The Influence of a Previous Implant-Based Breast Reconstruction on Postoperative Sensation of the Deep Inferior Epigastric Artery Perforator Flap

The Influence of a Previous Implant-Based Breast Reconstruction on Postoperative Sensation of the Deep Inferior Epigastric Artery Perforator Flap | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Influence of a Previous Implant-Based Breast Reconstruction on Postoperative Sensation of the Deep Inferior Epigastric Artery Perforator Flap Joep A.F. van Rooij, Ennie Bijkerk, René R.W.J. van der Hulst, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3059218/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Apr, 2024 Read the published version in Breast Cancer → Version 1 posted 4 You are reading this latest preprint version Abstract Background Implants and DIEP flaps have different outcomes regarding postoperative breast sensation. When compared to the preoperative healthy breast, implant-based breast reconstruction (IBBR) negatively influences postoperative breast sensation. However, it is currently unknown whether a prior IBBR also influences postoperative sensation of a replacing DIEP flap. The goal of this cohort study is to evaluate the influence of an IBBR on the postoperative sensation of a replacing DIEP flap. Methods Women were included if they received a DIEP flap reconstruction after mastectomy, with or without prior tissue expander (TE) and/or definitive breast implant. Sensation was measured at four intervals in 9 areas of the breast with Semmes-Weinstein monofilaments: T0 (preoperative, implant/no reconstruction), T1 (2–7 months postoperative, DIEP), T2 (± 12 months postoperative, DIEP), Tmax (maximum follow-up, DIEP). Linear mixed models were used to investigate the relationship between an implant/TE prior to the DIEP flap and recovery of breast sensation. Results 142 women comprising 206 breasts were included. 48 (23.3%) breasts did, and 158 (76.7%) breasts did not have a TE/IBBR prior to their DIEP. No statistically significant or clinically relevant relationships were found between a prior implant/TE and recovery of DIEP flap breast sensation for the flap skin, native skin, or total breast skin at T1, T2, or Tmax. There were also no relationships found after adjustment for the confounders radiation therapy, BMI, diabetes, age, flap weight, follow-up, and nerve coaptation. Conclusions An implant/TE prior to a DIEP flap does not influence the recovery of postoperative breast sensation of the DIEP flap. Breast reconstruction breast sensation implant-based breast reconstruction breast implants DIEP flap Figures Figure 1 Figure 2 Introduction The number of breast cancer patients is increasing annually.[ 1 ] Simultaneously, the percentage of women choosing breast reconstruction after mastectomy is increasing and has doubled from 13% in 1998 to 26% in 2007. In 2017, 30–40% of women chose a reconstruction after mastectomy in the Netherlands.[ 2 – 5 ] Two of the most common reconstructive options are implant-based breast reconstruction (IBBR) or autologous reconstruction, often by the deep inferior epigastric perforator (DIEP) flap.[ 6 – 8 ] Cosmetic outcomes have always played and still play an important role in the reconstructive result. However, functional outcomes such as breast sensation are gaining importance and are known to be paramount in improving quality of life after reconstruction.[ 9 , 10 ] Previous research has shown that breast sensation after mastectomy and IBBR is impaired.[ 11 , 12 ] In contrast, when accompanied by nerve coaptation, autologous reconstruction with a DIEP flap is shown to be superior in recovery of postoperative breast sensation.[ 13 – 16 ] Van Rooij et al. recently showed that it takes approximately 1.5 years after switching an IBBR for a DIEP flap reconstruction for sensation to recover back to the levels of IBBR.[ 17 ] In spite of this, the influence of a previous breast implant on the sensation of the replacing DIEP flap remains unknown. When considering a post-mastectomy reconstruction, the patient’s opinion plays the dominant role.[ 18 , 19 ] Providing sufficient information on breast reconstruction is essential for patients in the process of shared decision-making. Since breast sensation plays a major role in improving quality of life, the goal of this study is to compare sensation of the breast after DIEP flap reconstruction in patients with and patients without prior IBBR. This enables evaluation of whether or not implants have a negative influence on the postoperative sensation of the replacing DIEP flap. Materials and Methods In this cohort study, we included data of all patients who received a DIEP flap reconstruction after their mastectomy, with or without a prior tissue expander (TE) and/or definitive breast implant between August 2016 and August 2018 in the Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands. Patients with primary, secondary, and tertiary breast reconstruction were included. This study was approved by the local medical ethical review board. All participants have provided written informed consent. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Data collection/outcomes From August 2016 up until August 2018, all patients who underwent a DIEP flap breast reconstruction and Semmes-Weinstein monofilament (SWM) sensation measurements at the Department of Plastic, Reconstructive and Hand Surgery in the MUMC+, Maastricht, the Netherlands, were registered in a database.[ 20 ] The database contains surgical information and individual procedural details, patients’ medical characteristics, timing of reconstruction, tumor pathology, preliminary oncological treatment and postoperative complications or reoperations of the flap, as well as results of pre and postoperative SWM sensation measurements. For this study, we included all patients who had a DIEP flap breast reconstruction with or without prior IBBR and had data of pre and postoperative SWM measurements. Patients who received postoperative radiation therapy on their DIEP flap were excluded due to the effect on skin sensation. Patients who had both missing pre and postoperative breast sensation measurements were also excluded. The 20-piece SWM kit was used with index values ranging from 1.65 to 6.65 (monofilaments with increasing diameter). Several colors represent different grades of skin sensation, from best to worst sensation: green, normal touch (1.65–2.83); blue, diminished light touch (3.22–3.61); purple, diminished protective sensation (3.84–4.31); red, loss of protective sensation (4.56–6.45); and red, deep pressure sensation only (6.65). Measurements were performed with the patient in supine position and by either one of two researchers with extensive experience in sensation measurements with the SWM. For the primary outcome, we compared the difference in breast sensation measured by use of the SWM between two groups: one group of patients with a DIEP flap breast reconstruction without prior IBBR and one group of patients with a DIEP flap breast reconstruction with prior IBBR. Women received preoperative sensation measurements one day prior to their reconstructive surgery. The postoperative measurements were performed during four outpatient check-ups; a preoperative measurement (T0; either no reconstruction or TE/IBBR); a postoperative measurement moment 1 (T1; DIEP flap) including measurements between 2 and 7 months postoperatively; a postoperative measurement moment 2 (T2; DIEP flap) including measurements around 12 months postoperatively; and a postoperative measurement moment at the last outpatient check-up with maximum follow-up (Tmax; DIEP flap). For the sensation measurements, the breast was divided in 9 areas to be measured, based on anatomical references (Fig. 1 ). In a healthy breast or a breast with an IBBR, measuring points 1–4 correspond to the breast skin, while points 5–9 correspond to the nipple-areolar complex (NAC). In the autologously reconstructed breast, depending on the type of mastectomy, measuring points 5–9 are generally considered flap skin if the patient had a history of skin-sparing mastectomy. For reconstruction after a non-skin-sparing mastectomy reconstruction, generally all measuring points except 1 and 4 are considered flap skin. Individual patient differences in flap and native skin were registered in case of intraoperative variability in skin quality and mastectomy flaps. The breast of patients without pre-existent or remaining nipple was divided into four quadrants with one vertical line from midclavicular to the caudal portion of the breast and one horizontal line perpendicular to the first. The lines cross each other at the level of the contralateral nipple and the intersection formed the center of the circle for measuring points 5–9 (Fig. 2 ). Statistical analysis Descriptive statistics were used for patients’ baseline characteristics. A mean and standard error for the SWM measurements was calculated for the four follow-up moments T0, T1, T2, and Tmax. For each follow-up moment, means and standard error were calculated for flap skin, native skin, and the total breast according to the corresponding measuring points. With over 5% of incomplete postoperative SWM measurements due to missing data, multiple imputation was used to prevent a loss of statistical power and decrease the likelihood of biased results. The number of imputations was set to 20 and predictive mean matching was used to draw the values to be imputed. The logarithmically transformed values of the SWM were used for analysis, because they form normal distributed data, unlike their values in grams. Unit of analysis was the breast. Linear mixed models were used to investigate relationships between an implant or TE prior to the DIEP flap reconstruction and recovery of breast sensation. Hence, the patient population consists of women with and without an IBBR prior to their DIEP flap. We corrected for the following confounders: radiation therapy, BMI, diabetes, age at operation, flap weight, follow-up, and nerve coaptation. Nerve coaptation was only added to the analysis at T2 and Tmax, as the influence of the nerve will only start to be noticeable from 7 months postoperative. Results For this study we included 142 women, comprising 206 breasts in total. All women had a DIEP flap reconstruction. 