Exploring the Lived Experience of Undergoing an Immediate Versus Delayed Deep Inferior Epigastric Artery Perforator (DIEP) Flap Reconstruction in Women Who Require Post-Mastectomy Radiotherapy
Main Article Content
Abstract
Introduction
Post-mastectomy radiotherapy (PMRT) is recommended to women at high risk of local recurrence. There is a paucity of published work on the experience of women who undergo deep inferior epigastric perforator (DIEP) flap breast reconstruction in the context of requiring PMRT. The aim of the study was to explore and understand the patient experience of these women.
Methods
Purposive sampling was used to identify patients who had undergone an immediate reconstruction with PMRT and women who had undergone a delayed reconstruction after PMRT. Purposive sampling was used to identify and invite women to participate in the study. Semi-structured interviews were conducted using a grounded theory approach with a topic guide which was derived from relevant literature.
Results
Twenty women participated in the study. Ten women had undergone immediate reconstruction followed by PMRT and 10 women had undergone delayed reconstruction after PMRT. The results suggest that, regardless of the surgical pathway or the consequences of treatment, overall women were satisfied with the treatment decision they had made. Patients described the challenges around decision-making and their post-operative experience. However, patients were grateful to have had a breast reconstruction and in the most part happy with the treatment pathway they underwent.
Conclusion
The findings of this study suggest that women are motivated by a variety of factors when presented with the choice of immediate versus delayed breast reconstruction and can justify the treatment path they have taken. This study highlights the importance of discussing reconstruction options in terms of context of a person’s life and coping strategies. Patients appeared to use self-regulation in their behaviour to cope with their illness threat and decision-making. The women who chose delayed reconstruction were motivated by the delayed gratification of having a reconstruction that had not been subjected to PMRT.
Article Details
How to Cite
O’CONNELL, Rachel L et al.
Exploring the Lived Experience of Undergoing an Immediate Versus Delayed Deep Inferior Epigastric Artery Perforator (DIEP) Flap Reconstruction in Women Who Require Post-Mastectomy Radiotherapy.
Medical Research Archives, [S.l.], v. 9, n. 8, aug. 2021.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/2512>. Date accessed: 05 nov. 2024.
doi: https://doi.org/10.18103/mra.v9i8.2512.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. UK CR. http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/breast-cancer.
2. Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. Oct 2000;106(5):1014-25; discussion 1026-7. doi:10.1097/00006534-200010000-00010
3. Atisha D, Alderman AK, Lowery JC, Kuhn LE, Davis J, Wilkins EG. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. Ann Surg. Jun 2008;247(6):1019-28. doi:10.1097/SLA.0b013e3181728a5c
4. Nano MT, Gill PG, Kollias J, Bochner MA, Malycha P, Winefield HR. Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ J Surg. Nov 2005;75(11):940-7. doi:10.1111/j.1445-2197.2005.03517.x
5. Brandberg Y, Malm M, Blomqvist L. A prospective and randomized study, "SVEA," comparing effects of three methods for delayed breast reconstruction on quality of life, patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg. Jan 2000;105(1):66-74; discussion 75-6. doi:10.1097/00006534-200001000-00011
6. Ramon Y, Ullmann Y, Moscona R, et al. Aesthetic results and patient satisfaction with immediate breast reconstruction using tissue expansion: a follow-up study. Plast Reconstr Surg. Mar 1997;99(3):686-91.
7. Alderman AK, Kuhn LE, Lowery JC, Wilkins EG. Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study. J Am Coll Surg. Jan 2007;204(1):7-12. doi:10.1016/j.jamcollsurg.2006.09.022
8. Chao LF, Patel KM, Chen SC, et al. Monitoring patient-centered outcomes through the progression of breast reconstruction: a multicentered prospective longitudinal evaluation. Breast Cancer Res Treat. Jul 2014;146(2):299-308. doi:10.1007/s10549-014-3022-7
9. Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. Sep 2000;106(4):769-76. doi:10.1097/00006534-200009040-00003
10. Tykkä E, Asko-Seljavaara S, Hietanen H. Patient satisfaction with delayed breast reconstruction: a prospective study. Ann Plast Surg. Sep 2002;49(3):258-63. doi:10.1097/01.sap.0000015487.09561.62
11. Thiruchelvam PT, McNeill F, Jallali N, Harris P, Hogben K. Post-mastectomy breast reconstruction. Bmj. Oct 15 2013;347:f5903. doi:10.1136/bmj.f5903
12. Serletti JM, Fosnot J, Nelson JA, Disa JJ, Bucky LP. Breast reconstruction after breast cancer. Plast Reconstr Surg. Jun 2011;127(6):124e-135e. doi:10.1097/PRS.0b013e318213a2e6
13. Albornoz CR, Cordeiro PG, Hishon L, et al. A nationwide analysis of the relationship between hospital volume and outcome for autologous breast reconstruction. Plast Reconstr Surg. Aug 2013;132(2):192e-200e. doi:10.1097/PRS.0b013e31829586c1
14. Jeevan R, Mennie JC, Mohanna PN, O'Donoghue JM, Rainsbury RM, Cromwell DA. National trends and regional variation in immediate breast reconstruction rates. Br J Surg. Aug 2016;103(9):1147-56. doi:10.1002/bjs.10161
