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Keywords:

  • cancer;
  • oncology;
  • breast reconstruction;
  • body image;
  • sexual satisfaction;
  • partner relationship

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Conflict of interest
  8. Appendix: The body image scale
  9. References

Objective

Prospective studies regarding the psychosexual impact after different types of breast reconstruction (BR) are scarce. The impact of either implant or deep inferior epigastric artery perforator (DIEP) flap BR on body image and sexual relationship satisfaction was investigated in time.

Methods

At baseline, 98 women opting for delayed implant or DIEP flap BR after mastectomy for breast cancer completed a survey. The majority was followed up at 6 months (96%) and 20 months (86%) postoperatively. Questionnaires included the body image scale, Dutch Relationship Questionnaire, Short Form – 36 Health Survey and the Impact of Event Scale.

Results

Mixed modeling analyses indicated that preoperative body image improved significantly after 20 months (p < 0.001), and there was no statistically significant difference between the two types of BR. A better body image was related to a better general mental health (p = 0.02), less cancer distress (p < 0.001) and a higher partner relationship satisfaction (p < 0.001). Sexual relationship satisfaction also increased after 20 months (p = 0.01), and it was positively related to higher partner relationship satisfaction but negatively affected by hormonal therapy.

Conclusions

Body image and sexual relationship satisfaction significantly improved after BR, and this was not related to the BR type. Psychosexual consequences from previous cancer treatment may interfere. Lower general mental health, higher cancer distress, less partner relationship satisfaction or receiving hormonal therapy can negatively affect body image or sexual relationship satisfaction. Copyright © 2013 John Wiley & Sons, Ltd.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Conflict of interest
  8. Appendix: The body image scale
  9. References

Psychosexual changes after breast cancer treatment include fear of loss of fertility, negative body image, loss of femininity and attractiveness, and depression and anxiety [1-4]. A range of sexual complaints, such as dyspareunia, vaginal dryness, decreased sexual desire and/or sexual pleasure and numbness of the breasts, have been reported as a consequence of breast cancer treatment [5-13].

Generally, no differences have been found in body image and sexual satisfaction between women with breast-conserving therapy, mastectomy only, or mastectomy with breast reconstruction (BR); however, conflicting results have been reported [14-16]. This discrepancy suggests that different factors play a role in satisfaction with body image and sexuality after BR: direct and indirect effects of surgery, radiation, chemotherapy and hormonal therapy, as well as lowered physical and mental functionalities [5-13].

Several BR options exist after mastectomy: immediate as well as delayed reconstruction with implants, autologous tissue or a combination of both [17]. The deep inferior epigastric artery perforator (DIEP) flap is a relatively new technique using abdominal tissue generally leading to high patient satisfaction [18, 19] as well as more positive body image compared with implant BR [20-23].

As multiple factors affect outcomes after breast surgery, it is important to prospectively investigate these aspects in homogenous groups. The primary aim of this study was to prospectively investigate the impact of delayed implant and DIEP flap BR on body image and sexual satisfaction, which to the best of our knowledge has never been performed by others [21, 23, 24]. Secondly, to study whether other clinical and psychological variables were significantly related to changes in body image and/or sexual satisfaction.

Patients and methods

Patients

This study is part of a multicenter prospective follow-up study on the psychological impact of BR [25-27]. For the current study, women opting for a delayed BR after a history of breast cancer were included. Some women also underwent a contralateral prophylactic mastectomy followed by bilateral reconstruction. Reconstructions were either implant based usually preceded by tissue expansion or using a free vascularized DIEP flap1 from the abdomen [19].

Exclusion criteria were a previous BR, detection of recurrent locoregional or distant disease, and not being able to understand and speak the Dutch language sufficiently. Women who did not consent or who did not react 2 weeks after the invitation were considered as non-respondents. Patients were approached between December 2007 and May 2010, and ethics approval was obtained from all participating hospitals.2

Of the 131 invited patients who were scheduled for delayed BR, 105 women (80%) consented to participate (Figure 1).

image

Figure 1. Flow chart of patient inclusion

Download figure to PowerPoint

Procedure

Preoperatively, an invitation letter explaining the procedure and purpose of the study, an informed consent and a prepaid envelope were sent to all women on the BR waiting lists of the participating hospitals. A reminder was sent by letter if patients did not respond within 2 weeks, or they received a reminder by phone if surgery was planned on short term. Patients who returned informed consent received the survey, including a range of demographic, clinical and psychological questionnaires, which they were requested to complete preoperatively (T0), 6 months postoperatively (T1) and at the end of the BR procedure (T2), including nipple reconstruction if this was planned within the duration period of the study. T2 was on average 20 months after the initial breast mound reconstruction. Women who had not completely finished their BR course completed the questionnaires regarding the preliminary end result.

