Comparison of preoperative quality of life in breast reconstruction, breast aesthetic and non-breast plastic surgery patients: A cross-sectional study

A Scoping Review of the Application of BREAST-Q in Surgical Research

Background

Collection of patient-reported outcome (PRO) data can facilitate cost-effective, evidence-based, and patient-centered care. The BREAST-Q has become the gold standard tool to measure PRO data in breast surgery. The last review of its application indicated that it was underutilized. Considering the evolution in breast surgery, the purpose of this study was to perform a scoping review of BREAST-Q application since 2015 and identify emerging trends and potential persistent gaps to guide patient-centered practice and future research in breast surgery.

Methods

We performed an electronic literature review to identify publications published in English that used the BREAST-Q to assess patient outcomes. We excluded validation studies, review papers, conference abstracts, discussions, comments, and/or responses to previously published papers.

Results

We identified 270 studies that met our inclusion criteria. Specific data was extracted to examine the evolution of the BREAST-Q application and examine clinical trends and research gaps.

Discussion

Despite a significant increase in BREAST-Q studies, gaps in the understanding of the patient experience remain. The BREAST-Q is uniquely designed to measure quality of life and satisfaction with outcome and care. The prospective collection of center-specific data for every type of breast surgery will generate important information for the provision of patient-centered and evidence-based care.

How Postoperative Infection Affects Reoperations after Implant-based Breast Reconstruction: A National Claims Analysis of Abandonment of Reconstruction

Infection after implant-based breast reconstruction adversely affects surgical outcomes and increases healthcare utilization. This study aimed to quantify how postimplant breast reconstruction infections impact unplanned reoperations, hospital length of stay, and discontinuation of initially desired breast reconstruction.

Methods

We conducted a retrospective cohort study using Optum's de-identifed Clinformatics Data Mart Database to analyze women undergoing implant breast reconstruction from 2003 to 2019. Unplanned reoperations were identified via Current Procedural Terminology (CPT) codes. Outcomes were analyzed via multivariate linear regression with Poisson distribution to determine statistical significance at P < 0.00625 (Bonferroni correction).

Results

In our national claims-based dataset, post-IBR infection rate was 8.53%. Subsequently, 31.2% patients had an implant removed, 6.9% had an implant replaced, 3.6% underwent autologous salvage, and 20.7% discontinued further reconstruction. Patients with a postoperative infection were significantly associated with increased incidence rate of total reoperations (IRR, 3.11; 95% CI, 2.92-3.31; P < 0.001) and total hospital length of stay (IRR, 1.55; 95% CI, 1.48-1.63; P < 0.001). Postoperative infections were associated with significantly increased odds of abandoning reconstruction (OR, 2.92; 95% CI, 0.081-0.11; P < 0.001).

Conclusions

Unplanned reoperations impact patients and healthcare systems. This national, claims-level study shows that post-IBR infection was associated with a 3.11× and 1.55× increase in the incidence rate of unplanned reoperations and length of stay. Post-IBR infection was associated with 2.92× increased odds of abandoning further reconstruction after implant removal.

The Partner Perspective on Autologous and Implant-Based Breast Reconstruction

INTRODUCTION

Partner involvement in the decision-making process concerning breast reconstruction (BR) after a breast cancer diagnosis may be very supportive for the patient. So far, no study evaluates partner satisfaction with the outcome after BR and the relationship to patient satisfaction. The aim of this study was to assess and compare partner satisfaction of BR with autologous tissue (ABR) and prosthetic implants (IBR), respectively, and compare it to patient-reported outcomes.

PATIENTS AND METHODS

All patients undergoing ABR and IBR between January 2014 and December 2020 were asked to participate with their partners. Patient and partner satisfaction with breast reconstruction, overall outcome as well as patient's perceived and self-reported psychosocial well-being were evaluated using the Breast-Q and a modified partner questionnaire, respectively.

RESULTS

Fifty-three couples participated (IBR: n=30, ABR: n = 23). Patient and partner satisfaction with breast (r = 0.552), outcome (r = 0.465) as well as patient's perceived and self-report psychosocial well-being (r = 0.495) were highly correlated with partners scoring significantly higher (p<0.001). In terms of partner satisfaction, both reconstructive procedures achieved satisfactory results. ABR scored higher in terms of softness of breast and how natural the breast feels to touch whereas IBR was rated superior evaluating the breast size.

CONCLUSION

Both reconstructive procedures achieve satisfactory results in terms partner satisfaction whereas patient's psychosocial well-being was highly overestimated by their partners. Hence, partner inclusion in the regular psycho-oncological support might further sensitize them of the high psychological burden of a breast cancer diagnosis and therefore stabilize patients private support system.

