Patient satisfaction in relation to nipple reconstruction: The importance of information provision

A systematic review of patient regret after surgery- A common phenomenon in many specialties but rare within gender-affirmation surgery

Regret after gender-affirming surgery (GAS) is a complex issue. Comparing regret after GAS to regret after plastic surgery operations and other major life decisions is a novel approach that can provide insight into the magnitude of this issue. A systematic review of three databases was conducted to investigate regret after common plastic surgery operations. Three separate literature reviews on regret after GAS, regret after elective operations, and regret after major life decisions were performed. A total of 55 articles examining regret after plastic surgery were included. The percentage of patients reporting regret ranged from 0 to 47.1 ​% in breast reconstruction, 5.1-9.1 ​% in breast augmentation, and 10.82-33.3 ​% in body contouring. In other surgical subspecialties, 30 ​% of patients experience regret following prostatectomy and up to 19.5 ​% following bariatric surgery. Rate of regret after GAS is approximately 1 ​%. Other life decisions, such as having children and getting a tattoo have regret rates of 7 ​% and 16.2 ​%, respectively. When comparing regret after GAS to regret after other surgeries and major life decisions, the percentage of patients experiencing regret is extremely low.

A Cross-sectional Study of Regret in Cancer Patients After Sharing Test Results for Pathogenic Germline Variants of Hereditary Cancers With Relatives

BACKGROUND

Research on whole genome/exome sequencing is increasing worldwide. However, challenges are emerging in relation to receiving germline pathogenic variant results and sharing them with relatives.

OBJECTIVE

The aim of this study was to investigate the occurrence of and reasoning related to regret among patients with cancer who shared single-gene testing results and whole exome sequencing with family members.

METHODS

This was a single-center, cross-sectional study. The Decision Regret Scale was administered, and descriptive questionnaires were used with 21 patients with cancer.

RESULTS

Eight patients were classified as having no regret, 9 patients were classified as having mild regret, and 4 patients were classified as having moderate to strong regret. Reasons patients felt that sharing was the right decision included the following: to allow relatives and children to take preventive measures, the need for both parties to be aware of and ready for the hereditary transmission of cancer, and the need to be able to discuss the situation with others. On the other hand, some patients did not think it was a good decision to share the information because of the associated anxiety.

CONCLUSIONS

Regret over sharing test results for pathogenic germline variants of hereditary cancers with relatives tended to be low. The main reason was that patients believed that they were able to benefit others by sharing.

IMPLICATIONS FOR PRACTICE

Healthcare professionals need to understand the postsharing perceptions and experiences of patients and support them throughout the sharing process.

A multimetric health literacy analysis of online gender affirmation surgery materials: From facial to genital surgery

BACKGROUND

The transgender patient population is expanding, and gender affirming surgery (GAS) volume is increasing. Accurate, comprehensive, and easily navigable resources on GAS are lacking. We aim to evaluate the readability of online materials for specific gender affirming surgical procedures to identify mechanisms of improving information access for transgender patients.

MATERIALS AND METHODS

"Facial feminization", "facial masculinization", "MTF breast augmentation", "FTM chest masculinization", "MTF vaginoplasty", "metoidioplasty", and "FTM phalloplasty" were searched on Google. Per keyword, the first 75 text-containing results were included. Text was analyzed for reading difficulty using the Flesch-Kincaid Reading-Ease (FKRE) test and grade level using the Flesch-Kincaid Grade Level (FKGL) formula, Gunning Fog Index (GFI), Simple Measure of Gobbledygook (SMOG), and Coleman-Liau Index (CLI). Scores were compared using independent t-and ANOVA tests (α = 0.05).

RESULTS

Mean readability scores (FKRE 37.44) and grade-levels (FKGL 12.87, GFI 15.61, SMOG 11.91, CLI 15.00) correlated with college-level difficulty. Masculinizing surgical materials were more difficult to read than feminizing ones (p ≤ 0.023). Top surgery materials were easier to read than facial and genital surgery materials (p ≤ 0.013). Specifically, chest masculinization resources were more difficult to read than those for breast augmentation (p ≤ 0.006). No differences were found between facial feminization and masculinization surgery resources, nor between resources for different gender affirming genital surgeries.

