Accepted Manuscript DIEP flap for breast reconstruction: retrospective evaluation of patient satisfaction on abdominal results. J. Niddam, M.D R. Bosc, M.D F. Lange, M.D H. Chader, M.D B. Hersant, M.D V. Bigorie, M.D O. Hermeziu, M.D J.-P. Meningaud, M.D., PhD. PII:
S1748-6815(14)00077-1
DOI:
10.1016/j.bjps.2014.02.008
Reference:
PRAS 4094
To appear in:
British Journal of Plastic Surgery
Received Date: 17 January 2014 Accepted Date: 2 February 2014
Please cite this article as: Niddam J, Bosc R, Lange F, Chader H, Hersant B, Bigorie V, Hermeziu O, Meningaud J-P, DIEP flap for breast reconstruction: retrospective evaluation of patient satisfaction on abdominal results., British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.02.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT DIEP flap for breast reconstruction: retrospective evaluation of patient satisfaction on abdominal results.
J. Niddam, M.D.
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R. Bosc, M.D. F. Lange, M.D. H. Chader, M.D.
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B. Hersant, M.D.
O. Hermeziu, M.D. J.-P. Meningaud, M.D., PhD.
Affiliations
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V. Bigorie, M.D.
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Henri Mondor Hospital – University of Paris Est, FRANCE
Corresponding author Dr Jeremy Niddam
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51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, FRANCE
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Address: Henri Mondor Hospital-University of Paris-Est, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, FRANCE
Phone number: 00 33 1 49 81 25 24 GSM: 00 33 6 09 76 50 44 Fax: 00 33 1 49 81 25 32 Mail: [email protected]
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ACCEPTED MANUSCRIPT SUMMARY
Background
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Although some papers have analyzed patient satisfaction after traditional abdominoplasty, studies that have specifically assessed patient satisfaction on abdominal reconstruction after DIEP surgery are lacking. The aim of this study was to assess satisfaction, specifically for abdominoplasty results, in patients who underwent breast reconstruction with a single DIEP
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flap.
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Methods
This retrospective study included 53 consecutive patients who underwent unilateral breast reconstruction with a DIEP flap. The patients were all clinically evaluated during a specific consultation and answered a satisfaction survey based on a four-point scale (unsatisfied, satisfied, happy, very happy).
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Results
Fifty patients responded to the survey. The average age was 52.3 years. This study revealed
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that 52% of patients were happy or very happy with the aesthetic result of their abdomen. A total of 34% of patients confessed that they preferred their abdomen before surgery. A further
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analysis of the dissatisfied patients showed particular dissatisfaction with dog-ears (50%), residual abdominal overhang (18%), or the horizontal scar (12%). The average distance between the horizontal scar and vulvar anterior commissure was 10.6 cm. A total of 86% of patients were happy or very happy with the preoperative counseling. Conclusions The authors note the necessity to give detailed preoperative information to explain the final abdominal aesthetic result, which can be quite different from the patient’s expectations.
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ACCEPTED MANUSCRIPT KEYWORDS
DIEP flap Abdominoplasty
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Satisfaction survey
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Breast reconstruction
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ACCEPTED MANUSCRIPT INTRODUCTION
For twenty years, abdominal flaps have been considered a method of choice for mammary reconstruction (1–3). The absence of implants and its autologous character make it one of the
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most popular techniques, especially for women with abdominal pendulum. The use of a DIEP flap helps the surgeon to preserve the rectus muscle fascia and reduces the risk of post-
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operative hernia (4).
DIEP flap harvesting leads the surgeon to perform an abdominoplasty for abdominal closure.
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However, this abdominoplasty is not a classic one; indeed, several steps of the intervention are not usually done. For example, a liposuction of the abdomen could injure the flap vascularization, and a correction of the diastasis might increase thrombosis risk (5). Above all, the final scar, which should be hidden by underwear, can be located in the middle of the abdomen. Do the benefits of this breast reconstruction method lead some surgeons to slightly
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over-propose it to patients without sufficient abdominal pendulum?
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Plastic surgeons are trained to maximize the rate of aesthetic satisfaction of their patients, especially in breast reconstruction. Moreover, several studies have shown that patients who
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underwent DIEP flap surgery were very satisfied with their breast results (6–9).
Conversely, standard abdominoplasty continues to be associated with a high incidence of patient dissatisfaction and litigation for surgeons (10). Although some authors have analyzed patient satisfaction after traditional abdominoplasty, studies that have specifically assessed patient satisfaction on abdominal results after DIEP surgery are lacking.
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ACCEPTED MANUSCRIPT The aim of this study was to assess patient satisfaction specifically regarding the abdominoplasty outcomes of patients who underwent breast reconstruction with single DIEP flap.
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PATIENTS AND METHODS
This retrospective study included all consecutive patients who underwent a single DIEP flap
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for breast reconstruction by the same operator in a plastic, reconstructive and aesthetic surgery department between June 2010 and June 2013. Bilateral reconstructions and DIEP
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flaps for other injuries, such as limb traumas, were excluded for this study.
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SKIN MARKINGS
Only the abdominoplasty technique was described here. The skin marking was completed the day before intervention. Using CT scan and Doppler results, we marked the emergence of the
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best cutaneous artery perforators. Then, a right suprapubic inferior incision of 14 cm was marked. If possible, this incision was placed 7 cm above the anterior vulvar commissure, as in
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standard abdominoplasty (11–14).
Then, the two parts of this line met the two ASIS. The upper line was marked above the umbilicus and artery perforators in a gently curving fashion down to the lateral apex of the inferior line. Here, traction was used to verify that closure was possible (pinch test). If not, the lower incision was drawn a few centimeters higher.
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ACCEPTED MANUSCRIPT OPERATIVE TECHNIQUE
Only the abdominoplasty is described here. We began with the incisions of the upper and lower lines and moved down to the muscle fascia. At the lower level, we tried to preserve the
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SIEA vessels. Then, the umbilicus was incised with a 15 blade perpendicular to the stalk of the umbilicus on each side. The flap side was then elevated up to the artery perforators. The undermining in this time was performed above Scarpa’s fascia at the extremities to preserve
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followed through the rectus muscle until their origins.