LEVEL OF EVIDENCE III

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 .

Beauty Is in the Eye of the Beholder: Factors Influencing Disparity in Perceptions of Breast Reconstruction Aesthetic Outcomes

BACKGROUND

Patient-reported outcomes are the primary measurement of breast reconstruction success, but results may be affected by nontechnical factors such as socioemotional determinants. Third-party observers provide an independent assessment of aesthetic outcomes. Factors associated with disparity between patient and observer perceptions of outcomes are not well understood.

METHODS

One hundred forty-seven patients underwent breast reconstruction at the authors' institution between 2009 and 2011, completed the BREAST-Q, and had photographs graded by a diverse panel using the Validated Breast Aesthetic Scale. Patient satisfaction with breasts scores that aligned with observer scores were categorized as group 2; patient satisfaction that exceeded observer scores were group 1; and those lower than observer scores were group 3. Statistical analysis was performed using SPSS, with values of p < 0.05 considered statistically significant.

RESULTS

Twenty-eight patients (19 percent) were categorized as group 1, 93 (63 percent) in group 2, and 26 (18 percent) in group 3. Median overall appearance was highest in group 3 (median, 4.0; interquartile range, 4 to 4) and lowest in group 1 (median, 3.0; interquartile range, 2 to 3) ( p < 0.001). Psychosocial, sexual, and physical well-being were significantly associated with disparity (group 1 or 3 status) ( p < 0.01). Satisfaction with outcomes, nipples, abdomen, and breasts were significantly associated with disparity. Factors not significantly associated with disparity include age, body mass index, autologous or implant-based, adjuvant therapies, and timing of reconstruction.

CONCLUSIONS

Incongruously high patient satisfaction with breast reconstruction aesthetics relative to third-party perception of aesthetic outcomes is associated with high quality-of-life scores. Incongruously low patient satisfaction with breast cosmesis compared with higher third-party perceptions was associated with low quality-of-life scores.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

The effect of cosmetic surgery on mental self-image and life satisfaction in women undergoing breast augmentation: An intermediate role of evaluating the surgery as one of the most important life events

AIM

To estimate changes in self-perception and satisfaction in women undegoing breast augmentation surgery (BAS).

METHODS

Using a quasi-experimental questionnaire study design, we enrolled a cohort of BAS women treated at a private clinic during a 5-year interval. The primary predictor variable was treatment (before/after). The main outcome variables included effect of considering breast augmentation as one of the most important life events on self-image (BAOMILE), and subjective evaluation of physical appearance and life satisfaction. Other study variables were demographic data. The Mann-Whitney and the Wilcoxon signed-rank tests were used to compare the outcomes between before and after the surgery. The Spearman rank correlation and the Pearson chi-squared test were computed to analyze the relationships among variables.

RESULTS

The sample consisted of 53 subjects (52.3% married; 40.9% from medium-sized towns) with a mean age of 33.2 ± 6.4 years (range, 21-46). Life satisfaction was significantly increased after BAS in the whole cohort (preop., 7.83 vs. postop., 8.42; P = .003; 95% CI, -0.95 to -0.22) as well as in the BAOMILE subgroup (preop., 7.87 vs. postop., 8.56; P = .011; 95% CI, -1.20 to -0.17). Within the BAOMILE subgroup, there was a positive correlation between the appearance assessment and the number of positive traits before surgery (ρ = 0.63; P = .002; 95% CI, 0.27-0.83) and life satisfaction after surgery (ρ = 0.480; P = .03; 95% CI, 0.06-0.74).

CONCLUSIONS

The results of this study suggest that BAS improves self-perception and life satisfaction of the patients. The psychologist's role in understating patient's motivation for cosmetic surgery and the revision of their attitudes towards expected effects require further investigations.

Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Effects of Reconstruction Timing

BACKGROUND

Without reconstruction, mastectomy alone can produce significant detrimental effects on health-related quality of life. The magnitude of quality-of-life benefits following breast reconstruction may be unique based on timing of reconstruction. Facilitated by the BREAST-Q questionnaire, characterization of how reconstruction timing differentially affects patient-reported quality of life is essential for improved evidence-based clinical practice.

METHODS

Consecutive DIEP flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two different time intervals postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision/symmetry procedures, respectively. Postoperative flap and donor-site complications were recorded prospectively. Stratified by timing (immediate versus delayed) of reconstruction, preoperative clinical data, operative morbidity, and BREAST-Q scores were compared at all time points.

