A prospective study of psychosocial and psychodynamic patients' reactions to breast reconstruction

Patient-Reported Outcomes Following Breast Reconstruction Surgery and Therapeutic Mammoplasty: Prospective Evaluation 1 Year Post-Surgery with BREAST-Q Questionnaire

Breast Cancer (BC) treatment leads to mutilation and destruction of breast shape with negative effects on body image and self-esteem.One of the main goals of reconstructive and oncoplastic breast surgery is to satisfy patients and improve their quality of life (QoL).Therefore, it is important to assess the patient experience post-surgery by means of patient-reported outcome measures (PROMs) that focus on the patient's perception of the surgery and surgical care, as well as psychosocial well-being and physical functioning. The objective of the current study was to identify predictors of patient satisfaction such as breast appearance including implant type in a selective sample of women who underwent breast reconstruction surgery using implants. Participants in this prospective study were women, (age 26-75 years) that were newly diagnosed with breast carcinoma. All consecutive patients who underwent breast reconstruction between January 2013 and October 2014 were asked to complete the BREAST-Q questionnaire 1 year after surgery. 120 patients underwent unilateral breast reconstruction using implant. While 38 patients underwent reconstruction with opposite breast reduction symmertization, 27 patients underwent therapeutic mammoplasty. The response rate for BREAST-Q questionnaire completion was 98 % with 147 out of 150 study participants completed the questionnaire. From the data collected from 147 patients, the responses could be distributed into 4 distinct groups based on the reconstruction outcomes namely "very much satisfied" (93 %) or "definitely and mostly satisfied" (94 %) or "satisfied" with the outcome (88 %) or "definitely agree on having reconstruction rather than the alternative of having no breast "(91 %).The results showed significant improvement in all four areas that were evaluated after surgery namely satisfaction with the appearance of the breasts, psychosocial, sexual and physical well-being. While the reconstruction surgery had an overall positive impact on quality of life it was observed that in patients that did not undergo breast reconstruction psychological issues related to sexuality were observed. Many newly diagnosed BC patients do not opt for these new surgical procedures due to psychological trauma or lack of information. Based on these observations, we propose that Breast Cancer Management protocols should also include additional counselling support for the newly diagnosed BC patients on the option of breast reconstruction along with conventional medical treatment counselling by the Oncosurgeon.

Circumvertical mastectomy incision: refinement in the surgical scar of implant-based breast reconstruction

Different surgical incisions have been proposed for skin-sparing mastectomy in an attempt to better disguise the remaining scar. These techniques are more hidden than the Stewart incision but can still leave scars in visible places and can restrict the natural shape of the upper pole. They can also add complexity and time to the mastectomy, requiring extensive retraction that could damage the salvaged skin flaps to perform an adequate mastectomy. We present a circumvertical mastectomy incision technique, which limits the mastectomy scar to the inferior pole, provides natural lateral contour, superior pole fullness, and contributes to a more youthful breast projection. Between November 2011 and November 2012, 51 women underwent circumvertical AlloDerm/tissue expansion reconstruction at our institution by a single surgeon. The reconstruction was bilateral in 30 patients and unilateral in 21 patients for a total of 81 breasts. Of the 81 reconstructed breasts, 5 patients went on to require a latissimus dorsi flap for definitive reconstruction and 3 failed breast reconstruction for a completion rate of 96%. The goal of creating breast reconstruction results comparable to those of cosmetic breast surgery is becoming a reality. Circumvertical incision is a technique that can prevent visible upper hemispheric breast scarring, limit upper pole constriction by scar placement, and preserves or restores breast projection. Following the principles of aesthetic breast surgery and repositioning the mastectomy scar, one can reconstruct a breast with a more disguised scar, which can be hidden from the patient's downward gaze.

Satisfaction with outcome and attitudes towards scarring among women undergoing breast reconstructive surgery

OBJECTIVE

Surgical breast reconstruction following mastectomy often results in scarring not only to the breast but often to the donor-site area. However, few studies have been devoted to the potential effects of scarring among women who underwent breast reconstruction. The aim of the study was to explore these women's attitudes towards scarring.

METHOD

Fifteen women who had undergone Transversus Abdominis Myocutaneous (TRAM) flap breast reconstruction surgery (mean age 50 years) took part in a semi-structured qualitative interview. The interview examined their experiences of breast reconstruction surgery, post-surgical adjustment and the impact of scarring.

RESULTS

Scarring, particularly donor-site scarring, emerged as the main area of dissatisfaction with the breast reconstruction process. Expectations of the surgery and information provided prior to surgery were also found to relate to women' reports of overall satisfaction.

CONCLUSION

This study highlighted that satisfaction with breast reconstruction surgery included relief at not needing to wear prostheses and increased body confidence. However, some women reported unrealistic expectations regarding the outcomes of breast reconstruction surgery including extended recovery time and donor-site scarring.

PRACTICE IMPLICATIONS

Future patients may therefore benefit from a patient-centred evaluation of their information needs incorporating both their preferences for type and amount of information at each stage of treatment and recovery as well as their understanding and interpretation of the information given to them.

The psychological effect of mastectomy with or without breast reconstruction: a prospective, multicenter study

A multicenter, prospective study ( = 103) examined the psychological implications of women's decisions for or against breast reconstruction. Recognized measures of anxiety, depression, body image, and quality of life were completed before the operation, and 6 and 12 months later. A reduction in psychological distress over the year following the operation was evident in each surgical group (mastectomy alone or immediate or delayed reconstruction), indicating that reconstructive surgery can offer psychological benefits to some women; however, others report improved psychological functioning without this surgical procedure. In contrast to existing retrospective research, the prospective design enabled the process of adjustment during the first year after the operation to be examined. The results indicate that breast reconstruction is not a universal panacea for the emotional and psychological consequences of mastectomy. Women still reported feeling conscious of altered body image 1 year postoperatively, regardless of whether or not they had elected breast reconstruction. Health professionals should be careful of assuming that breast reconstruction necessarily confers psychological benefits compared with mastectomy alone.

Psychological aspects of breast reconstruction: a review of the literature

AIM

This paper critically examines the research literature relating to the psychological aspects of breast reconstruction. Particular attention is given to the role of specialist breast care nurses in supporting women faced with the decision of whether or not to opt for reconstructive surgery.

BACKGROUND

Breast reconstruction is intended to offer psychological benefits (e.g. improvements to quality of life, body image, anxiety and depression) to women treated by mastectomy following diagnosis of breast cancer.

METHODS

A literature search was carried out on the PSYCHINFO, MEDLINE and CINAHL databases using the terms "breast reconstruction", "mastectomy", "reconstructive surgery", "breast surgery", "breast implants", "transverse rectus adominis myocutaneous (TRAM) flap" and "Lat-dorsi". Further relevant articles were identified from the reference lists of papers detected by this literature search. Finally, proceedings of recent psychological and surgical meetings were scrutinized to identify any conference papers on this topic.

FINDINGS

A thorough search of the existing literature revealed a lack of theoretically based studies examining breast reconstruction in terms of relevant psychological constructs, especially in relation to coping and decision-making. This review highlights the methodological flaws with much of the existing research in this area, in particular the reliance upon retrospective designs and the inappropriate use of randomised controlled trials. Suggestions are given for further research in this topical area.

CONCLUSIONS

Existing research into the psychological aspects of breast reconstruction is limited and not sufficiently conclusive to inform changes to policy and the provision of care. More methodologically rigorous research is needed.