Measurements

Demographic information and clinical data were collected in the survey, and the latter were confirmed by checking medical records. The following questionnaires had to be completed for at least 75% of the items to calculate scale scores.

Primary outcome measures

Body image

A study-specific body image scale (BIS) was developed on the basis of Lodder et al. [28], and it is described elsewhere [29]. The scale consists of 13 items, which are scored on a 5-point Likert scale, ranging from 1 to 5 (totally disagree, disagree, neutral, agree and totally agree, respectively). After recoding the negative items (items 4, 5, 11 and 13), a mean scale score was calculated (1–5) where a higher score indicates a more positive body image. Two items were only completed by patients with a partner; nevertheless, for the single women, a mean scale score was calculated for the remaining 10 items (75%). The internal consistency of the BIS scale was high in the current study sample (Cronbach's a = 0.89).

Sexual relationship satisfaction

To investigate the course of satisfaction with the sexual relationship, the subscale ‘sexuality’ of the Dutch Relationship Questionnaire (NRV) was used [30]. The NRV has shown good psychometric properties and a total score on the subscale sexuality below eight (range 0–12) indicates below average or low sexual relationship satisfaction and a bad sexual compatibility with the partner [30]. The NRV was completed only by women with a partner.

Secondary outcome measures

Satisfaction with the overall partner relationship was investigated with the NRV as well. Normally, the total score of the NRV can be used to provide this satisfaction score. However, to correct for the impact of sexual satisfaction, the score of the sexuality subscale was subtracted from the total score. Therefore, scores under 49 (range 0–68) indicate below average or low satisfaction with the partner relationship, excluding sexual satisfaction.

Breast cancer specific distress was measured using the 15-item Impact of Event Scale (IES) [31, 32]. The total IES score was used in this study ranging from 0 to 75. Reported reliability and validity of the IES are satisfactory [31, 33]. The categorization of the IES score is not indicative for specific clinical diagnoses, but a cutoff score of 20 or higher can be used to indicate high symptom levels [33, 34].

Changes between baseline and follow-up measurements of general mental and physical health were assessed with the Dutch version of the 36-item Short-Form Health Survey (SF-36), designed to measure health related quality of life. General physical and mental complaints were measured with the Physical Component Summary (PCS) and the Mental Component Summary (MCS) of the SF-36, respectively [35-37]. In this norm-based scoring method, each scale has the same mean value (50) and standard deviation (10). Consequently, a scale score below 50 indicates a health status below average [36].

Statistical analyses

Descriptive statistics were calculated for all variables. Differences between respondents and non-respondents, and between implant and DIEP flap BR patients were investigated using Student's t-tests, Mann–Whitney U-tests and Fisher's Exact tests.

To investigate changes in time in the primary psychological outcome measures (body image and sexual satisfaction) after implant and DIEP flap BR, multilevel regression analyses (MLA) were performed, which can handle incomplete time-series data efficiently with a minimal loss of information. These analyses also compensate for different numbers of participants within the subgroups and for dropout when dropout is dependent on variables that are included in the regression model [38]. Saturated models were postulated with time, time squared and relevant covariates. The time variable was coded 0, 6 and 20, respecting the uneven time spans between the measurements. The number of covariates in the models is limited by the number of participants and repeated measures. The number of 98 participants is sufficient for the determination of 6 medium-sized covariates [39]. This is a conservative calculation, the three repeated measures allow for more covariates.

