RESEARCH ARTICLE

Body Posture After Mastectomy: Comparison Between

Immediate Breast Reconstruction Versus Mastectomy
Alone
Ana Carolina Atanes Mendes Peres1*, Maria do Rosário Dias de Oliveira Latorre2,
Jonathan Yugo Maesaka3, José Roberto Filassi4, Edmund Chada Baracat4 &
Elizabeth Alves Gonçalves Ferreira5
1
Department of Physical Therapy Speech and Occupational Therapy, Medical School, University of São Paulo, São Paulo, Brazil
2
Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil
3
Mastology Service, Department of Gynecology, Medical School, University of São Paulo, São Paulo, Brazil
4
Department of Gynecology, Medical School, University of São Paulo, São Paulo, Brazil
5
Department of Physiotherapy, Speech Therapy and Occupational Therapy, Medical School, University of São Paulo, São Paulo, Brazil

Abstract
Background. Immediate breast reconstruction has been increasingly incorporated as part of breast cancer treatment,
especially for the psychological benefits. Currently, there are many options for breast reconstruction surgery, but the
impact of the different techniques on body posture has not been widely studied. One study demonstrated that imme-
diate breast reconstruction with a Beker-25 prosthesis could help to preserve body posture after mastectomy; however,
there is no evidence regarding the effect of surgery on the body posture of women after breast reconstruction when
using autologous tissue. Purpose. The purpose of this paper is to compare the body postures of women who underwent
immediate breast reconstruction using an abdominal flap with those of women who underwent mastectomy alone.
Design. This is a cross-sectional study. Subjects. Seventy-six women diagnosed with breast cancer underwent mastec-
tomy, between 1 and 5 years after the diagnosis, are the participants of the study. Two groups were defined: women who
underwent mastectomy and immediate breast reconstruction (n = 38) and women who underwent mastectomy alone
(n = 38). Procedure. To assess body posture, specific anatomical points for obtaining photographs were located and
marked in anterior, posterior and right-side and left-side views. The photographs were analysed using Postural Analysis
Software/Software de Análise Postural (PAS/SAPO). Results. In the left lateral view, there was a significant difference in
the vertical alignment of the trunk (4.2 vs 3.1; p = 0.05). There were no significant differences between the two groups
for the variables in the anterior, posterior or right-side views. Conclusion. Women who underwent mastectomy alone,
compared with women who underwent immediate breast reconstruction with abdominal flaps, showed differences in
the vertical alignment of the trunk, with greater asymmetry between the acromion and greater trochanter, which can
mean trunk rotation. No significant differences were found between the two groups in the alignment of the head,
shoulders, scapula, or pelvis. Copyright © 2015 John Wiley & Sons, Ltd.

Received 14 February 2014; Revised 28 February 2015; Accepted 6 May 2015

Keywords
breast neoplasms; breast reconstruction; mastectomy; posture

*Correspondence
Ana Carolina Atanes Mendes Peres, Department of Physical Therapy Speech and Occupational Therapy, Medical School, University of São
Paulo, São Paulo, Brazil.
E-mail: anacarolinaamperes@gmail.com

Published online 16 September 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1642