CONCLUSION

Online GAS materials are written above the recommended 6th grade reading-level, with resources for transgender men being significantly more challenging to understand. Improving readability of online resources can help overcome barriers to care for the transgender patient population.

Public perception of "laser-assisted" blepharoplasty versus "blade-assisted" blepharoplasty

OBJECTIVE

To evaluate perceptions of blade- versus laser-based blepharoplasty before and after being provided educational information.

DESIGN/PARTICIPANTS/METHODS

This interventional pre-post study included 145 randomly selected participants (Maisonneuve-Rosemont Hospital, Montreal, Canada, August 2020) who were asked about their perceptions surrounding blepharoplasty. Participants then received information about the techniques before answering final questions.

RESULTS

Participants perceived no difference in outcomes for blade (37%) versus laser (40%) blepharoplasty precounselling. This increased to laser blepharoplasty postintervention (56%, p < 0.001) despite being told that there was no difference in outcomes. The higher the level of education among participants, the more likely they were to correctly believe that both techniques had similar outcomes (p = 0.049). Most participants would choose laser blepharoplasty initially (64%), and this percentage increased postintervention (81%, p < 0.001). The preintervention perception of blade blepharoplasty recovery time (20.1 ± 32.6 days) was longer than that for laser blepharoplasty (13.5 ± 32.0 days, p = 0.01) and increased for both techniques postintervention (p < 0.001). Perceived pain was lower for laser blepharoplasty. Postintervention, participants responded that additional costs of ($975 ± $1,091) would justify laser over blade blepharoplasty.

CONCLUSION

Elucidating patient perceptions and preferences for blade- versus laser-based blepharoplasty provides surgeons with perspective on how to tailor preoperative counselling. Before and after the intervention, participants had a bias toward choosing laser blepharoplasty. The intervention seems to falsely convince people that laser blepharoplasty leads to better outcomes. Because the doctor's advice can greatly impact patients' decisions, physicians have to be careful not to give false expectations when counselling patients. Inaccurate recall of key educational takeaways suggests that information should be vulgarized and delivered actively to patients.

Secondary nipple reconstruction using two surgical techniques

Background

Although the initial projection after primary nipple reconstruction is excellent, nipple projection gradually flattens in most cases due to multiple causes. Although various methods have been reported to rebuild the nipple after nipple flattening, the most effective method of secondary nipple reconstruction remains unknown. The aim of this study was to review our institution’s experiences with secondary nipple reconstruction.

Methods

We conducted a retrospective review from March 2012 to January 2019. We performed secondary nipple reconstruction if the primary reconstructed nipple height differed by more than 6 mm from the normal nipple height. We chose the method of nipple revision according to the degree of tissue scarring and the remaining nipple projection.

Results

We performed secondary nipple reconstruction on a total of 27 nipples, using pursestring sutures for 19 nipples and star flaps in eight nipples. The median follow-up period was 8 months (range, 6–19 months) after the final nipple reconstruction. Among the 19 nipples reconstructed using purse-string sutures, 10 (53%) demonstrated acceptable projection of more than 5 mm. Among the eight nipples reconstructed using star flaps, six (75%) showed acceptable projection of more than 5 mm. Most of the patients (73%) were satisfied (scores of 4 or 5) with the nipple reconstruction overall.

Conclusions

Few studies have presented favorable outcomes of secondary nipple reconstruction. When the star flap and purse-string suture methods were used depending on the remaining nipple height and scarring, appropriate projection could be achieved.

'My face in someone else's hands': a qualitative study of medical tattooing in women with hair loss

The psychological and social impact of hair loss and its ongoing treatment can be considerable. Medical treatments are not always successful, and alternative treatments, such as medical tattooing, are growing in popularity. The aims of this study were to explore adults' motivations, experiences, and self-perceived outcomes in relation to medical tattooing. Individual telephone interviews were conducted with 22 women from the United Kingdom aged 26-67 years who had undergone medical tattooing in the past 5 years related to hair loss. Interviews were transcribed and inductive thematic analysis was performed. Appearance concerns, loss of self-confidence/identity, and the practicalities of daily upkeep were cited as reasons for seeking a semi-permanent solution. Trust in the practitioner and the ongoing costs of tattoo maintenance were important considerations in participants' decision-making process and their overall satisfaction with treatment outcomes. Participants felt the emotional impact of hair loss and the subsequent need for appearance-restoring treatment remains unrecognised. This study provides insight into participants' perceptions of an under-researched and unregulated but widely accessible treatment. Implications for the decision-making process are discussed, and suggestions for health professionals are offered.

