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 A. C. A. M. Peres et al.

Introduction Letterman and Schurter (1980) who analysed the re-

lationship between the breast volume and the vertebral
Immediate breast reconstruction has been an impor- column reported that voluminous breasts can cause
tant option for women who were diagnosed for breast changes in the centre of gravity with accentuation of
cancer and recommended to have mastectomy. Cur- the physiological curvature of the vertebral column
rently, there are many different surgical procedures, in- and increased tension of the cervical extensor muscles.
cluding expander/implant, autologous tissue and Findikcioglu et al. (2007) who also analysed the corre-
combined autologous tissue/implant (Cordeiro, 2008). lation between the breast volume and the vertebral col-
The choice of breast reconstruction method depends umn concluded that voluminous breasts can exacerbate
on several factors, such as the biotype of the patient, the angle of thoracic kyphosis and lumbar lordosis.
size and shape of the breast, availability of autologous Despite the many improvements and major ad-
tissue, breast cancer treatment and presence of vances in breast cancer treatment, including the impor-
comorbidities. tance of breast reconstruction surgery on the quality of
For the technique that involves the use of implant life of these patients, little is known about the effects of
without prior expansion, it is necessary that the skin mastectomy and the different breast reconstruction
flap that remains after a mastectomy is adequate, but surgical procedures on body posture. There is some ev-
normally, the skin flap is not of sufficient size to cover idence that after mastectomy, changes can occur in the
the implant, especially when an implant without prior alignment of the shoulders, scapulas, trunk and pelvis
expansion is performed. Therefore, tissue expansion (Rostkowska et al., 2006; Ciesla and Polom, 2010),
followed by a permanent implant is a common tech- and that immediate breast reconstruction with the
nique for breast reconstruction (Petit et al., 2001; Becker-25 prosthesis (permanent expansive breast im-
Roostaeian et al., 2012). The expander or implant is plant) helps to preserve body posture after mastectomy
placed in a subpectoral pocket, under the pectoralis (Ciesla and Polom, 2010). However, studies could not
major and serratus anterior muscles (Cordeiro, 2008), be found in the literature that evaluated body posture
and thus leads to a change in the position of these mus- in women who underwent immediate breast recon-
cles. However, it has been reported that this change in struction with autologous tissue, especially with ab-
position only leads to slight loss of function of the dominal flap.
pectoralis major and serratus anterior muscles. The Postural assessment is the starting point to instruct
most commonly used autologous reconstructive proper physiotherapy conduct, helping the detection
methods, however, are the pedicled transverse rectus of possible muscle imbalances that could lead to poten-
myocutaneous flap (TRAM) and latissimus flaps. In a tial injury, wear of the joint and pain that can signifi-
pedicled TRAM flap, the rectus muscle and overlying cantly affect the quality of life (Derewiecki et al.,
skin and subcutaneous tissue are rotated into the mas- 2013; Riskowski et al., 2013; Araújo et al., 2014).
tectomy, and the inferior epigastric artery is severed There are several qualitative and quantitative
(Kaya and Serel, 2013; Dunlop and Caminer, 2014). methods for postural analysis (Singla and Veqar,
One of the disadvantages of this method is that most 2014), but the measurement of body angles and dis-
of the women take 2 to 4 months to return to their pre- tances in photographs on the anterior, posterior and
vious level of capacity, and because the position of the sagittal views (two sides) seems to be the fastest and
muscles changes, there is a greater decline in upper ab- most comprehensive evaluation method (Fortin et al.,
dominal strength in these patients (Atisha and Alder- 2011). The Postural Analysis Software/Software
man, 2009). Another option with the TRAM flap is to de Análise Postural (PAS/SAPO) used in this study en-
perform a free transfer of the abdominal tissue to the ables the analysis of various angles in various views
surgery area, which requires a longer surgical proce- and is an easy-to-use tool, which underwent an intra-
dure but minimizes the risk of injuries in the abdomi- rater and inter-rater reliability validation (Ferreira
nal area (Petit et al., 2001; Serletti, 2006). In the same et al., 2010).
manner, as with the mastectomy, the surgical proce- It is important for the physiotherapist to under-
dure used in breast reconstruction can also affect the stand the effect that the absence of the breast and a
biomechanics of the body (Atisha and Alderman, reconstruction surgery that involves the muscles of
2009; Nizet and Piérard, 2009; Crosbie et al., 2010). the abdomen can cause on posture. In this context,

