QUALITY OF LIFE BEFORE RECONSTRUCTIVE BREAST SURGERY:A PREOPERATIVE COMPARISON OF PATIENTS WITH IMMEDIATE,DELAYED, AND MAJOR REVISION RECONSTRUCTION

GEDGE D. ROSSON, M.D.,1* SACHIN M. SHRIDHARANI, M.D.,1 MICHAEL MAGARAKIS, M.D.,1 MICHELE A. MANAHAN, M.D.,1

BASAK BASDAG, M.H.S.,1,2 MARTA M. GILSON, Ph.D.,2 and ANDREA L. PUSIC, M.D.3

Background: Women undergo breast reconstruction at different time-points in their cancer care; knowing patients’ preoperative quality oflife (QoL) is critical in the overall care of the patient with breast cancer. Our objective was to describe presurgical QoL among womenundergoing immediate, delayed, or major revision breast reconstructive surgery at our institution. Methods: From March 2008 to February2009, we administered preoperative BREAST-Q questionnaires to women who presented to our institution for breast reconstruction. Univar-iate and multivariate analyses were performed to compare patient cohorts across multiple QoL domains including body image, physicalwell-being, psychosocial well-being, and sexual well-being. Results: Of the 231 patients who presented for preoperative consultation, 176returned the questionnaire (response rate 76%; 117 from the immediate, 21 from the delayed, and 32 from the major revision reconstruc-tion groups, plus 6 mixed or unknown). The three groups differed significantly (P < 0.05) across four of the six domains: body image (sat-isfaction with breasts), psychosocial well-being, sexual well-being, and physical well-being of the chest and upper body. The immediatereconstruction group had higher (better) scores than the delayed reconstruction group, which had higher (better) scores than the major re-vision group. Conclusion: These data suggest that women presenting for breast reconstruction at different stages of reconstruction havedifferent baseline QoL. Such data may help us better understand patient selection, education, and expectations, and may lead to improvedpatient–surgeon communication. VVC 2013 Wiley Periodicals, Inc. Microsurgery 33:253–258, 2013.

Breast cancer is the second leading cause of cancer

deaths among women in the United States. The American

Cancer Society estimated that in 2011, there would be an

estimated 230,480 new cases of invasive breast cancer as

well as 39,520 deaths.1 In addition to breast conserving

treatments, mastectomy can be another important and de-

finitive treatment option for certain patients. However,

mastectomy is often associated with substantial psycho-

logical, social, and sexual sequelae, as well as significant

body image distortion.2–5 Modern breast reconstruction

surgery offers a wide range of options with the potential

to significantly improve quality of life (QoL) for breast

cancer survivors.3,6–9

Although studies in the surgical literature have exten-

sively evaluated many options for breast reconstruction, a

limited number of studies have addressed the timing of

reconstruction with respect to QoL. The timing of breast

reconstruction after mastectomy is determined through a

combination of patient-related factors, including patient

preference and the likelihood that the patient will require

post-mastectomy radiation therapy.10,11 Typically, breast

reconstruction can occur at the time of mastectomy

(termed ‘‘immediate’’ breast reconstruction) or at a laterdate to accommodate radiation, chemotherapy, or patientpreference (‘‘delayed’’ reconstruction). In certain cases,revision reconstruction can be performed on an alreadyreconstructed breast to try to correct problems with theprevious surgery, such as implant capsular contracture,abnormal scarring, and dissatisfaction with the recon-structed breast’s appearance. These cases are designatedas breast reconstruction ‘‘major revision’’ operations.

In general, breast reconstruction may reduce the dis-

tress of mastectomy,3,12–15 and several studies have

shown that patients with delayed reconstruction are more

likely to be distraught and less satisfied than patients

with immediate reconstruction.3,14,16 The higher level of

distress in patients in the delayed reconstruction group is

a likely consequence of these women dealing with the

complete absence of their breast(s) and feeling self-con-

scious about having a ‘‘deformity.’’ Patient perceptions ofthe impact of disease and surgical intervention on physi-cal, psychosocial, and sexual well-being have become anintegral part of the surgical algorithm. Clinical researchendeavors have increasingly focused on determining thelevel of satisfaction and the QoL of different patientgroups.