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the lateral cutaneous nerves (11,12). Then, the DIEP perforators were individualized and
After the flap was harvested, the undermining was continued at the level above the muscular fascia, up to the costal margins and xiphoid. Then, hemostasis was controlled, and the rectus sheath was repaired. That was achieved with many strong U stitches of Vicryl 1 and a running
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double-strand suture to secure this closure.
At the end of the intervention, the new skin site of the umbilicus was marked and incised in a
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V shape, and we performed a selective defatting to provide a natural periombilical depression. The new umbilicus was then externalized. Two drains were placed beneath the abdominal
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flap, exiting the pubic region. The skin edges were approximated from lateral to medial to prevent the formation of dog-ears. Scarpa’s fascia, skin, and umbilicus were sutured in that order (15).
DESIGN OF THE STUDY
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ACCEPTED MANUSCRIPT This study was designed as a questionnaire survey. Each patient was contacted by phone and then seen in consultation by a senior surgeon (not the operator) for a semi-directive interview and a standardized questionnaire. The questionnaire was composed of questions on various aspects of the outcome. Four answers were set up using a four-point satisfaction scales
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(unsatisfied, satisfied, happy, and very happy), with the possibility of adding free text (10). Patients answered the other questions with a yes or no. The questionnaire is presented in
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Table 1.
Furthermore, during the follow-up, several lengths were measured, as follows: between the
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scar and vulvar anterior commissure, between the scar and umbilicus, and the eventual displacement of the umbilicus from the medial line. We took pictures of all patients before and after surgery.
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All information and data from patients were collected, gathered and computerized following
RESULTS
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the ethical recommendations of our clinical investigation unit.
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Fifty-three patients underwent single DIEP flap surgery for breast reconstruction during this period, and 50 patients answered the survey. Three patients were lost to follow-up.
The average age was 52.3 years (34-74), and the mean Body Mass Index (BMI) was 26.4 (22.8-33.1). The median follow up was 18.3 months (6-34).
Results are given for each of the questions.
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Twenty-six patients (52%) were either happy or very happy with the global result of their abdomen (figure 1). The most frequently cited area of dissatisfaction was dog-ears, which were reported by 25 patients (50%) (figure 2). Thirty-three patients (66%) preferred their
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abdomen now.
Thirty-three patients (66%) were either happy or very happy with the appearance of their
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umbilicus (figure 3). Thirty-five patients (70%) were either happy or very happy with the
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appearance of the scar (figure 4), which was hidden by underwear in 30 patients (60%).
None of the patients were dissatisfied with the preoperative counseling, with 43 patients (86%) being either happy or very happy (figure 5).
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The average duration of wearing the girdle was 59 days.
For 20 patients (40%), the opportunity for the abdominoplasty was the main criterion that
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influenced their choice of the DIEP flap procedure.
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The other answers are presented in Table 2 and 3.
The average measurements were 10.6 cm from the vulvar anterior commissure to the scar and 8.8 cm from the scar to the umbilicus. The average lateral displacement of the umbilicus from the abdominal medial line was 0.42 cm.
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ACCEPTED MANUSCRIPT DISCUSSION
Our study showed that 52% of patients were happy or very happy with the final appearance of
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their abdomen.
Over the past few years, abdominoplasty has changed from primarily being a repairing surgery to an aesthetic surgery. The standard level in terms of results has become equivalent
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to other purely aesthetic interventions. Abdominoplasty has continued to be associated with a high incidence of patient dissatisfaction and litigation for surgeons (10). In the literature, few
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papers have analyzed satisfaction after a classic abdominoplasty. In most studies, this satisfaction rate was on average between 70 and 90% (10,16).
In 2006, Bragg et al. showed that, in a selected group of NHS patients, one in four was
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dissatisfied with their final aesthetic results (10). In their study, they assessed patients’ satisfaction using a four-point scale evaluation. We have designed our survey on the same
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model (Unsatisfied, satisfied, happy, very happy).
Obtaining an optimal result often requires two operational stages, a data element that was
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described as essential to the patients (17). In the literature the revision rate is on average between 14 and 43% (16,18,19). In 2005, Stewart et al. analyzed 278 consecutive abdominoplasties. They found dog-ears in 12%, localized fat excess in 10%, and unsatisfactory scars in 8% (19). In our study, the revision rate to improve the aesthetic result of the abdominoplasty, such as scar or dog-ear revision, was 46%.
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ACCEPTED MANUSCRIPT This could be explained by the fact that, during DIEP flap harvesting, some procedures are not performed. For example, liposuction is not carried out in our DIEP protocol because of the risk of perforating vessel injury. This can lead to some abdominal overhang or dog-ears. The correction of diastasis was often not performed to decrease the thrombo-embolism risk,
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which is known to be elevated in this type of surgery (5). To prevent postoperative hernia, the rectus sheath, at the side of the flap, was strongly repaired, with many stitches and doublestrand sutures; this procedure could also lead to a lateral displacement of umbilicus. In the
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end, the final aesthetic results could sometimes be considered far from those of a standard
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abdominoplasty (11).
Some reflections could be brought to improve the aesthetic results. The principal cause of disappointment in our study was the formation of dog-ears. Liposuction could be dangerous before the flap undermining but may be less so at the end of the surgery (20). This procedure
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could be performed at the extremities of the scar to prevent the formation of dog-ears. Furthermore, this procedure would not increase the duration of surgery.
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For some authors, umbilical malposition is far more difficult to correct. In our opinion, preoperative midline marking is the best option for its prevention. Furthermore, during the
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surgery, some plastic surgery teams have realized an opposite plicature of the aponeurosis in the mirror of the flap side in correcting the lateral umbilicus displacement. However, if the malposition is diagnosed postoperatively, it is necessary to wait for the entire cicatrisation of the abdominal wall, which might take many months. Only after such a wait can the entire flap be undermined, the umbilicus centered, and a new complete closure performed (20).
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ACCEPTED MANUSCRIPT Scar problems also cannot be solved easily. In standard abdominoplasty, authors recommend the placement of the final horizontal scar between five and seven cm above the vulvar anterior commissure (11). In our study, the placement was, on average, 10.6 cm. In our experience, the significant benefits of the DIEP flap breast reconstruction method may lead us to propose this
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technique to patients without large abdominal pendulum (21,22) and, subsequently, to a higher primary horizontal abdominal scar. In 40% of patients, this scar was not hidden by underwear. Patients presenting with a low pendulum must be informed of this risk and, at
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least, should be informed about other breast reconstruction methods, such as latissimus dorsi flaps, for example. For the same reason, the umbilicus, which was usually located at least at
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11 cm from the scar, was 8.8 cm from the scar, on average, in our study (11) (figures 6, 7, 8).