The spare-parts technique: A safe and efficient single-stage nipple and areola reconstruction

BACKGROUND

The authors hypothesized that optimization of nipple-areolar reconstruction using full-thickness skin graft and cartilage graft can be completed safely in a single-stage procedure.

METHODS

A retrospective analysis of abdominal-based flap breast reconstruction patients who underwent nipple-areolar reconstruction (NAR) using the modified double-opposing tab (mDOT)¹ flap technique was conducted. Complication rates were compared between patients who underwent NAR in a traditional staged procedure versus a single stage. The single-stage group of patients had NAR performed at the time of revision surgery. Reconstruction was performed with full-thickness skin graft from the abdominal standing-cone deformity and costal cartilage that was removed at the time of breast reconstruction and banked subcutaneously until the revision surgery.

RESULTS

In this study, 1,233 nipple reconstructions were reviewed, of which 113 procedures using themDOT technique were analyzed. No significant differences in complication rates were found between the single-stage and the traditional staged NAR, including the risk of total loss of reconstruction or delayed skin graft take. However, the risk of delayed wound healing of the nipple reconstruction was higher in the single-stage group.

CONCLUSIONS

Our study shows that optimizing NAR results by adding cartilage to the nipple construct and enhancing the areolar component by full-thickness skin grafting can be achieved safely in a single stage at the time of flap revision. This represents potential for better long-term nipple projection and better areolar texture mimicry of NAR for breast reconstruction patients.

Satisfaction, disappointment and regret surrounding fertility preservation decisions in the paediatric and adolescent cancer population

PURPOSE

With over 80% of paediatric and adolescent cancer patients surviving into adulthood, quality-of-life issues such as future fertility are increasingly important. However, little is known about regret around decisions to pursue or forgo fertility preservation (FP). We investigated the risk of decision regret in families involved in making a FP decision and explored contributive factors.

METHODS

Parents and patients ≥ 15 years were invited to participate. Participants completed a 10-item survey, including a validated Decision Regret Scale. Scores ≥ 30 indicated high regret. Free-text response items allowed participants to provide reasons for satisfaction or regret.

RESULTS

A total of 108 parents and 30 patients participated. Most (81.4%) reported low regret (mean score 13.7). On multivariate analysis, predictors of low regret included having a FP procedure and a fertility discussion pre-treatment. Most participants believed that FP offers hope for future fertility. Some reported dissatisfaction with the process of decision-making.

CONCLUSION

Overall levels of regret in the study population were low, with factors associated with quality, timely discussion and belief in the success of FP technology being predictors of low regret. However, dissatisfaction with the decision-making process itself revealed that refinements to the programme are required to meet families' needs.

Determinants of regret in elderly dialysis patients

AIMS

In Singapore, most elderly end-stage renal disease (ESRD) patients choose dialysis over palliative management. However, dialysis may not be the optimal treatment option given only moderate survival benefits and high costs and treatment burden compared to non-dialysis management. Elderly patients may therefore come to regret this decision. This study investigated: (i) extent of patients' decision regret after starting dialysis, and (ii) potentially modifiable predictors of regret: satisfaction with chronic kidney disease education, decisional conflict, and decision-making involvement.

METHODS

The present study was a cross-sectional study of 103 dialysis patients above 70 years of age, surveyed at Singapore General Hospital's renal medicine clinics between March and June 2017. Participants reported their levels of decision regret on the Decision Regret Scale (DRS), retrospective decisional conflict on the Decisional Conflict Scale, information satisfaction, and decision-making involvement.

RESULTS

In total, 81% of participants reported no decision regret (DRS score < 50), 11% ambivalence (DRS = 50), and 8% regret (DRS >50). In individual DRS items, 19% felt dialysis had done them harm and 16% would not make the same decision again. In multivariable analyses, lower information satisfaction [b = -0.07 (95% CI: -0.13, -0.01)] and decisional conflict [b = 0.004 (95% CI: 0.002, 0.006)] were significantly associated with decision regret.