1Department of Plastic Surgery, The Johns Hopkins University School ofMedicine, Baltimore, MD2The Center for Surgical Trials & Outcomes Research, the Department ofSurgery, The Johns Hopkins University School of Medicine, Baltimore, MD3The Plastic and Reconstructive Surgical Service, the Department of Sur-gery, Memorial Sloan Kettering Cancer Center, New York, NY

The BREAST-Q is jointly owned by Memorial Sloan-Kettering Cancer Centerand the University of British Columbia. Dr. Pusic is a co-developer of theBREAST-Q and, as such, receives a share of any license revenues based onthe inventor sharing policies of these two institutions.

Presented at the 26th Annual Meeting of the American Society of Recon-structive Microsurgery, Boca Raton, Florida, January 10, 2010. Poster pre-sentation at the 96th Annual Clinical Congress of the American College ofSurgeons, Washington, DC, October 6, 2010.

Grant sponsor: Safeway Foundation; Grant sponsor: Sidney Kimmel Compre-hensive Cancer Center; Johns Hopkins Medical Institutions; Baltimore, Maryland

*Correspondence to: Gedge D. Rosson, MD, Director of Breast Reconstruc-tion, Department of Plastic Surgery, The Johns Hopkins Hospital OutpatientCenter, 601 N. Caroline St., McElderry 8161, Baltimore, Maryland 21287.E-mail: gedge@jhmi.edu.

Received 3 June 2012; Revision accepted 16 November 2012; Accepted26 November 2012

Published online 17 February 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.22081

VVC 2013 Wiley Periodicals, Inc.

The BREAST-Q is a new patient-reported outcome

measure that evaluates patients’ experiences with recon-

structive breast surgery.8,17 The BREAST-Q was carefully

developed and validated in accordance with internationally

recognized guidelines.17 Specifically, the BREAST-Q asks

patients to report their views and feelings across multiple

domains including satisfaction with breasts and abdomen,

psychosocial well-being, physical well-being (chest and ab-

domen), and sexual well-being. Although numerous studies

have investigated patient satisfaction and QoL after breast

reconstruction, to the authors’ knowledge, only one has

examined QoL parameters before reconstructive surgery

and compared them among patients in various presentation

cohorts.18 The goal of this study was to use the six domains

of the BREAST-Q to assess the presurgical QoL and patient

satisfaction of women seeking immediate, delayed, or

major revision breast reconstruction.

METHODS

During a 1-year period from March 2008 to February

2009, the preoperative BREAST-Q, a self-administered,

validated, breast reconstruction-specific questionnaire,

was routinely given to all patients during the initial con-

sultation for breast reconstruction surgery at our institu-

tion. The conceptual framework and scale structure of the

BREAST-Q address both QoL (psychosocial well-being;

sexual well-being; physical well-being: chest and upper

body; and physical well-being: abdomen) and patient sat-

isfaction (body image: satisfaction with breasts; and body

image: satisfaction with abdomen).15 The BREAST-Q

was developed with strict adherence to internationally

accepted guidelines and all scales fulfill traditional psy-

chometric criteria (including: Person Separation Indices:

0.76–0.96; Cronbach’s alphas: 0.81–0.97; and test–retest

reproducibility: 0.73–0.96).17

We investigated three groups of patients. The first

group included patients diagnosed with breast cancer and

interested in immediate reconstruction at the time of their

mastectomy (immediate group). The second group

included patients that had already undergone a mastec-

tomy for breast cancer and were now interested in breast

reconstruction (delayed group). The third group included

patients that had already undergone a breast reconstruction

at various time-points in the past but were not satisfied with

the results. These patients were interested in revision recon-

struction to improve their breast contour and/or symmetry

(major revision group). All women who presented to our

breast center for potential mastectomy and reconstruction,

prior mastectomy desiring delayed reconstruction, or prior

mastectomy with prior reconstruction were included, as the

BREAST-Q was given to all new patients as part of routine

clinical work-flow. Patients were only excluded if they pre-

sented with desire for lumpectomy with oncoplasty recon-

struction or prior lumpectomy and desire for revision sur-

gery (i.e., non-mastectomy).