15. NICE guidelines [CG80]. Early and locally advanced breast cancer: Diagnosis and treatment. 2009.
16. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg. May 2004;113(6):1617-28.
17. Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg. Feb 2010;125(2):463-74. doi:10.1097/PRS.0b013e3181c82d58
18. Rusby J. Current national practice: Reconstruction and post mastectomy radiotherapy – results of an ABS survey. 3rd April 2021, 2021.
19. Kronowitz SJ. Current status of autologous tissue-based breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. Aug 2012;130(2):282-92. doi:10.1097/PRS.0b013e3182589be1
20. Schaverien MV, Macmillan RD, McCulley SJ. Is immediate autologous breast reconstruction with postoperative radiotherapy good practice?: a systematic review of the literature. J Plast Reconstr Aesthet Surg. Dec 2013;66(12):1637-51. doi:10.1016/j.bjps.2013.06.059
21. Khajuria A, Charles WN, Prokopenko M, et al. Immediate and delayed autologous abdominal microvascular flap breast reconstruction in patients receiving adjuvant, neoadjuvant or no radiotherapy: a meta-analysis of clinical and quality-of-life outcomes. BJS Open. Apr 2020;4(2):182-196. doi:10.1002/bjs5.50245
22. Kelley BP, Ahmed R, Kidwell KM, Kozlow JH, Chung KC, Momoh AO. A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal? 10.1245/s10434-014-3494-z doi. AnnSurgOncol. 2014;21(5):1732-1738. NOT IN FILE.
23. Chatterjee JS, Lee A, Anderson W, et al. Effect of postoperative radiotherapy on autologous deep inferior epigastric perforator flap volume after immediate breast reconstruction. Br J Surg. Oct 2009;96(10):1135-40. doi:10.1002/bjs.6693
24. Hershenhouse KS, Bick K, Shauly O, et al. "Systematic review and meta-analysis of immediate versus delayed autologous breast reconstruction in the setting of post-mastectomy adjuvant radiation therapy". J Plast Reconstr Aesthet Surg. Dec 5 2020;doi:10.1016/j.bjps.2020.11.027
25. Glaser BG, Strauss AL. Discovery of grounded theory: Strategies for qualitative research. Routledge; 2017.
26. Birks M, Mills J. Grounded theory: A practical guide. Sage; 2015.
27. Bryant A, Charmaz K. The Sage handbook of grounded theory. Sage; 2007.
28. Kaššák F, Rossier C, Picardi C, Bernier J. Postmastectomy radiotherapy in T1-2 patients with one to three positive lymph nodes - Past, present and future. Breast. Dec 2019;48:73-81. doi:10.1016/j.breast.2019.09.008
29. McGale P, Taylor C, Correa C, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. Jun 21 2014;383(9935):2127-35. doi:10.1016/s0140-6736(14)60488-8
30. O'Connell RL, Di Micco R, Khabra K, et al. Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy. Plast Reconstr Surg. 09 2018;142(3):594-605. doi:10.1097/PRS.0000000000004676
31. Steele KH, Macmillan RD, Ball GR, Akerlund M, McCulley SJ. Multicentre study of patient-reported and clinical outcomes following immediate and delayed Autologous Breast Reconstruction And Radiotherapy (ABRAR study). J Plast Reconstr Aesthet Surg. Feb 2018;71(2):185-193. doi:10.1016/j.bjps.2017.10.030
32. Ananthakrishnan P, Lucas A. Options and considerations in the timing of breast reconstruction after mastectomy. Cleve Clin J Med. Mar 2008;75 Suppl 1:S30-3. doi:10.3949/ccjm.75.suppl_1.s30
