First, aesthetic outcome was measured with 2 methods for the objective result: Breast size measurements by using 4 parameters and breast volume calculation (Fig.1).

It was designed by incorporating multiple subjective questions to evaluate the patients’aesthetic satisfaction.

Second, the patients’satisfaction was evaluated at postoperative 1 year with the self-assessment questionnaire.

The overall score of the self satisfaction analysis was graded in 10 subjects. The investigated items included breast contour and volume, NAC position (malposition, degree of rotation), symmetry, color (degree of discoloration), size, shape (degree of distortion), projection, degree of scar formation (size, shape), and need for additional revision surgery.

But, in order to choose a free TRAM flap for breast reconstruction, a skillful microanastomosis technique and a positive frame of mind are required for free flap survival. Therefore, in this study, the authors selected a free TRAM flap for breast reconstruction. Nipple sparing mastectomy and immediate breast reconstruction with muscle-sparing free TRAM flap is not only aesthetically satisfying and but it is also oncologically safe, and therefore it should be considered as a surgical treatment option in women who need to undergo breast cancer surgery and reconstruction.

Third, the assessment of oncologic safety and complications was done through regular outpatient monitoring with radiologic imaging study and clinical examination about local and systemic recurrence and newly developed cancer.

2. Breast volume measurement was performed by the plaster casting method.

*After summing up the scores of the 10 subjects, the cumulative score was reassessed using the overall scores as follows: a score of 0 to 24 was regarded as aesthetically poor; a score of 25 to 34 as aesthetically bad; a score of 35 to 39 as aesthetically fair; a score of 40 to 44 as aesthetically good; a score of 45 to 49 as aesthetically very good; a score of 50 as aesthetically superior.

The scores were classified into 6 grades as follows: 0, very bad; 1, bad; 2, fair; 3, good; 4, very good; 5, excellent. After summing up the scores of the 10 subjects, the cumulative score was reassessed using the overall scores as follows: a score of 0 to 24 was regarded as aesthetically poor; a score of 25 to 34 as aesthetically bad; a score of 35 to 39 as aesthetically fair; a score of 40 to 44 as aesthetically good; a score of 45 to 49 as aesthetically very good; a score of 50 as aesthetically superior.

In conclusion, free TRAM flap can be applied to the patients with a larger breast and the patients with a previous history of irradiation after receiving a free flap²³.