Physiother. Res. Int. 22 (2017) e1642 © 2015 John Wiley & Sons, Ltd. 1 of 9
Body Posture After Mastectomy
Introduction
Immediate breast reconstruction has been an impor-
tant option for women who were diagnosed for breast
cancer and recommended to have mastectomy. Cur-
rently, there are many different surgical procedures, in-
cluding expander/implant, autologous tissue and
combined autologous tissue/implant (Cordeiro, 2008).
The choice of breast reconstruction method depends
on several factors, such as the biotype of the patient,
size and shape of the breast, availability of autologous
tissue, breast cancer treatment and presence of
comorbidities.
For the technique that involves the use of implant
without prior expansion, it is necessary that the skin
flap that remains after a mastectomy is adequate, but
normally, the skin flap is not of sufficient size to cover
the implant, especially when an implant without prior
expansion is performed. Therefore, tissue expansion
followed by a permanent implant is a common tech-
nique for breast reconstruction (Petit et al., 2001;
Roostaeian et al., 2012). The expander or implant is
placed in a subpectoral pocket, under the pectoralis
major and serratus anterior muscles (Cordeiro, 2008),
and thus leads to a change in the position of these mus-
cles. However, it has been reported that this change in
position only leads to slight loss of function of the
pectoralis major and serratus anterior muscles. The
most commonly used autologous reconstructive
methods, however, are the pedicled transverse rectus
myocutaneous flap (TRAM) and latissimus flaps. In a
pedicled TRAM flap, the rectus muscle and overlying
skin and subcutaneous tissue are rotated into the mas-
tectomy, and the inferior epigastric artery is severed
(Kaya and Serel, 2013; Dunlop and Caminer, 2014).
One of the disadvantages of this method is that most
of the women take 2 to 4 months to return to their pre-
vious level of capacity, and because the position of the
muscles changes, there is a greater decline in upper ab-
dominal strength in these patients (Atisha and Alder-
man, 2009). Another option with the TRAM flap is to
perform a free transfer of the abdominal tissue to the
surgery area, which requires a longer surgical proce-
dure but minimizes the risk of injuries in the abdomi-
nal area (Petit et al., 2001; Serletti, 2006). In the same
manner, as with the mastectomy, the surgical proce-
dure used in breast reconstruction can also affect the
biomechanics of the body (Atisha and Alderman,
2009; Nizet and Piérard, 2009; Crosbie et al., 2010).
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A. C. A. M. Peres et al.
Letterman and Schurter (1980) who analysed the re-
lationship between the breast volume and the vertebral
column reported that voluminous breasts can cause
changes in the centre of gravity with accentuation of
the physiological curvature of the vertebral column
and increased tension of the cervical extensor muscles.
Findikcioglu et al. (2007) who also analysed the corre-
lation between the breast volume and the vertebral col-
umn concluded that voluminous breasts can exacerbate
the angle of thoracic kyphosis and lumbar lordosis.
Despite the many improvements and major ad-
vances in breast cancer treatment, including the impor-
tance of breast reconstruction surgery on the quality of
life of these patients, little is known about the effects of
mastectomy and the different breast reconstruction
surgical procedures on body posture. There is some ev-
idence that after mastectomy, changes can occur in the
alignment of the shoulders, scapulas, trunk and pelvis
(Rostkowska et al., 2006; Ciesla and Polom, 2010),
and that immediate breast reconstruction with the
Becker-25 prosthesis (permanent expansive breast im-
plant) helps to preserve body posture after mastectomy
(Ciesla and Polom, 2010). However, studies could not
be found in the literature that evaluated body posture
in women who underwent immediate breast recon-
struction with autologous tissue, especially with ab-
dominal flap.
Postural assessment is the starting point to instruct
proper physiotherapy conduct, helping the detection
of possible muscle imbalances that could lead to poten-
tial injury, wear of the joint and pain that can signifi-
cantly affect the quality of life (Derewiecki et al.,
2013; Riskowski et al., 2013; Araújo et al., 2014).
There are several qualitative and quantitative
methods for postural analysis (Singla and Veqar,
2014), but the measurement of body angles and dis-
tances in photographs on the anterior, posterior and
sagittal views (two sides) seems to be the fastest and
most comprehensive evaluation method (Fortin et al.,
