title: Comparison of Aesthetic Outcomes Between Vertical and Horizontal Flap Insets in Breast Reconstruction with the TRAM or DIEP Flaps.
abstract: BACKGROUND
  Tissue transfer, such as use of the transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) free flaps, is considered a standard method. However, outcomes may vary among inset methods. Here we compared the aesthetic outcomes of breast reconstructions using vertical and horizontal flap inset methods.
  
  
  METHODS
  We, respectively, reviewed 274 patients who underwent unilateral post-mastectomy breast reconstruction using TRAM or DIEP free flaps between April 2006 and December 2013. Photographs (frontal and bilateral oblique views) obtained 6 months post-operatively were evaluated. Symmetry scores and regional volume discrepancy scores were compared between the vertical and horizontal inset groups. Symmetry scores were adjusted for 11 potential confounding factors on multivariate regression analysis.
  
  
  RESULTS
  The vertical inset method was associated with higher total symmetry scores, projection, and ptotic naturalness scores. On multivariate regression analysis, the inset method was an independent predictor of outcomes. Regional volume discrepancy score analysis showed a greater tendency for more symmetrical volumes in the upper, medial, and lateral poles with the vertical inset.
  
  
  CONCLUSIONS
  The flap inset method is one of the key determinants of aesthetic breast reconstruction outcomes. The vertical inset method was associated with superior aesthetic outcomes and enabled balanced distribution of flap volume to the four poles of the breast.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
authors.affiliation: Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
authors.forename: Woo Shik
authors.initials: WS
authors.lastname: Jeong
authors.affiliation: Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
authors.forename: Wooyeon
authors.initials: W
authors.lastname: Han
authors.affiliation: Department of Plastic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea. jinsupp@amc.seoul.kr.
authors.forename: Jin Sup
authors.initials: JS
authors.lastname: Eom
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery; D015331:Cohort Studies; D019074:Epigastric Arteries / Q000601:surgery*; D004954:Esthetics; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D064827:Myocutaneous Flap / Q000637:transplantation*; D061525:Perforator Flap / Q000098:blood supply / Q000637:transplantation*; D017568:Rectus Abdominis / Q000098:blood supply / Q000637:transplantation*; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome
keywords: Aesthetic outcome; Breast reconstruction; DIEP flap; TRAM flap