Michigan Breast Reconstruction Outcome Study Research Articles

Patient-reported outcomes in breast oncology: a review of validated outcome instruments.

Patient-reported outcomes (PROs) include areas of health-related quality of life but also broader concepts such as patient satisfaction with care. The aim of this review is to give an account of all instruments with potential use in patients with a history of treatment for breast cancer (including surgery, chemotherapy and/or radiotherapy) with evidence of validation in the breast cancer population. All instruments included in this review were identified as PRO measures measuring breast-related quality of life and/or satisfaction that had undergone development and validation with breast oncology patients. We specifically looked for PRO measures examining patient satisfaction and/or quality of life after breast cancer treatment. Following an evaluation of 323 papers, we identified 15 instruments that were able to satisfy our inclusion criteria. These instruments are the EORTC QOL-C30 and QLQ-BR23 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Breast Cancer Module), the FACT-B (Functional Assessment of Cancer Therapy-Breast Cancer), the SLDS-BC (Satisfaction with Life Domains Scale for Breast Cancer), the BIBCQ (Body Image after Breast Cancer Questionnaire), the HIBS (Hopwood Body Image Scale), the PBIS (Polivy Body Image Scale), the MBROS (Michigan Breast Reconstruction Outcomes Study) Satisfaction and Body Image Questionnaires, the BREAST-Q, the BCTOS (Breast Cancer Treatment Outcome Scale), the BCQ, the FACT-ES (Functional Assessment of Cancer Therapy-Endocrine System), the MAS (Mastectomy Attitude Scale), and the Breast Cancer Prevention Trial Symptom Checklist (BCPT). Suggestions for future directions include (1) to use and utilize validated instruments tailored to clinical practice; (2) to develop a comprehensive measurement of surgical outcome requiring the combination of objective and subjective measures; (3) to aim for a compromise between these two competing considerations in the form of a scale incorporating both generalizability in cancer-related QOL and specificity in breast cancer issues.

One Staged Silicone Implant Breast Reconstruction Following Bilateral Nipple-Sparing Prophylactic Mastectomy In High-Risk Breast Patients

INTRODUCTION: Diverse opinions are encountered in the literature regarding the indications, incisions to be chosen or reconstruction method following prophylactic mastectomy. In addition, the biggest handicap in most studies concerning either patient's satisfaction or operation results is the lack of group homogeneity. The purpose of the study was to evaluate the patient satisfaction rate and the operation technique used in homogeneous group of patient for prophylactic mastectomy. METHODS: In our center thirteen bilateral prophylactic mastectomies due to high-risk breasts and simultaneous reconstruction of the breasts using submuscular placed medium height high profile silicone implants were performed between the years 2008-2011. Two of the main mastectomy indications were occurrence of breast cancer in a first-degree relative and multiple cysts in the breast and/or multiple suspicious micro-calcifications in mammographic imaging. The patients were divided in two main groups according to having either small breasted (7 patients) or large/ptotic breasted patients (6 patients). A periareolar incision was used in small-breasted subjects. In large/ptotic breasted patients planning was similar to the vertical mastopexy pattern. Satisfaction outcomes were evaluated by using questionnaire previously used in the Michigan Breast Reconstruction Outcome Study. RESULTS: The satisfaction rate about the questions, which assess the general satisfaction, was 100% in our patients. With regard to the aesthetic outcomes of the operation, 92.3% of patients were satisfied (Figure 1).Figure 1: Preoperative image of a ptotic breasted patient (left). The vertical mastopexy incision and postoperative images after bilateral prophylactic mastectomy and silicone implant reconstruction (right).CONCLUSION: We obtained very good aesthetic results with low complication rates using this echnique in this group of patients. A larger study that compares the use of this technique in similar patients with homogeneous patient groups that underwent different mastectomy and reconstruction techniques will provide more objective findings and data about the treatment method.

