Patient Satisfaction with Breast Reconstruction during the Long-Term Survivorship Period

Emily S. Hu, MD; Andrea L. Pusic, MD; Jennifer F. Waljee, MD, MPH; Latoya Kuhn, MPH; Edwin G. Wilkins, MD; Amy K. Alderman, MD, MPH

INTRODUCTION: Understanding reconstructive outcomes in the breast cancer survivorship period has important implications for patient counseling and shared-medical decision-making. Unfortunately, long-term data on patient-reported satisfaction with breast reconstruction are limited. The previous Michigan Breast Reconstruction Outcomes Study (MBROS) on patient satisfaction at one year post-breast reconstruction showed that patients who underwent autogenous reconstruction were significantly more satisfied, as compared to the expander/implant population.1 However, recent follow-up of these same patients two years post-reconstruction revealed that the type of technique had no significant effect on general patient satisfaction.2 Expander/implant and autogenous tissue breast reconstructions have different aging processes, and the time when these processes stabilize is unclear. Few studies have adequately assessed long-term patient-reported satisfaction outcomes in the breast reconstruction population.3-10 Our goal was to evaluate long-term patient satisfaction with the processes of care, the decision-making process, and final physical appearance between implant and autogenous tissue techniques.

METHODS: A cross-sectional self-administered questionnaire was given to University of Michigan patients who were diagnosed with breast cancer between 1977 and 2006 and had had breast reconstruction (response rate 70%). The sample included post-mastectomy patients with expander/implant (E/I) (N=109) and free and pedicle transverse rectus abdominus flap (TRAM) reconstructions (N=109). Each group was stratified into three post-reconstructive time periods: short-term (≤5 years), intermediate (6-8 years), and long-term (>8 years). Validated satisfaction items were scored on a 5-point Likert scale ranging from very dissatisfied to very satisfied. Responses were dichotomized into “satisfied” versus “not satisfied” using the following criteria: scores of “very satisfied” or “satisfied” (a 4 or 5 on the 5-point Likert scale) for all questions were considered “satisfied;” all other scores were considered “not satisfied.” Chi-square was used for the analyses.

RESULTS: Mean follow-up time after reconstruction was 6.5 years (range 1-18 years). Procedure type had no effect on outcomes in the short-term. However, in the intermediate and long-term, the type of reconstructive procedure considerably impacted patient satisfaction. At 6 to 8 years post-reconstruction, TRAM patients, compared to E/I patients, were significantly more satisfied with the reconstructed breast appearance (p<.01), size (p<.01), shape (p<.03), softness (p<.01) and projection (p<.01). In addition, patients with TRAM, compared to E/I procedures, were significantly more satisfied with the process of reconstruction and had greater decisional satisfaction. Patients with TRAM, compared to E/I procedures, felt more strongly that their outcome matched their expectations (p<.01), that they would recommend their type of reconstruction to others (p<.03), that they had a positive experience p (<.03), and that they did not need more surgery to improve the appearance of their breasts (p<.04). Patients with TRAM compared to E/I procedures also reported greater satisfaction with surgical counseling in regards to postoperative appearance and pain. All of these differences remained significant at > 8 years post-reconstruction.

Univariate Analysis of Patients’ Satisfaction with Expander/Implant and TRAM Breast Reconstruction
Outcomes / Expander
%† / TRAM
% / P value#
Satisfaction with breast appearance
≤ 5 years / 83 / 74 / .297
6 – 8 years / 60 / 85 / .010*
> 8 years / 45 / 80 / .010*
Satisfaction with the results of breast reconstruction
≤ 5 years / 86 / 74 / .168
6 – 8 years / 70 / 85 / .088
> 8 years / 35 / 87 / <.01*
Would recommend their type of reconstruction
≤ 5 years / 77 / 74 / .745
6 – 8 years / 73 / 71 / .860
8 years / 52 / 80 / .031*
Do not feel further surgery is needed to improve appearance
≤ 5 years / 65 / 53 / .279
6 – 8 years / 52 / 63 / .309
8 years / 23 / 52 / .036*
† Percent who scored positively on Likert scale (4 or 5)
# Pearson chi-square to test for differences between the women with and without breast reconstruction
* Significant result with p-value <.05

CONCLUSION: At greater than 8 years after breast reconstruction, women with TRAM, compared to expander/implant procedures, appear to have significantly greater aesthetic satisfaction and decisional satisfaction, as well as more satisfaction with the process of reconstruction. These long-term data have important implications for women’s health in the cancer survivorship period and will be useful for women navigating the complex decision-making process of breast reconstruction.

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