In the first step, we reduced the number of relevant potential covariates, by calculating Spearman's correlation coefficients with all clinical pretreatment characteristics (Table 1) and with an estimate of change of the psychological outcomes during the entire BR course (partner relationship satisfaction, cancer distress, general mental and physical health, and body image or sexual satisfaction). Secondly, the variables that significantly correlated with change in the primary outcomes (p < 0.05) were entered in the MLA as covariates. Continuous covariates (e.g., age, cancer distress and general mental health) were centered for ease of interpretation. In this way, the intercept indicates the estimated value for a woman at the mean of the covariates. Changes in the secondary outcomes were investigated with separate MLA for each outcome including time effects only.

Table 1. Baseline characteristics of 98 women with either a delayed implant or deep inferior epigastric perforator (DIEP) flap breast reconstruction after mastectomy for breast cancer
 Implant BRDIEP-flap BR 
 N = 25N = 73p-valueb
  1. M, mastectomy; BC, breast cancer; BMI, body mass index; DIEP, deep inferior epigastric artery perforator; BR, breast reconstruction; SD, standard deviation.

  2. a

    brca1/brca2/familial risk;

  3. b

    Fisher's Exact tests were applied unless indicated otherwise;

  4. c

    Student's t-test (on transformed data for time since mastectomy and cancer distress);

  5. d

    Mann–Whitney U-test; p-value is significant at <0.05.

Mean age at time of breast reconstruction (sd)48.7 (9.2)49.4 (7.9)0.73c
Mean years since mastectomy (sd)2.9 (4.1)3.2 (2.7)0.03c
Having a partner (%)24 (96.0)59 (80.8)0.11
Having children (%)23 (92.0)63 (86.3)0.73
Education level (%)   
Low6 (24.0)11 (15.1) 
Intermediate7 (28.0)28 (38.4) 
High12 (48.0)34 (46.6)0.77d
Inherited predisposition for BCa (%)7 (28.0)15 (20.5)0.58
Laterality (%)   
Unilateral M + BR because of BC13 (52.0)62 (84.9)0.002
Bilateral M + BR because of BC4 (16.0)4 (5.5)0.20
Immediate contralateral prophylactic8 (32.0)7 (9.6)0.02
M + BR
Mean BMI (sd)24.8 (4.4)27.5 (3.6)10.004c
Radiation therapy (%)13 (52.0)49 (67.1)0.23
Chemotherapy therapy (%)6 (24.0)24 (32.9)0.46
Hormonal therapy (%)8 (32.0)40 (54.8)0.06
Body image (1–5) (sd)3.0 (0.8)3.0 (0.7)20.63c
Sexual relationship satisfaction (0–12) (sd)8.8 (3.1)7.3 (3.3)0.07c
Partner relationship satisfaction (0–68) (sd)58.0 (8.7)57.7 (8.6)0.88c
Cancer distress (0–75) (sd)25.2 (15.4)19.5 (12.6)0.12c
General mental health (sd)49.8 (10.5)49.7 (10.5)0.96c
General physical health (sd)55.0 (6.7)52.8 (8.7)0.28c

In a backward procedure all non-significant effects (p > 0.05) were removed from the model, until a parsimonious model was reached. Effect sizes (Cohen's d) were calculated by dividing the difference between the follow-up estimates and baseline by the estimated standard deviation. An effect size of 0.20 was considered small, 0.50 medium and 0.80 large [40]. Two-sided p-values < 0.05 were considered statistically significant. Version 20 of IBM-SPSS Statistics (SPSS Inc., Chicago, IL, USA) was used for statistical analyses.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Conflict of interest
  8. Appendix: The body image scale
  9. References

Non-respondents

Non-respondents (n = 26) and respondents (n = 105) did not significantly differ in age, laterality and type of BR, and therefore, we presumed the respondents were representative for the total group (t(131) = 0.026, p = 0.98; Fisher's Exact tests: p = 0.28 and p = 1.00, respectively).

Lost to follow-up

Seven of the 105 women were excluded from analyses due to the development of metastases or recurrent disease (Figure 1), leaving 98 women for analyses at T0. After T0 four patients dropped out, leaving 94 women for analyses at T1. At T2, 84 women remained for analyses. The dropouts (n = 21) did not differ significantly from the participating patients at T2 (n = 84) regarding demographic variables (data not shown). However, dropouts had a significantly less positive baseline body image (Student's t(101) = 2.35, p = 0.021). Analyses were performed on data of the 98 participants. The NRV was completed only by participants with a partner, and partner status did not significantly change during the study (Chi2 = 0.54, p = 0.76, Figure 1). Furthermore, occasionally not every questionnaire was totally completed, which explains different sample sizes per outcome.