A total of 34% of patients confessed that they preferred their abdomen before the surgery. However, 96% of patients would recommend the procedure to a friend, and 84% would
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consent to the same procedure if they had to do it again. This contradiction between these data could be explained by the fact that, when the patients answered questions regarding the procedure, it was difficult for them to distinguish their breast results from their abdominal
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results; most of the time, they were very satisfied with their breast reconstruction. Even if we had explained in our survey that they should focus on the abdomen only, it is complicated for
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patients who underwent breast reconstruction not to think about the two together.
We excluded double DIEP flap from analysis in this study because, in such cases of double reconstruction, we used mesh to repair the fascia, and the risk of postoperative hernia could be greater than in single DIEP. In this case we have considered that the inclusion of double DIEP flap surgery could be a confounding factor for abdominal aesthetic outcomes evaluation. Nevertheless, in our cohort of 50 single DIEP patients, two patients presented
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ACCEPTED MANUSCRIPT postoperative hernias at one-year follow-up. During the process of Nipple Areola Complex (NAC) reconstruction and breast symmetrization, these two patients underwent an abdominal wall reconstruction with fascial non-absorbable mesh.
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The average BMI was 26.4 in this study. This result was similar to the BMIs of patients in abdominoplasty studies. Many studies have shown that a BMI >30 kg/m2 is associated with a significant increase in complications (23). In this study, we did not find a correlation in the
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relationship between preoperative BMI and patient satisfaction. However, women with important preoperative pendulum and subsequently with important abdominal resections
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during the surgery seemed to be happier about the final aesthetic result than the others.
The average duration of wearing the girdle was 59 days in this study. In our practice, we recommend that patients wear the girdle at least 45 days, even at night, as recommended in
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other studies. We did not notice here that extended wear of the girdle decreased the risk of aesthetic impairments such as bulge formation.
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Patients frequently complained about the loss of sensitivity of the abdomen wall (16,24). Our study identified a disorder of abdominal sensitivity in 44% of patients. We analyzed tactile
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skin sensitivity only. In a retrospective evaluation of 133 abdominoplasties, Floros and Davis found that the most common complication was an injury to the lateral cutaneous nerve of the abdomen, which appears in one third of cases (16). The undermining of the flap’s extremities above Scarpa’s fascia was intended to decrease the risk of nervous injury, which we achieved (11,24).
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ACCEPTED MANUSCRIPT Changes resulting from an abdominoplasty may have a large impact on sexual life and body image (6,25). In 2012, De Brito et al. analyzed this impact on 19 women who underwent abdominoplasty and found a significant improvement in body image and sexual life in their cohort (26). Our study showed other results; body image was worse in 32% of patients, and
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sexual life was most often unchanged. Some patients explained that the appearance of the scar or abdominal overhang could prevent them, for example, from getting naked or in a bikini in
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the summer.
A total of 86% of women were very happy with the preoperative counseling in our study. As
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most of breast reconstruction surgeons, we considered that preoperative information was very important in this type of surgery to explain the surgical procedure, possible complications, final scar and aesthetic result (27,28). Up until now, we have no standardized written patient
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information for breast reconstruction, specifically with a DIEP flap process.
There are several reasons why a patient would chose a DIEP flap for breast reconstruction: no implant, lasting results, surgeon influence, or secondary benefits of the abdominoplasty (7,9).
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In our study, for 20 patients (40%), the opportunity to receive an abdominoplasty was the main criterion that influenced their choice of a DIEP flap. For these patients, a poor final
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result of their abdominal reconstruction was even more difficult to accept. We also observed that these patients were often the most dissatisfied.
CONCLUSION
This study was one of the first, which provide an analysis of satisfaction resulting from the abdominoplasty of patients who underwent breast reconstruction with a DIEP flap.
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Preoperative counseling was very important, especially in patients for whom the secondary benefit of abdominoplasty was high (27,28). Regarding our results, it seemed necessary to improve our information to patients to prepare them for potentially less aesthetic results
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compared to their expectations (7).
For breast reconstruction, we believe that abdominal pendulum should be considered as a flap
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donor site, as well as the skin from thighs, back or buttocks for the TUG, the Latissimus dorsi or the SGAP flap, respectively. Patients and surgeons should consider all of these possibilities
Conflict of interest statement
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to confirm the DIEP flap choice or to select another breast reconstruction technique (9).
None of the authors has a financial or personal relationships with other people or
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organisations that could inappropriately influence (bias) their work.
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ACCEPTED MANUSCRIPT REFERENCES
1.
Healy C, Allen RJ. The Evolution of Perforator Flap Breast Reconstruction: Twenty
2.
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Years after the First DIEP Flap. J Reconstr Microsurg. 2013;25. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with the deep
inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg. 2006;59;571-9.
Bodin F, Zink S, Lutz J-C, Kadoch V, Wilk A, Bruant-Rodier C. Quel est le palmarès
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3.
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des techniques de reconstruction mammaire à long terme ? Ann Chir Plast Esthet. 2010;55;547-52. 4.
Bottero L, Lefaucheur J-P, Fadhul S, Raulo Y, Collins ED, Lantieri L.
Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery. Plast Reconstr Surg. 2004;113;156-61. Miszkiewicz K, Perreault I, Landes G, et al. Venous thromboembolism in plastic
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5.
surgery: incidence, current practice and recommendations. J Plast Reconstr Aesthet Surg.
6.
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2009;62;580-8.
Gopie JP, Ter Kuile MM, Timman R, Mureau MAM, Tibben A. Impact of delayed
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implant and DIEP flap breast reconstruction on body image and sexual satisfaction: a prospective follow-up study. Psychooncology. 2013;27. 7.
Pusic AL, Klassen AF, Snell L, et al. Measuring and managing patient expectations
for breast reconstruction: impact on quality of life and patient satisfaction. Expert Rev Pharmacoecon Outcomes Res. 2012;12;149-58. 8.