2011). The Postural Analysis Software/Software
de Análise Postural (PAS/SAPO) used in this study en-
ables the analysis of various angles in various views
and is an easy-to-use tool, which underwent an intra-
rater and inter-rater reliability validation (Ferreira
et al., 2010).
It is important for the physiotherapist to under-
stand the effect that the absence of the breast and a
reconstruction surgery that involves the muscles of
the abdomen can cause on posture. In this context,
Physiother. Res. Int. 22 (2017) e1642 © 2015 John Wiley & Sons, Ltd.
A. C. A. M. Peres et al.
the aim of this study was to compare the body pos-
tures of women who underwent immediate breast re-
construction using an abdominal flap with those of
women who underwent mastectomy alone.
Methods
Design, setting and subjects
This cross-sectional study was performed between July
2012 and June 2013, at the Mastology Department of
the Cancer Institute of the state of São Paulo, Brazil.
The women, diagnosed with breast cancer and mastec-
tomy, were divided into two groups: group 1, women
without breast reconstruction (mastectomy alone
[MA]) (n = 38) and group 2, women with immediate
breast reconstruction with abdominal flap (mastec-
tomy and immediate breast reconstruction [M + IBR])
(n = 38).
Women aged 35–70 years, 1 to 5 years post-surgery
and not having undergone chemotherapy or radiother-
apy in the last 6 months were included in the study. Ex-
clusion criteria were bilateral mastectomy, upper-limb
lymphoedema and orthopaedic, rheumatologic or neu-
rological sequelae.
The sample size was calculated considering a differ-
ence of 1.3° in the horizontal alignment of acromion,
with a standard deviation of two points (Ciesla and
Polom, 2010). A statistical power of 80% and 5% sig-
nificance were used, with the required sample size be-
ing 38 patients in each group.
The study was conducted with the approval of the
ethics committee of the School of Medicine, University
of São Paulo (330/11). All participants signed the free
and informed terms of consent form.
Instruments
For the postural analysis, PAS/SAPO (version 0.68)
(Ferreira et al., 2010) was used. The tool is free, is avail-
able at http://puig.pro.br/sapo/, has scientific tutorials
and is a study of reliability inter-rater and intra-rater
evaluators. The PAS/SAPO was developed and validated
by Ferreira et al. (2010) and provides various functions
such as image calibration, zoom, simultaneous viewing
of photos, tagging of free anatomical points or by the
PAS/SAPO protocol and measurements of angles and
distances. There are 27 anatomical points on the ante-
rior view, 41 on the posterior view and 31 seen in the
Physiother. Res. Int. 22 (2017) e1642 © 2015 John Wiley & Sons, Ltd.
Body Posture After Mastectomy
lateral view, and from these points, angles and dis-
tances can be measured of the posture.
For the photographs, a digital camera (Sony Cyber-
shot DSC-H70, 16.1 MP, Sony, Japan) was used with
a tripod, a plumb line with three styrofoam balls (for
image calibration), styrofoam balls of 15 mm diameter
as markers and double-sided adhesive tape.
The camera was placed 2.00 m away from the par-
ticipant on a tripod 90 cm high. The plumb line
marked with three polystyrene balls was used to en-
able calibration of the image. The photos were taken
and transferred to a computer for evaluation using
the PAS/SAPO.
Procedure
The women’s medical charts were used to recruit the
participants and collect their demographic and clinical
data. All of the women underwent one single evalua-
tion, including having their photographs taken. A sin-
gle evaluator made the evaluation of all women, and
the statistical analysis was performed by a professional
statistician not involved in the study. The women
who did not undergo reconstruction were asked to an-
swer questions in order to obtain information about
the use of an external prosthesis and the length of use.
The photographs were taken after markers were
placed on specific anatomical points, located and
marked with small polystyrene balls on the skin with
double-sided adhesive tape. All the procedures were
performed with the subjects in standing position. The
marked anatomical points were as follows: the medial
point between the tragus and acromion; spinous pro-
cess of C7 and T3; inferior angles of the scapulas;
anterior–superior iliac spines; posterior–superior iliac
spines; and greater trochanter of the femur.
After marking the anatomical points, the women
were instructed to stand in a comfortable posture and
were photographed in anterior, posterior, right and left
views. To ensure that the same base of support was
kept in all four views, the participants’ feet were
outlined on cardboard, and they were instructed to