CONCLUSION

Although the majority of elderly dialysis patients were comfortable with their decision to start dialysis, a proportion was ambivalent or regretted this choice. Regret was more likely among those who experienced decisional conflict and/or expressed poorer information satisfaction. Healthcare professionals should recognize these risk factors and take steps to minimize chances of regret among this population subset.

Simultaneous Nipple-Areola Complex Reconstruction Technique: Combination Nipple Sharing and Tattooing

BACKGROUND

Nipple-areola complex (NAC) reconstruction is the final critical process used to achieve breast symmetry, patient satisfaction, and overall reconstruction completeness. Here, we introduce our simplified simultaneous NAC reconstruction approach with nipple sharing and tattooing that resulted in minimal morbidity, high patient satisfaction, and a shortened total reconstructive period.

METHODS

Patients who underwent simultaneous nipple sharing and tattooing between July 2012 and December 2017 after the final operative procedure or adjuvant therapy were included. We retrospectively evaluated breast reconstruction type, interval between breast and NAC reconstruction, mean operation time for simultaneous nipple sharing and tattooing, and postoperative complications. Overall patient satisfaction and willingness to undergo simultaneous NAC reconstruction again were assessed.

RESULTS

The mean interval between the final operative procedure or adjuvant therapy and NAC reconstruction was 4.4, 4.4, and 6.7 months in non-adjuvant patients, those who underwent chemotherapy, and those who underwent radiotherapy, respectively. The mean operation time for simultaneous NAC reconstruction was 46 min. No major complications such as infection or total nipple loss were observed regardless of breast reconstruction type at least 6 months postoperatively. The average overall satisfaction was 8.0 on a 10-point scale, and 96.9% of patients indicated that they would undergo this simultaneous NAC reconstruction again.

CONCLUSIONS

Our simplified technique of simultaneous nipple sharing and tattooing is safe and reliable and features high patient satisfaction rates. Additionally, it can be performed in the clinical setting and is convenient for patients and surgeons alike since it features a decreased total reconstruction period.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does nipple-areolar tattooing matter in breast reconstruction? A cohort study using the BREAST-Q

Background

Breast reconstruction is achieved through a series of surgical procedures often concluded with nipple-areolar reconstruction tattoo. The purpose of the tattoo is to increase the patients' satisfaction with the appearance of the breast, however, no published studies quantitatively compare patient satisfaction before vs. after tattoo. In recent times nurse practitioners are increasingly performing this specialised procedure previously undertaken by the plastic surgeon, but there is no evidence to compare patient satisfaction according to clinician.

Purpose

The objectives of this study are to examine patient satisfaction pre- and post-nipple-areolar tattooing utilising a validated patient-reported outcome measure the BREAST-Q, and to identify any differences in patient satisfaction between the nurse practitioner and plastic surgeon.

Methods

Data was collected from all breast reconstruction patients who underwent nipple-areolar reconstruction tattooing over a six-year period in a dedicated Breast Reconstruction Unit and had completed a pre- and post-tattoo BREAST- Q questionnaire. Analysis of data included paired t-test of pre- and post-tattoo scores and ANCOVA to compare clinicians and tattoo laterality.

Results

93 patients with completed pre- and post-tattoo questionnaires within the date criteria were included from the 204 patientswho had a nipple-areolar tattoo. There was a significant improvement in patient satisfaction with nipple reconstruction from pre-tattoo (m = 74.4) to post-tattoo (m = 81.0), p = 0.013 (2-tailed), with no significant difference between clinicians.

Conclusion

Patients reported through completion of the BREAST-Q, that nipple-areolar tattooing significantly improves satisfaction with their nipple reconstruction.

