***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : To prospect ively evaluate the psychosocial outcomes and body image of patients 2 years postmastectomy reconstruction  using a multicenter , multisurgeon approach . Background : Although breast reconstruction has been shown to confer significant psychosocial benefits in breast cancer patients at year 1 postreconstruction , we considered the possibility that psychosocial outcomes may remain in a state of flux for years after surgery . Methods : Patients were recruited as part of the Michigan Breast Reconstruction Outcome Study , a 12 center , 23 surgeon prospect i ve cohort study of mastectomy reconstruction patients . Two-sided paired sample t tests were used to compare change scores for the various psychosocial subscales . Multiple regression analysis was used to determine whether the magnitude of the change score varied by procedure type . Results : Preoperative and postoperative year 2 surveys were received from 173 patients ; 116 with immediate and 57 with delayed reconstruction . For the immediate reconstruction cohort , significant improvements were observed in all psychosocial subscales except for body image . This occurred essentially independent of procedure type . In the cohort with delayed reconstruction , significant change scores were observed only in body image . Women with transverse rectus abdominis musculocutaneous flaps had significantly greater gains in body image scores ( P = 0.003 and P = 0.034 , respectively ) when compared with exp and er/implants . Conclusions : General psychosocial benefits and body image gains continued to manifest at 2 years postmastectomy reconstruction . In addition , procedure type had a surprisingly limited effect on psychosocial well being . With outcomes evolving beyond year 1 , these data support the need for additional longitudinal breast reconstruction outcome studies Although it is thought that transverse rectus abdominis muscle ( TRAM ) flap breast reconstruction produces excellent cosmetic results that are maintained over the long term , there is little objective evidence in the literature to support this . One hundred seventy‐one consecutive patients who underwent TRAM flap reconstruction  were prospect ively analyzed over an 8‐year period to assess their morbidity and late cosmetic outcome . The early patient complication rate ( < 2 months ) was 37.4 percent , the late hernia and fat necrosis rates ( > 2 months ) were 8.8 and 13.5 percent , respectively , and the contralateral symmetrization rate was 33.9 percent . The cosmetic results were evaluated prospect ively using an objective five‐point global scale . Each patient was scored at each visit once surgery was completed . Follow‐up continued until a flap was lost , a patient died , or the point of last patient contact was reached . Six patients died during the study . The actuarial percentage cosmetic outcome remained stable during the study period , with an acceptable result in 96.4 percent of patients at 2 years and in 94.2 percent of patients at 5 years . Only five patients in this series obtained poor cosmetic outcomes , with three due to substantial flap necrosis and two because of poor flap design . Two free TRAM flaps were also lost . Log‐rank analysis revealed that neither patient age nor timing of surgery significantly affected the cosmetic outcome . Single pedicle and supercharged ( single pedicle ) TRAM flaps produced slightly better results than bipedicle and free TRAM flaps . In this prospect i ve longitudinal study , TRAM flap reconstructions were shown to produce aesthetically pleasing results . Moreover , with long‐term follow‐up , it was demonstrated that these reconstructions maintained their stability . ( Plast . Reconstr . Surg . 107 : 1710 , 2001 . In the past decade , changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy . Although investigators have documented the psychological , social , emotional , and functional benefits of breast reconstruction , little research has evaluated the effects of procedure choice on these outcomes . The current study prospect ively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction : tissue exp and er/implant , pedicle TRAM , and free TRAM techniques . In a prospect i ve cohort design , patients undergoing postmastectomy reconstruction for the first time with exp and er/implant , pedicle TRAM , or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada . Before reconstruction and at 1 year after reconstruction , patients were evaluated by a battery of question naires consisting of both generic and condition-specific surveys . Outcomes assessed included emotional well-being , vitality , general mental health , social functioning , functional well-being , social well-being , and body image . Baseline ( preoperative ) scores and the change in scores ( the difference between postoperative and preoperative scores ) were compared across procedure types using t tests and analysis of covariance . Preoperative and 1-year postoperative surveys were obtained from 273 patients . Procedure type was reported in 250 patients , of whom 56 received implant reconstructions , 