stand within the borders of the outlines when being
photographed.
Four photographs of each participant were analysed
(anterior, posterior and lateral views). The analysis was
conducted by only one physiotherapist carrying out the
following routine: accessing the photo, zooming 100%,
calibrating the image from the plumb line, marking the
3 of 9
Body Posture After Mastectomy
anatomical points by PAS/SAPO protocol and making
a report.
The results of the analysis of the photographs are
presented in degrees for the anterior view, right and left
sides and in percentages for the posterior view.
In the analysis of the anterior view, the positive and
negative signs indicate which direction the difference is
in alignment between two anatomical landmarks. For
two anatomical points that should be symmetrical, for
example the acromion, the positive sign indicates that
the slope is to the right (left shoulder higher) and the
negative sign indicates that the slope is to the left (right
shoulder higher); zero represents symmetry between
the two acromion. These are the convention signs used
for the software based on mathematical rules (Ferreira
et al., 2011).
Analysis of the side of surgery and postural devia-
tion was performed only for the anterior view, be-
cause in this case, the deviations occur between the
right and left sides in the frontal plane. This analysis
was not conducted in the posterior and lateral views
because in the posterior view, the analysed variable
refers to the alignment of the scapulas, which is sym-
metrical when the result is zero and the asymmetry
value is expressed as a percentage. In the side views,
deviations occur in the sagittal plane, and the use of
signs are not necessary to indicate the direction of
inclination.
Table 1, adapted from Ferreira et al. (2011), shows
the postural alignment variables in the anterior, poste-
rior and lateral views, as well as the anatomical points
used for the measurements.
Table 1. Postural alignment variables and anatomical points and measures
Variables
Anterior view
Horizontal alignment of the head
Horizontal alignment of the acromions
Horizontal alignment of the ASISs
Angle between acromions and ASISs
Posterior view
Asymmetry of the scapulas related to T3
Lateral view
Horizontal alignment of the head
Vertical alignment of the trunk
Horizontal alignment of the pelvis
ASISs = anterior–superior iliac spines; PSIS = posterior–superior iliac spine; C7 = seventh cervical vertebra; T3 = third thoracic vertebra.
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A. C. A. M. Peres et al.
Statistical analysis
A descriptive analysis was performed for all quantita-
tive (mean and standard deviation) and qualitative (to-
tal value and percentage) variables. Adherence to the
normal curve was checked using the Kolmogorov–
Smirnov test. The groups were compared according
to the following variables: age, weight, height, body
mass index, time of surgery, weight of breast tissue
resected, type of surgery, side of surgery, tumour stage,
histological type, oncological treatment (chemother-
apy, radiotherapy or hormone therapy) and meno-
pause. The chi-square test for qualitative variables and
Student’s t-test for quantitative variables were used to
compare the groups. The level of statistical difference
was set at p ≤ 0.05. The statistical analysis was performed
with SPSS version 15.0 (SPSS Inc., Chicago, Illinois, USA).
Results
Six women refused to participate in the study, and two
women were excluded because they presented
lymphoedema. Therefore, 76 women diagnosed with
breast cancer who underwent mastectomy were in-
cluded. Of these women, 38 had MA, and 38 had im-
mediate reconstruction with abdominal flap (M
+ IBR). In the M + IBR group, 23 women (60.5%)
underwent the transverse abdominis muscle with flap
technique (TRAM), six (15.8%) underwent the deep
inferior epigastric perforator flap technique and six
(15.8%) underwent the superficial inferior epigastric
artery flap technique. It was not possible to obtain the
reconstruction surgery data of three of the women
Anatomical points and measures
Angle between the two tragi and a horizontal line
Angle between the two acromions and a horizontal line
Angle between the two ASISs and a horizontal line
Angle between the two acromions and the two ASISs
Spinous process of the T3 and inferior angle of the scapulas
Angle between the C7 spinal process and tragus and a horizontal line
Angle between the acromion greater trochanter of the femur and a vertical line
Angle between the ASIS and PSIS and a horizontal line
Physiother. Res. Int. 22 (2017) e1642 © 2015 John Wiley & Sons, Ltd.
A. C. A. M. Peres et al. Body Posture After Mastectomy