RESULTS

Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Collectively, breast satisfaction, psychosocial well-being, and sexual well-being scores significantly (p < 0.001) increased postoperatively versus baseline. Chest and abdominal physical well-being scores returned to baseline levels by postoperative time point B. Preoperatively, patients undergoing delayed breast reconstruction reported significantly (p < 0.05) lower breast satisfaction, psychosocial well-being, and sexual well-being scores compared to immediate reconstruction patients. Postoperatively, delayed and immediate reconstruction patients reported similar quality-of-life scores. Outcome satisfaction and flap and donor-site morbidity were similar between groups irrespective of timing of reconstruction.

CONCLUSIONS

In this prospective study, patient-reported outcomes demonstrate significant improvements in breast satisfaction, psychosocial well-being, and sexual well-being among patients following DIEP flap reconstruction. Moreover, preoperative differences in quality-of-life scores among delayed/immediate reconstruction patients were eliminated postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Understanding Preoperative Breast Satisfaction among Patients Undergoing Mastectomy and Immediate Reconstruction: BREAST-Q Insights

BACKGROUND

This study aims to present normative values for satisfaction with breasts among preoperative breast reconstruction patients as assessed using the BREAST-Q instrument and to delineate factors associated with preoperative breast satisfaction.

METHODS

A retrospective analysis of prospectively collected data was performed examining women undergoing postmastectomy breast reconstruction at a tertiary care center who preoperatively completed the BREAST-Q from 2010 to 2017. Because breast satisfaction scores were nonnormally distributed, scores were categorized into quartiles for analysis. Patient- and treatment-level variables were tested in a multivariable ordinal logistic regression model as predictors of breast satisfaction. Preoperative satisfaction was also tested for association with choice of reconstructive modality.

RESULTS

Among 1306 postmastectomy reconstruction patients included in the study, mean preoperative Satisfaction with Breasts score was 61.8 ± 21.5 and the median score was 58.0 (interquartile range, 48 to 70). Factors associated with significantly lower preoperative satisfaction included history of psychiatric diagnosis, preoperative radiotherapy, marital status (married), and higher body mass index. Factors associated with significantly higher scores were malignancy (localized tumor), medium bra size (B to C cup), and self-identification as black. Preoperative breast satisfaction was lower among patients who elected autologous reconstruction than among those with implant reconstruction (p < 0.001).

CONCLUSIONS

Preoperative breast satisfaction is influenced by multiple factors. Understanding these factors may improve preoperative counseling and expectation management for patients who undergo postmastectomy breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Differences between Breast Cancer Reconstruction and Institutionally Established Normative Data Using the BREAST-Q Reconstruction Module: A Comparative Study

BACKGROUND

Evidence is limited for BREAST-Q scores in women without breast cancer or breast surgery to establish baseline values for clinical interpretation. The primary aim of this study was to compare differences in breast satisfaction and quality of life in women without breast cancer and without breast surgery to patients undergoing breast reconstruction using the BREAST-Q.

METHODS

The authors performed a single-center, patient-reported outcomes comparative study. A sample of 300 women attending gynecology appointments completed a study-specific demographics form and preoperative BREAST-Q reconstruction module. Eligible women had no history of breast cancer or breast surgery and were not currently pregnant (control group). The authors compared prospectively collected control group data to demographics and preoperative and 12-month postoperative BREAST-Q scores in 300 breast reconstruction patients, retrospectively selected from a prospectively collected registry.

RESULTS

Control group BREAST-Q scores were higher in Satisfaction with Breasts (mean, 59.3 versus 55.3; p < 0.042) and Physical Well-being Chest scores (mean, 84.1 versus 78.8; p < 0.001), and lower for Physical Well-being Abdomen scores (mean, 81.9 versus 88.7; p < 0.001) when compared to breast reconstruction patients' preoperative scores. When compared with breast reconstruction patients' 12-month postoperative scores, control group scores were lower in Satisfaction with Breasts (mean, 59.3 versus 65.5; p < 0.002) and Psychosocial Well-being (mean, 69.5 versus 76.2; p < 0.001) and higher in Physical Well-being Chest (mean, 84.1 versus 78.2; p < 0.001).

CONCLUSIONS

The authors found differences in preoperative and 12-month postoperative BREAST-Q scores between breast reconstruction patients and a comparable control population. Establishing normative BREAST-Q data could serve as an important baseline for breast outcomes research and better understanding of patients' ability to recover quality of life following reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Establishing Institution-Specific Normative Data for the BREAST-Q Reconstruction Module: A Prospective Study

BACKGROUND

Breast satisfaction in general female populations is relatively unknown and prior research populations do not reflect our community.

OBJECTIVES

We sought to assess breast satisfaction in a cohort of female participants utilizing the BREAST-Q and determine the impact of participant-related factors.

METHODS

Females with no history of breast cancer or breast surgery attending gynecology appointments completed preoperative BREAST-Q reconstruction modules and demographic forms in this prospective, single-center, patient-reported outcomes study. We also assessed participant-related factors capable of influencing BREAST-Q scores.

