Impact of medical discipline and observer gender on cosmetic outcome evaluation in breast reconstruction using transverse rectus abdominis myocutaneous (TRAM) flap and radiotherapy

Background: Despite the complication rate, the majority of studies report a satisfactory cosmetic outcome in patients undergoing transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction both before and after radiotherapy (RT). The lack of a universal agreement on the use of a validated scale for cosmetic assessment in clinical practise leads to subjective criteria of evaluation and causes a great deal of interobserver variability. This study investigates whether there is any difference in the evaluation of cosmesis according to gender and specialisation of the observer. Methods: Fifty-two photographs of the patients who had undergone TRAM reconstruction for breast cancer, divided into three groups according to the treatment (TRAM only, TRAM→RT, RT→TRAM), were evaluated by 21 specialists, 10 male and 11 female from radiotherapy, breast surgery and plastic reconstructive surgery. Cosmetic outcome was classified using the four-category Harvard scale: a score of excellent/good was considered acceptable. Results: The overall rate of good/excellent ratings was 66.6%, which was lower than the score reported in the literature. A significantly worse score was registered in the TRAM→RT group compared with the other groups. The probability for male physicians to award a positive judgement is 24% higher than that of female ones. In general, there is a decent agreement among the judgement raters. Conclusions: No statistically significant difference in cosmetic evaluation was noted overall between male physicians and female ones. However, within each specialisation, the difference between the two genders was great. Breast surgeons gave the worst opinion, and among them female surgeons judged most severely, whereas plastic surgeons gave the best opinion, and among them females provided the highest favourable judgement.