(7.9%) because their procedures were performed in an-
other institution.
In the MA group, 26 women (68%) answered that
they used an external prosthesis; of these women, 17
(65.3%) only removed it to sleep, and 9 (34.7%) used
it only when going out.
The demographic and clinical characteristics of the
samples are summarized in Table 2. There were no sta-
tistical differences in the demographic variables, except
for age; the MA group was composed of older women
(59.2 vs 50.0 years; p < 0.01). The groups were similar
in terms of time of surgery, weight of breast tissue
resected and surgical and oncological treatment. There
was a significant difference in the rate of menopause
between the two groups, with the MA group having a
higher number of menopausal women (94.7% vs
76.3%; p = 0.05). In both groups, all of the women were
right-handed.
The posture assessment results are shown in
Table 3. The mean value was calculated in module
(without positive and negative signs) because the
signs only indicate the direction of postural change
and calculating they nullify, compromising the value
of the average. No significant differences were found
between the two groups, except for the vertical
alignment of the trunk in the left lateral view; the
MA group had a higher mean (4.2 vs 3.1; p = 0.05)
(Table 3).
Table 4 shows, in the anterior view, the body’s devi-
ation to one side according to the side of the surgery for
each group. There were no significant differences in ei-
ther group, indicating that the side of surgery had no
Table 3. Comparison of means of postural alignment variables in
degrees for anterior, left-side and right-side views and percentage
of posterior view variable