Data analyses focused on detecting differences

between the three patient groups with respect to the

BREAST-Q in four QoL domains: psychosocial well-being;

sexual well-being; body image: satisfaction with breasts;

and physical well-being: chest and upper body. Raw scores

were recorded for each question. BREAST-Q question val-

ues were transformed and scored using QScore, a statistical

program developed specifically for the BREAST-Q by

RUMM laboratories (Perth, Australia). The BREAST-Q

transformed and scored values were used for analysis.

Patients who did not answer at least half of the ques-

tions for a specific subscale were removed from analysis

of that subscale. Univariate nonparametric statistical anal-

yses (Kruskal–Wallis test) were performed to compare

the immediate, delayed, and major revision patient

groups’ age, body mass index (BMI), and QoL scores.

Statistical significance was set a priori at P < 0.05. Mul-

tiple regression analyses were used to determine if the

three groups’; (immediate, delayed, and major revision)

QoL scores differed while adjusting for age and BMI.

The Johns Hopkins Medicine Institutional Review

Board approved this study.

Table 1. Patient characteristics by reconstruction type (delayed, immediate, or major revision)

Immediate (N 5 117) Delayed (N 5 21) Major revision (N 5 32) Total (N 5 170) P valuea

Race

White 85 (73%) 18 (86%) 23 (72%) 126 (74%)

Black 16 (14%) 2 (10%) 7 (22%) 25 (15%) 0.7958 F

Asian 6 (5%) 0 0 6 (4%)

Hispanic 4 (3%) 1 (5%) 1 (3%) 6 (4%)

Other 6 (5%) 0 1 (3%) 7 (4%)

Age in years

Mean 6 SD 49.5 6 9.6 50.7 6 8.1 53 6 10.0 50.3 6 9.5 0.2330 KW

Median [IQR] 49 [42–55] 52 [45–56] 49.5 [45.5–60] 49 [43-56]

BMI N 5116 N 5 21 N 5 31 N 5 168

Mean 6 SD 26.7 6 6.3 27.0 6 6.1 24.8 6 5.4 26.4 6 6.1 0.2622 KW

Median [IQR] 25.2 [21.7–30.0] 25 [22.6–30.5] 22.9 [21.1–27.5] 25.0 [21.6–29.6]

Percents may not add up to 100% due to rounding.F, Fisher’s exact P-value; KW, Kruskal–Wallis P-value.

254 Rosson et al.

Microsurgery DOI 10.1002/micr

RESULTS

Of the 231 patients who presented for consultation

during this time period, 176 returned the questionnaire

(response rate 76%). Five questionnaires were excluded

because the patients did not fit exclusively into any one

of our three groups. In addition, one questionnaire was

excluded because the patient answered less than half the

questions for every ‘‘subscale’’ in the BREAST-Q. There

were a total of 170 completed questionnaires: 117 were in

the immediate group, 21 in the delayed group, and 32 in

the major revision group. Table 1 presents the patient

characteristics. Mean patient age was 50 years (range: 29–

84 years). All patients had pathology-proven stage 0–III

breast carcinoma. There were no patients with stage IV

breast carcinoma. BMI was available for 168 patients: 2

(1%) were underweight (BMI < 18.5), 82 (49%) normal

weight (BMI: 18.5–24.9), 44 (26%) overweight (BMI:

25–29.9), and 40 (24%) obese (BMI � 30). Of the 40

obese patients, 21 were class I (BMI: 30–34.9), 11 were

class II (BMI: 35–39.9), and 8 were class III (BMI � 40).