128 pedicle TRAM flaps , and 66 free TRAM flaps . A total of 161 immediate and 89 delayed reconstructions were performed . Among women receiving immediate reconstruction , significant improvements were observed in all psychosocial variables except body image . However , no significant effects of procedure type on these changes over time existed . Similarly , delayed reconstruction patients had significant increases in emotional well-being , vitality , general mental health , functional well-being , and body image . Although the choice of reconstructive technique did not significantly impact most of these outcomes , significant differences existed among procedure types for three psychosocial subscales . Patients undergoing delayed exp and er/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures . By contrast , delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed exp and er-implant reconstruction . The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients . Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction , our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction BACKGROUND Previously , we found  patient satisfaction with breast reconstruction at postoperative year 1 significantly higher in the autogenous tissue compared with the exp and er/implant population . But breast reconstructive procedures have different " aging " processes , and the point at which outcomes stabilize is unclear . So we evaluated patient satisfaction with breast reconstruction  at postoperative year 2 and compared the results with those from our previous study . STUDY DESIGN As part of the Michigan Breast Reconstruction Outcomes Study , women undergoing mastectomy reconstruction ( including exp and er/implants and pedicle and free transverse rectus abdominis musculocutaneous flaps [ TRAM ] )  were prospect ively evaluated . Preoperatively and at postoperative years 1 and 2 , women completed a question naire that collected a variety of vali date d health status information . The postoperative question naire had an additional seven items assessing both general and esthetic satisfaction as separate subscales . To assess the effects of procedure on satisfaction and control for possible confounding , multiple logistic regression was used . RESULTS At year 2 , patients with TRAM flaps ( both free and pedicle ) continued to have higher levels of esthetic satisfaction compared with exp and er/implant patients ( odds ratio 2.8 , p < 0.01 ) . But no significant differences were appreciated in esthetic satisfaction between women with free and pedicle TRAM flaps . In regard to general satisfaction , the type of reconstruction ( exp and er/implant , pedicle TRAM , and free TRAM ) had no statistically significant effect . CONCLUSIONS At postoperative year 2 , procedural differences initially found in women 's general satisfaction with breast reconstruction diminish . Specifically , women with pedicle TRAM flaps , free TRAM flaps , and exp and er/implants had similar levels of general satisfaction . But at year 2 , patients continue to be more esthetically satisfied with autogenous tissue than with exp and er/implant reconstructions Twenty-seven  free transverse rectus abdominis musculocutaneous ( TRAM ) and 16 pedicled TRAM flap breast reconstruction patients  were studied for 7 to 41 months ( mean , 23 months ) postoperatively to compare abdominal sequelae after these two operations . The patient groups were demographically similar ; mean age was 47 years in both groups . Subjective grading of the results was similar in both groups . The incidence of minor lower abdominal bulges was higher ( 44 % , 7/16 ) in the pedicled group than in the free TRAM flap group ( 4 % , 1/27 ) . No hernias were found . Delayed healing of the abdominal scar occurred in 3 free TRAM flap and 1 pedicled TRAM flap patients . Two free TRAM flap ( 8 % ) and 7 pedicled TRAM ( 44 % ) flap patients had minor edge necrosis of the breast . Trunk strength was tested using an isokinetic device ( Lido Multi Joint II ) , and peak torque for flexion ( mean , 111 Nm ± 25 Nm in the free TRAM flap group and 123 Nm ± 28 Nm in the pedicled TRAM flap group ) and extension ( mean , 144 Nm ± 38 Nm and 167 Nm ± 45 Nm ) were measured . No statistical differences occurred between these groups . Sit-up performance was tested and grade d from 1 to 6 . Both groups performed equally ( 4.8 and 4.8 ) and within normal values for this age group . Ultrasonography of the rectus muscles revealed that in the free TRAM flap group , the rectus muscle of the operated side was significantly thinner ( cranial segment 6.8 mm vs. 7.8 mm , p < 0.05 ) , thus the harvesting of a segment of muscle below the umbilicus seems to disturb the quality of the entire muscle . The mean size of the muscular defect in the free TRAM flap group was 4.3 x 6.1 cm . In this study no differences in patient satisfaction or trunk strength could be found between free and pedicled TRAM flap patients Background : Functional outcomes in breast reconstruction are important quality measures and aid in patients ' decision-making process . To address the concerns of abdominal wall morbidity with