33. Cameron LD, Leventhal H. The self-regulation of health and illness behaviour. 2003;
34. Rachman S. Contributions to medical psychology. Elsevier; 2013.
35. Peters G-JY, Ruiter RAC, Kok G. Threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory. Health psychology review. 2013;7(Suppl 1):S8-S31. doi:10.1080/17437199.2012.703527
36. Keating NL, Weeks JC, Borbas C, Guadagnoli E. Treatment of early stage breast cancer: do surgeons and patients agree regarding whether treatment alternatives were discussed? Breast Cancer Res Treat. May 2003;79(2):225-31. doi:10.1023/a:1023903701674
37. Keating NL, Guadagnoli E, Landrum MB, Borbas C, Weeks JC. Treatment decision making in early-stage breast cancer: should surgeons match patients' desired level of involvement? J Clin Oncol. Mar 15 2002;20(6):1473-9. doi:10.1200/jco.2002.20.6.1473
38. Waljee JF, Hawley S, Alderman AK, Morrow M, Katz SJ. Patient satisfaction with treatment of breast cancer: does surgeon specialization matter? J Clin Oncol. Aug 20 2007;25(24):3694-8. doi:10.1200/jco.2007.10.9272
39. Katz SJ, Lantz PM, Janz NK, et al. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol. Aug 20 2005;23(24):5526-33. doi:10.1200/jco.2005.06.217
40. Goodwin PJ, Black JT, Bordeleau LJ, Ganz PA. Health-related quality-of-life measurement in randomized clinical trials in breast cancer--taking stock. J Natl Cancer Inst. Feb 19 2003;95(4):263-81. doi:10.1093/jnci/95.4.263
41. Sheridan SL, Harris RP, Woolf SH. Shared decision making about screening and chemoprevention. a suggested approach from the U.S. Preventive Services Task Force. Am J Prev Med. Jan 2004;26(1):56-66. doi:10.1016/j.amepre.2003.09.011
42. Kaplan RM. Shared medical decision making. A new tool for preventive medicine. Am J Prev Med. 2004:81-3. vol. 1.
43. Briss P, Rimer B, Reilley B, et al. Promoting informed decisions about cancer screening in communities and healthcare systems. Am J Prev Med. Jan 2004;26(1):67-80. doi:10.1016/j.amepre.2003.09.012
44. Ashraf AA, Colakoglu S, Nguyen JT, et al. Patient involvement in the decision-making process improves satisfaction and quality of life in postmastectomy breast reconstruction. J Surg Res. Sep 2013;184(1):665-70. doi:10.1016/j.jss.2013.04.057
45. Flitcroft K, Brennan M, Spillane A. Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice. Qual Life Res. Sep 2017;26(9):2287-2319. doi:10.1007/s11136-017-1555-z
46. Duggal CS, Metcalfe D, Sackeyfio R, Carlson GW, Losken A. Patient motivations for choosing postmastectomy breast reconstruction. Ann Plast Surg. May 2013;70(5):574-80. doi:10.1097/SAP.0b013e3182851052
47. Gopie JP, Hilhorst MT, Kleijne A, et al. Women's motives to opt for either implant or DIEP-flap breast reconstruction. J Plast Reconstr Aesthet Surg. Aug 2011;64(8):1062-7. doi:10.1016/j.bjps.2011.03.030
2. Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. Oct 2000;106(5):1014-25; discussion 1026-7. doi:10.1097/00006534-200010000-00010
3. Atisha D, Alderman AK, Lowery JC, Kuhn LE, Davis J, Wilkins EG. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. Ann Surg. Jun 2008;247(6):1019-28. doi:10.1097/SLA.0b013e3181728a5c
4. Nano MT, Gill PG, Kollias J, Bochner MA, Malycha P, Winefield HR. Psychological impact and cosmetic outcome of surgical breast cancer strategies. ANZ J Surg. Nov 2005;75(11):940-7. doi:10.1111/j.1445-2197.2005.03517.x
5. Brandberg Y, Malm M, Blomqvist L. A prospective and randomized study, "SVEA," comparing effects of three methods for delayed breast reconstruction on quality of life, patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg. Jan 2000;105(1):66-74; discussion 75-6. doi:10.1097/00006534-200001000-00011
6. Ramon Y, Ullmann Y, Moscona R, et al. Aesthetic results and patient satisfaction with immediate breast reconstruction using tissue expansion: a follow-up study. Plast Reconstr Surg. Mar 1997;99(3):686-91.