On univariate analysis, the three patient groups had

statistically different scores on four subscales: body

image: satisfaction with breasts (P < 0.0001), psychoso-

cial well-being (P < 0.0001), sexual well-being (P <0.0001), and physical well-being: chest and upper body

(P 5 0.0011) (Table 2). The immediate group had

higher (better) scores than the delayed group, which in

turn had higher (better) scores than the major revision

group. Pairwise comparisons confirmed differences

between the immediate and delayed group and the im-

mediate and major revision group (respectively) for

three of the four subscales, (body image: satisfaction

with breasts (P < 0.0001, P < 0.0001), psychosocial

well-being (P 5 0.0002, P < 0.0001), sexual well-being

(P < 0.0001, P < 0.0001)). Pairwise comparisons of the

subscale physical well-being: chest and upper body sub-

scale were not statistically significant between the imme-

diate and delayed group (P 5 0.6875) but were signifi-

cantly different between the immediate and major revision

group (p50.0003). Pairwise comparisons between delayedand major revision groups were not statistically significant

except for the physical well-being: chest and upper body

subscale (P 5 0.0181). With respect to body image: satis-faction with abdomen, and physical well-being: abdomen

subscale scores, there was not a statistically significant dif-

ference between the three groups, but pairwise compari-sons showed major revision patients had significantlylower scores than the immediate group in the physicalwell-being: abdomen subscale (P 5 0.0238).

Multiple regression to adjust for age and BMI was

used to further examine differences between the three

patient groups for the 152 patients with complete data

(Table 3). For three of the subscales: body image: satis-

faction with breasts, psychosocial well-being, and sexual

Table

2.

Bre

ast-

Qsubsca

lescore

sby

reconst

ruction

type:

univ

ariate

analy

sis

Mean6

SD

Media

n[I

QR

]

Kru

skal–

Walli

sP

-valu

eIm

media

te(N

5117)

Dela

yed

(N5

21)

Majo

rre

vis

ion

(N5

32)

Tota

l(N

5170)

Body

image:

satisfa

ction

with

bre

asts

N5

117

N5

21

N5

32

N5

170

<0.0

001

59.2

66

20.2

138.0

56

13.4

635.3

46

22.3

652.1

46

22.5

1

58

[48-7

0]

38

[33-4

3]

33

[22-4

7]

53

[38

–63]

Body

image:

satisfa

ction

with

abdom

en

N5

113

N5

20

N5

30

N5

163

0.7

872

45.1

16

30.3

441.3

56

33.8

443.1

633.5

44.2

86

31.2

0

43

[43–61]

43

[0–61]

43

[0–61]

43

[0–61]

Psy

chosoci

alw

ell-

bein

gN

5116

N5

20

N5

32

N5

168

<0.0

001

69.1

36

17.1

954.4

56

14.5

950.1

96

18.4

863.7

76

18.8

9

67

[58–82]

51.5

[47–61.5

]51.5

[40.5

–62.0

]63

[52–75]

Sexualw

ell-

bein

gN

5106

N5

19

N5

31

N5

156

<0.0

001

59.0

76

17.0

640.5

36

15.8

031.2

66

19.7

751.2

86

20.9

2

60

[47–67]

37

[32–47]

34

[22–43]

51[3

8–63]

Physic

alw

ell-

bein

g:

chest

and

upper

body

N5

115

N5

21

N5

32

N5

168

0.0

011

77.2

36

15.5

976.3

86

13.4

963.3

86

18.1

074.4

96

16.6

7

81

[65–91]

71

[68–85]

68

[50–75.5

]74

[63–85]

Physic

alw

ell-

bein

g:

abdom

en

N5

115

N5

20

N5

32

N5

167

0.0

701

86.1

26

15.2

686.5

611.8

276.6

96

22.6

084.3

66

16.8

9

80

[80–100]

80

[80–100]

80

[65.5

–100]

80

[80–100]

Percents

maynotaddupto

100%

dueto

rounding.