Determinants of satisfaction with cosmetic outcome in breast cancer survivors: A cross-sectional study

Little research has been done into cosmetic outcomes in non-Western breast cancer populations. We aimed to study the prevalence and determinants of dissatisfaction with cosmetic outcome after breast cancer surgery of Asian breast cancer survivors, and its association with patient-reported anxiety, depression, and quality of life. In a hospital-based cross-sectional study, 384 breast cancer survivors of at least 12 months after diagnosis completed questionnaires on satisfaction with cosmetic appearance, quality of life (EORTC-QLQ-C30) and anxiety and depression (HADS). Cumulative logit models were used to examine the adjusted association between dissatisfaction with cosmetic appearance and demographic and clinical characteristics. Kruskal-Wallis test was used to test for associations between dissatisfaction with cosmetic appearance and patient-reported outcomes. Overall, 20% of women reported to be (very) dissatisfied with cosmetic appearance. Survivors of Chinese ethnicity were more likely dissatisfied with cosmetic appearance compared to Malay survivors (22% and 14% respectively, adjusted OR = 2.4, 95%CI: 1.4-3.9). Women with DCIS (adjusted OR = 2.2, 95%CI: 1.3-3.7) or advanced stage disease (adjusted OR = 2.2, 95%CI: 1.2-3.9) had a higher risk of being dissatisfied with their cosmetic appearance. Women treated with mastectomy were at a higher risk of dissatisfaction with cosmetic appearance (adjusted OR = 1.7, 95%CI: 1.1-2.5). Dissatisfaction with cosmetic appearance was associated with increased depression scores. In this South-East Asian population, one in five breast cancer patients were (very) dissatisfied with the cosmetic outcome of treatment. Chinese women, women with larger tumors and women treated with mastectomy were most likely to report dissatisfaction with cosmetic appearance.

Upward counterfactual thinking and depression: A meta-analysis

This meta-analysis examined the strength of association between upward counterfactual thinking and depressive symptoms. Forty-two effect sizes from a pooled sample of 13,168 respondents produced a weighted average effect size of r=.26, p<.001. Moderator analyses using an expanded set of 96 effect sizes indicated that upward counterfactuals and regret produced significant positive effects that were similar in strength. Effects also did not vary as a function of the theme of the counterfactual-inducing situation or study design (cross-sectional versus longitudinal). Significant effect size heterogeneity was observed across sample types, methods of assessing upward counterfactual thinking, and types of depression scale. Significant positive effects were found in studies that employed samples of bereaved individuals, older adults, terminally ill patients, or university students, but not adolescent mothers or mixed samples. Both number-based and Likert-based upward counterfactual thinking assessments produced significant positive effects, with the latter generating a larger effect. All depression scales produced significant positive effects, except for the Psychiatric Epidemiology Research Interview. Research and theoretical implications are discussed in relation to cognitive theories of depression and the functional theory of upward counterfactual thinking, and important gaps in the extant research literature are identified.

Nipple-areolar complex reconstruction and patient satisfaction: a systematic review and meta-analysis

BACKGROUND

Nipple-areola complex (NAC) reconstruction transforms a mound of soft tissue into a breast and often marks the final stage of breast reconstruction after mastectomy.

METHODS

A systematic review and meta-analysis were conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Articles were classified based on the nipple reconstructive technique-either composite nipple sharing or local flap with nipple-sparing mastectomy (NSM) used as a control. A standardized "Satisfaction Score" (SS) for "nipple appearance" and "nipple sensation" was calculated for each technique. A Fisher's exact test was used to compare the SS with local flap reconstruction with NSM.

RESULTS

Twenty-three studies met the systematic review inclusion criteria. Nine NSM articles were identified with patient satisfaction data from 473 patients. The weighted average SS for NSM was 80.5%. Fourteen local flap technique articles were identified with satisfaction data from 984 patients and a weighted average SS of 73.9%. This was a statistically significant difference (P=0.0079). C-V and badge local flap techniques were associated with the highest SS, 92.6% and 90.5%, respectively. C-V and modified C-V flap technique was associated with a higher SS when compared to those using one or more other flap techniques (P=0.0001).

CONCLUSIONS

While patient satisfaction with nipple reconstruction is high regardless of technique, it is higher with NSM. When NSM is not an option, local flap reconstruction with a C-V or modified C-V flap may be associated with higher satisfaction than alternative local flap techniques.

A systematic review of risks and benefits with nipple-areola-reconstruction

BACKGROUND

Most women who have their breast reconstructed are offered NAC reconstruction. Nonetheless, it is unclear what scientific evidence there is for the procedure. The aims of the present systematic review were to evaluate the quality of evidence for benefits and risks with NAC reconstruction, and to examine the evidence for different techniques.

