During the last 30 years, many methods for delayed breast reconstruction have been described. There is a lack of prospective randomized trials comparing reconstruction methods. The present study (SVEA), conducted 1995 to 1996, describes the impacts of three methods: the lateral thoracodorsal flap, the latissimus dorsi flap, and the pedicled transverse rectus abdominis muscle flap (TRAM), on important areas of life, patients' perception of cosmetic result, and quality of life. Questionnaires were completed before randomization and at 6 and 12 months postoperatively. The preoperative questionnaire concerned the impact of breast loss and expectations on reconstruction. Follow-up questionnaires dealt with satisfaction with cosmetic result and impact on important areas of life. A health-related quality-of-life questionnaire (SF-36) was completed at all points of assessment. A total of 75 of 87 randomized patients underwent breast reconstruction: 16 patients with the lateral thoracodorsal flap, 30 with the latissimus dorsi flap, and 29 with the TRAM flap. The majority were very satisfied with the cosmetic result. Most women reported improvements in important areas of life, and quality of life in terms of "social functioning" and "mental health" increased significantly after the reconstruction. The latissimus dorsi flap and TRAM flap scored significantly higher as compared with the lateral thoracodorsal flap for similarity with the contralateral breast and reduced problems in social situations. No differences between irradiated and nonirradiated patients were found. All methods were considered to produce good cosmetic results and improvements in patient-defined problem areas of life and quality of life. No negative effects were recorded. Thus, irrespective of method, breast reconstruction is a valuable tool for the mastectomized woman to cope with problems in everyday life.

Seventy-five women, of whom 30 had received postoperative radiotherapy, were tested for range of motion (ROM) and shoulder strength with a goniometer and an isokinetic device (Orthotron II), respectively. On the individual level, irradiated patients exhibited significantly reduced range of motion (varying from p < 0.05 to p < 0.001) for all movements compared with the non-operated side. In contrast, in the non-irradiated patients only flexion was significantly reduced (p < 0.05). The same individual pattern was evident for shoulder strength where all movements except external rotation were significantly reduced in irradiated patients (varying from p < 0.05 to p < 0.001). Non-irradiated patients exhibited a significant reduction in shoulder strength for flexion and abduction (p < 0.05), whereas other movements were less affected. The observed differences in ROM and strength were less pronounced when analyzed on a group level, but were still significant for ROM (p < 0.001) for flexion and abduction. Group level analysis also showed reduced shoulder strength for all movements but only rotation was significantly (p < 0.01) impaired.

The aim of this investigation was to follow the metabolism of myocutaneous flaps using microdialysis. After subcutaneous implantation of a microdialysis catheter into the flap tissue, serial samples were collected and changes in composition of the extracellular fluid assessed. Ten women underwent reconstructions with transverse rectus abdominis myocutaneous (TRAM) or latissimus dorsi flaps. Glucose, glycerol, and lactate concentrations were measured in the flaps and compared with those in adipose control tissue located over the hip. A transient rise in glucose was observed initially in the flaps. The glycerol concentration also increased significantly, and remained increased for approximately 12 hours after the operation. The lactate concentration changed in the same direction, but stayed elevated in the flap tissue during the entire investigation (24 hours). Neither of these parameters changed to the same extent in the control tissue. In one of the patients a haematoma developed postoperatively in the flap. This incident was accompanied by a sharp decline in glucose, and marked additional increases in glycerol and lactate concentrations. It may well be that this "metabolic pattern" in flap tissue signals threatening flap ischaemia. If so, this new microdialysis technique may be useful as a postoperative surveillance tool in myocutaneous flap surgery.

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