Demographic and clinical characteristics

In both reconstruction groups, patients had a mean age of 49 years. Twenty-two patients had an increased risk for developing breast cancer due to an inherited predisposition for breast cancer (Table 1). Time since mastectomy was longer for DIEP flap BR than implant BR patients. More women with bilateral mastectomy received implant than DIEP flap BR. Women opting for DIEP flap BR had a higher mean body mass index (BMI) compared with women receiving implant BR. There were no significant differences in baseline psychological scores between the two reconstruction groups. The mean follow-up time at T2 was 20.2 months (sd = 6.1).

Changes in preoperative and postoperative body image and sexual satisfaction

Body image

In the first step, Spearman's correlation coefficients revealed that age (r = 0.24, p < 0.001), mental health (r = 0.39, p < 0.001), sexual (r = 0.25, p < 0.001) and partner relationship satisfaction (r = 0.37, p < 0.001) as well as cancer distress (r = −0.31, p < 0.001) were significantly correlated with change in body image over time. Consequently, these variables with body image time interactions were entered into the saturated multilevel models.

For body image, a significant linear and a quadratic time effect was found (Table 2). These indicate a body image of 3.74 after 6 months (3.0425 + 6 × 0.1481 − 36 × 0.0053 = 3.74), an improvement of 0.70 (d = 1.24, p < 0.001, Table 3). After 20 months, an improvement of 0.85 was found compared with baseline (d = 1.51, p < 0.001). No significant relationship was detected with the type of BR (p = 0.55).

Table 2. Changes in primary and secondary outcomes and covariates
 Estimate (95% CI)Std. errorp-value
  1. CI, confidence interval; std. error, standard error.

  2. p-value is significant at <0.05.

Body image   
Intercept3.0425 [2.2917–3.1684]0.06380<0.001
Time0.1481 [0.1152–0.1811]0.01662<0.001
Time squared−0.0053 [−0.0068–−0.0038]0.00077<0.001
Partner relationship satisfaction0.0178 [0.0079–0.0276]0.00499<0.001
Cancer distress−0.0141 [−0.0204–−0.0077]0.00320<0.001
General mental health0.0104 [0.0017–0.0190]0.004400.019
Sexual relationship satisfaction  
Intercept8.483 [7.700–9.266]0.3944<0.001
Time0.031 [0.0077–0.055]0.01200.010
Hormonal therapy−1.473 [−2.614–−0.332]0.57390.012
Partner relationship satisfaction0.187 [0.146–0.228]0.0210<0.001
Cancer distress   
Intercept20.384 [17.813–22.954]1.2986<0.001
Time−0.2428 [−0.3557–−0.1299]0.0572<0.001
General physical health   
Intercept53.275 [51.660–54.890]0.8177<0.001
Time−0.763 [−1.088–−0.438]0.6149<0.001
Time squared0.0367 [0.0216–0.0519]0.0077<0.001
Table 3. Estimations and effect sizes at time points and covariate effects
 EstimateDifference with pre-reconstruction
[95% CI]p-valueEffect size*
  • CI, confidence interval; sd, standard deviation.

  • *

    Cohen's d; p-value is significant at <0.05.

Body image    
At mean of covariates    
Pre-reconstruction3.04   
6 months3.740.70 [0.55–0.84]<0.0011.24
20 months3.890.85 [0.70–1.00]<0.0011.51
Additional covariate effects    
Partner relationship + 1 sd0.150.15 [0.07–0.24]0.0010.27
Cancer distress + 1 sd−0.19−0.19 [−0.27–−0.10]<0.001−0.33
General mental health + 1 sd0.110.11 [0.02–0.20]0.0190.19
Sexual relationship satisfaction    
At mean of covariates    
Pre-reconstruction8.48   
6 months8.670.19 [0.04–0.33]0.0100.06
20 months9.110.63 [0.15–1.10]0.0100.22
Additional covariate effects    
Hormonal therapy−1.47−1.47 [−2.61–−0.33]0.012−0.51
Partner relationship satisfaction + 1 sd1.541.54 [1.20–1.88]<0.0010.54
Cancer distress    
Pre-reconstruction20.4   
6 months18.9−1.46 [−2.13–−0.78]<0.001−0.11
20 months15.5−4.86 [−7.11–−2.60]<0.001−0.36
General physical health    
Pre-reconstruction53.3   
6 months50.0−3.56 [−4.68–−1.83]<0.001−0.41
20 months52.7−0.58 [−2.06–0.89]0.43−0.07