158 of 206 breasts (76.7%) did not have an IBBR prior to the DIEP flap reconstruction. 48 of 206 breasts (23.3%) did have an IBBR prior to the DIEP flap (Table 1, baseline characteristics). The mean age of the women with a prior implant was 50.2 years. The mean age of women without a prior implant was 51.8 years. 87 women (55.1%) in the non-implant group and 19 women (39.6%) in the implant group had a history of radiation therapy. Mean follow-up for the implant group was 4.6 ±1.8 months for T1, 14.1 ±4.7 months for T2, and 16.3 ±5.5 months for Tmax. Mean follow-up for the non-implant group was 4.6 ±1.5 months for T1, 12.3 ±2.9 months for T2, and 18.2 ±5.7 for Tmax. For T1 (follow-up 2-7 months), T2 (follow-up around 12 months), and Tmax (maximum follow-up) we calculated crude and adjusted values for flap skin, native skin, and total breast skin. The p-value for all coefficients was >0.05 and hence no relationship was found between a previous implant and postoperative sensation of the replacing DIEP flap (Table 2). Absolute SWM values between the DIEP group with and the DIEP group without a prior implant are displayed in Table 3. At T0, prior to the DIEP, absolute SWM values were higher for the group with an implant compared to the group without an implant. This was the case for the native skin, flap skin, and total skin. At T1, T2, and Tmax, there were minimal sensation differences left between the implant and non-implant group for the native, flap, and total skin. Discussion In this cohort study, we compared sensation of the breast after DIEP flap reconstruction in patients with and patients without prior IBBR to evaluate the influence of an implant or TE on the postoperative sensation of the replacing DIEP flap. The goal of this study was to further map out breast sensation after breast reconstruction. The outcomes are important to be able to better inform women preoperatively about what to expect of their postoperative breast sensation; questions which women ask on a regular basis at our outpatient clinic. We have analyzed breast sensation at different time points: T0, T1, T2, and Tmax, for the total breast skin, flap skin and native skin. Our results show no significant difference in breast sensation between women with and without an implant prior to their DIEP flap reconstruction, even not after adjusting for the confounders of radiation therapy, BMI, diabetes, age, flap weight, length of follow-up, and performed nerve anastomosis. These results are further emphasized by the absolute SWM values, as can be seen in Table 3 . There is an increasing focus on postoperative breast sensation after reconstruction, especially since high levels of cosmetic result can be achieved with current autologous breast reconstructive techniques. Many recent studies have focused on breast sensation after reconstruction. Several of these have shown the positive effect of improved sensation on quality of life, and the importance of postoperative breast sensation is underlined by the recent development of the Sensation module of the BREAST-Q.[ 10 , 21 , 22 ] As an alternative to implant reconstruction, Beugels et al. has demonstrated in a number of studies that recovery of breast sensation is positively influenced by performing a nerve coaptation accompanying the DIEP flap.[ 14 , 16 ] Van Rooij et al. recently showed that swapping an implant reconstruction for a DIEP flap initially decreases postoperative sensation, but that sensation levels return to their preoperative value after approximately 1.5 years.[ 17 ] However, whether an implant does or does not influence postoperative sensation of the DIEP flap had not been studied before. To analyze a hypothetical relationship between a previous implant and the sensation of the replacing DIEP flap, we have used a linear mixed model analysis. Despite being statistically insignificant, the coefficients retrieved from the linear mixed model were also not clinically relevant. None of the coefficients reached a value close to -1 or 1, with the largest deviation from zero being − 0.15. Bijkerk et al. found that breast sensation decreases after mastectomy but decreases even further after reconstructing the breast with an implant.[ 11 , 12 ] They also found IBBR to be significantly associated with impaired sensation. Reflecting these results on our population, this could mean that the group with an implant before their DIEP flap could have worse breast sensation than the group without an implant before their DIEP flap. However, our results show no significant impact of an implant on the postoperative sensation of the DIEP flap, both at short and long-term follow-up. This indicates that the implant does not permanently damage the nerve endings in the skin and does not directly influence the sensory nerves or nerve regrowth of the replacing DIEP flap. When the implants are in place, they may act as a temporary physical barrier to block the sprouting nerves partially reinnervating the overlying skin.[ 23 ] However, after the implant has been removed and the DIEP flap is in place, the sensory innervation seems to start recovering from baseline again. Our study has some limitations. First, we have not distinguished between TE and IBBR for our analysis. However, we do not expect its effects on sensation to be different. Both have a similar outer shell and the decrease in sensation caused by an implant seems to be primarily caused by its barrier effect preventing nerve regrowth to the surface, based on our results and previous studies.[ 12 ] One might argue that the volume of the implant or inflation of the TE can cause extra nerve or skin damage, but Van Rooij et al. have found no correlation between implant volume and breast sensation when the implant is in place.[ 17 ] Second, the data used in our study has been collected prospectively for another study but has been retrospectively analyzed for the current study. Hence, we have included as much patients as possible but have not performed a power analysis specifically for this study. The number of patients included in combination with a large number of confounders added to the multivariate logistic regression analysis may have influenced the statistical significance of our study. Last, the intrarater and interrater-reliability of the SWM has been debated.[ 24 ] To increase reliability of the measurements and decrease of bias, we have used the same two experienced researchers for performing the sensation measurements. Future studies should further focus on the underlying physiology of sensation of the breast after autologous reconstruction and, especially, focus on discovering techniques to further improve the sensation of the breast. As stated earlier, improvement in sensation means improvement in breast-related quality of life, which makes it paramount in optimizing the outcomes of breast reconstruction. We are currently conducting a double-blinded, randomized controlled trial in our hospital to compare the quality of life and objectively measured sensation of the reconstructed breast in women with and without nerve coaptation accompanying the DIEP flap. Conclusions In conclusion, an implant preceding a DIEP flap reconstruction does not influence the postoperative sensation or recovery of sensation of the reconstructed breast, even after adjusting for the confounders radiation therapy, BMI, diabetes, age, flap weight, length of follow-up and performed nerve anastomosis. The results of this study can be used in patient counseling and providing women with information about what to expect regarding breast sensation after autologous breast reconstruction. Declarations Funding Statement The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Data Availability Statement The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at the Maastricht University Medical Center. Compliance with Ethical Standards Declaration of Interest The authors have no relevant financial or non-financial interests to disclose. Ethics Approval This study was approved by the local medical ethical review board (Date: June 10 2021 / No METC 2021-2722). The work described has been carried out in accordance with The Declaration of Helsinki and the Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals. Consent to Participate Informed consent was obtained from all individual participants included in the study. References Siegel Mph RL, Miller KD, Sandeep N, Mbbs W, Ahmedin |, Dvm J, et al. Cancer statistics, 2023. CA Cancer J Clin 2023;73:17–48. https://doi.org/10.3322/caac.21763. Sisco M, Du H, Warner JP, Howard MA, Winchester DP, Yao K. Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new millennium? Evidence from the national cancer data base. J Am Coll Surg 2012;215:658–66; discussion 666. https://doi.org/10.1016/j.jamcollsurg.2012.07.008. Dutch Institute for Clinical Auditing (DICA). Jaarrapportage 2017 - Registraties. 