QoL Measures Before Breast Reconstruction 255

Microsurgery DOI 10.1002/micr

well-being, both the delayed group (P < 0.0001, P 5

0.0004, and P < 0.0001, respectively) and the major revi-

sion group (P < 0.0001, P < 0.0001, and P < 0.0001,

respectively) were statistically significantly different from

the immediate group (reference group) while adjusting for

age and BMI. While adjusting for age and BMI, the physi-

cal well-being: chest and upper body subscale as well as the

physical well-being: abdomen subscale showed a signifi-

cant difference between the immediate and major revision

groups (P < 0.0001 and P 5 0.0112, respectively), but the

delayed group was not significantly different from the im-

mediate group (P 5 0.9863 and P 5 0.6755, respectively).

There were no statistically significant differences between

any of the groups with respect to body image: satisfaction

with abdomen subscale scores (P 5 0.6874 (delayed), P 5

0.4559 (major revision)).

DISCUSSION

Breast cancer is the second most common cancer in

women in the United States, and many women diagnosed

with this cancer may require (or choose) therapeutic mas-

tectomy.1 Currently in the United States, mastectomy

rates are increasing among patients with early-stage can-

cer. Contralateral prophylactic mastectomy rates are also

increasing. Although several factors have contributed to

these trends, perhaps the most important is the increased

use of skin-sparing mastectomy along with immediate or

delayed breast reconstruction surgery.19 Accordingly,

breast reconstruction is becoming an integral part of the

breast cancer care algorithm.

Women who undergo breast reconstruction may expe-

rience less psychological morbidity and may be more sat-

isfied with their surgical results compared to women who

receive mastectomy alone.14 Studies have tried to show a

correlation between the timing of reconstruction and

patient satisfaction. Multiple studies have reported imme-

diate breast reconstruction to be superior to delayed

reconstruction in overall aesthetics, psychological well-

being, and cost effectiveness.3,14,16,20–23 Only one such

study was a truly prospective randomized controlled

trial,21 and that study is thoroughly reviewed in a

Cochrane Review article.24

To the authors’ knowledge, however, only one study

has examined patients’ psychological state of mind and

QoL specifically prior to breast reconstruction using vali-

dated questionnaires,18 but unfortunately that study did

not use a breast reconstruction-specific validated ques-

tionnaire. Thus, the objective of this study was to quan-

tify potential baseline differences in QoL among women

presenting for reconstruction at different time points in

their cancer care using the BREAST-Q. Looking at the

timing of breast reconstruction with respect to QoL, we

note that women in the major revision group, when com-

pared to women in the delayed and immediate groups,

reported the lowest QoL. This clearly indicates the mag-

nitude of the effect that unsatisfactory breast reconstruc-

tion may have on patients’ psychological well-being. Spe-

cifically, ‘‘failed’’ breast reconstruction may place the

patients’ psychological ‘‘plateau’’ at a level lower than

that of patients who have had mastectomies without

reconstruction (delayed group). For surgeons who per-

form breast reconstruction, this presents an important

insight and highlights the importance of successful recon-

struction. In some cases, delayed reconstruction may be

advisable if the patient presents with potential risk factors

(e.g. smoking, obesity). In addition, patients should be

provided counsel regarding complications and their poten-

tial impact on QoL. It is hypothesized that adequate pre-

operative counseling could potentially prevent some of

the negative psychological sequelae of an unsatisfactory

outcome.

It is quite interesting that the one previous study that

investigated preoperative quality of life; Roth et al.,18

found patients presenting for immediate reconstruction

had lower QoL scores than those presenting for delayed

reconstruction, whereas our study found the opposite.