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A. C. A. M. Peres et al. Body Posture After Mastectomy

the aim of this study was to compare the body pos- lateral view, and from these points, angles and dis-
tures of women who underwent immediate breast re- tances can be measured of the posture.
construction using an abdominal flap with those of For the photographs, a digital camera (Sony Cyber-
women who underwent mastectomy alone. 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
Methods as markers and double-sided adhesive tape.
Design, setting and subjects The camera was placed 2.00 m away from the par-
ticipant on a tripod 90 cm high. The plumb line
This cross-sectional study was performed between July
marked with three polystyrene balls was used to en-
2012 and June 2013, at the Mastology Department of
able calibration of the image. The photos were taken
the Cancer Institute of the state of São Paulo, Brazil.
and transferred to a computer for evaluation using
The women, diagnosed with breast cancer and mastec-
the PAS/SAPO.
tomy, were divided into two groups: group 1, women
without breast reconstruction (mastectomy alone
[MA]) (n = 38) and group 2, women with immediate Procedure
breast reconstruction with abdominal flap (mastec-
The women’s medical charts were used to recruit the
tomy and immediate breast reconstruction [M + IBR])
participants and collect their demographic and clinical
(n = 38).
data. All of the women underwent one single evalua-
Women aged 35–70 years, 1 to 5 years post-surgery
tion, including having their photographs taken. A sin-
and not having undergone chemotherapy or radiother-
gle evaluator made the evaluation of all women, and
apy in the last 6 months were included in the study. Ex-
the statistical analysis was performed by a professional
clusion criteria were bilateral mastectomy, upper-limb
statistician not involved in the study. The women
lymphoedema and orthopaedic, rheumatologic or neu-
who did not undergo reconstruction were asked to an-
rological sequelae.
swer questions in order to obtain information about
The sample size was calculated considering a differ-
the use of an external prosthesis and the length of use.
ence of 1.3° in the horizontal alignment of acromion,
The photographs were taken after markers were
with a standard deviation of two points (Ciesla and
placed on specific anatomical points, located and
Polom, 2010). A statistical power of 80% and 5% sig-
marked with small polystyrene balls on the skin with
nificance were used, with the required sample size be-
double-sided adhesive tape. All the procedures were
ing 38 patients in each group.
performed with the subjects in standing position. The
The study was conducted with the approval of the
marked anatomical points were as follows: the medial
ethics committee of the School of Medicine, University
point between the tragus and acromion; spinous pro-
of São Paulo (330/11). All participants signed the free
cess of C7 and T3; inferior angles of the scapulas;
and informed terms of consent form.
anterior–superior iliac spines; posterior–superior iliac
spines; and greater trochanter of the femur.
After marking the anatomical points, the women
Instruments
were instructed to stand in a comfortable posture and
For the postural analysis, PAS/SAPO (version 0.68) were photographed in anterior, posterior, right and left
(Ferreira et al., 2010) was used. The tool is free, is avail- views. To ensure that the same base of support was
able at http://puig.pro.br/sapo/, has scientific tutorials kept in all four views, the participants’ feet were
and is a study of reliability inter-rater and intra-rater outlined on cardboard, and they were instructed to
evaluators. The PAS/SAPO was developed and validated stand within the borders of the outlines when being
by Ferreira et al. (2010) and provides various functions photographed.
such as image calibration, zoom, simultaneous viewing Four photographs of each participant were analysed
of photos, tagging of free anatomical points or by the (anterior, posterior and lateral views). The analysis was
PAS/SAPO protocol and measurements of angles and conducted by only one physiotherapist carrying out the
distances. There are 27 anatomical points on the ante- following routine: accessing the photo, zooming 100%,
rior view, 41 on the posterior view and 31 seen in the calibrating the image from the plumb line, marking the

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Body Posture After Mastectomy A. C. A. M. Peres et al.