Variables MA M + IBR p-value*

Table 2. Clinical and demographic characteristics of the study
(n = 38) (n = 38)
participants
Mean (SD) Mean (SD)
Characteristics MA (n = 38) M + IBR (n = 38) p-value*
Anterior view
Mean (SD) Horizontal alignment 2.8 (2.5) 2.8 (1.9) 0.94
Age (years) 59.2 (8.5) 50.0 (7.7) <0.001* of the head
Weight (kg) 68.4 (12.9) 69.8 (9.2) 0.48 Horizontal alignment 2.0 (1.4) 1.9 (1.4) 0.82
Height (m) 1.57 (0.1) 1.58 (0.1) 0.25 of the acromions
2
BMI (kg m ) 27.7 (4.5) 27.6 (2.6) 0.67 Horizontal alignment 1.5 (1.5) 1.5 (1.1) 0.94
Time since 2.3 (1.3) 2.1 (1.0) 0.76 of the ASISs
surgery (years) Angle between acromions 2.0 (1.7) 2.4 (1.6) 0.25
Mass of resected 722.7 (554.3) 650.6 (300.7) 0.54 and ASISs
breast tissue (g)
n (%) Posterior view
Type of surgery Asymmetry of the scapulas 16.9 (11.3) 16.1 (14.8) 0.77
MRM 28 (73.7) 24 (63.2) 0.45 related to T3
Other 10 (26.3) 14 (36.8) Right-side view
Side of surgery Horizontal alignment of 45.7 (5.2) 47.3 (6.7) 0.24
Right 18 (47.4) 18 (47.4) 1.00 the head
Left 20 (52.6) 20 (52.6) Vertical alignment of 4.2 (2.2) 3.6 (2.4) 0.31
Cancer stage the trunk
Early (0, I, II) 29 (76.3) 27 (71.1) 0.79 Horizontal alignment 16.0 (7.0) 14.6 (5.6) 0.34
Advanced (III, IV) 9 (23.7) 11 (28.9) of the pelvis
Radiotherapy
Yes 25 (65.8) 23 (60.5) 0.81 Left-side view
Chemotherapy Horizontal alignment 46.6 (5.7) 47.3 (7.1) 0.62
Yes 31 (81.6) 33 (86.8) 0.75 of the head
Hormone therapy Vertical alignment 4.2 (2.6) 3.1 (2.1) 0.05*
Yes 30 (78.9) 32 (84.2) 0.76 of the trunk
Menopause Horizontal alignment 16.6 (6.4) 15.5 (5.1) 0.41
Yes 36 (94.7) 29 (76.3) 0.05* of the pelvis

SD = standard deviation; BMI = body mass index; MRM = modified ASISs = anterior–superior iliac spines; PSIS = posterior–superior iliac
radical mastectomy; M + IBR, mastectomy and immediate breast re- spine; T3 = third thoracic vertebra; M + IBR, mastectomy and imme-
construction; MA, mastectomy alone. diate breast reconstruction; MA, mastectomy alone.
*p-value (≤0.05) of differences between groups. *means stastically significative

Physiother. Res. Int. 22 (2017) e1642 © 2015 John Wiley & Sons, Ltd. 5 of 9
Body Posture After Mastectomy A. C. A. M. Peres et al.