Patient-Reported Outcomes in Breast Oncology: A Review of Validated Outcome Instruments

Patient-reported outcomes (PROs) include areas of health-related quality of life but also broader concepts such as patient satisfaction with care. The aim of this review is to give an account of all instruments with potential use in patients with a history of treatment for breast cancer (including surgery, chemotherapy and/or radiotherapy) with evidence of validation in the breast cancer population. All instruments included in this review were identified as PRO measures measuring breast-related quality of life and/or satisfaction that had undergone development and validation with breast oncology patients. We specifically looked for PRO measures examining patient satisfaction and/or quality of life after breast cancer treatment. Following an evaluation of 323 papers, we identified 15 instruments that were able to satisfy our inclusion criteria. These instruments are the EORTC QOL-C30 and QLQ-BR23 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Breast Cancer Module), the FACT-B (Functional Assessment of Cancer Therapy-Breast Cancer), the SLDS-BC (Satisfaction with Life Domains Scale for Breast Cancer), the BIBCQ (Body Image after Breast Cancer Questionnaire), the HIBS (Hopwood Body Image Scale), the PBIS (Polivy Body Image Scale), the MBROS (Michigan Breast Reconstruction Outcomes Study) Satisfaction and Body Image Questionnaires, the BREAST-Q, the BCTOS (Breast Cancer Treatment Outcome Scale), the BCQ, the FACT-ES (Functional Assessment of Cancer Therapy-Endocrine System), the MAS (Mastectomy Attitude Scale), and the Breast Cancer Prevention Trial Symptom Checklist (BCPT). Suggestions for future directions include (1) to use and utilize validated instruments tailored to clinical practice; (2) to develop a comprehensive measurement of surgical outcome requiring the combination of objective and subjective measures; (3) to aim for a compromise between these two competing considerations in the form of a scale incorporating both generalizability in cancer-related QOL and specificity in breast cancer issues.

Assessing the clinical effectiveness of breast reconstruction through patient-reported outcome measures

Breast cancer remains the most common malignancy in women worldwide. Early detection and treatment means that over 70 per cent survive for more than 10 years, with approximately 60 per cent of women predicted to be alive 20 years following their initial diagnosis1. There is an increasing focus on the issues of ‘survivorship’ and the impact of surgical and other treatments on patients’ health-related quality of life (HRQoL). Although the growing practice of oncoplastic breast surgery has increased the use of breast conservation therapy for stage I and II disease, about a third of the 44 000 women diagnosed annually with breast cancer in the UK have mastectomy recommended or choose it as their preferred option1,2. In assessing clinical effectiveness, evidence of the importance of considering not only patient morbidity and mortality, but also patient perceptions of the results of surgery is increasing3. The growth of research into patient-reported outcome measures (PROMs) is based on the main goal of breast reconstruction to satisfy the patient with respect to psychosocial sequelae, physical function and perception of the aesthetic result3. PROMs are questionnaires that quantify HRQoL and/or other significant outcome variables, such as patient satisfaction3. The US Food and Drug Administration has defined PROMs as a ‘measurement of any aspect of a patient’s health status that comes directly from the patient’3. PROMs should assess the impact of disease, treatment and surgical intervention on various aspects of outcome. They should be clinically meaningful, scientifically sound and practical3,4. PROMs may differ significantly from those recorded by a clinical evaluator, and are important complementary assessments of clinical effectiveness. HRQoL measurement covers the impact of breast cancer and its treatment on some aspect of physical or psychological well-being or function, for example physical, role, cognitive or social5. There is a an underlying belief that mastectomy has important consequences on a patient’s quality of life, including psychosocial, physical, aesthetic, body image and sexual effects6. The evidence for this, however, remains equivocal, based on a systematic review of HRQoL outcomes in all types of immediate and delayed breast reconstructions from 1978 to 20097. Thirty-four studies were included and evaluated according to the Efficace criteria, which define a minimum standard checklist for quality of methodological reporting of HRQoL8. The quality of the evidence was still generally poor with only 13 level I (n = 2) and level II (n = 11) studies. Although some used breast cancerspecific instruments that have been validated in line with internationally accepted criteria for assessing HRQoL, including the Functional Assessment of Cancer Therapy for Breast Cancer (FACT-B), the European Organization for Research and Treatment of Cancer breast cancer module (EORTC QLQ-BR23) and the Body Image Scale, none has been specifically validated inwomen undergoing breast reconstruction7. They may prove valid and reliable, but have not been designed specifically to reflect changes resulting from breast reconstruction4. A systematic review to identify PROMs developed and validated for use in cosmetic and reconstructive breast surgery revealed that only seven of 227 PROMsmeasuring satisfaction and/or breast-related quality of life had undergone development and validation in a cosmetic or reconstructive breast surgery population4. Of these, only two were applicable to breast reconstruction, both related to the Michigan Breast ReconstructionOutcomes Study (MBROS). One examined patient satisfaction (MBROS-S) and the other body image (MBROSI)4. Neither questionnaire, however, was developed in keeping with current internationally accepted criteria, nor did they specifically address key issues relating to either the donor site, nipple reconstruction or the reconstructed breast. As they were developed exclusively in the context of expander/implant or transverse rectus abdominis myocutaneous flap reconstruction, neither has been validated across the spectrum of breast reconstructive procedures such as preservation of the skin envelope and/or nipple-sparing mastectomy with a variety of immediate breast reconstructionmethods, and delayed methods that relate to the use of implantonly, implant-assisted tissue flaps or