The final model for body image (Table 2) also indicated that during the entire course of BR a higher partner relationship satisfaction, less cancer distress and a better general mental health were positively significantly related to a better body image of which the estimates, p-values and effect sizes are again demonstrated in Table 3. Age and sexual relationship satisfaction were not significantly related to body image (p = 0.068 and p = 0.21, respectively) and were therefore removed from the model.

Sexual relationship satisfaction

In the first step, correlation coefficients with potential covariates revealed significant relations with age (r = 0.13, p = 0.04), previous radiotherapy (r = −0.16, p = 0.018) and hormonal therapy (r = −0.18, p = 0.006), general mental health (r = 0.27, p < 0.001), partner relationship satisfaction (r = 0.55, p < 0.001) and body image (r = 0.25, p < 0.001).

Satisfaction with the sexual relationship improved significantly in time (d = 0.22, p = 0.010 after 20 months, Table 3). Hormonal therapy was negatively related (d = −0.51, p = 0.012), and partner relationship satisfaction (d = 0.54, p < 0.001) was positively related to sexual relationship satisfaction. The observed baseline effect of the type of BR presented in Table 1 (p = 0.07), suggesting that women with DIEP flap BR tended to be less satisfied with their sexual relationship, remained statistically insignificant in the MLA (p = 0.085).

Changes in preoperative and postoperative secondary outcomes

Cancer distress reduced significantly in time (d = −0.36, p < 0.001) after 20 months. General physical health temporarily decreased at 6 months (d = −0.41, p < 0.001), but returned toward baseline at 20 months (Table 3). No significant time effects were found for satisfaction with the partner relationship (p = 0.29) and general mental health (p = 0.58).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Conflict of interest
  8. Appendix: The body image scale
  9. References

This is the first prospective study showing that body image improves after delayed implant as well as DIEP flap BR and that it is not related to type of BR.

The two patient groups did not significantly differ in most baseline variables. However, the fact that DIEP flap BR was only performed at specialized centers may impede the generality of the results, as the team of experts may be more aware of impact on body image and therefore, may be more focused to reach the best outcomes after BR. Furthermore, most bilateral BRs were performed using implants, which can be explained by logistic and financial limitations for bilateral DIEP flap BR in the Netherlands [41].

Evidently, DIEP flap BR patients had a significantly higher BMI as this type of surgery requires sufficient autologous tissue. Additionally, a high BMI may have been a contraindication for implant BR as this enhances the complication risk and a poor outcome [42]. The majority of patients had received radiotherapy previously, which could potentially lead to complications, particularly after implant BR. There might have been an interaction between radiotherapy and type of BR, which was not investigated in this study.

A significant improvement in sexual satisfaction after both reconstruction types was detected, after correcting for relevant variables. Partner relationship satisfaction was positively related to sexual relationship satisfaction, highlighting the significant impact on the partner relationship if sexual function or satisfaction changes after breast cancer [43, 44]. Hormonal therapy was related to a lower sexual relationship satisfaction score, as adjuvant therapy may induce premature menopause with negative sexual side effects including loss of libido and vaginal dryness [4, 5, 7, 8, 10-13, 45]. BMI was not related to the sexual satisfaction score, but there might have been an interaction with the type of BR as well as women with DIEP flap BR had a higher BMI [46]. However, these were not the main research questions and therefore, not investigated in the current study.

A large improvement in body image was observed, which was significantly related to less cancer distress, higher satisfaction with the partner relationship and a better general mental health during the entire BR course. It has been previously demonstrated that changes in body image are related to psychological distress after mastectomy with or without reconstruction [47-49]. In accordance with previous findings, we found that mental health is positively related to body image as well [50].