7. Alderman AK, Kuhn LE, Lowery JC, Wilkins EG. Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study. J Am Coll Surg. Jan 2007;204(1):7-12. doi:10.1016/j.jamcollsurg.2006.09.022
8. Chao LF, Patel KM, Chen SC, et al. Monitoring patient-centered outcomes through the progression of breast reconstruction: a multicentered prospective longitudinal evaluation. Breast Cancer Res Treat. Jul 2014;146(2):299-308. doi:10.1007/s10549-014-3022-7
9. Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. Sep 2000;106(4):769-76. doi:10.1097/00006534-200009040-00003
10. Tykkä E, Asko-Seljavaara S, Hietanen H. Patient satisfaction with delayed breast reconstruction: a prospective study. Ann Plast Surg. Sep 2002;49(3):258-63. doi:10.1097/01.sap.0000015487.09561.62
11. Thiruchelvam PT, McNeill F, Jallali N, Harris P, Hogben K. Post-mastectomy breast reconstruction. Bmj. Oct 15 2013;347:f5903. doi:10.1136/bmj.f5903
12. Serletti JM, Fosnot J, Nelson JA, Disa JJ, Bucky LP. Breast reconstruction after breast cancer. Plast Reconstr Surg. Jun 2011;127(6):124e-135e. doi:10.1097/PRS.0b013e318213a2e6
13. Albornoz CR, Cordeiro PG, Hishon L, et al. A nationwide analysis of the relationship between hospital volume and outcome for autologous breast reconstruction. Plast Reconstr Surg. Aug 2013;132(2):192e-200e. doi:10.1097/PRS.0b013e31829586c1
14. Jeevan R, Mennie JC, Mohanna PN, O'Donoghue JM, Rainsbury RM, Cromwell DA. National trends and regional variation in immediate breast reconstruction rates. Br J Surg. Aug 2016;103(9):1147-56. doi:10.1002/bjs.10161
15. NICE guidelines [CG80]. Early and locally advanced breast cancer: Diagnosis and treatment. 2009.
16. Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg. May 2004;113(6):1617-28.
17. Kronowitz SJ. Delayed-immediate breast reconstruction: technical and timing considerations. Plast Reconstr Surg. Feb 2010;125(2):463-74. doi:10.1097/PRS.0b013e3181c82d58
18. Rusby J. Current national practice: Reconstruction and post mastectomy radiotherapy – results of an ABS survey. 3rd April 2021, 2021.
19. Kronowitz SJ. Current status of autologous tissue-based breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. Aug 2012;130(2):282-92. doi:10.1097/PRS.0b013e3182589be1
20. Schaverien MV, Macmillan RD, McCulley SJ. Is immediate autologous breast reconstruction with postoperative radiotherapy good practice?: a systematic review of the literature. J Plast Reconstr Aesthet Surg. Dec 2013;66(12):1637-51. doi:10.1016/j.bjps.2013.06.059
21. Khajuria A, Charles WN, Prokopenko M, et al. Immediate and delayed autologous abdominal microvascular flap breast reconstruction in patients receiving adjuvant, neoadjuvant or no radiotherapy: a meta-analysis of clinical and quality-of-life outcomes. BJS Open. Apr 2020;4(2):182-196. doi:10.1002/bjs5.50245
22. Kelley BP, Ahmed R, Kidwell KM, Kozlow JH, Chung KC, Momoh AO. A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal? 10.1245/s10434-014-3494-z doi. AnnSurgOncol. 2014;21(5):1732-1738. NOT IN FILE.
23. Chatterjee JS, Lee A, Anderson W, et al. Effect of postoperative radiotherapy on autologous deep inferior epigastric perforator flap volume after immediate breast reconstruction. Br J Surg. Oct 2009;96(10):1135-40. doi:10.1002/bjs.6693
24. Hershenhouse KS, Bick K, Shauly O, et al. "Systematic review and meta-analysis of immediate versus delayed autologous breast reconstruction in the setting of post-mastectomy adjuvant radiation therapy". J Plast Reconstr Aesthet Surg. Dec 5 2020;doi:10.1016/j.bjps.2020.11.027