anatomical points by PAS/SAPO protocol and making Statistical analysis

a report.
A descriptive analysis was performed for all quantita-
The results of the analysis of the photographs are
tive (mean and standard deviation) and qualitative (to-
presented in degrees for the anterior view, right and left
tal value and percentage) variables. Adherence to the
sides and in percentages for the posterior view.
normal curve was checked using the Kolmogorov–
In the analysis of the anterior view, the positive and
Smirnov test. The groups were compared according
negative signs indicate which direction the difference is
to the following variables: age, weight, height, body
in alignment between two anatomical landmarks. For
mass index, time of surgery, weight of breast tissue
two anatomical points that should be symmetrical, for
resected, type of surgery, side of surgery, tumour stage,
example the acromion, the positive sign indicates that
histological type, oncological treatment (chemother-
the slope is to the right (left shoulder higher) and the
apy, radiotherapy or hormone therapy) and meno-
negative sign indicates that the slope is to the left (right
pause. The chi-square test for qualitative variables and
shoulder higher); zero represents symmetry between
Student’s t-test for quantitative variables were used to
the two acromion. These are the convention signs used
compare the groups. The level of statistical difference
for the software based on mathematical rules (Ferreira
was set at p ≤ 0.05. The statistical analysis was performed
et al., 2011).
with SPSS version 15.0 (SPSS Inc., Chicago, Illinois, USA).
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 Results
right and left sides in the frontal plane. This analysis Six women refused to participate in the study, and two
was not conducted in the posterior and lateral views women were excluded because they presented
because in the posterior view, the analysed variable lymphoedema. Therefore, 76 women diagnosed with
refers to the alignment of the scapulas, which is sym- breast cancer who underwent mastectomy were in-
metrical when the result is zero and the asymmetry cluded. Of these women, 38 had MA, and 38 had im-
value is expressed as a percentage. In the side views, mediate reconstruction with abdominal flap (M
deviations occur in the sagittal plane, and the use of + IBR). In the M + IBR group, 23 women (60.5%)
signs are not necessary to indicate the direction of underwent the transverse abdominis muscle with flap
inclination. technique (TRAM), six (15.8%) underwent the deep
Table 1, adapted from Ferreira et al. (2011), shows inferior epigastric perforator flap technique and six
the postural alignment variables in the anterior, poste- (15.8%) underwent the superficial inferior epigastric
rior and lateral views, as well as the anatomical points artery flap technique. It was not possible to obtain the
used for the measurements. reconstruction surgery data of three of the women

Table 1. Postural alignment variables and anatomical points and measures

Variables Anatomical points and measures

Anterior view
Horizontal alignment of the head Angle between the two tragi and a horizontal line
Horizontal alignment of the acromions Angle between the two acromions and a horizontal line
Horizontal alignment of the ASISs Angle between the two ASISs and a horizontal line
Angle between acromions and ASISs Angle between the two acromions and the two ASISs

Posterior view
Asymmetry of the scapulas related to T3 Spinous process of the T3 and inferior angle of the scapulas

Lateral view
Horizontal alignment of the head Angle between the C7 spinal process and tragus and a horizontal line
Vertical alignment of the trunk Angle between the acromion greater trochanter of the femur and a vertical line
Horizontal alignment of the pelvis Angle between the ASIS and PSIS and a horizontal line

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. Body Posture After Mastectomy

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

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

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A. C. A. M. Peres et al. Body Posture After Mastectomy