Although our study was focusing on the QoL scores

at presentation to our institution, prior to selecting any

surgical plan with us, it should be noted that these

patients were presenting to our institution for all types of

reconstructions, whether autologous or implant-based. We

primarily offer DIEP, SGAP, TUG autologous options,

and one-stage direct implant or two-stage expander-

implant alloplastic options.25,26 We did not use any

Becker-type implants during this time period (2008–

Table 3. Multiple regression coefficients (and P-values) of Breast-Q 2 subscale scores as a function of reconstruction type (delayed or

major revision; immediate is reference group): adjusting for age and BMI for 152 patients with complete data

Intercept (immediate) Delayed Major Revision Age BMI

Body image: satisfaction with breasts 107.86 (<0.0001) 220.30 (<0.0001) 225.67 (<0.0001) 20.30 (0.1029) 21.26 (<0.0001)

Body image: satisfaction with abdomen 118.87 (<0.0001) 22.93 (0.6874) 24.62 (0.4559) 20.55 (0.0528) 21.77 (<0.0001)

Psychosocial well-being 95.13 (<0.0001) 214.62 (0.0004) 221.26 (<0.0001) 20.08 (0.6032) 20.81 (0.0003)

Sexual well-being 85.70 (<0.0001) 218.26 (<0.0001) 228.34 (<0.0001) 20.10 (0.5327) 20.82 (0.0006)

Physical well-being: chest and upper body 79.87 (<0.0001) 0.07 (0.9863) 214.61 (<0.0001) 0.02 (0.9090) 20.14 (0.5251)

Physical well-being: abdomen 120.81 (<0.0001) 1.71 (0.6755) 28.93 (0.0112) 20.37 (0.0203) 20.64 (0.0045)

Each row of the table is a separate model.

256 Rosson et al.

Microsurgery DOI 10.1002/micr

2009). Typically, those patients with dissatisfaction with

or failure of prior implant-based reconstruction were often

presenting to us with a request for autologous reconstruc-

tion. Those patients with prior failed autologous reconstruc-

tion often had radiation, so they might need a second auto-

logous flap. Those patients presenting for delayed recon-

struction could choose either autologous or implant,

depending on their body habitus and radiation status. Those

patients presenting for immediate reconstruction often

chose a babysitter technique with placement of a tissue ex-

pander; however, immediate autologous reconstruction is

common for patients with early stage disease, small tumors

and no chance for post-mastectomy radiation therapy.

Limitations of our study include the manner in which

the patients were selected, incomplete response rate,

incomplete knowledge of which ‘‘major revision’’ patients

had a prior TRAM flap, and potential lack of statistical

power for certain subgroups. First, this study was not

designed prospectively; rather, the BREAST-Q is routinely

given as part of the clinical care of the patients at our insti-

tution. Furthermore, while our response rate was high, it is

clear that we were not able to capture all patients seen at

our institution. In addition, comments about abdominal sat-

isfaction with appearance and abdominal physical well-

being in the ‘‘major revision’’ patients may not be meaning-

ful without clearly linking this to whether or not a woman

has had a TRAM. The post-op breast-Q does not ask about

abdominal satisfaction if the patient undergoes TUG/

SGAP/Implant reconstructions (those questions are

skipped), so those pre-op data are then not used. For this

study, we simply included all data, as we did not know

which surgery the patients would undertake. These ques-

tionnaires were all filled out prior to the patient deciding on

their surgical plan at our institution. Finally, our study may

not have been adequately powered to detect difference, par-

ticularly given the limited number of patients in the delayed

reconstruction group (n 5 21). Since the time of this study,

we have implemented prospective collection of QoL data

throughout the breast reconstruction process to better

understand how these patient-reported outcomes may

change following surgery and over time.

In conclusion, these data suggest that women present-

ing for breast reconstruction at different stages in their

cancer care have different baseline QoL. The immediate

reconstruction group had higher (better) scores than the

delayed reconstruction group, which had higher (better)

scores than the major revision group. Understanding these

differences may improve communication between the sur-

geon and the patient.

ACKNOWLEDGMENTS

We thank Terri Carter, Department of Surgery, The

Johns Hopkins University, for her assistance with editing

this manuscript, and Raghunandan Venkat, MD, MPH,

Department of Surgery, The Johns Hopkins University,

for his assistance with some statistical analysis.

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