Sugrue R, MacGregor G, Sugrue M, Curran S, Murphy L. An evaluation of patient
reported outcomes following breast reconstruction utilizing Breast Q. Breast. 2013;22;158-61. 9.
Yueh JH, Slavin SA, Adesiyun T, Nyame TT, Gautam S, Morris DJ, et al. Patient
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ACCEPTED MANUSCRIPT satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125;1585-95. 10.
Bragg TWH, Jose RM, Srivastava S. Patient satisfaction following abdominoplasty: an
NHS experience. J Plast Reconstr Aesthet Surg. 2007;60;75-8. Le Louarn C, Pascal JF. High superior tension abdominoplasty. Aesthetic Plast Surg.
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11.
2000;24;375-81. 12.
Nahai FR. Anatomic considerations in abdominoplasty. Clin Plast Surg. 2010;37;407-
Jobe Fix R. Standard abdominoplasty. Operative Techniques in Plastic and
Reconstructive Surgery. 1996;3;15-22. 14.
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13.
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14.
Matarasso A. Classification and patient selection in abdominoplasty. Operative
Techniques in Plastic and Reconstructive Surgery. 1996;3;7-14.
Matarasso A. Traditional abdominoplasty. Clin Plast Surg. 2010;37;415-37.
16.
Floros C, Davis PK. Complications and long-term results following abdominoplasty: a
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15.
retrospective study. Br J Plast Surg. 1991;44;190-94. 17.
Gliksman J, Himy S, Ringenbach P, Andreoletti J-B. L'abdominoplastie: vers une
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chirurgie en deux temps? Etude rétrospective des complications postopératoires à propos de 100 cas. Ann Chir Plast Esthet. 2006;51;151-56. Stevens WG, Spring MA, Stoker DA, Cohen R, Vath SD, Hirsch EM. Ten years of
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18.
outpatient abdominoplasties: safe and effective. Aesthet Surg J. 2007;27;269-75. 19.
Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM, Waterhouse N.
Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg. 2006;59;1152-5. 20.
Hunstad JP. Revision abdominoplasty: Complications and their management.
Operative Techniques in Plastic and Reconstructive Surgery. 1996;3;67-76.
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ACCEPTED MANUSCRIPT 21.
Sozer SO, Agullo FJ, Santillan AA, Wolf C. Decision making in abdominoplasty.
Aesthetic Plast Surg. 2007;31;117-27. 22.
Salgarello M, Tambasco D, Farallo E. DIEP flap donor site versus elective
2012;36;363-9. 23.
Momeni A, Heier M, Bannasch H, Stark GB. Complications in abdominoplasty: a risk
factor analysis. J Plast Reconstr Aesthet Surg. 2009;62;1250-4.
Castus P, Grandjean F-X, Tourbach S, Heymans O. Sensibilité de la paroi abdominale
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24.
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abdominoplasty short-term complication rates: a meta-analysis. Aesthetic Plast Surg.
après abdominoplastie haute tension. Ann Chir Plast Esthet. 2009;54;545-50. Von Soest T, Kvalem IL, Roald HE, Skolleborg KC. The effects of cosmetic surgery
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25.
on body image, self-esteem, and psychological problems. J Plast Reconstr Aesthet Surg. 2009;62;1238-44. 26.
De Brito MJA, Nahas FX, Bussolaro RA, Shinmyo LM, Barbosa MVJ, Ferreira LM.
27.
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Effects of abdominoplasty on female sexuality: a pilot study. J Sex Med. 2012;9;918-26. Malahias M, Lemonas P, Schreuder F, Ghorbanian S. Abdominoplasty: to inform
about TRAM flaps or not? J Plast Reconstr Aesthet Surg. 2011;64;78-79. Matarasso A. Awareness and avoidance of abdominoplasty complications. Aesthet
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28.
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Surg J. 1997;17;256, 258-61.
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ACCEPTED MANUSCRIPT Figure Legends
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Figure 1: Global satisfaction.
Figure 2: Reasons of disappointment.
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Figure 3: Umbilicus satisfaction.
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Figure 4: Scar satisfaction.
Figure 5: Quality of preoperative counseling.
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Figure 6: Result 30 months after the DIEP flap surgery in a woman with a low preoperative pendulum. Here, the distance from the scar to the vulvar anterior commissure was 10 cm, and
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the distance to the umbilicus was 4.5 cm. She was not happy about the aesthetic result. Her
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weight has increased by 15kg since the operation.
Figure 7: Woman with low preoperative pendulum. Result at 18 months. The final scar is high, 10 cm from the vulvar anterior commissure. Despite this, she is happy with the aesthetic result.
Figure 8: Woman with moderate preoperative pendulum. Results 9 months after surgery. The scar was 8cm from the vulvar anterior commissure and 10cm from the umbilicus. She was very happy about the aesthetic result.
ACCEPTED MANUSCRIPT Regarding the outcome of your abdominoplasty, how do you assess: -
Your global satisfaction? If you are not very happy, which aspects are you not
-
The aspect of your umbilicus?
-
The aspect of your scar? Is it hidden by your underwear?
-
The quality of pre-operative counseling?
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satisfied with?
Did you receive a reoperation to improve the result of your abdomen? Would you recommend the procedure to a friend? If you had the time again, would you consent to the same procedure?
How much time did you wear the girdle? Do you feel the touch on your abdomen?
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Did your abdominoplasty change your body image?
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Do you prefer your abdomen now or before the procedure?
Did your abdominoplasty change your sexual life?
Was the opportunity to benefit from an abdominoplasty the main criterion that guided your choice of this reconstruction technique?
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Table 1: Satisfaction survey.
ACCEPTED MANUSCRIPT No
Did you receive a reoperation?
23
27
Would you recommend to a friend?
48
2
Would you consent to the same procedure?
42
8
Do you feel the touch on your abdomen?
28
22
Was abdominoplasty your main criterion?
20
30
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Yes
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Table 2: Answers to the survey by yes or no.
ACCEPTED MANUSCRIPT No
Negative change
Positive change
Change in body image?
17
16
17
Change in sexual life?
40
8
2
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Table 3: Results regarding body image and sexual life.