64% of women reported improvement of the abdo- mastectomy, and the comparison of women who
men, 72% noted improvement of the appearance of underwent surgery recently with women who
the abdomen and 20% noticed an improved posture underwent surgery many years ago is inadvisable.
(Mizgala et al., 1994). There are few studies regarding body posture in
The majority of the women (60.5%) in our study women after mastectomy. Rostkowska et al. (2006)
had breast reconstruction with transverse rectus reported that women with mastectomy had greater
abdominis muscle (TRAM) flap. This procedure in- asymmetry in the alignment of the shoulders and
volves a skin flap, fat and one or both rectus abdominis scapulas, greater angle of rotation of the pelvis and
muscles passed through a tunnel under the skin to the anterior and lateral inclination of the trunk. The an-
mastectomy site (Hartrampf et al., 1982). This surgical terior inclination of the trunk was observed in
technique differs from a free TRAM flap, which is women who had recently undergone surgery, and it
made from the overlying muscle attached to the infe- was attributed to the effects of analgesics and a pro-
rior epigastric vessels. This flap is completely separated tective position after mastectomy. It is important to
from the abdomen and transferred to the region of the note that the study compared healthy women with
mastectomy where it is anastomosed to either the women who had undergone mastectomy, which dif-
thoracodorsal or internal mammary vessels (Serletti, fers from the present study where we evaluated only
2006). One commonly expressed concern regarding women between 1 and 5 years after mastectomy. In
the TRAM procedure is the effect on abdominal wall accordance with our study, Rostkowska et al. (2006)
function following breast reconstruction (Dulin et al., also did not find any correlation between the side
2004; Bonde et al., 2007). A systematic review by Atisha of surgery and the direction of asymmetry, except
and Alderman (2009) revealed that considering evalua- for the scapula positioning on the operated side. On
tions with dynamometry up to a 23% deficit in trunk the other hand, some postural changes described by
flexion can be seen in pedicle TRAM patients and up Rostkowska et al. (2006) were not observed in the
to an 18% deficit in free TRAM patients. In the trunk present study, most likely because one study com-
extension evaluation, pedicle TRAM patients demon- pares women with and without mastectomy, whereas
strated up to a 14% deficit, and free TRAM patients the other study compares women with MA against
showed minimal or no deficit of strength. Considering mastectomy and breast reconstruction.
the data of the articles cited and the results obtained in The method of evaluation used by Rostkowska et al.
the present study, it is possible that TRAM flap may af- (2006) article was the Moire topography that is based
fect abdominal wall function; however, no impact on on ‘Moire effect; when light is viewed between two
postural alignment was observed in the present study, structures of equal, but phase shifted frequencies, lines
at least not up to 5 years after surgery. of interference or Moire fringes, are created. Clinically,
An important strength of our study was the homo- the creation of Moire patterns is achieved by shining a
geneity of the sample with respect to time of surgery high powered light through a wire grid onto a subject’s
and complementary breast cancer treatment. None of back. Moire fringes are produced from the interaction
the women in the two groups was undergoing che- of the grid and the shadow of the grid.’ (Kawchuk
motherapy or radiotherapy, which could influence and McArthur, 1997). Moire topography is based on
the results of the body posture assessment due to the contour of surface, and the photogrammetry is
physical discomfort or adherence of the skin. Women based on the alignment of anatomical points.
with upper lymphoedema were also excluded from The method used to assess body posture is a rele-
the study. We opted not to include women who vant issue. Most studies that evaluated the body pos-
had undergone mastectomy less than 1 year prior to ture of women after mastectomy used Moiré
the study, because the presence of pain and decreased topography (Rostkowska et al., 2006; Ciesla and
range of motion of the upper limb could have trig- Polom, 2010; Malicka et al., 2010), which makes a
gered an adaptive change in posture (Crosbie et al., quantitative analysis of posture from the overlapping
2010; Nesvold et al., 2011). There is evidence that af- shadows obtained in a single image on the posterior
ter 1 year post-surgery, the majority of women re- view (Takasaki, 1982). In the present study, body pos-
cover shoulder function (Springer et al., 2010). The ture was analysed by taking measurements between
study of posture should consider the time of bony structures as reference angles in specific views,

Physiother. Res. Int. 22 (2017) e1642 © 2015 John Wiley & Sons, Ltd. 7 of 9
Body Posture After Mastectomy A. C. A. M. Peres et al.

interpreted by specially developed software for pos- Clinical implications

tural evaluation. This method differs from the one
This study contributes to the improvement of the phys-
used in the study of Malicka et al. (2010), which eval-
iotherapy approach for mastectomy patients in both
uated the body posture of women after treatment for
the immediate and late post-operative periods. A better
breast cancer according to categories of degree of spi-
understanding of the effects each type of surgery can
nal curvature (very good, good, faulty and poor). The
have on biomechanics and body alignment contributes
authors determined that 82.3% of women with breast
to more assertive physical therapy and the prevention
cancer surgery had faulty body posture compared with
of postural changes or functionality.
35.1% of healthy women. Women with mastectomy,
There is a tendency to worry mainly with the
breast-conserving surgery and bilateral surgery were
lymphoedema and with the shoulder’s range of motion
all included in the same study.
after the mastectomy, which is correct, but exercises for
The only evidence we found in the literature re-
the trunk should also be valued in the rehabilitation
garding body posture in women after breast recon-
programme.
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- Limitation of the study
thesis helped preserve proper body posture after In this study, it was not possible to analyse the trunk
mastectomy. The Becker-25 prosthesis is a permanent rotation in three dimensions. We suggest that further
tissue expander fixed in the inferior border of the research be performed for this purpose.
pectoralis major muscle (Becker, 1987). Because it
does not use muscle flaps, it is a different breast re- Conclusion
construction procedure than the one performed on
the women in the present study. In this study, women who underwent MA, when com-
Regarding the use of an external prosthesis, we ob- pared with women who underwent immediate breast
served in our study that most of the women used their reconstruction with abdominal flap, showed differ-
prosthesis regularly and only removed it to sleep, which ences in the vertical alignment of the trunk, with
may have contributed to the maintenance of postural greater asymmetry between the acromion and greater
alignment. However, this statement is not consistent, trochanter, which can probably indicate trunk rotation.
as we found no studies on the effects of the use of ex- It should be noted, however, that no significant differ-
ternal prostheses on body posture, although some au- ences were found between the two groups in alignment
thors mentioned external prosthesis use as a benefit of the head, shoulders, scapula or pelvis.
in maintaining postural alignment (Rostkowska et al.,
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