METHODS

Relevant databases were searched. Inclusion criteria were controlled studies comprising ≥20 patients and a case series of ≥50 patients. Included articles had to meet criteria defined in a PICO (Patient, Intervention, Comparison, and Outcome). Data extraction and collection were performed according to the QUADAS tool. The level of evidence of the selected articles was assessed according to the Oxford Centre for Evidence-Based Medicine 2009 guidelines, and total evidence for the different research questions was graded according to the GRADE-system.

RESULTS

A total of 362 abstracts were retrieved following the search. Of these 325 did not meet the inclusion criteria and were excluded, leaving 37 studies to be included in the review. Among these, 36 were case series and one a small randomised non-blinded study Conclusions: The existing quality of evidence for risks and benefits of the operation is very low. It is unclear what the complication frequencies are after the reconstruction, and what effect on quality-of-life the operation has. Prospective studies of high quality are needed to evaluate the health effects and risks with NAC reconstruction.

More primary care patients regret health decisions if they experienced decisional conflict in the consultation: a secondary analysis of a multicenter descriptive study

Background

We sought to estimate the extent of decision regret among primary care patients and identify risk factors associated with regret.

Methods

Secondary analysis of an observational descriptive study conducted in two Canadian provinces. Unique patient-physician dyads were recruited from 17 primary care clinics and data on patient, physician and consultation characteristics were collected before, during and immediately after consultations, as well as two weeks post-consultation, when patients completed the Decision Regret Scale (DRS). We examined the DRS score distribution and performed ordinal logistic regression analysis to identify predictors of regret.

Results

Among 258 unique patient-physicians dyads, mean ± standard deviation of decision regret scores was 11.7 ± 15.1 out of 100. Overall, 43 % of patients reported no regret, 45 % reported mild regret and 12 % reported moderate to strong regret. In multivariate analyses, higher decision regret was strongly associated with increased decisional conflict and less significantly associated with patient age and education, as well with male (vs. female) physicians and residents (vs. teachers).

Conclusion

After consulting family physicians, most primary care patients experience little decision regret, but some experience more regret if there is decisional conflict. Strategies for reducing decisional conflict in primary care, such as shared decision-making with decision aids, seem warranted.

Nipple-areola complex reconstruction improves psychosocial and sexual well-being in women treated for breast cancer

INTRODUCTION

Women choose to undergo nipple-areola complex (NAC) reconstruction as part of breast reconstruction following breast cancer treatment. However, the effect of this procedure on psychosocial and sexual well-being is not well studied. The present study aimed to evaluate how NAC reconstruction affects patient satisfaction with regard to psychosocial and sexual well-being.

METHODS

A retrospective chart review was performed for all patients who underwent NAC reconstruction at Magee-Women's Hospital from January 1, 2004 to July 31, 2011. A letter and questionnaire based on the BREAST-Q were mailed to patients to request their participation in the study. Patient satisfaction and health-related quality of life were measured before and after NAC reconstruction.

RESULTS

In total, 107 of 328 patients (32.6%) completed the survey. The BREAST-Q scale score for satisfaction with outcome following NAC reconstruction was 85.1 ± 15.8, with higher satisfaction scores for patients with a follow-up of <1.5 years than those with a follow-up of >2.5 years (82.5 ± 21.7 vs. 69.5 ± 19.5; p < 0.01). No significant differences were found in satisfaction with the breast mound before and after NAC reconstruction. Women scored significantly higher on the psychosocial and sexual well-being scales after NAC reconstruction (p < 0.002 and 0.00004, respectively).

CONCLUSIONS

This study indicates that patients are highly satisfied after undergoing NAC reconstruction. Satisfaction with the procedure, however, may decrease over time. NAC reconstruction significantly contributes to patient psychosocial and sexual well-being, and this effect did not change over time. NAC reconstruction improves patient outcomes in those who choose to undergo the procedure.

