK, Kuzon WM Jr, Wilkins EG. A two-year prospective analysis of trunk function in TRAM breast reconstructions. Plast Reconstr Surg 2006; 117:2131.
  103. Kroll SS, Marchi M. Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction. Plast Reconstr Surg 1992; 89:1045.
  104. Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg 1991; 87:1054.
  105. Dulin WA, Avila RA, Verheyden CN, Grossman L. Evaluation of abdominal wall strength after TRAM flap surgery. Plast Reconstr Surg 2004; 113:1662.
  106. Atisha D, Alderman AK. A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction. Ann Plast Surg 2009; 63:222.
  107. Hamdi M, Weiler-Mithoff EM, Webster MH. Deep inferior epigastric perforator flap in breast reconstruction: experience with the first 50 flaps. Plast Reconstr Surg 1999; 103:86.
  108. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997; 50:322.
  109. Helvie MA, Bailey JE, Roubidoux MA, et al. Mammographic screening of TRAM flap breast reconstructions for detection of nonpalpable recurrent cancer. Radiology 2002; 224:211.
  110. Lee JM, Georgian-Smith D, Gazelle GS, et al. Detecting nonpalpable recurrent breast cancer: the role of routine mammographic screening of transverse rectus abdominis myocutaneous flap reconstructions. Radiology 2008; 248:398.
  111. Langstein HN, Cheng MH, Singletary SE, et al. Breast cancer recurrence after immediate reconstruction: patterns and significance. Plast Reconstr Surg 2003; 111:712.
  112. Chagpar A, Langstein HN, Kronowitz SJ, et al. Treatment and outcome of patients with chest wall recurrence after mastectomy and breast reconstruction. Am J Surg 2004; 187:164.