transverse rectus abdominis musculocutaneous ( TRAM ) flap reconstructions , the authors prospect ively evaluated the long-term effects of postmastectomy breast reconstruction on trunk function using objective clinical measures . Methods : Using a multicenter prospect i ve cohort design , they recruited women undergoing first-time immediate or delayed breast reconstructions from 12 centers and 23 plastic surgeons . Trunk functional data , objective ly measured with Cybex machines , for patients with an exp and er/implant , pedicle TRAM , and free TRAM reconstructions  were evaluated preoperatively and at postoperative years 1 and 2 in 183 patients . The effects of procedure type , timing , and laterality on trunk peak torque and range of motion were analyzed using linear regression . Results : At 2 years postoperatively , procedure type , timing , and laterality did not significantly affect the range of motion for trunk flexion and extension . Peak torque for trunk flexion at year 2 was significantly decreased in patients with TRAM compared with exp and er/implant reconstructions ( p < 0.05 ) , with a 6 to 19 percent decrease in flexion peak torque . However , no significant difference in flexion peak torque was found between patients with free and pedicle TRAM reconstructions . Conclusions : The authors found that ( 1 ) breast cancer patients with TRAM reconstructions had a less than 20 percent long-term deficit in trunk flexion peak torque and ( 2 ) there was no significant difference in trunk function between patients receiving pedicle and free TRAM reconstructions Objective The authors prospect ively studied the impact of immediate breast reconstruction on patients undergoing mastectomy .  Summary Background Data Despite the advocation of a breast-conserving approach to the treatment of breast cancer , many women continue to medically require or choose  mastectomy  for the treatment of breast cancer . In recent years , immediate breast reconstruction has become an alternative to either mastectomy alone or to delayed reconstruction . Methods A prospect i ve data base of 216 patients who underwent mastectomy with immediate reconstruction was established . In this series , 94 procedures involved implants or tissue exp and ers , and 124 tissue transfers were performed . Results The overall complication rate was 15.3 % ; only 9 % of patients who underwent autologous tissue transfers required secondary procedures . When implants were performed , the overall rate of prosthetic loss was 8 % . The majority of patients ( n = 101 ) underwent transverse rectus abdominis musculocutaneous ( TRAM ) flaps . Twenty-six of the 38 ( 17.5 % ) patients who required transfusion were from this group . Partial flap losses in this group ( 7 % ) were correlated to a history of heavy smoking . With a median follow-up of 33.2 months , only two patients had recurred locally . According to patient opinion , autologous tissue transfers result ed in a statistically better cosmetic result . Conclusions Immediate reconstruction can be performed safely and with excellent cosmetic results Abdominal weakness is a known potential complication of breast reconstruction with a pedicled or free TRAM flap .  It has been presumed that the DIEP flap , which involves no muscle resection , does not compromise abdominal muscle strength but little objective research exists to substantiate this . The aims of this retrospective study were to compare abdominal muscle strength following free TRAM flap and DIEP flap , to compare both groups with a control group and to establish the effect of both procedures on functional activities . Fifty women ( 23 with a DIEP flap , 27 with a free TRAM flap ) plus 32 non-operated controls underwent assessment of their abdominal and back extensor muscle strength on a KIN COM isokinetic dynamometer . Two question naires were used to establish the impact on function . The TRAM flap group had significant weakness of the abdominal and back extensor muscles compared with the DIEP flap group and the control group . The trend was for the DIEP flap group to 
    Output:
    
However , none of the comparative studies of pedicle and free TRAM procedures found significant differences in abdominal wall function between the 2 groups .
Free TRAM groups experienced minimal deficit in rectus muscle function , whereas DIEP flaps returned to baseline for both rectus and oblique muscle function .
Subjective measures of abdominal wall function were similar across unipedicle TRAM , free TRAM , and DIEP flap procedures .
Patients with bilateral pedicle or free TRAM reconstruction also experienced a significant decrease in the ability to perform sit-ups and a significant decrease in activities of daily living , recreational , and laborious activities .
With the exception of those who had bipedicled TRAM or bilateral free TRAM procedures , most women reported return to their preoperative function without a decrease in their ability to perform activities of daily living .
Although some studies report an objective advantage of DIEP flaps , this does not appear to translate to detriments in the performance of activities of daily living .