2017. Schreuder K, van Bommel ACM, de Ligt KM, Maduro JH, Vrancken Peeters MTFD, Mureau MAM, et al. Hospital organizational factors affect the use of immediate breast reconstruction after mastectomy for breast cancer in the Netherlands. The Breast 2017;34:96–102. https://doi.org/10.1016/j.breast.2017.05.011. Ilonzo N, Tsang A, Tsantes S, Estabrook A, Thu Ma AM. Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes. Breast 2017;32:7–12. https://doi.org/10.1016/j.breast.2016.11.023. Sbitany H. Breast Reconstruction. Surg Clin North Am 2018;98:845–57. https://doi.org/10.1016/j.suc.2018.03.011. Allen RJ, Treece P. Deep Inferior Epigastric Perforator Flap for Breast Reconstruction. Ann Plast Surg 1994;32:32–8. https://doi.org/10.1097/00000637-199401000-00007. Healy C, Allen R. The Evolution of Perforator Flap Breast Reconstruction: Twenty Years after the First DIEP Flap. J Reconstr Microsurg 2013;30:121–6. https://doi.org/10.1055/s-0033-1357272. Temple CLF, Tse R, Bettger-Hahn M, MacDermid J, Gan BS, Ross DC. Sensibility following Innervated Free TRAM Flap for Breast Reconstruction. Plast Reconstr Surg 2006;117:2119–27. https://doi.org/10.1097/01.prs.0000218268.59024.cc. Cornelissen AJM, Beugels J, van Kuijk SMJ, Heuts EM, Rozen SM, Spiegel AJ, et al. Sensation of the autologous reconstructed breast improves quality of life: a pilot study. Breast Cancer Res Treat 2018;167:687–95. https://doi.org/10.1007/s10549-017-4547-3. Shridharani S, Magarakis M, Stapleton S, Basdag B, Seal S, Rosson G. Breast Sensation after Breast Reconstruction: A Systematic Review. J Reconstr Microsurg 2010;26:303–10. https://doi.org/10.1055/s-0030-1249313. Bijkerk E, van Kuijk SMJ, Beugels J, Cornelissen AJM, Heuts EM, van der Hulst RRWJ, et al. Breast sensibility after mastectomy and implant-based breast reconstruction. Breast Cancer Res Treat 2019;175:369–78. https://doi.org/10.1007/s10549-019-05137-8. Bijkerk E, van Kuijk SMJ, Lataster A, van der Hulst RRWJ, Tuinder SMH. Breast sensibility in bilateral autologous breast reconstruction with unilateral sensory nerve coaptation. Breast Cancer Res Treat 2020;181:599–610. https://doi.org/10.1007/S10549-020-05645-Y. Beugels J, Cornelissen AJM, van Kuijk SMJ, Lataster A, Heuts EM, Piatkowski A, et al. Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction. Plast Reconstr Surg 2019;144:178e–88e. https://doi.org/10.1097/PRS.0000000000005802. Spiegel AJ, Menn ZK, Eldor L, Kaufman Y, Dellon AL. Breast Reinnervation: DIEP Neurotization Using the Third Anterior Intercostal Nerve. Plast Reconstr Surg Glob Open 2013;1:e72. https://doi.org/10.1097/GOX.0000000000000008. Beugels J, Bijkerk E, Lataster A, Heuts EM, van der Hulst RRWJ, Tuinder SMH. Nerve Coaptation Improves the Sensory Recovery of the Breast in DIEP Flap Breast Reconstruction. Plast Reconstr Surg 2021;148:273–84. https://doi.org/10.1097/PRS.0000000000008160. van Rooij JAF, Bijkerk E, van der Hulst RRJW, van Kuijk SMJ, Tuinder SMH. Implant-based and DIEP flap breast reconstruction: a comparison of breast sensation and quality of life within a singular patient sample. Plast Reconstr Surg 2023. https://doi.org/10.1097/PRS.0000000000010315. Gu J, Groot G, Boden C, Busch A, Holtslander L, Lim H. Review of Factors Influencing Women’s Choice of Mastectomy Versus Breast Conserving Therapy in Early Stage Breast Cancer: A Systematic Review. Clin Breast Cancer 2018;18:e539–54. https://doi.org/10.1016/j.clbc.2017.12.013. Hargraves I, LeBlanc A, Shah ND, Montori VM. Shared Decision Making: The Need For Patient-Clinician Conversation, Not Just Information. Health Aff (Millwood) 2016;35:627–9. https://doi.org/10.1377/hlthaff.2015.1354. Baseline® Tactile TM Semmes-Weinstein type monofilaments. n.d. Temple CLF, Ross DC, Kim S, Tse R, Bettger-Hahn M, Gan BS, et al. Sensibility following innervated free TRAM flap for breast reconstruction: Part II. Innervation improves patient-rated quality of life. Plast Reconstr Surg 2009;124:1419–25. https://doi.org/10.1097/PRS.0B013E3181B98963. Tsangaris E, Klassen AF, Kaur MN, Voineskos S, Bordeleau L, Zhong T, et al. Development and Psychometric Validation of the BREAST-Q Sensation Module for Women Undergoing Post-Mastectomy Breast Reconstruction. Ann Surg Oncol 2021;28:7842–53. https://doi.org/10.1245/S10434-021-10094-Y. Beugels J, van Kuijk SMJ, Lataster A, van der Hulst RRWJ, Tuinder SMH. Sensory Recovery of the Breast following Innervated and Noninnervated Lateral Thigh Perforator Flap Breast Reconstruction. Plast Reconstr Surg 2021;147:281–92. https://doi.org/10.1097/PRS.0000000000007547. Collins S, Visscher P, De Vet HC, Zuurmond WWA, Perez RSGM. Reliability of the Semmes Weinstein Monofilaments to measure coetaneous sensibility in the feet of healthy subjects. Disabil Rehabil 2010;32:2019–27. https://doi.org/10.3109/09638281003797406. Tables Table 1 – Baseline characteristics Characteristic Reconstruction without prior implant (%) (n=158) Missing Reconstruction with prior implant (%) (n=48) Missing Age (years) 50.2 - 51.8 - Follow-up (months) T1 (mean) T2 (mean) Tmax (mean) 4.6 (±1.5; range 2-7) 12.3 (±2.9; range 8-20) 18.2 (±5.7; range 9-34) 15 22 30 4.6 (±1.8; range 2-7) 14.1 (±4.7; range 9-29) 16.3 (±5.5; range 9-29) 6 6 6 Reconstruction timing Primary Secondary Tertiary 110 (69.6) 48 (30.4) 0 (0) - - - 0 (0) 0 (0) 100 (100) - - - Implants in place (months) N.A. - 81.2 (±73.0; range 4-327) Nerve anastomosis Yes No 87 (55.1) 71 (44.9) - - 19 (39.6) 29 (60.4) - - BMI (kg/m 2 ) 27.5 (±4.3) 3 26.7 (±3.7) - Smoking Yes No 4 (2.5) 154 (97.5) - 4 (8.7) 44 (91.7) - Diabetes Yes No 2 (1.3) 156 (98.7) - 0 (0.0) 48 (100.0) - Radiation therapy Yes No 38 (24.5) 117 (75.5) 3 11 (22.9) 37 (77.1) - Chemotherapy Yes No 77 (49.7) 78 (50.3) 3 23 (47.9) 25 (52.1) - Hormone therapy Yes No 42 (27.1) 113 (72.9 3 16 (33.3) 32 (66.7) - Necrosis mastectomy skin 12 (12.8) 64 0 (0.0) 19 Breast complications Yes Venous congestion Infection Wound problems Fat necrosis Hematoma Seroma No 19 (12.2) 2 (1.3) 14 (8.9) 32 (20.4) 9 (5.7) 9 (5.7) 3 (1.9) 137 (87.8) 2 1 1 1 1 1 1 7 (14.9) 1 (2.1) 4 (8.5) 5 (10.6) 2 (4.3) 3 (6.4) 2 (4.3) 40 (85.1) 1 1 1 1 1 1 2 Table 2 – Linear mixed models analysis of postoperative breast sensation and a previous implant Time point Number of breasts Breast skin Coefficient 95% CI (upper bound – lower bound) p-value T1 206 (158+48) 206 (158+48) 206 (158+48) Total Crude Adjusted a Flap Crude Adjusted a Native Crude Adjusted a 0.030 -0.048 0.030 -0.048 0.027 -0.020 -0.20 – 0.26 -0.31 – 0.21 -0.20 – 0.26 -0.31 – 0.21 -0.34 – 0.40 -0.42 – 0.38 0.80 0.72 0.80 0.72 0.89 0.92 T2 206 (158+48) 203 (155+48) 206 (158+48) Total Crude Adjusted b Flap Crude Adjusted b Native Crude Adjusted b 0.061 -0.0051 0.080 -0.010 0.12 0.14 -0.19 – 0.31 -0.28 – 0.27 -0.22 – 0.38 -0.32 – 0.30 -0.21 – 0.45 -0.24 – 0.52 0.64 0.97 0.60 0.95 0.47 0.48 Tmax 206 (158+48) 204 (155+48) 206 (158+48) Total Crude Adjusted b Flap Crude Adjusted b Native Crude Adjusted b 0.088 0.068 0.10 0.13 0.20 0.12 -0.15 – 0.32 -0.27 – 0.41 -0.16 – 0.36 -0.25 – 0.51 -0.12 – 0.53 -0.32 – 0.55 0.47 0.69 0.43 0.50 0.22 0.60 CI = confidence interval a Adjusted for radiation therapy, BMI, diabetes, age at operation, flap weight, and follow-up b Adjusted for radiation therapy, BMI, diabetes, age at operation, flap weight, follow-up, and nerve anastomosis Table 3 – Absolute monofilament values of the groups with and without an implant prior to their DIEP flap Without implant SWM category With implant SWM category Absolute difference (= with implant – without implant) T0 (n=without/with) Mean native (n=158/48) Mean flap a (n=158/48) Mean total (n=158/48) 2.70 3.02 2.90 ##### ##### ##### 3.34 3.82 3.69 ##### ##### ##### +0.64 +0.80 +0.79 T1 (n=without/with) Mean native (n=158/48) Mean flap (n=158/48) Mean total (n=158/48) 4.51 5.43 5.11 ##### ##### ##### 4.51 5.45 5.06 ##### ##### ##### 0.00 +0.02 -0.05 T2 (n=without/with) Mean native (n=158/48) Mean flap b (n=155/48) Mean total (n=158/48) 4.13 4.92 4.65 ##### ##### ##### 4.23 4.94 4.64 ##### ##### ##### +0.10 +0.02 -0.05 Tmax (n=without/with) Mean native (n=158/48) Mean flap b (n=155/48) Mean total (n=158/48) 4.09 4.77 4.52 ##### ##### ##### 4.29 4.88 4.60 ##### ##### ##### +0.20 +0.11 +0.08 SWM = Semmes-Weinstein monofilaments; SWM categories = green, normal touch (1.65-2.83); blue, diminished light touch (3.22-3.61); purple, diminished protective sensation (3.84-4.31); red, loss of protective sensation (4.56-6.45); and red, deep pressure sensation only (6.65). a Mean of preoperative breast areas corresponding to postoperative flap skin areas b Two patients/three breasts missing postoperative flap values due to skin island removed in secondary procedure SWM = Semmes-Weinstein monofilaments; SWM categories = green, normal touch (1.65-2.83); blue, diminished light touch (3.22-3.61); purple, diminished protective Cite Share Download PDF Status: Published Journal Publication published 06 Apr, 2024 Read the published version in Breast Cancer → Version 1 posted Reviewers agreed at journal 20 Jun, 2023 Reviewers invited by journal 20 Jun, 2023 Editor assigned by journal 15 Jun, 2023 First submitted to journal 13 Jun, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3059218","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":211708668,"identity":"c8822267-4656-43b6-9c51-445fcf673973","order_by":0,"name":"Joep A.F. van