To our knowledge, this is the first prospective study on body image and sexual satisfaction in patients with either delayed implant or DIEP flap BR [21]. We could not detect a statistically significant difference in body image and sexual satisfaction between implant and DIEP flap BR, whereas previous findings suggested a better outcome after autologous techniques, such as DIEP flap BR [18, 20-23]. This can be explained by the retrospective designs and/or the inclusion of heterogeneous patient groups, such as patients with immediate as well as delayed BR. Timing of BR is important for body image and sexual satisfaction, as more positive outcomes have been found after autologous reconstructions if BR was delayed [18, 20, 22, 51]. In addition, a relatively new approach of delayed-immediate BR might reduce complication rates after radiotherapy, while preserving the skin and delaying breast reconstruction until radiotherapy is completed, which might positively influence body image as well.

The current study concerned a homogenous group of patients all having delayed BR. However, these women may experience a greater increase in body image compared with women with immediate BR, as the latter never have to live without their breast(s).

Ideally, each BR group in the present study should have included patients with immediate BR as well; however, in the Netherlands, immediate DIEP flap BR after mastectomy for breast cancer is hardly performed because of logistic limitations [41]. In contrast, the delayed implant BR group was relatively small, as generally, immediate implant BR is provided. Understandably, patients could not be assigned randomly to a reconstruction type, as patients would subsequently have been withdrawn from complete information provision. Suggestions for the future include comprehensive validation of the BIS questionnaire, the use of a breast reconstruction-specific questionnaire such as the Breast-Q [52] and the inclusion of sexual satisfaction measurements of single women.

In conclusion, body image improved significantly after both BR techniques and a better general mental health, less cancer distress and a better partner relationship satisfaction were related to a better body image during the entire BR course. Sexual relationship satisfaction also improved, particularly if higher partner relationship satisfaction was reported. However, the psychosexual consequences of previous hormonal therapy for breast cancer should be taken into account. Future follow-up measurements should identify the longer term outcomes after BR, and patient needs should be explored as well, with regard to potential counseling for intimate problems after mastectomy and adjuvant breast cancer treatment.

Clinical implications

It is important for clinicians to be aware of psychosocial aspects during the process of mastectomy followed by BR, next to satisfaction with aesthetic outcome. During postoperative follow-up consultations, the plastic surgeon and/or mamma-care nurse could specifically ask for the psychosocial impact of the breast cancer diagnosis and treatment, including the reconstructive procedure. Patients expressing they experience problems should be referred for psychological help to improve mental health, which can positively affect body image as well as physical health [53-55].

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Conflict of interest
  8. Appendix: The body image scale
  9. References

We would like to thank all participants and the involved specialists G. K. van Drunen, M.B.E. Menke-Pluymers, C. Seynaeve, J. F. A. van der Werff, N. A. S. Posch, D. P. M. Goossens and Annelies Kleijne for data management. This study was supported by the Dutch Cancer Society (UL 2007–3726).

Appendix: The body image scale

  1. Top of page
  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Conflict of interest
  8. Appendix: The body image scale
  9. References
1. I was happy with my appearance when dressed.
2. I felt very feminine.
3. I was satisfied with my naked appearance.
4. I had trouble looking at my naked self.
5. I had trouble touching my breasts.
6. I was satisfied with the appearance of my breasts.
7. My breasts felt pleasantly.
8. I felt sexually attractive.
9. I felt comfortable enough to wear V-necked clothes.
10. I felt comfortable enough to wear swimwear.
11. I was embarrassed for my naked body.
12¤. I felt comfortable when my partner touched my breasts.
13¤. I had qualms about getting undressed in the presence of my partner.
¤: completed only by patients with a partner; item score 1–5: 1 = totally disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = totally agree
Notes
  1. 1

    DIEP flaps were performed only at Erasmus University Medical Center Rotterdam (EMCR) and the Haga Teaching (Haga) Hospital

  2. 2

    Leiden University Medical Center (LUMC), EMCR/Daniel den Hoed Cancer Center, Haga Hospital, Rijnland Hospital Leiderdorp, Admiraal de Ruyter Hospital Goes and Vlissingen and the Hospital Zorgsaam Zeeuws-Vlaanderen.

References

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  2. Abstract
  3. Introduction
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Conflict of interest
  8. Appendix: The body image scale
  9. References
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