Postmastectomy Radiation Therapy and Breast Reconstruction: An Analysis of Complications and Patient Satisfaction.

Abstract Introduction: The indications for postmastectomy radiation therapy (PMRT) have expanded over the past decade. Plastic surgeons are reluctant to perform an immediate reconstruction followed by radiation because of their perception this sequence results in worse results. This study examines the relationship between the use and sequencing of radiation therapy on complication rates and patient satisfaction following reconstrucion.Methods: A retrospective chart review was performed of all women at an academic institution who underwent mastectomy and reconstruction from 1999-2006. The 769 reconstructed breasts were separated into 4 groups: PMRT prior to delayed reconstruction (n = 60); immediate reconstruction then PMRT (n = 56); reconstruction without PMRT (n = 540); and reconstruction after breast-conserving therapy with RT (BCT-RT, n = 113). The median length of follow-up was 44 months. All operative complications were categorized into early (≤90 days) or late. A questionnaire based on the Michigan Breast Reconstruction Outcomes Study assessed general and aesthetic satisfaction (response rate, 73.2%). Dichotomous variables were evaluated using the Fisher's exact or chi-squared test; statistical significance was set at p <0.05.Results: The overall complication rate for patients having PMRT (given before or after reconstruction) was higher than for patients with reconstruction only (36% vs. 27%, p = 0.048). The overall complication rate for women receiving PMRT then reconstruction was lower than for reconstruction then PMRT, although this was not statistically significant (28% vs. 45%, p = 0.068). Patients having reconstruction then PMRT had increased overall and late complication rates compared to patients having reconstruction only (45% vs.27.%, p = 0.006; 34% vs. 21%, p = 0.023, respectively). Results were similar when subdivided by the kind of reconstruction, except for increased late complications for patients having implant/expanders who had reconstruction then PMRT (62%, 8/13) compared to reconstruction alone (20%, 26/129) (p=0.003). General satisfaction was similar among all four groups. Aesthetic satisfaction was significantly lower in the PMRT then reconstruction group, compared to reconstruction only (48% vs. 65%, p = 0.029). Patients who underwent reconstruction then PMRT had similar aesthetic satisfaction compared to patients having reconstruction only (62% vs. 65%).Conclusions: Patients who have reconstruction prior to PMRT have increased overall and late complication rates compared to patients having reconstruction without radiation, but they have similar rates of general and aesthetic satisfaction. In contrast, patients who receive PMRT prior to delayed reconstruction have similar complication rates and general satisfaction levels to patients undergoing reconstruction only; however, the former patients report decreased aesthetic satisfaction. Patients requiring PMRT should consider both the risk of complications and likelihood of satisfaction in their decision-making process. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4102.

Prospective Analysis of Long-term Psychosocial Outcomes in Breast Reconstruction: Two-year Postoperative Results From the Michigan Breast Reconstruction Outcomes Study

Prospective Analysis of Long-term Psychosocial Outcomes in Breast Reconstruction: Two-year Postoperative Results From the Michigan Breast Reconstruction Outcomes Study