RESULTS

Three hundred females were included. Increasing body mass index had significant associations with lower Satisfaction with Breasts and Psychosocial Well-being scores. Increasing age was associated with significantly lower Sexual Well-being scores. African Americans had significantly higher scores for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being compared with Caucasians. Bra cup sizes A and C were associated with significantly higher Psychosocial Well-being scores than other sizes. Bra cup sizes A, B, and C were associated with significantly higher Sexual Well-being and Physical Well-being: Chest scores than larger sizes. Bra cup sizes B and C were associated with significantly higher Physical Well-being: Abdomen scores than size DD. Bra cup size A was associated with significantly higher Satisfaction with Breasts scores than sizes DD and >DD. Bra cup size C was associated with significantly higher Satisfaction with Breasts scores than larger sizes.

CONCLUSIONS

Body mass index, age, race, and bra cup sizes significantly impact BREAST-Q scores in our population. Determining normative BREAST-Q scores in female populations could represent important baselines for breast outcomes research.

Level of Evidence: 2.

Outcomes of immediate versus delayed breast reconstruction: Results of a multicenter prospective study

BACKGROUND

Previous studies suggest that immediate reconstruction following mastectomy produces superior results over delayed procedures. However, for medical or oncological reasons, some patients may be poor candidates for immediate reconstruction. We compared complications and patient-reported outcomes between immediate and delayed breast reconstructions in a prospective, multicenter study.

METHODS

1957 patients (1806 immediate, 151 delayed) met eligibility criteria. Demographic data, major complications, infections, and reconstructive failure rates were evaluated. Patient-reported outcomes were assessed with BREAST-Q, PROMIS, and EORTC QLQ-BR23 surveys, pre- and two years post-operatively. Subscale scores were compared across cohorts using mixed-effects regression models, controlling for patient characteristics and hospitals.

FINDINGS

Complete data were available in 1639 immediate and 147 delayed reconstruction patients. There were significant baseline differences between immediate and delayed cohorts in age, BMI, prevalence of diabetes, lymph node management, use of radiation, and chemotherapy. Controlling for clinical covariates, the delayed group had lower odds of any (OR 0.38, p < 0.001) and major (OR 0.52, p = 0.016) complications, compared with immediate patients. Furthermore, delayed reconstruction was associated with a significantly lower failure rates (6% vs. 1.3%, p = 0.032). However, multivariate analyses found no significant differences in patient satisfaction or in psychosocial, sexual, or physical well-being at two years.

CONCLUSIONS

Compared with immediate techniques, delayed reconstruction following mastectomy was associated with lower rates of overall and major complication, while providing equivalent patient satisfaction and quality of life benefits. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delaying reconstruction does not appear to compromise clinical or patient-reported outcomes.

Oncologic Outcomes after Immediate Breast Reconstruction Following Total Mastectomy in Patients with Breast Cancer: A Matched Case-Control Study

Purpose

The use of immediate breast reconstruction (IBR) following total mastectomy (TM) has increased markedly in patients with breast cancer. As the indications for IBR have been broadened and more breast-conserving surgery-eligible patients are undergoing IBR, comparing the oncologic safety between TM only and IBR following TM becomes more difficult. This study aimed to analyze the oncologic outcomes between TM only and IBR following TM via a matched case-control methodology.

Methods

A retrospective review was conducted to identify all patients who underwent TM between 2008 and 2014. We excluded patients who underwent neoadjuvant chemotherapy, including palliative chemotherapy, and had a follow-up duration <12 months, inflammatory breast cancer, or incomplete data. We divided the remaining patients into two groups: those who underwent TM only (control group) and those who underwent IBR following TM (study group). The groups were propensity score-matched. Matched variables included age, pathologic stage, estrogen or progesterone receptor status, human epidermal growth factor receptor 2 status, and year of operation.

Results

After matching, 878 patients were enrolled in the control group and 580 patients in the study group. The median follow-up duration was 43.4 months (range, 11–100 months) for the control group and 41.3 months (range, 12–100 months) for the study group (p=1.000). The mean age was 47.3±8.46 years for the control group and 43.9±7.14 years for the study group (p>0.050). Matching was considered successful for the matching variables and other factors, such as family history, histology, multiplicity, and lymphovascular invasion. There were no significant differences in overall survival (log-rank p=0.454), disease-free survival (log-rank p=0.186), local recurrence-free survival (log-rank p=0.114), or distant metastasis-free survival rates (logrank p=0.537) between the two groups.

Conclusion

Our results suggest that IBR following TM is a feasible treatment option for patients with breast cancer.