Rooij","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYBACxgZkXgKPDZRVQLyWNCjLgHhbDxPWwtzefOwBY5tdHoP04YMPHsicjza4dvgBcwEeLYw9x9INGNuSixn40pINEnhu5264nWbAPAOflhk5ZhIMZ5gTG3h4zCQgWnIYmHnwasn/BtRSD9NyjhgtOWwSDBWHYVoOEKGl55i5QULF8cQ2HjaQX5JzZwL9chifFsP25mcPPhhUJ/bzMB98+LPHLrfvdvLDxzwVeLQ0MLAxJAAZbBA7IaIHcGtgYJCHKoaCH/jUjoJRMApGwUgFAA3QSlMxHfjlAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-5066-7909","institution":"Maastricht University Medical Centre+: Maastricht Universitair Medisch Centrum+","correspondingAuthor":true,"prefix":"","firstName":"Joep","middleName":"A.F. van","lastName":"Rooij","suffix":""},{"id":211708669,"identity":"54921182-5d61-463a-aebd-df73129d4f37","order_by":1,"name":"Ennie Bijkerk","email":"","orcid":"","institution":"Maastricht University Medical Centre+: Maastricht Universitair Medisch Centrum+","correspondingAuthor":false,"prefix":"","firstName":"Ennie","middleName":"","lastName":"Bijkerk","suffix":""},{"id":211708670,"identity":"78aaf14e-888b-4551-9dd9-44345b9f8c10","order_by":2,"name":"René R.W.J. van der Hulst","email":"","orcid":"","institution":"Maastricht University Medical Centre+: Maastricht Universitair Medisch Centrum+","correspondingAuthor":false,"prefix":"","firstName":"René","middleName":"R.W.J. van der","lastName":"Hulst","suffix":""},{"id":211708671,"identity":"96964273-80a9-4cb3-998a-0c3703af3e41","order_by":3,"name":"Stefania M.H. Tuinder","email":"","orcid":"https://orcid.org/0000-0001-9046-3962","institution":"Maastricht University Medical Centre+: Maastricht Universitair Medisch Centrum+","correspondingAuthor":false,"prefix":"","firstName":"Stefania","middleName":"M.H.","lastName":"Tuinder","suffix":""}],"badges":[],"createdAt":"2023-06-13 16:06:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3059218/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3059218/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12282-024-01558-6","type":"published","date":"2024-04-06T15:01:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":39186748,"identity":"53085df6-5b36-4f25-a10f-0b21e5559566","added_by":"auto","created_at":"2023-06-27 19:02:26","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45009,"visible":true,"origin":"","legend":"\u003cp\u003eThe breast divided in 9 areas for Semmes-Weinstein monofilament measurements (1-4 = peripheral breast, 5-9 = NAC) with scars after reconstruction as dashed lines following skin-sparing mastectomy (right) and following non-skin-sparing mastectomy (left)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3059218/v1/ed757eada471abda22df60df.jpeg"},{"id":39186747,"identity":"6ba5ade3-78cf-448e-97c6-4984f9a64bc9","added_by":"auto","created_at":"2023-06-27 19:02:26","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":69575,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThe breast without nipple immediately post-mastectomy (A) and after implant-based breast reconstruction (B) divided into 9 areas\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3059218/v1/9905b9c96165933ded9a170c.jpeg"},{"id":54303903,"identity":"87680df1-6773-4750-86af-6b7502b05d81","added_by":"auto","created_at":"2024-04-08 15:12:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":456076,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3059218/v1/44a08d68-9221-4bcb-ac8b-e49f7a28c8c7.pdf"}],"financialInterests":"","formattedTitle":"The Influence of a Previous Implant-Based Breast Reconstruction on Postoperative Sensation of the Deep Inferior Epigastric Artery Perforator Flap","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe number of breast cancer patients is increasing annually.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Simultaneously, the percentage of women choosing breast reconstruction after mastectomy is increasing and has doubled from 13% in 1998 to 26% in 2007. In 2017, 30\u0026ndash;40% of women chose a reconstruction after mastectomy in the Netherlands.[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTwo of the most common reconstructive options are implant-based breast reconstruction (IBBR) or autologous reconstruction, often by the deep inferior epigastric perforator (DIEP) flap.[\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Cosmetic outcomes have always played and still play an important role in the reconstructive result. However, functional outcomes such as breast sensation are gaining importance and are known to be paramount in improving quality of life after reconstruction.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Previous research has shown that breast sensation after mastectomy and IBBR is impaired.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] In contrast, when accompanied by nerve coaptation, autologous reconstruction with a DIEP flap is shown to be superior in recovery of postoperative breast sensation.[\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Van Rooij et al. recently showed that it takes approximately 1.5 years after switching an IBBR for a DIEP flap reconstruction for sensation to recover back to the levels of IBBR.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] In spite of this, the influence of a previous breast implant on the sensation of the replacing DIEP flap remains unknown.\u003c/p\u003e \u003cp\u003eWhen considering a post-mastectomy reconstruction, the patient\u0026rsquo;s opinion plays the dominant role.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Providing sufficient information on breast reconstruction is essential for patients in the process of shared decision-making. Since breast sensation plays a major role in improving quality of life, the goal of this study is to compare sensation of the breast after DIEP flap reconstruction in patients with and patients without prior IBBR. This enables evaluation of whether or not implants have a negative influence on the postoperative sensation of the replacing DIEP flap.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eIn this cohort study, we included data of all patients who received a DIEP flap reconstruction after their mastectomy, with or without a prior tissue expander (TE) and/or definitive breast implant between August 2016 and August 2018 in the Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands. Patients with primary, secondary, and tertiary breast reconstruction were included. This study was approved by the local medical ethical review board. All participants have provided written informed consent. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection/outcomes\u003c/h2\u003e \u003cp\u003eFrom August 2016 up until August 2018, all patients who underwent a DIEP flap breast reconstruction and Semmes-Weinstein monofilament (SWM) sensation measurements at the Department of Plastic, Reconstructive and Hand Surgery in the MUMC+, Maastricht, the Netherlands, were registered in a database.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] The database contains surgical information and individual procedural details, patients\u0026rsquo; medical characteristics, timing of reconstruction, tumor pathology, preliminary oncological treatment and postoperative complications or reoperations of the flap, as well as results of pre and postoperative SWM sensation measurements.\u003c/p\u003e \u003cp\u003eFor this study, we included all patients who had a DIEP flap breast reconstruction with or without prior IBBR and had data of pre and postoperative SWM measurements. Patients who received postoperative radiation therapy on their DIEP flap were excluded due to the effect on skin sensation. Patients who had both missing pre and postoperative breast sensation measurements were also excluded.\u003c/p\u003e \u003cp\u003eThe 20-piece SWM kit was used with index values ranging from 1.65 to 6.65 (monofilaments with increasing diameter). Several colors represent different grades of skin sensation, from best to worst sensation: green, normal touch (1.65\u0026ndash;2.83); blue, diminished light touch (3.22\u0026ndash;3.61); purple, diminished protective sensation (3.84\u0026ndash;4.31); red, loss of protective sensation (4.56\u0026ndash;6.45); and red, deep pressure sensation only (6.65). Measurements were performed with the patient in supine position and by either one of two researchers with extensive experience in sensation measurements with the SWM.\u003c/p\u003e \u003cp\u003eFor the primary outcome, we compared the difference in breast sensation measured by use of the SWM between two groups: one group of patients with a DIEP flap breast reconstruction without prior IBBR and one group of patients with a DIEP flap breast reconstruction with prior IBBR. Women received preoperative sensation measurements one day prior to their reconstructive surgery. The postoperative measurements were performed during four outpatient check-ups; a preoperative measurement (T0; either no reconstruction or TE/IBBR); a postoperative measurement moment 1 (T1; DIEP flap) including measurements between 2 and 7 months postoperatively; a postoperative measurement moment 2 (T2; DIEP flap) including measurements around 12 months postoperatively; and a postoperative measurement moment at the last outpatient check-up with maximum follow-up (Tmax; DIEP flap).