25. Glaser BG, Strauss AL. Discovery of grounded theory: Strategies for qualitative research. Routledge; 2017.
26. Birks M, Mills J. Grounded theory: A practical guide. Sage; 2015.
27. Bryant A, Charmaz K. The Sage handbook of grounded theory. Sage; 2007.
28. Kaššák F, Rossier C, Picardi C, Bernier J. Postmastectomy radiotherapy in T1-2 patients with one to three positive lymph nodes - Past, present and future. Breast. Dec 2019;48:73-81. doi:10.1016/j.breast.2019.09.008
29. McGale P, Taylor C, Correa C, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. Jun 21 2014;383(9935):2127-35. doi:10.1016/s0140-6736(14)60488-8
30. O'Connell RL, Di Micco R, Khabra K, et al. Comparison of Immediate versus Delayed DIEP Flap Reconstruction in Women Who Require Postmastectomy Radiotherapy. Plast Reconstr Surg. 09 2018;142(3):594-605. doi:10.1097/PRS.0000000000004676
31. Steele KH, Macmillan RD, Ball GR, Akerlund M, McCulley SJ. Multicentre study of patient-reported and clinical outcomes following immediate and delayed Autologous Breast Reconstruction And Radiotherapy (ABRAR study). J Plast Reconstr Aesthet Surg. Feb 2018;71(2):185-193. doi:10.1016/j.bjps.2017.10.030
32. Ananthakrishnan P, Lucas A. Options and considerations in the timing of breast reconstruction after mastectomy. Cleve Clin J Med. Mar 2008;75 Suppl 1:S30-3. doi:10.3949/ccjm.75.suppl_1.s30
33. Cameron LD, Leventhal H. The self-regulation of health and illness behaviour. 2003;
34. Rachman S. Contributions to medical psychology. Elsevier; 2013.
35. Peters G-JY, Ruiter RAC, Kok G. Threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory. Health psychology review. 2013;7(Suppl 1):S8-S31. doi:10.1080/17437199.2012.703527
36. Keating NL, Weeks JC, Borbas C, Guadagnoli E. Treatment of early stage breast cancer: do surgeons and patients agree regarding whether treatment alternatives were discussed? Breast Cancer Res Treat. May 2003;79(2):225-31. doi:10.1023/a:1023903701674
37. Keating NL, Guadagnoli E, Landrum MB, Borbas C, Weeks JC. Treatment decision making in early-stage breast cancer: should surgeons match patients' desired level of involvement? J Clin Oncol. Mar 15 2002;20(6):1473-9. doi:10.1200/jco.2002.20.6.1473
38. Waljee JF, Hawley S, Alderman AK, Morrow M, Katz SJ. Patient satisfaction with treatment of breast cancer: does surgeon specialization matter? J Clin Oncol. Aug 20 2007;25(24):3694-8. doi:10.1200/jco.2007.10.9272
39. Katz SJ, Lantz PM, Janz NK, et al. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol. Aug 20 2005;23(24):5526-33. doi:10.1200/jco.2005.06.217
40. Goodwin PJ, Black JT, Bordeleau LJ, Ganz PA. Health-related quality-of-life measurement in randomized clinical trials in breast cancer--taking stock. J Natl Cancer Inst. Feb 19 2003;95(4):263-81. doi:10.1093/jnci/95.4.263
41. Sheridan SL, Harris RP, Woolf SH. Shared decision making about screening and chemoprevention. a suggested approach from the U.S. Preventive Services Task Force. Am J Prev Med. Jan 2004;26(1):56-66. doi:10.1016/j.amepre.2003.09.011
42. Kaplan RM. Shared medical decision making. A new tool for preventive medicine. Am J Prev Med. 2004:81-3. vol. 1.
43. Briss P, Rimer B, Reilley B, et al. Promoting informed decisions about cancer screening in communities and healthcare systems. Am J Prev Med. Jan 2004;26(1):67-80. doi:10.1016/j.amepre.2003.09.012
44. Ashraf AA, Colakoglu S, Nguyen JT, et al. Patient involvement in the decision-making process improves satisfaction and quality of life in postmastectomy breast reconstruction. J Surg Res. Sep 2013;184(1):665-70. doi:10.1016/j.jss.2013.04.057
45. Flitcroft K, Brennan M, Spillane A. Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice. Qual Life Res. Sep 2017;26(9):2287-2319. doi:10.1007/s11136-017-1555-z
46. Duggal CS, Metcalfe D, Sackeyfio R, Carlson GW, Losken A. Patient motivations for choosing postmastectomy breast reconstruction. Ann Plast Surg. May 2013;70(5):574-80. doi:10.1097/SAP.0b013e3182851052
47. Gopie JP, Hilhorst MT, Kleijne A, et al. Women's motives to opt for either implant or DIEP-flap breast reconstruction. J Plast Reconstr Aesthet Surg. Aug 2011;64(8):1062-7. doi:10.1016/j.bjps.2011.03.030