Prospective Analysis of Long-term Psychosocial Outcomes in Breast Reconstruction

To prospectively evaluate the psychosocial outcomes and body image of patients 2 years postmastectomy reconstruction using a multicenter, multisurgeon approach. Although breast reconstruction has been shown to confer significant psychosocial benefits in breast cancer patients at year 1 postreconstruction, we considered the possibility that psychosocial outcomes may remain in a state of flux for years after surgery. Patients were recruited as part of the Michigan Breast Reconstruction Outcome Study, a 12 center, 23 surgeon prospective cohort study of mastectomy reconstruction patients. Two-sided paired sample t tests were used to compare change scores for the various psychosocial subscales. Multiple regression analysis was used to determine whether the magnitude of the change score varied by procedure type. Preoperative and postoperative year 2 surveys were received from 173 patients; 116 with immediate and 57 with delayed reconstruction. For the immediate reconstruction cohort, significant improvements were observed in all psychosocial subscales except for body image. This occurred essentially independent of procedure type. In the cohort with delayed reconstruction, significant change scores were observed only in body image. Women with transverse rectus abdominis musculocutaneous flaps had significantly greater gains in body image scores (P = 0.003 and P = 0.034, respectively) when compared with expander/implants. General psychosocial benefits and body image gains continued to manifest at 2 years postmastectomy reconstruction. In addition, procedure type had a surprisingly limited effect on psychosocial well being. With outcomes evolving beyond year 1, these data support the need for additional longitudinal breast reconstruction outcome studies.

Prospective analysis of longterm psychosocial outcomes in breast reconstruction: Two-year postoperative results from the Michigan breast reconstruction outcomes study

Prospective analysis of longterm psychosocial outcomes in breast reconstruction: Two-year postoperative results from the Michigan breast reconstruction outcomes study

Does Patient Satisfaction with Breast Reconstruction Change over Time? Two-Year Results of the Michigan Breast Reconstruction Outcomes Study

Previously, we found patient satisfaction with breast reconstruction at postoperative year 1 significantly higher in the autogenous tissue compared with the expander/implant population. But breast reconstructive procedures have different "aging" processes, and the point at which outcomes stabilize is unclear. So we evaluated patient satisfaction with breast reconstruction at postoperative year 2 and compared the results with those from our previous study. As part of the Michigan Breast Reconstruction Outcomes Study, women undergoing mastectomy reconstruction (including expander/implants and pedicle and free transverse rectus abdominis musculocutaneous flaps [TRAM]) were prospectively evaluated. Preoperatively and at postoperative years 1 and 2, women completed a questionnaire that collected a variety of validated health status information. The postoperative questionnaire had an additional seven items assessing both general and esthetic satisfaction as separate subscales. To assess the effects of procedure on satisfaction and control for possible confounding, multiple logistic regression was used. At year 2, patients with TRAM flaps (both free and pedicle) continued to have higher levels of esthetic satisfaction compared with expander/implant patients (odds ratio 2.8, p < 0.01). But no significant differences were appreciated in esthetic satisfaction between women with free and pedicle TRAM flaps. In regard to general satisfaction, the type of reconstruction (expander/implant, pedicle TRAM, and free TRAM) had no statistically significant effect. At postoperative year 2, procedural differences initially found in women's general satisfaction with breast reconstruction diminish. Specifically, women with pedicle TRAM flaps, free TRAM flaps, and expander/implants had similar levels of general satisfaction. But at year 2, patients continue to be more esthetically satisfied with autogenous tissue than with expander/implant reconstructions.

Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study.

In this study, the effects of procedure type, timing, and other clinical variables on complication rates in mastectomy reconstruction were prospectively evaluated. Using a prospective cohort design, women undergoing first-time, immediate or delayed breast reconstruction were recruited from 12 centers and 23 plastic surgeons. Complication data for expander/implant, pedicle transverse rectus abdominis musculocutaneous (TRAM) flap, and free TRAM flap procedures were evaluated 2 years after surgery in 326 patients. For each patient, the total number of complications was recorded and the complication data were dichotomized in two ways: (1) total complications and (2) major complications (those requiring reoperation, rehospitalization, or nonperioperative intravenous antibiotic treatment). The effects of procedure type, timing, radiotherapy, chemotherapy, age, smoking, and body mass index on complication rates were analyzed using logistic regression. Immediate reconstructions had significantly higher total as well as major complication rates, compared with delayed procedures (p = 0.011 and 0.005, respectively). Furthermore, higher body mass indexes were associated with significantly higher total and major complication rates (p = 0.005 and p < 0.001, respectively). No significant effects on complication rates were noted for procedure type or for the other independent variables, although there was evidence of trends for higher total and major complication rates in implant patients who received radiotherapy and a trend for higher major complication rates in TRAM flap patients who received chemotherapy. It was concluded that (1) immediate reconstructions were associated with significantly higher complication rates than delayed procedures, and (2) procedure type had no significant effect on complication rates.

Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy

Purpose: To compare the rates of complications and patient satisfaction among breast cancer patients treated with mastectomy and tissue expander/implant reconstruction with and without radiotherapy. Methods and Materials: As part of the Michigan Breast Reconstruction Outcome Study (MBROS), breast cancer patients undergoing mastectomy with reconstruction were prospectively evaluated with respect to complications, general patient satisfaction with reconstruction, and esthetic satisfaction. Included in this study was a cohort of women who underwent breast reconstruction using an expander/implant (E/I). A subset of these patients also received radiotherapy (RT). At 1 and 2 years postoperatively, a survey was administered which included 7 items assessing both general satisfaction with their reconstruction and esthetic satisfaction. Complication data were also obtained at the same time points using hospital chart review. Radiotherapy patients identified in the University of Michigan Radiation Oncology database that underwent expander/implant reconstruction but not enrolled in the MBROS study were also added to the analysis. Results: Eighty-one patients underwent mastectomy and E/I reconstruction. Nineteen patients received RT and 62 underwent reconstruction without RT. The median dose delivered to the reconstructed breast/chest wall, including boost, was 60.4 Gy (range, 50.0–66.0 Gy) in 1.8- to 2.0-Gy fractions. With a median follow-up of 31 months from the date of surgery, complications occurred in 68% (13/19) of the RT patients compared to 31% (19/62) in the no RT group ( p = 0.006). Twelve of 81 patients (15%) had a breast reconstruction failure. Reconstruction failure was significantly associated with experiencing a complication ( p = 0.0001) and the use of radiotherapy ( p = 0.005). The observed reconstruction failure rates were 37% (7/19) and 8% (5/62) for patients treated with and without radiotherapy, respectively. Tamoxifen was associated with a borderline risk of complications ( p = 0.07) and a significant risk of reconstruction failure ( p = 0.01). Sixty-six patients of the study group completed the satisfaction survey; 15 patients did not. To offset potential bias for patients not completing the survey, we analyzed satisfaction data assuming “dissatisfaction” scores for surveys not completed. In the analysis of patients with unilateral E/I placement, reconstruction failure was significantly associated with a lower general satisfaction ( p = 0.03). Ten percent of patients experiencing a reconstruction failure were generally satisfied compared to 23% who completed E/I reconstruction. In addition, tamoxifen use was associated with a significantly decreased esthetic satisfaction ( p = 0.03). Radiotherapy was not associated with significantly decreased general or esthetic satisfaction. Conclusion: Irradiated patients had a higher rate of expander/implant reconstruction failure and complications than nonirradiated patients. Despite these differences, our pilot data suggest that both general satisfaction and patient esthetic satisfaction were not significantly different following radiotherapy compared to patients who did not receive RT. Although statistical power was limited in the present study and larger patient numbers are needed to validate these results, this study suggests comparable patient assessment of cosmetic outcome with or without radiotherapy in women who successfully complete expander/implant reconstruction.

Prospective Analysis of Psychosocial Outcomes in Breast Reconstruction: One-Year Postoperative Results from the Michigan Breast Reconstruction Outcome Study by Edwin G. Wilkins, M.D., M.S., Paul S. Cederna, M.D., Julie C. Lowery, Ph.D., Jennifer A. Davis, M.H.S.A., Hyungjin Myra Kim, Sc.D., Randy S. Roth, Ph.D. Sherry Goldfarb, M.P.H., Paul H. Izenberg, M.D., Herman P. Houin, M.D., and Kenneth W. Shaheen, M.D.

From the Division of Plastic Surgery, University of Minnesota, Minneapolis. Received for publication June 8, 2000. Bruce L. Cunningham, M.D. Division of Plastic Surgery University of Minnesota 420 Delaware St. SE, Box 122 Minneapolis, Minn. 55455

Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study.