\u003c/p\u003e \u003cp\u003eFor the sensation measurements, the breast was divided in 9 areas to be measured, based on anatomical references (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In a healthy breast or a breast with an IBBR, measuring points 1\u0026ndash;4 correspond to the breast skin, while points 5\u0026ndash;9 correspond to the nipple-areolar complex (NAC). In the autologously reconstructed breast, depending on the type of mastectomy, measuring points 5\u0026ndash;9 are generally considered flap skin if the patient had a history of skin-sparing mastectomy. For reconstruction after a non-skin-sparing mastectomy reconstruction, generally all measuring points except 1 and 4 are considered flap skin. Individual patient differences in flap and native skin were registered in case of intraoperative variability in skin quality and mastectomy flaps. The breast of patients without pre-existent or remaining nipple was divided into four quadrants with one vertical line from midclavicular to the caudal portion of the breast and one horizontal line perpendicular to the first. The lines cross each other at the level of the contralateral nipple and the intersection formed the center of the circle for measuring points 5\u0026ndash;9 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used for patients\u0026rsquo; baseline characteristics. A mean and standard error for the SWM measurements was calculated for the four follow-up moments T0, T1, T2, and Tmax. For each follow-up moment, means and standard error were calculated for flap skin, native skin, and the total breast according to the corresponding measuring points.\u003c/p\u003e \u003cp\u003eWith over 5% of incomplete postoperative SWM measurements due to missing data, multiple imputation was used to prevent a loss of statistical power and decrease the likelihood of biased results. The number of imputations was set to 20 and predictive mean matching was used to draw the values to be imputed.\u003c/p\u003e \u003cp\u003eThe logarithmically transformed values of the SWM were used for analysis, because they form normal distributed data, unlike their values in grams. Unit of analysis was the breast. Linear mixed models were used to investigate relationships between an implant or TE prior to the DIEP flap reconstruction and recovery of breast sensation. Hence, the patient population consists of women with and without an IBBR prior to their DIEP flap. We corrected for the following confounders: radiation therapy, BMI, diabetes, age at operation, flap weight, follow-up, and nerve coaptation. Nerve coaptation was only added to the analysis at T2 and Tmax, as the influence of the nerve will only start to be noticeable from 7 months postoperative.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFor this study we included 142 women, comprising 206 breasts in total. All women had a DIEP flap reconstruction. 158 of 206 breasts (76.7%) did not have an IBBR prior to the DIEP flap reconstruction. 48 of 206 breasts (23.3%) did have an IBBR prior to the DIEP flap (Table 1, baseline characteristics). The mean age of the women with a prior implant was 50.2 years. The mean age of women without a prior implant was 51.8 years. 87 women (55.1%) in the non-implant group and 19 women (39.6%) in the implant group had a history of radiation therapy.\u003c/p\u003e\n\u003cp\u003eMean follow-up for the implant group was 4.6 \u0026plusmn;1.8 months for T1, 14.1 \u0026plusmn;4.7 months for T2, and 16.3 \u0026plusmn;5.5 months for Tmax. Mean follow-up for the non-implant group was 4.6 \u0026plusmn;1.5 months for T1, 12.3 \u0026plusmn;2.9 months for T2, and 18.2 \u0026plusmn;5.7 for Tmax.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor T1 (follow-up 2-7 months), T2 (follow-up around 12 months), and Tmax (maximum follow-up) we calculated crude and adjusted values for flap skin, native skin, and total breast skin. The p-value for all coefficients was \u0026gt;0.05 and hence no relationship was found between a previous implant and postoperative sensation of the replacing DIEP flap (Table 2).\u003c/p\u003e\n\u003cp\u003eAbsolute SWM values between the DIEP group with and the DIEP group without a prior implant are displayed in Table 3. At T0, prior to the DIEP, absolute SWM values were higher for the group with an implant compared to the group without an implant. This was the case for the native skin, flap skin, and total skin. At T1, T2, and Tmax, there were minimal sensation differences left between the implant and non-implant group for the native, flap, and total skin.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this cohort study, we compared sensation of the breast after DIEP flap reconstruction in patients with and patients without prior IBBR to evaluate the influence of an implant or TE on the postoperative sensation of the replacing DIEP flap. The goal of this study was to further map out breast sensation after breast reconstruction. The outcomes are important to be able to better inform women preoperatively about what to expect of their postoperative breast sensation; questions which women ask on a regular basis at our outpatient clinic. We have analyzed breast sensation at different time points: T0, T1, T2, and Tmax, for the total breast skin, flap skin and native skin. Our results show no significant difference in breast sensation between women with and without an implant prior to their DIEP flap reconstruction, even not after adjusting for the confounders of radiation therapy, BMI, diabetes, age, flap weight, length of follow-up, and performed nerve anastomosis. These results are further emphasized by the absolute SWM values, as can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThere is an increasing focus on postoperative breast sensation after reconstruction, especially since high levels of cosmetic result can be achieved with current autologous breast reconstructive techniques. Many recent studies have focused on breast sensation after reconstruction. Several of these have shown the positive effect of improved sensation on quality of life, and the importance of postoperative breast sensation is underlined by the recent development of the Sensation module of the BREAST-Q.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] As an alternative to implant reconstruction, Beugels et al. has demonstrated in a number of studies that recovery of breast sensation is positively influenced by performing a nerve coaptation accompanying the DIEP flap.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Van Rooij et al. recently showed that swapping an implant reconstruction for a DIEP flap initially decreases postoperative sensation, but that sensation levels return to their preoperative value after approximately 1.5 years.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] However, whether an implant does or does not influence postoperative sensation of the DIEP flap had not been studied before.\u003c/p\u003e \u003cp\u003eTo analyze a hypothetical relationship between a previous implant and the sensation of the replacing DIEP flap, we have used a linear mixed model analysis. Despite being statistically insignificant, the coefficients retrieved from the linear mixed model were also not clinically relevant. None of the coefficients reached a value close to -1 or 1, with the largest deviation from zero being \u0026minus;\u0026thinsp;0.15. Bijkerk et al. found that breast sensation decreases after mastectomy but decreases even further after reconstructing the breast with an implant.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] They also found IBBR to be significantly associated with impaired sensation. Reflecting these results on our population, this could mean that the group with an implant before their DIEP flap could have worse breast sensation than the group without an implant before their DIEP flap. However, our results show no significant impact of an implant on the postoperative sensation of the DIEP flap, both at short and long-term follow-up. This indicates that the implant does not permanently damage the nerve endings in the skin and does not directly influence the sensory nerves or nerve regrowth of the replacing DIEP flap. When the implants are in place, they may act as a temporary physical barrier to block the sprouting nerves partially reinnervating the overlying skin.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] However, after the implant has been removed and the DIEP flap is in place, the sensory innervation seems to start recovering from baseline again.\u003c/p\u003e \u003cp\u003eOur study has some limitations. First, we have not distinguished between TE and IBBR for our analysis. However, we do not expect its effects on sensation to be different. Both have a similar outer shell and the decrease in sensation caused by an implant seems to be primarily caused by its barrier effect preventing nerve regrowth to the surface, based on our results and previous studies.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] One might argue that the volume of the implant or inflation of the TE can cause extra nerve or skin damage, but Van Rooij et al. have found no correlation between implant volume and breast sensation when the implant is in place.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Second, the data used in our study has been collected prospectively for another study but has been retrospectively analyzed for the current study. Hence, we have included as much patients as possible but have not performed a power analysis specifically for this study. The number of patients included in combination with a large number of confounders added to the multivariate logistic regression analysis may have influenced the statistical significance of our study. Last, the intrarater and interrater-reliability of the SWM has been debated.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] To increase reliability of the measurements and decrease of bias, we have used the same two experienced researchers for performing the sensation measurements.