Table 4. Side of posture deviation according to side of surgery for each group in the anterior view

Variables Deviation MA p-value M + IBR p-value

Side of surgery, n (%) Side of surgery, n (%)

L R Total L R Total

Horizontal alignment of the head L 7 (41.2) 8 (53.3) 15 (46.9) 0.49 3 (15.0) 6 (35.3) 9 (24.3) 0.15
R 10 (58.8) 7 (46.7) 17 (53.1) 17 (85.0) 11 (64.7) 28 (75.7)
Horizontal alignment of the acromions L 11 (55.0) 8 (47.1) 19 (51.4) 0.63 6 (33.3) 5 (31.2) 11 (32.4) 0.89
R 9 (45.0) 9 (52.9) 18 (48.6) 12 (66.7) 11 (68.8) 23 (67.6)
Horizontal alignment of the ASISs L 5 (35.7) 10 (58.8) 15 (48.4) 0.20 12 (66.7) 14 (77.8) 26 (72.2) 0.45
R 9 (64.3) 7 (41.2) 16 (51.6) 6 (33.3) 4 (22.2) 10 (27.8)
Angle between acromions and the ASISs L 8 (44.4) 11 (61.1) 19 (52.8) 0.31 17 (85.0) 13 (72.2) 30 (78.9) 0.33
R 10 (55.6) 7 (38.9) 17 (47.2) 3 (15.0) 5 (27.8) 8 (21.1)

ASISs = anterior–superior iliac spines; L = left; R = right; M + IBR, mastectomy and immediate breast reconstruction; MA, mastectomy alone.

influence on the direction of asymmetry. Women who
had symmetry were excluded from the respective vari-
able in Table 4.
Discussion
There is still a lack of research on determining the real ef-
fects of mastectomy and breast reconstruction surgeries on
body posture and functionality. Identifying the effect of
each type of reconstruction on body posture is important
to define the most appropriate physical therapy approach.
This study compared the body postures of women
with mastectomy alone (MA) with those of women
who had immediate breast reconstruction with an ab-
dominal flap (M + IBR). There was a significant differ-
ence between the two groups in the vertical alignment
of the trunk in the left lateral view, with a greater angle
in the MA group. The vertical alignment of the trunk
was measured by the angle between the vertical line
and the line that connects the acromion and the greater
trochanter of the femur. In the MA women, the align-
ment of the acromion was posterior to the greater tro-
chanter of the femur. This finding indicates an
extension or a rotation of the trunk, such that the posi-
tion of the shoulder is more posterior than that of the
greater trochanter of the femur. The fact that this find-
ing is not bilateral decreases the possibility of an exten-
sion of the trunk and strengthens the hypothesis of a
rotation of the trunk, in this case, to the left side. The
results showed that, in a period of 1 to 5 years post-
surgery, there were no differences between the two
groups as regards the alignment of the head, the shoul-
ders, the scapulas or the pelvis. The difference between
the vertical alignment of the trunk in patients with and
without breast reconstruction was small, but statisti-
cally significant. Angle variations tend to occur in few
degrees ranges when measured with photogrammetry
(Ferreira et al., 2011), except in some specific situations
such as pregnancy or pain (antalgic posture) (Saxton,
1993). Considering the tendency of trunk rotation in
women with mastectomy without breast reconstruc-
tion, physical therapy should include preventive exer-
cises that focus on improving the stabilization of the
trunk and on upper-limb symmetry. It is not possible
to say what caused a greater trunk rotation in the group
of women with MA, but it is important to discuss as-
pects that may have influenced in this finding. The ab-
sence of the breast has physical and emotional
repercussions and possibly leads to functional adapta-
tions that, repeated for a certain time, can generate
changes in posture, such as trunk rotation.
The physiotherapy programme must take into ac-
count the specific procedure used for breast recon-
struction. Different from a simple placement of a
prosthesis, the procedure may have involved the
latissimus dorsi muscles and the transverse rectus
abdominis, which have different roles in maintaining
body alignment and in the functionality of the trunk
and the upper limbs. The choice of the exercises can
be more specific based on this piece of information,
and posture’s compensatory changes can prevented.
The TRAM reconstruction involves the abdominal
wall, including muscles and connective tissue compo-
nents (fascia and ligament), which can change the
trunk support mechanism. The stability of the trunk
depends on the balance between its anterior (abdomi-
nal) and posterior walls (Monteiro, 1997). A study of
150 women with TRAM reconstruction noted that