In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy. Although investigators have documented the psychological, social, emotional, and functional benefits of breast reconstruction, little research has evaluated the effects of procedure choice on these outcomes. The current study prospectively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction: tissue expander/implant, pedicle TRAM, and free TRAM techniques. In a prospective cohort design, patients undergoing postmastectomy reconstruction for the first time with expander/implant, pedicle TRAM, or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada. Before reconstruction and at 1 year after reconstruction, patients were evaluated by a battery of questionnaires consisting of both generic and condition-specific surveys. Outcomes assessed included emotional well-being, vitality, general mental health, social functioning, functional well-being, social well-being, and body image. Baseline (preoperative) scores and the change in scores (the difference between postoperative and preoperative scores) were compared across procedure types using t tests and analysis of covariance. Preoperative and 1-year postoperative surveys were obtained from 273 patients. Procedure type was reported in 250 patients, of whom 56 received implant reconstructions, 128 pedicle TRAM flaps, and 66 free TRAM flaps. A total of 161 immediate and 89 delayed reconstructions were performed. Among women receiving immediate reconstruction, significant improvements were observed in all psychosocial variables except body image. However, no significant effects of procedure type on these changes over time existed. Similarly, delayed reconstruction patients had significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image. Although the choice of reconstructive technique did not significantly impact most of these outcomes, significant differences existed among procedure types for three psychosocial subscales. Patients undergoing delayed expander/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures. By contrast, delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed expander-implant reconstruction. The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients. Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction, our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction.

Determinants of patient satisfaction in postmastectomy breast reconstruction.

In today's increasingly competitive health care marketplace, consumer satisfaction has become an important measure of quality. Furthermore, measures of satisfaction with treatment inteerventions are influential factors in determining patients' and payers' choices of health care. This study sought to evaluate satisfaction with postmastectomy breast reconstruction and to assess the effects of procedure type and timing on patient satisfaction. As part of the Michigan Breast Reconstruction Outcome Study, patients undergoing first-time mastectomy reconstruction were prospectively evaluated, including cohorts of women choosing expander/implant, pedicle TRFAM flap, and free TRAM flap procedures. Preoperatively and 1 year postoperatively, participants completed a questionnaire that collected a variety of health status information. The postoperative questionnaire had an additional seven items assessing both general satisfaction with reconstruction (five items) and aesthetic satisfaction (two items) as separate subscales. Patients were asked to respond to each item using a five-point Likert scale. Item responses ranged from 1, indicating high satisfaction, to 5, reflecting low satisfaction. In the data analysis, only patients responding with a 1 or 2 for all of the items within a subscale were classified as "satisfied" for the subscale. To assess the effects of procedure type (implant, pedicle TRAM flap, and free TRAM flap) and timing (immediate versus delayed) on satisfaction and to control for possible confounding effects from other independent variables, multiple logistic regression was employed. In our analysis, odds ratios and associated 95 percent confidence intervals were calculated for each independent variable in the regression. Statistical significance was designated at the p < or = 0.05 level. A total of 212 patients were followed during the period of 1994 to 1997, including 141 immediate and 71 delayed reconstructions. The study population consisted of 49 expander/implant, 102 pedicle TRAM flap, and 61 free TRAM flap reconstruction patients. The analysis showed a significant association between procedure type and patient satisfaction. TRAM flap patients (both free and pedicle) appeared to have significantly greater general and aesthetic satisfaction compared with expander/implant patients (p = 0.03 and 0.001, respectively). Furthermore, pedicle TRAM flap patients were more aesthetically satisfied than those with free TRAM flaps (p = 0.072). The other independent variables of age and procedure timing did not appear to significantly affect either general or aesthetic satisfaction. However, preoperative physical activity was positively correlated with general satisfaction at the p = 0.034 level. The choice of procedure seems to have a significant effect on both aesthetic and general patient satisfaction with breast reconstruction. In this study, autogenous tissue reconstructions produced higher levels of patient aesthetic and general satisfaction compared with implant techniques. Pedicle and free TRAM flap patients do not seem to differ significantly in general satisfaction. However, women receiving pedicle TRAM flaps reported greater aesthetic satisfaction compared with patients undergoing free TRAM flaps. Furthermore, patient age and procedure timing may not have an effect on patient satisfaction with breast reconstruction.