\u003c/p\u003e \u003cp\u003eFuture studies should further focus on the underlying physiology of sensation of the breast after autologous reconstruction and, especially, focus on discovering techniques to further improve the sensation of the breast. As stated earlier, improvement in sensation means improvement in breast-related quality of life, which makes it paramount in optimizing the outcomes of breast reconstruction. We are currently conducting a double-blinded, randomized controlled trial in our hospital to compare the quality of life and objectively measured sensation of the reconstructed breast in women with and without nerve coaptation accompanying the DIEP flap.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, an implant preceding a DIEP flap reconstruction does not influence the postoperative sensation or recovery of sensation of the reconstructed breast, even after adjusting for the confounders radiation therapy, BMI, diabetes, age, flap weight, length of follow-up and performed nerve anastomosis. The results of this study can be used in patient counseling and providing women with information about what to expect regarding breast sensation after autologous breast reconstruction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at the Maastricht University Medical Center.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the local medical ethical review board (Date: June 10 2021 / No METC 2021-2722). The work described has been carried out in accordance with The Declaration of Helsinki and the Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSiegel Mph RL, Miller KD, Sandeep N, Mbbs W, Ahmedin |, Dvm J, et al. Cancer statistics, 2023. CA Cancer J Clin 2023;73:17\u0026ndash;48. https://doi.org/10.3322/caac.21763.\u003c/li\u003e\n\u003cli\u003eSisco M, Du H, Warner JP, Howard MA, Winchester DP, Yao K. Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new millennium? Evidence from the national cancer data base. J Am Coll Surg 2012;215:658\u0026ndash;66; discussion 666. https://doi.org/10.1016/j.jamcollsurg.2012.07.008.\u003c/li\u003e\n\u003cli\u003eDutch Institute for Clinical Auditing (DICA). Jaarrapportage 2017 - Registraties. 2017.\u003c/li\u003e\n\u003cli\u003eSchreuder K, van Bommel ACM, de Ligt KM, Maduro JH, Vrancken Peeters MTFD, Mureau MAM, et al. Hospital organizational factors affect the use of immediate breast reconstruction after mastectomy for breast cancer in the Netherlands. The Breast 2017;34:96\u0026ndash;102. https://doi.org/10.1016/j.breast.2017.05.011.\u003c/li\u003e\n\u003cli\u003eIlonzo N, Tsang A, Tsantes S, Estabrook A, Thu Ma AM. Breast reconstruction after mastectomy: A ten-year analysis of trends and immediate postoperative outcomes. Breast 2017;32:7\u0026ndash;12. https://doi.org/10.1016/j.breast.2016.11.023.\u003c/li\u003e\n\u003cli\u003eSbitany H. Breast Reconstruction. Surg Clin North Am 2018;98:845\u0026ndash;57. https://doi.org/10.1016/j.suc.2018.03.011.\u003c/li\u003e\n\u003cli\u003eAllen RJ, Treece P. Deep Inferior Epigastric Perforator Flap for Breast Reconstruction. Ann Plast Surg 1994;32:32\u0026ndash;8. https://doi.org/10.1097/00000637-199401000-00007.\u003c/li\u003e\n\u003cli\u003eHealy C, Allen R. The Evolution of Perforator Flap Breast Reconstruction: Twenty Years after the First DIEP Flap. J Reconstr Microsurg 2013;30:121\u0026ndash;6. https://doi.org/10.1055/s-0033-1357272.\u003c/li\u003e\n\u003cli\u003eTemple CLF, Tse R, Bettger-Hahn M, MacDermid J, Gan BS, Ross DC. Sensibility following Innervated Free TRAM Flap for Breast Reconstruction. Plast Reconstr Surg 2006;117:2119\u0026ndash;27. https://doi.org/10.1097/01.prs.0000218268.59024.cc.\u003c/li\u003e\n\u003cli\u003eCornelissen AJM, Beugels J, van Kuijk SMJ, Heuts EM, Rozen SM, Spiegel AJ, et al. Sensation of the autologous reconstructed breast improves quality of life: a pilot study. Breast Cancer Res Treat 2018;167:687\u0026ndash;95. https://doi.org/10.1007/s10549-017-4547-3.\u003c/li\u003e\n\u003cli\u003eShridharani S, Magarakis M, Stapleton S, Basdag B, Seal S, Rosson G. Breast Sensation after Breast Reconstruction: A Systematic Review. J Reconstr Microsurg 2010;26:303\u0026ndash;10. https://doi.org/10.1055/s-0030-1249313.\u003c/li\u003e\n\u003cli\u003eBijkerk E, van Kuijk SMJ, Beugels J, Cornelissen AJM, Heuts EM, van der Hulst RRWJ, et al. Breast sensibility after mastectomy and implant-based breast reconstruction. Breast Cancer Res Treat 2019;175:369\u0026ndash;78. https://doi.org/10.1007/s10549-019-05137-8.\u003c/li\u003e\n\u003cli\u003eBijkerk E, van Kuijk SMJ, Lataster A, van der Hulst RRWJ, Tuinder SMH. Breast sensibility in bilateral autologous breast reconstruction with unilateral sensory nerve coaptation. Breast Cancer Res Treat 2020;181:599\u0026ndash;610. https://doi.org/10.1007/S10549-020-05645-Y.\u003c/li\u003e\n\u003cli\u003eBeugels J, Cornelissen AJM, van Kuijk SMJ, Lataster A, Heuts EM, Piatkowski A, et al. Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction. Plast Reconstr Surg 2019;144:178e\u0026ndash;88e. https://doi.org/10.1097/PRS.0000000000005802.\u003c/li\u003e\n\u003cli\u003eSpiegel AJ, Menn ZK, Eldor L, Kaufman Y, Dellon AL. Breast Reinnervation: DIEP Neurotization Using the Third Anterior Intercostal Nerve. Plast Reconstr Surg Glob Open 2013;1:e72. https://doi.org/10.1097/GOX.0000000000000008.\u003c/li\u003e\n\u003cli\u003eBeugels J, Bijkerk E, Lataster A, Heuts EM, van der Hulst RRWJ, Tuinder SMH. Nerve Coaptation Improves the Sensory Recovery of the Breast in DIEP Flap Breast Reconstruction. Plast Reconstr Surg 2021;148:273\u0026ndash;84. https://doi.org/10.1097/PRS.0000000000008160.\u003c/li\u003e\n\u003cli\u003evan Rooij JAF, Bijkerk E, van der Hulst RRJW, van Kuijk SMJ, Tuinder SMH. Implant-based and DIEP flap breast reconstruction: a comparison of breast sensation and quality of life within a singular patient sample. Plast Reconstr Surg 2023. https://doi.org/10.1097/PRS.0000000000010315.\u003c/li\u003e\n\u003cli\u003eGu J, Groot G, Boden C, Busch A, Holtslander L, Lim H. Review of Factors Influencing Women\u0026rsquo;s Choice of Mastectomy Versus Breast Conserving Therapy in Early Stage Breast Cancer: A Systematic Review. Clin Breast Cancer 2018;18:e539\u0026ndash;54. https://doi.org/10.1016/j.clbc.2017.12.013.\u003c/li\u003e\n\u003cli\u003eHargraves I, LeBlanc A, Shah ND, Montori VM. Shared Decision Making: The Need For Patient-Clinician Conversation, Not Just Information. Health Aff (Millwood) 2016;35:627\u0026ndash;9. https://doi.org/10.1377/hlthaff.2015.1354.\u003c/li\u003e\n\u003cli\u003eBaseline\u0026reg; Tactile\u003csup\u003eTM\u003c/sup\u003e Semmes-Weinstein type monofilaments. n.d.\u003c/li\u003e\n\u003cli\u003eTemple CLF, Ross DC, Kim S, Tse R, Bettger-Hahn M, Gan BS, et al. Sensibility following innervated free TRAM flap for breast reconstruction: Part II. Innervation improves patient-rated quality of life. Plast Reconstr Surg 2009;124:1419\u0026ndash;25. https://doi.org/10.1097/PRS.0B013E3181B98963.\u003c/li\u003e\n\u003cli\u003eTsangaris E, Klassen AF, Kaur MN, Voineskos S, Bordeleau L, Zhong T, et al. Development and Psychometric Validation of the BREAST-Q Sensation Module for Women Undergoing Post-Mastectomy Breast Reconstruction. Ann Surg Oncol 2021;28:7842\u0026ndash;53. https://doi.org/10.1245/S10434-021-10094-Y.\u003c/li\u003e\n\u003cli\u003eBeugels J, van Kuijk SMJ, Lataster A, van der Hulst RRWJ, Tuinder SMH. Sensory Recovery of the Breast following Innervated and Noninnervated Lateral Thigh Perforator Flap Breast Reconstruction. Plast Reconstr Surg 2021;147:281\u0026ndash;92. https://doi.org/10.1097/PRS.0000000000007547.\u003c/li\u003e\n\u003cli\u003eCollins S, Visscher P, De Vet HC, Zuurmond WWA, Perez RSGM. Reliability of the Semmes Weinstein Monofilaments to measure coetaneous sensibility in the feet of healthy subjects. Disabil Rehabil 2010;32:2019\u0026ndash;27. https://doi.org/10.3109/09638281003797406.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 \u0026ndash; Baseline characteristics\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"685\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReconstruction without prior implant (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=158)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMissing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReconstruction with prior implant (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=48)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMissing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e50.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e51.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eFollow-up (months)\u003c/p\u003e\n \u003cp\u003eT1 (mean)\u003c/p\u003e\n \u003cp\u003eT2 (mean)\u003c/p\u003e\n \u003cp\u003eTmax (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.6 (\u0026plusmn;1.5; range 2-7)\u003c/p\u003e\n \u003cp\u003e12.3 (\u0026plusmn;2.9; range 8-20)\u003c/p\u003e\n \u003cp\u003e18.2 (\u0026plusmn;5.7; range 9-34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.6 (\u0026plusmn;1.8; range 2-7)\u003c/p\u003e\n \u003cp\u003e14.1 (\u0026plusmn;4.7; range 9-29)\u003c/p\u003e\n \u003cp\u003e16.3 (\u0026plusmn;5.5; range 9-29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eReconstruction timing\u003c/p\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e110 (69.6)\u003c/p\u003e\n \u003cp\u003e48 (30.4)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003cp\u003e100 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eImplants in place (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003eN.A.