ACCEPTED MANUSCRIPT
20 15 10
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5 0 happy
satisfied
unsatisfied
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very happy
ACCEPTED MANUSCRIPT
30 25 20 15 10
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5 0 abdominal overhang
scar
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SC
dog-ears
ACCEPTED MANUSCRIPT
20 15 10
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5 0 happy
satisfied
unsatisfied
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very happy
ACCEPTED MANUSCRIPT
25 20 15 10
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5 0 happy
satisfied
unsatisfied
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very happy
ACCEPTED MANUSCRIPT
50 40 30 20
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10 0 happy
satisfied
unsatisfied
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very happy
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EP
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SC
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
S1748-6815(14)00077-1
DOI:
10.1016/j.bjps.2014.02.008
Reference:
PRAS 4094
To appear in:
British Journal of Plastic Surgery
Received Date: 17 January 2014 Accepted Date: 2 February 2014
Please cite this article as: Niddam J, Bosc R, Lange F, Chader H, Hersant B, Bigorie V, Hermeziu O, Meningaud J-P, DIEP flap for breast reconstruction: retrospective evaluation of patient satisfaction on abdominal results., British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2014.02.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT DIEP flap for breast reconstruction: retrospective evaluation of patient satisfaction on abdominal results.
J. Niddam, M.D.
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R. Bosc, M.D. F. Lange, M.D. H. Chader, M.D.
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B. Hersant, M.D.
O. Hermeziu, M.D. J.-P. Meningaud, M.D., PhD.
Affiliations
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V. Bigorie, M.D.
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Henri Mondor Hospital – University of Paris Est, FRANCE
Corresponding author Dr Jeremy Niddam
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51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, FRANCE
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Address: Henri Mondor Hospital-University of Paris-Est, 51 avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, FRANCE
Phone number: 00 33 1 49 81 25 24 GSM: 00 33 6 09 76 50 44 Fax: 00 33 1 49 81 25 32 Mail: [email protected]
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ACCEPTED MANUSCRIPT SUMMARY
Background
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Although some papers have analyzed patient satisfaction after traditional abdominoplasty, studies that have specifically assessed patient satisfaction on abdominal reconstruction after DIEP surgery are lacking. The aim of this study was to assess satisfaction, specifically for abdominoplasty results, in patients who underwent breast reconstruction with a single DIEP
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flap.
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Methods
This retrospective study included 53 consecutive patients who underwent unilateral breast reconstruction with a DIEP flap. The patients were all clinically evaluated during a specific consultation and answered a satisfaction survey based on a four-point scale (unsatisfied, satisfied, happy, very happy).
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Results
Fifty patients responded to the survey. The average age was 52.3 years. This study revealed
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that 52% of patients were happy or very happy with the aesthetic result of their abdomen. A total of 34% of patients confessed that they preferred their abdomen before surgery. A further
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analysis of the dissatisfied patients showed particular dissatisfaction with dog-ears (50%), residual abdominal overhang (18%), or the horizontal scar (12%). The average distance between the horizontal scar and vulvar anterior commissure was 10.6 cm. A total of 86% of patients were happy or very happy with the preoperative counseling. Conclusions The authors note the necessity to give detailed preoperative information to explain the final abdominal aesthetic result, which can be quite different from the patient’s expectations.
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ACCEPTED MANUSCRIPT KEYWORDS
DIEP flap Abdominoplasty
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Satisfaction survey
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Breast reconstruction
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ACCEPTED MANUSCRIPT INTRODUCTION
For twenty years, abdominal flaps have been considered a method of choice for mammary reconstruction (1–3). The absence of implants and its autologous character make it one of the
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most popular techniques, especially for women with abdominal pendulum. The use of a DIEP flap helps the surgeon to preserve the rectus muscle fascia and reduces the risk of post-
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operative hernia (4).
DIEP flap harvesting leads the surgeon to perform an abdominoplasty for abdominal closure.
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However, this abdominoplasty is not a classic one; indeed, several steps of the intervention are not usually done. For example, a liposuction of the abdomen could injure the flap vascularization, and a correction of the diastasis might increase thrombosis risk (5). Above all, the final scar, which should be hidden by underwear, can be located in the middle of the abdomen. Do the benefits of this breast reconstruction method lead some surgeons to slightly
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over-propose it to patients without sufficient abdominal pendulum?
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Plastic surgeons are trained to maximize the rate of aesthetic satisfaction of their patients, especially in breast reconstruction. Moreover, several studies have shown that patients who
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underwent DIEP flap surgery were very satisfied with their breast results (6–9).
Conversely, standard abdominoplasty continues to be associated with a high incidence of patient dissatisfaction and litigation for surgeons (10). Although some authors have analyzed patient satisfaction after traditional abdominoplasty, studies that have specifically assessed patient satisfaction on abdominal results after DIEP surgery are lacking.
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ACCEPTED MANUSCRIPT The aim of this study was to assess patient satisfaction specifically regarding the abdominoplasty outcomes of patients who underwent breast reconstruction with single DIEP flap.
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PATIENTS AND METHODS
This retrospective study included all consecutive patients who underwent a single DIEP flap
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for breast reconstruction by the same operator in a plastic, reconstructive and aesthetic surgery department between June 2010 and June 2013. Bilateral reconstructions and DIEP
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flaps for other injuries, such as limb traumas, were excluded for this study.
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SKIN MARKINGS
Only the abdominoplasty technique was described here. The skin marking was completed the day before intervention. Using CT scan and Doppler results, we marked the emergence of the
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best cutaneous artery perforators. Then, a right suprapubic inferior incision of 14 cm was marked. If possible, this incision was placed 7 cm above the anterior vulvar commissure, as in
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standard abdominoplasty (11–14).
Then, the two parts of this line met the two ASIS. The upper line was marked above the umbilicus and artery perforators in a gently curving fashion down to the lateral apex of the inferior line. Here, traction was used to verify that closure was possible (pinch test). If not, the lower incision was drawn a few centimeters higher.
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ACCEPTED MANUSCRIPT OPERATIVE TECHNIQUE
Only the abdominoplasty is described here. We began with the incisions of the upper and lower lines and moved down to the muscle fascia. At the lower level, we tried to preserve the
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SIEA vessels. Then, the umbilicus was incised with a 15 blade perpendicular to the stalk of the umbilicus on each side. The flap side was then elevated up to the artery perforators. The undermining in this time was performed above Scarpa’s fascia at the extremities to preserve
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followed through the rectus muscle until their origins.