Psychosocial and Sexual Well-Being Following Nipple-Sparing Mastectomy and Reconstruction

Nipple-sparing mastectomy (NSM) is considered an oncologically safe option for select patients. As many patients are candidates for nipple-sparing or skin-sparing mastectomy (SSM), reliable patient-reported outcome data are crucial for decision-making. The objective of this study was to determine whether patient satisfaction and/or health-related quality of life (HRQOL) were improved by preservation of the nipple with NSM compared to SSM and nipple reconstruction. Subjects were identified from a prospectively maintained database of patients who completed the BREAST-Q following mastectomy and breast reconstruction between March and October 2011 at Memorial Sloan Kettering Cancer Center. Fifty-two patients underwent NSM followed by immediate expander-implant reconstruction. A comparison group consisted of 202 patients who underwent SSM followed by immediate expander-implant reconstruction and later nipple reconstruction. HRQOL and satisfaction domains as measured by BREAST-Q scores were compared in multivariate linear regression analyzes that controlled for potential confounding factors. NSM patients reported significantly higher scores in the psychosocial (p = 0.01) and sexual well-being (p = 0.02) domains compared to SSM patients. There was no significant difference in the BREAST-Q physical well-being, satisfaction with breast, or satisfaction with outcome domains between the NSM and SSM groups. NSM is associated with higher psychosocial and sexual well-being compared to SSM and nipple reconstruction. Preoperative discussion of such HRQOL outcomes with patients may facilitate informed decision-making and realistic postoperative expectations.

Extent and Predictors of Decision Regret about Health Care Decisions: A Systematic Review

BACKGROUND

People often face difficult decisions about their health and may later regret the choice that they made. However, little is known about the extent of decision regret in health care or its predictors. We systematically reviewed evidence about the extent of decision regret and its risk factors among individuals making health decisions.

METHODS

The data sources were Medline, Embase, and reverse citation searches in Google Scholar and Web of Science. Studies using the Decision Regret Scale (DRS) to measure decision regret among individuals making nonhypothetical health decisions were included. There were no restrictions on study design, setting, or language. We extracted characteristics of included studies, measures of central tendency for DRS scores (0 = no regret, 100 = high regret), and all risk factors from published analyses. Quality appraisal was conducted using the Mixed Methods Appraisal Tool. A narrative synthesis was performed owing to the heterogeneity of studies.

RESULTS

The initial search yielded 372 unique titles, and 59 studies were included. The overall mean DRS score across studies was 16.5, and the median of the mean scores was 14.3 (standard deviation range = 2.2-34.5) (n = 44 studies). The risk factors most frequently reported to be associated with decision regret in multivariate analyses included higher decisional conflict, lower satisfaction with the decision, adverse physical health outcomes, and greater anxiety levels.

CONCLUSIONS

The extent of decision regret as assessed with the DRS in nonhypothetical health decisions was often low but reached high levels for some decisions. Several risk factors related to the decision-making process significantly predicted decision regret. Additional research into the psychometrics of the DRS and the relevance of scores for clinicians and patients would increase the validity of decision regret as a patient-reported outcome.

Assessment of online patient materials for breast reconstruction

BACKGROUND

Limited health literacy affects nearly half of American adults and adversely affects patient participation, satisfaction, health care costs, and overall outcomes. As patients increasingly search the Internet for health information, accessibility of online material is critical. Previous studies examining this topic have focused on the readability of these materials. This study evaluates online breast reconstruction resources with regard to reading level, however, adds new metrics to assess degree of complexity, and suitability for the intended audience.

METHODS

The 10 most popular patient Web sites for "breast reconstruction" were identified using the largest Internet search engine. The content of each site was assessed for readability using the simple measure of gobbledygook analysis, complexity using the PMOSE/iKIRSCH formula, and suitability using the suitability assessment of materials instrument. Resulting scores were analyzed overall and by Web site.

RESULTS

Readability analysis revealed an overall average grade level of 13.4 (range 10.7-15.8). All sites exceeded the recommended sixth grade level. Complexity evaluation revealed a mean PMOSE/iKIRSCH score of 6.3, consistent with "low" complexity and requiring an 8th-12th grade education; individual sites ranged from "very low" to "high" complexity. Suitability assessment overall produced a mean 41.2% score, interpreted as "adequate" for the intended patient audience. Five of the 10 sites were found to be "not suitable" when examined individually; the remaining five were "adequate."

CONCLUSIONS

Available online patient material for breast reconstruction is often too difficult for many patients to understand based on readability, complexity, and suitability metrics. Comprehensive assessment is needed to design appropriate patient material and minimize disparities related to limited health literacy.