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e81.2 (\u0026plusmn;73.0; range 4-327)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eNerve anastomosis\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e87 (55.1)\u003c/p\u003e\n \u003cp\u003e71 (44.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (39.6)\u003c/p\u003e\n \u003cp\u003e29 (60.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e27.5 (\u0026plusmn;4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e26.7 (\u0026plusmn;3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (2.5)\u003c/p\u003e\n \u003cp\u003e154 (97.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (8.7)\u003c/p\u003e\n \u003cp\u003e44 (91.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (1.3)\u003c/p\u003e\n \u003cp\u003e156 (98.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003cp\u003e48 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eRadiation therapy\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38 (24.5)\u003c/p\u003e\n \u003cp\u003e117 (75.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (22.9)\u003c/p\u003e\n \u003cp\u003e37 (77.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e77 (49.7)\u003c/p\u003e\n \u003cp\u003e78 (50.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23 (47.9)\u003c/p\u003e\n \u003cp\u003e25 (52.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eHormone therapy\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42 (27.1)\u003c/p\u003e\n \u003cp\u003e113 (72.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (33.3)\u003c/p\u003e\n \u003cp\u003e32 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eNecrosis mastectomy skin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e12 (12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32116788321168%\" valign=\"top\"\u003e\n \u003cp\u003eBreast complications\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eVenous congestion\u003c/p\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003cp\u003eWound problems\u003c/p\u003e\n \u003cp\u003eFat necrosis\u003c/p\u003e\n \u003cp\u003eHematoma\u003c/p\u003e\n \u003cp\u003eSeroma\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.277372262773724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (12.2)\u003c/p\u003e\n \u003cp\u003e2 (1.3)\u003c/p\u003e\n \u003cp\u003e14 (8.9)\u003c/p\u003e\n \u003cp\u003e32 (20.4)\u003c/p\u003e\n \u003cp\u003e9 (5.7)\u003c/p\u003e\n \u003cp\u003e9 (5.7)\u003c/p\u003e\n \u003cp\u003e3 (1.9)\u003c/p\u003e\n \u003cp\u003e137 (87.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.321167883211679%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.153284671532848%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (14.9)\u003c/p\u003e\n \u003cp\u003e1 (2.1)\u003c/p\u003e\n \u003cp\u003e4 (8.5)\u003c/p\u003e\n \u003cp\u003e5 (10.6)\u003c/p\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003cp\u003e3 (6.4)\u003c/p\u003e\n \u003cp\u003e2 (4.3)\u003c/p\u003e\n \u003cp\u003e40 (85.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.927007299270073%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 \u0026ndash; Linear mixed models analysis of postoperative breast sensation and a previous implant\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime point\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.066225165562914%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of breasts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.019867549668874%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreast skin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoefficient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.165562913907284%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(upper bound \u0026ndash; lower bound)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.066225165562914%\" valign=\"top\"\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003cp\u003e(158+48)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003cp\u003e(158+48)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003cp\u003e(158+48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.019867549668874%\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003cp\u003eAdjusted\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eFlap\u003c/p\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003cp\u003eAdjusted\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eNative\u003c/p\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003cp\u003eAdjusted\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003cp\u003e-0.048\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003cp\u003e-0.048\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003cp\u003e-0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.165562913907284%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.20 \u0026ndash; 0.26\u003c/p\u003e\n \u003cp\u003e-0.31 \u0026ndash; 0.21\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.20 \u0026ndash; 0.26\u003c/p\u003e\n \u003cp\u003e-0.31 \u0026ndash; 0.21\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.34 \u0026ndash; 0.40\u003c/p\u003e\n \u003cp\u003e-0.42 \u0026ndash; 0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eT2\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.066225165562914%\" valign=\"top\"\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003cp\u003e(158+48)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e203\u003c/p\u003e\n \u003cp\u003e(155+48)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003cp\u003e(158+48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.019867549668874%\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003cp\u003eAdjusted\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eFlap\u003c/p\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003cp\u003eAdjusted\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eNative\u003c/p\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003cp\u003eAdjusted\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003cp\u003e-0.0051\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003cp\u003e-0.010\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.165562913907284%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.19 \u0026ndash; 0.31\u003c/p\u003e\n \u003cp\u003e-0.28 \u0026ndash; 0.27\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.22 \u0026ndash; 0.38\u003c/p\u003e\n \u003cp\u003e-0.32 \u0026ndash; 0.30\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.21 \u0026ndash; 0.45\u003c/p\u003e\n \u003cp\u003e-0.24 \u0026ndash; 0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eTmax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.066225165562914%\" valign=\"top\"\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003cp\u003e(158+48)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003cp\u003e(155+48)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003cp\u003e(158+48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.019867549668874%\" valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003cp\u003eAdjusted\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eFlap\u003c/p\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003cp\u003eAdjusted\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eNative\u003c/p\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003cp\u003eAdjusted\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.70860927152318%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.088\u003c/p\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.165562913907284%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.15 \u0026ndash; 0.32\u003c/p\u003e\n \u003cp\u003e-0.27 \u0026ndash; 0.41\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.16 \u0026ndash; 0.36\u003c/p\u003e\n \u003cp\u003e-0.25 \u0026ndash; 0.51\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.12 \u0026ndash; 0.53\u003c/p\u003e\n \u003cp\u003e-0.32 \u0026ndash; 0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76158940397351%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCI = confidence interval\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Adjusted for radiation therapy, BMI, diabetes, age at operation, flap weight, and follow-up\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Adjusted for radiation therapy, BMI, diabetes, age at operation, flap weight, follow-up, and nerve anastomosis\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eTable 3 \u0026ndash; Absolute monofilament values of the groups with and without an implant prior to their DIEP flap\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.3pt;border: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.9pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eWithout implant\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.7pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eSWM category\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.85pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eWith implant\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.05pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eSWM category\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eAbsolute difference (= with implant \u0026ndash; without implant)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eT0\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e(n=without/with)\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean\u003cem\u003e\u0026nbsp;\u003c/em\u003enative\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean flap\u003csup\u003ea\u003c/sup\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean total\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e2.70\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e3.02\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e2.90\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:lime;background:lime;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:lime;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:lime;background:lime;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:lime;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:lime;background:lime;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:lime;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e3.34\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e3.82\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e3.69\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:blue;background:blue;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:fuchsia;background:fuchsia;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:fuchsia;background:fuchsia;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e+0.64\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e+0.80\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e+0.79\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eT1\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e(n=without/with)\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean native\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean flap\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean total\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.51\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e5.43\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e5.11\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.51\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e5.45\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e5.06\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e0.00\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e+0.02\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e-0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eT2\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e(n=without/with)\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean native\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean flap\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=155/48)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean total\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.13\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.92\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.65\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:fuchsia;background:fuchsia;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.23\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.94\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.64\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:fuchsia;background:fuchsia;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e+0.10\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e+0.02\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e-0.05\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eTmax\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cem\u003e\u003cspan style='font-size:13px;line-height:150%;font-family:\"Times New Roman\",serif;'\u003e(n=without/with)\u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 112.3pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean native\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean flap\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=155/48)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eMean total\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e(n=158/48)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.9pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.09\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.77\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.52\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:fuchsia;background:fuchsia;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.29\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.88\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.60\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54.05pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:fuchsia;background:fuchsia;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;color:red;background:red;'\u003e#####\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e+0.20\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e+0.11\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e+0.08\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSWM = Semmes-Weinstein monofilaments; SWM categories = green, normal touch (1.65-2.83); blue, diminished light touch (3.22-3.61); purple, diminished protective sensation (3.84-4.31); red, loss of protective sensation (4.56-6.45); and red, deep pressure sensation only (6.65).\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003eMean of preoperative breast areas corresponding to postoperative flap skin areas\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u0026nbsp;\u003c/sup\u003eTwo patients/three breasts missing postoperative flap values due to skin island removed in secondary procedure\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style='font-size:15px;line-height:150%;font-family:\"Times New Roman\",serif;color:white;'\u003eSWM = Semmes-Weinstein monofilaments; SWM categories = green, normal touch (1.65-2.83); blue, diminished light touch (3.22-3.61); purple, diminished protective\u0026nbsp;\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Breast reconstruction, breast sensation, implant-based breast reconstruction, breast implants, DIEP flap","lastPublishedDoi":"10.21203/rs.3.rs-3059218/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3059218/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eImplants and DIEP flaps have different outcomes regarding postoperative breast sensation. When compared to the preoperative healthy breast, implant-based breast reconstruction (IBBR) negatively influences postoperative breast sensation. However, it is currently unknown whether a prior IBBR also influences postoperative sensation of a replacing DIEP flap. The goal of this cohort study is to evaluate the influence of an IBBR on the postoperative sensation of a replacing DIEP flap.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWomen were included if they received a DIEP flap reconstruction after mastectomy, with or without prior tissue expander (TE) and/or definitive breast implant. Sensation was measured at four intervals in 9 areas of the breast with Semmes-Weinstein monofilaments: T0 (preoperative, implant/no reconstruction), T1 (2\u0026ndash;7 months postoperative, DIEP), T2 (\u0026plusmn;\u0026thinsp;12 months postoperative, DIEP), Tmax (maximum follow-up, DIEP). Linear mixed models were used to investigate the relationship between an implant/TE prior to the DIEP flap and recovery of breast sensation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e142 women comprising 206 breasts were included. 48 (23.3%) breasts did, and 158 (76.7%) breasts did not have a TE/IBBR prior to their DIEP. No statistically significant or clinically relevant relationships were found between a prior implant/TE and recovery of DIEP flap breast sensation for the flap skin, native skin, or total breast skin at T1, T2, or Tmax. There were also no relationships found after adjustment for the confounders radiation therapy, BMI, diabetes, age, flap weight, follow-up, and nerve coaptation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAn implant/TE prior to a DIEP flap does not influence the recovery of postoperative breast sensation of the DIEP flap.\u003c/p\u003e","manuscriptTitle":"The Influence of a Previous Implant-Based Breast Reconstruction on Postoperative Sensation of the Deep Inferior Epigastric Artery Perforator Flap","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-27 19:02:21","doi":"10.21203/rs.3.rs-3059218/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2023-06-21T01:54:22+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-06-20T23:04:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-06-15T06:13:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Breast Cancer","date":"2023-06-13T12:06:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"breast-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"brca","sideBox":"Learn more about [Breast Cancer](http://link.springer.com/journal/12282)","snPcode":"12282","submissionUrl":"https://www.editorialmanager.com/brca/default2.aspx","title":"Breast Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7273455b-ceca-4c48-be3a-c28de8139744","owner":[],"postedDate":"June 27th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-04-08T15:06:06+00:00","versionOfRecord":{"articleIdentity":"rs-3059218","link":"https://doi.org/10.1007/s12282-024-01558-6","journal":{"identity":"breast-cancer","isVorOnly":false,"title":"Breast Cancer"},"publishedOn":"2024-04-06 15:01:34","publishedOnDateReadable":"April 6th, 2024"},"versionCreatedAt":"2023-06-27 19:02:21","video":"","vorDoi":"10.1007/s12282-024-01558-6","vorDoiUrl":"https://doi.org/10.1007/s12282-024-01558-6","workflowStages":[]},"version":"v1","identity":"rs-3059218","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3059218","identity":"rs-3059218","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}