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the lateral cutaneous nerves (11,12). Then, the DIEP perforators were individualized and
After the flap was harvested, the undermining was continued at the level above the muscular fascia, up to the costal margins and xiphoid. Then, hemostasis was controlled, and the rectus sheath was repaired. That was achieved with many strong U stitches of Vicryl 1 and a running
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double-strand suture to secure this closure.
At the end of the intervention, the new skin site of the umbilicus was marked and incised in a
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V shape, and we performed a selective defatting to provide a natural periombilical depression. The new umbilicus was then externalized. Two drains were placed beneath the abdominal
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flap, exiting the pubic region. The skin edges were approximated from lateral to medial to prevent the formation of dog-ears. Scarpa’s fascia, skin, and umbilicus were sutured in that order (15).
DESIGN OF THE STUDY
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ACCEPTED MANUSCRIPT This study was designed as a questionnaire survey. Each patient was contacted by phone and then seen in consultation by a senior surgeon (not the operator) for a semi-directive interview and a standardized questionnaire. The questionnaire was composed of questions on various aspects of the outcome. Four answers were set up using a four-point satisfaction scales
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(unsatisfied, satisfied, happy, and very happy), with the possibility of adding free text (10). Patients answered the other questions with a yes or no. The questionnaire is presented in
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Table 1.
Furthermore, during the follow-up, several lengths were measured, as follows: between the
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scar and vulvar anterior commissure, between the scar and umbilicus, and the eventual displacement of the umbilicus from the medial line. We took pictures of all patients before and after surgery.
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All information and data from patients were collected, gathered and computerized following
RESULTS
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the ethical recommendations of our clinical investigation unit.
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Fifty-three patients underwent single DIEP flap surgery for breast reconstruction during this period, and 50 patients answered the survey. Three patients were lost to follow-up.
The average age was 52.3 years (34-74), and the mean Body Mass Index (BMI) was 26.4 (22.8-33.1). The median follow up was 18.3 months (6-34).
Results are given for each of the questions.
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Twenty-six patients (52%) were either happy or very happy with the global result of their abdomen (figure 1). The most frequently cited area of dissatisfaction was dog-ears, which were reported by 25 patients (50%) (figure 2). Thirty-three patients (66%) preferred their
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abdomen now.
Thirty-three patients (66%) were either happy or very happy with the appearance of their
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umbilicus (figure 3). Thirty-five patients (70%) were either happy or very happy with the
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appearance of the scar (figure 4), which was hidden by underwear in 30 patients (60%).
None of the patients were dissatisfied with the preoperative counseling, with 43 patients (86%) being either happy or very happy (figure 5).
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The average duration of wearing the girdle was 59 days.
For 20 patients (40%), the opportunity for the abdominoplasty was the main criterion that
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influenced their choice of the DIEP flap procedure.
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The other answers are presented in Table 2 and 3.
The average measurements were 10.6 cm from the vulvar anterior commissure to the scar and 8.8 cm from the scar to the umbilicus. The average lateral displacement of the umbilicus from the abdominal medial line was 0.42 cm.
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ACCEPTED MANUSCRIPT DISCUSSION
Our study showed that 52% of patients were happy or very happy with the final appearance of
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their abdomen.
Over the past few years, abdominoplasty has changed from primarily being a repairing surgery to an aesthetic surgery. The standard level in terms of results has become equivalent
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to other purely aesthetic interventions. Abdominoplasty has continued to be associated with a high incidence of patient dissatisfaction and litigation for surgeons (10). In the literature, few
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papers have analyzed satisfaction after a classic abdominoplasty. In most studies, this satisfaction rate was on average between 70 and 90% (10,16).
In 2006, Bragg et al. showed that, in a selected group of NHS patients, one in four was
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dissatisfied with their final aesthetic results (10). In their study, they assessed patients’ satisfaction using a four-point scale evaluation. We have designed our survey on the same
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model (Unsatisfied, satisfied, happy, very happy).
Obtaining an optimal result often requires two operational stages, a data element that was
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described as essential to the patients (17). In the literature the revision rate is on average between 14 and 43% (16,18,19). In 2005, Stewart et al. analyzed 278 consecutive abdominoplasties. They found dog-ears in 12%, localized fat excess in 10%, and unsatisfactory scars in 8% (19). In our study, the revision rate to improve the aesthetic result of the abdominoplasty, such as scar or dog-ear revision, was 46%.
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ACCEPTED MANUSCRIPT This could be explained by the fact that, during DIEP flap harvesting, some procedures are not performed. For example, liposuction is not carried out in our DIEP protocol because of the risk of perforating vessel injury. This can lead to some abdominal overhang or dog-ears. The correction of diastasis was often not performed to decrease the thrombo-embolism risk,
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which is known to be elevated in this type of surgery (5). To prevent postoperative hernia, the rectus sheath, at the side of the flap, was strongly repaired, with many stitches and doublestrand sutures; this procedure could also lead to a lateral displacement of umbilicus. In the
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end, the final aesthetic results could sometimes be considered far from those of a standard
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abdominoplasty (11).
Some reflections could be brought to improve the aesthetic results. The principal cause of disappointment in our study was the formation of dog-ears. Liposuction could be dangerous before the flap undermining but may be less so at the end of the surgery (20). This procedure
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could be performed at the extremities of the scar to prevent the formation of dog-ears. Furthermore, this procedure would not increase the duration of surgery.
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For some authors, umbilical malposition is far more difficult to correct. In our opinion, preoperative midline marking is the best option for its prevention. Furthermore, during the
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surgery, some plastic surgery teams have realized an opposite plicature of the aponeurosis in the mirror of the flap side in correcting the lateral umbilicus displacement. However, if the malposition is diagnosed postoperatively, it is necessary to wait for the entire cicatrisation of the abdominal wall, which might take many months. Only after such a wait can the entire flap be undermined, the umbilicus centered, and a new complete closure performed (20).