6 of 9 Physiother. Res. Int. 22 (2017) e1642 © 2015 John Wiley & Sons, Ltd.
A. C. A. M. Peres et al.
64% of women reported improvement of the abdo-
men, 72% noted improvement of the appearance of
the abdomen and 20% noticed an improved posture
(Mizgala et al., 1994).
The majority of the women (60.5%) in our study
had breast reconstruction with transverse rectus
abdominis muscle (TRAM) flap. This procedure in-
volves a skin flap, fat and one or both rectus abdominis
muscles passed through a tunnel under the skin to the
mastectomy site (Hartrampf et al., 1982). This surgical
technique differs from a free TRAM flap, which is
made from the overlying muscle attached to the infe-
rior epigastric vessels. This flap is completely separated
from the abdomen and transferred to the region of the
mastectomy where it is anastomosed to either the
thoracodorsal or internal mammary vessels (Serletti,
2006). One commonly expressed concern regarding
the TRAM procedure is the effect on abdominal wall
function following breast reconstruction (Dulin et al.,
2004; Bonde et al., 2007). A systematic review by Atisha
and Alderman (2009) revealed that considering evalua-
tions with dynamometry up to a 23% deficit in trunk
flexion can be seen in pedicle TRAM patients and up
to an 18% deficit in free TRAM patients. In the trunk
extension evaluation, pedicle TRAM patients demon-
strated up to a 14% deficit, and free TRAM patients
showed minimal or no deficit of strength. Considering
the data of the articles cited and the results obtained in
the present study, it is possible that TRAM flap may af-
fect abdominal wall function; however, no impact on
postural alignment was observed in the present study,
at least not up to 5 years after surgery.
An important strength of our study was the homo-
geneity of the sample with respect to time of surgery
and complementary breast cancer treatment. None of
the women in the two groups was undergoing che-
motherapy or radiotherapy, which could influence
the results of the body posture assessment due to
physical discomfort or adherence of the skin. Women
with upper lymphoedema were also excluded from
the study. We opted not to include women who
had undergone mastectomy less than 1 year prior to
the study, because the presence of pain and decreased
range of motion of the upper limb could have trig-
gered an adaptive change in posture (Crosbie et al.,
2010; Nesvold et al., 2011). There is evidence that af-
ter 1 year post-surgery, the majority of women re-
cover shoulder function (Springer et al., 2010). The
study of posture should consider the time of
Physiother. Res. Int. 22 (2017) e1642 © 2015 John Wiley & Sons, Ltd.
Body Posture After Mastectomy
mastectomy, and the comparison of women who
underwent surgery recently with women who
underwent surgery many years ago is inadvisable.
There are few studies regarding body posture in
women after mastectomy. Rostkowska et al. (2006)
reported that women with mastectomy had greater
asymmetry in the alignment of the shoulders and
scapulas, greater angle of rotation of the pelvis and
anterior and lateral inclination of the trunk. The an-
terior inclination of the trunk was observed in
women who had recently undergone surgery, and it
was attributed to the effects of analgesics and a pro-
tective position after mastectomy. It is important to
note that the study compared healthy women with
women who had undergone mastectomy, which dif-
fers from the present study where we evaluated only
women between 1 and 5 years after mastectomy. In
accordance with our study, Rostkowska et al. (2006)
also did not find any correlation between the side
of surgery and the direction of asymmetry, except
for the scapula positioning on the operated side. On
the other hand, some postural changes described by
Rostkowska et al. (2006) were not observed in the
present study, most likely because one study com-
pares women with and without mastectomy, whereas
the other study compares women with MA against
mastectomy and breast reconstruction.
The method of evaluation used by Rostkowska et al.
(2006) article was the Moire topography that is based
on ‘Moire effect; when light is viewed between two
structures of equal, but phase shifted frequencies, lines
of interference or Moire fringes, are created. Clinically,
the creation of Moire patterns is achieved by shining a
high powered light through a wire grid onto a subject’s
back. Moire fringes are produced from the interaction
of the grid and the shadow of the grid.’ (Kawchuk
and McArthur, 1997). Moire topography is based on
the contour of surface, and the photogrammetry is
based on the alignment of anatomical points.
The method used to assess body posture is a rele-
vant issue. Most studies that evaluated the body pos-
ture of women after mastectomy used Moiré
topography (Rostkowska et al., 2006; Ciesla and
Polom, 2010; Malicka et al., 2010), which makes a
quantitative analysis of posture from the overlapping
shadows obtained in a single image on the posterior
view (Takasaki, 1982). In the present study, body pos-
ture was analysed by taking measurements between
bony structures as reference angles in specific views,
7 of 9
Body Posture After Mastectomy
interpreted by specially developed software for pos-
tural evaluation. This method differs from the one
used in the study of Malicka et al. (2010), which eval-
uated the body posture of women after treatment for
breast cancer according to categories of degree of spi-
nal curvature (very good, good, faulty and poor). The
authors determined that 82.3% of women with breast
cancer surgery had faulty body posture compared with
35.1% of healthy women. Women with mastectomy,
breast-conserving surgery and bilateral surgery were
all included in the same study.
The only evidence we found in the literature re-
garding body posture in women after breast recon-
struction was an article by Ciesla and Polom (2010).
In a prospective study, the authors noted that imme-
diate breast reconstruction with the Becker-25 pros-
thesis helped preserve proper body posture after
mastectomy. The Becker-25 prosthesis is a permanent
tissue expander fixed in the inferior border of the
pectoralis major muscle (Becker, 1987). Because it
does not use muscle flaps, it is a different breast re-
construction procedure than the one performed on
the women in the present study.
Regarding the use of an external prosthesis, we ob-
served in our study that most of the women used their
prosthesis regularly and only removed it to sleep, which
may have contributed to the maintenance of postural
alignment. However, this statement is not consistent,
as we found no studies on the effects of the use of ex-
ternal prostheses on body posture, although some au-
thors mentioned external prosthesis use as a benefit
in maintaining postural alignment (Rostkowska et al.,
2006; Ciesla and Polom, 2010).
In the present study, the women who underwent im-
mediate breast reconstruction were younger than the
women who had mastectomy alone. Younger women
usually choose immediate breast reconstruction, as
they are more concerned with sexuality and body im-
age. Older women tend to consider other aspects
beyond sexuality and body image, and more impor-
tantly, they consider treatment of the disease more than
they do breast reconstruction, although not to the ex-
tent of having conflicting attitudes. As regards the age
range of the subjects, the present study is consistent
with other research, such as that of Ciesla and Polom
(2010) in which the groups were between 29 and
68 years old and the study of Rostkowska et al. (2006)
in which the group of women who underwent mastec-
tomy were between 35 and 79 years old.
8 of 9
A. C. A. M. Peres et al.
Clinical implications
This study contributes to the improvement of the phys-
iotherapy approach for mastectomy patients in both
the immediate and late post-operative periods. A better
understanding of the effects each type of surgery can
have on biomechanics and body alignment contributes
to more assertive physical therapy and the prevention
of postural changes or functionality.
There is a tendency to worry mainly with the
lymphoedema and with the shoulder’s range of motion
after the mastectomy, which is correct, but exercises for
the trunk should also be valued in the rehabilitation
programme.
Limitation of the study
In this study, it was not possible to analyse the trunk
rotation in three dimensions. We suggest that further
research be performed for this purpose.
Conclusion
In this study, women who underwent MA, when com-
pared with women who underwent immediate breast
reconstruction with abdominal flap, showed differ-
ences in the vertical alignment of the trunk, with
greater asymmetry between the acromion and greater
trochanter, which can probably indicate trunk rotation.
It should be noted, however, that no significant differ-
ences were found between the two groups in alignment
of the head, shoulders, scapula or pelvis.
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