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ACCEPTED MANUSCRIPT Scar problems also cannot be solved easily. In standard abdominoplasty, authors recommend the placement of the final horizontal scar between five and seven cm above the vulvar anterior commissure (11). In our study, the placement was, on average, 10.6 cm. In our experience, the significant benefits of the DIEP flap breast reconstruction method may lead us to propose this
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technique to patients without large abdominal pendulum (21,22) and, subsequently, to a higher primary horizontal abdominal scar. In 40% of patients, this scar was not hidden by underwear. Patients presenting with a low pendulum must be informed of this risk and, at
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least, should be informed about other breast reconstruction methods, such as latissimus dorsi flaps, for example. For the same reason, the umbilicus, which was usually located at least at
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11 cm from the scar, was 8.8 cm from the scar, on average, in our study (11) (figures 6, 7, 8).
A total of 34% of patients confessed that they preferred their abdomen before the surgery. However, 96% of patients would recommend the procedure to a friend, and 84% would
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consent to the same procedure if they had to do it again. This contradiction between these data could be explained by the fact that, when the patients answered questions regarding the procedure, it was difficult for them to distinguish their breast results from their abdominal
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results; most of the time, they were very satisfied with their breast reconstruction. Even if we had explained in our survey that they should focus on the abdomen only, it is complicated for
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patients who underwent breast reconstruction not to think about the two together.
We excluded double DIEP flap from analysis in this study because, in such cases of double reconstruction, we used mesh to repair the fascia, and the risk of postoperative hernia could be greater than in single DIEP. In this case we have considered that the inclusion of double DIEP flap surgery could be a confounding factor for abdominal aesthetic outcomes evaluation. Nevertheless, in our cohort of 50 single DIEP patients, two patients presented
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ACCEPTED MANUSCRIPT postoperative hernias at one-year follow-up. During the process of Nipple Areola Complex (NAC) reconstruction and breast symmetrization, these two patients underwent an abdominal wall reconstruction with fascial non-absorbable mesh.
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The average BMI was 26.4 in this study. This result was similar to the BMIs of patients in abdominoplasty studies. Many studies have shown that a BMI >30 kg/m2 is associated with a significant increase in complications (23). In this study, we did not find a correlation in the
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relationship between preoperative BMI and patient satisfaction. However, women with important preoperative pendulum and subsequently with important abdominal resections
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during the surgery seemed to be happier about the final aesthetic result than the others.
The average duration of wearing the girdle was 59 days in this study. In our practice, we recommend that patients wear the girdle at least 45 days, even at night, as recommended in
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other studies. We did not notice here that extended wear of the girdle decreased the risk of aesthetic impairments such as bulge formation.
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Patients frequently complained about the loss of sensitivity of the abdomen wall (16,24). Our study identified a disorder of abdominal sensitivity in 44% of patients. We analyzed tactile
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skin sensitivity only. In a retrospective evaluation of 133 abdominoplasties, Floros and Davis found that the most common complication was an injury to the lateral cutaneous nerve of the abdomen, which appears in one third of cases (16). The undermining of the flap’s extremities above Scarpa’s fascia was intended to decrease the risk of nervous injury, which we achieved (11,24).
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ACCEPTED MANUSCRIPT Changes resulting from an abdominoplasty may have a large impact on sexual life and body image (6,25). In 2012, De Brito et al. analyzed this impact on 19 women who underwent abdominoplasty and found a significant improvement in body image and sexual life in their cohort (26). Our study showed other results; body image was worse in 32% of patients, and
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sexual life was most often unchanged. Some patients explained that the appearance of the scar or abdominal overhang could prevent them, for example, from getting naked or in a bikini in
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the summer.
A total of 86% of women were very happy with the preoperative counseling in our study. As
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most of breast reconstruction surgeons, we considered that preoperative information was very important in this type of surgery to explain the surgical procedure, possible complications, final scar and aesthetic result (27,28). Up until now, we have no standardized written patient
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information for breast reconstruction, specifically with a DIEP flap process.
There are several reasons why a patient would chose a DIEP flap for breast reconstruction: no implant, lasting results, surgeon influence, or secondary benefits of the abdominoplasty (7,9).
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In our study, for 20 patients (40%), the opportunity to receive an abdominoplasty was the main criterion that influenced their choice of a DIEP flap. For these patients, a poor final
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result of their abdominal reconstruction was even more difficult to accept. We also observed that these patients were often the most dissatisfied.
CONCLUSION
This study was one of the first, which provide an analysis of satisfaction resulting from the abdominoplasty of patients who underwent breast reconstruction with a DIEP flap.
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Preoperative counseling was very important, especially in patients for whom the secondary benefit of abdominoplasty was high (27,28). Regarding our results, it seemed necessary to improve our information to patients to prepare them for potentially less aesthetic results
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compared to their expectations (7).
For breast reconstruction, we believe that abdominal pendulum should be considered as a flap
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donor site, as well as the skin from thighs, back or buttocks for the TUG, the Latissimus dorsi or the SGAP flap, respectively. Patients and surgeons should consider all of these possibilities
Conflict of interest statement
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to confirm the DIEP flap choice or to select another breast reconstruction technique (9).
None of the authors has a financial or personal relationships with other people or
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organisations that could inappropriately influence (bias) their work.
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ACCEPTED MANUSCRIPT REFERENCES
1.
Healy C, Allen RJ. The Evolution of Perforator Flap Breast Reconstruction: Twenty
2.
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Years after the First DIEP Flap. J Reconstr Microsurg. 2013;25. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with the deep
inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg. 2006;59;571-9.
Bodin F, Zink S, Lutz J-C, Kadoch V, Wilk A, Bruant-Rodier C. Quel est le palmarès
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des techniques de reconstruction mammaire à long terme ? Ann Chir Plast Esthet. 2010;55;547-52. 4.
Bottero L, Lefaucheur J-P, Fadhul S, Raulo Y, Collins ED, Lantieri L.
Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery. Plast Reconstr Surg. 2004;113;156-61. Miszkiewicz K, Perreault I, Landes G, et al. Venous thromboembolism in plastic
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surgery: incidence, current practice and recommendations. J Plast Reconstr Aesthet Surg.
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2009;62;580-8.
Gopie JP, Ter Kuile MM, Timman R, Mureau MAM, Tibben A. Impact of delayed
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implant and DIEP flap breast reconstruction on body image and sexual satisfaction: a prospective follow-up study. Psychooncology. 2013;27. 7.
Pusic AL, Klassen AF, Snell L, et al. Measuring and managing patient expectations
for breast reconstruction: impact on quality of life and patient satisfaction. Expert Rev Pharmacoecon Outcomes Res. 2012;12;149-58. 8.
Sugrue R, MacGregor G, Sugrue M, Curran S, Murphy L. An evaluation of patient
reported outcomes following breast reconstruction utilizing Breast Q. Breast. 2013;22;158-61. 9.
Yueh JH, Slavin SA, Adesiyun T, Nyame TT, Gautam S, Morris DJ, et al. Patient
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ACCEPTED MANUSCRIPT satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125;1585-95. 10.
Bragg TWH, Jose RM, Srivastava S. Patient satisfaction following abdominoplasty: an
NHS experience. J Plast Reconstr Aesthet Surg. 2007;60;75-8. Le Louarn C, Pascal JF. High superior tension abdominoplasty. Aesthetic Plast Surg.
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Nahai FR. Anatomic considerations in abdominoplasty. Clin Plast Surg. 2010;37;407-
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Matarasso A. Classification and patient selection in abdominoplasty. Operative
Techniques in Plastic and Reconstructive Surgery. 1996;3;7-14.
Matarasso A. Traditional abdominoplasty. Clin Plast Surg. 2010;37;415-37.
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Floros C, Davis PK. Complications and long-term results following abdominoplasty: a
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retrospective study. Br J Plast Surg. 1991;44;190-94. 17.
Gliksman J, Himy S, Ringenbach P, Andreoletti J-B. L'abdominoplastie: vers une
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chirurgie en deux temps? Etude rétrospective des complications postopératoires à propos de 100 cas. Ann Chir Plast Esthet. 2006;51;151-56. Stevens WG, Spring MA, Stoker DA, Cohen R, Vath SD, Hirsch EM. Ten years of
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outpatient abdominoplasties: safe and effective. Aesthet Surg J. 2007;27;269-75. 19.
Stewart KJ, Stewart DA, Coghlan B, Harrison DH, Jones BM, Waterhouse N.
Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg. 2006;59;1152-5. 20.
Hunstad JP. Revision abdominoplasty: Complications and their management.
Operative Techniques in Plastic and Reconstructive Surgery. 1996;3;67-76.
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ACCEPTED MANUSCRIPT 21.
Sozer SO, Agullo FJ, Santillan AA, Wolf C. Decision making in abdominoplasty.
Aesthetic Plast Surg. 2007;31;117-27. 22.
Salgarello M, Tambasco D, Farallo E. DIEP flap donor site versus elective
2012;36;363-9. 23.
Momeni A, Heier M, Bannasch H, Stark GB. Complications in abdominoplasty: a risk
factor analysis. J Plast Reconstr Aesthet Surg. 2009;62;1250-4.
Castus P, Grandjean F-X, Tourbach S, Heymans O. Sensibilité de la paroi abdominale
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abdominoplasty short-term complication rates: a meta-analysis. Aesthetic Plast Surg.
après abdominoplastie haute tension. Ann Chir Plast Esthet. 2009;54;545-50. Von Soest T, Kvalem IL, Roald HE, Skolleborg KC. The effects of cosmetic surgery
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De Brito MJA, Nahas FX, Bussolaro RA, Shinmyo LM, Barbosa MVJ, Ferreira LM.
27.
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Effects of abdominoplasty on female sexuality: a pilot study. J Sex Med. 2012;9;918-26. Malahias M, Lemonas P, Schreuder F, Ghorbanian S. Abdominoplasty: to inform
about TRAM flaps or not? J Plast Reconstr Aesthet Surg. 2011;64;78-79. Matarasso A. Awareness and avoidance of abdominoplasty complications. Aesthet
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28.
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Surg J. 1997;17;256, 258-61.
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ACCEPTED MANUSCRIPT Figure Legends
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Figure 1: Global satisfaction.
Figure 2: Reasons of disappointment.
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Figure 3: Umbilicus satisfaction.
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Figure 4: Scar satisfaction.
Figure 5: Quality of preoperative counseling.
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Figure 6: Result 30 months after the DIEP flap surgery in a woman with a low preoperative pendulum. Here, the distance from the scar to the vulvar anterior commissure was 10 cm, and
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the distance to the umbilicus was 4.5 cm. She was not happy about the aesthetic result. Her
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weight has increased by 15kg since the operation.
Figure 7: Woman with low preoperative pendulum. Result at 18 months. The final scar is high, 10 cm from the vulvar anterior commissure. Despite this, she is happy with the aesthetic result.
Figure 8: Woman with moderate preoperative pendulum. Results 9 months after surgery. The scar was 8cm from the vulvar anterior commissure and 10cm from the umbilicus. She was very happy about the aesthetic result.
ACCEPTED MANUSCRIPT Regarding the outcome of your abdominoplasty, how do you assess: -
Your global satisfaction? If you are not very happy, which aspects are you not
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The aspect of your umbilicus?
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The aspect of your scar? Is it hidden by your underwear?
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The quality of pre-operative counseling?
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satisfied with?
Did you receive a reoperation to improve the result of your abdomen? Would you recommend the procedure to a friend? If you had the time again, would you consent to the same procedure?
How much time did you wear the girdle? Do you feel the touch on your abdomen?
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Did your abdominoplasty change your body image?
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Do you prefer your abdomen now or before the procedure?
Did your abdominoplasty change your sexual life?
Was the opportunity to benefit from an abdominoplasty the main criterion that guided your choice of this reconstruction technique?
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Table 1: Satisfaction survey.
ACCEPTED MANUSCRIPT No
Did you receive a reoperation?
23
27
Would you recommend to a friend?
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2
Would you consent to the same procedure?
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8
Do you feel the touch on your abdomen?
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22
Was abdominoplasty your main criterion?
20
30
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Yes
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Table 2: Answers to the survey by yes or no.
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Negative change
Positive change
Change in body image?
17
16
17
Change in sexual life?
40
8
2
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Table 3: Results regarding body image and sexual life.
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20 15 10
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5 0 happy
satisfied
unsatisfied
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very happy
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30 25 20 15 10
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5 0 abdominal overhang
scar
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dog-ears
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20 15 10
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5 0 happy
satisfied
unsatisfied
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very happy
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25 20 15 10
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5 0 happy
satisfied
unsatisfied
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very happy
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50 40 30 20
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10 0 happy
satisfied
unsatisfied
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very happy
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