BREAST-Q Survey Research Articles

Patient-reported Outcomes following Implant Removal for Breast Implant Illness

PURPOSE: Current evidence has not linked breast implants to autoimmune or other systemic diseases; however, women continue to pursue explantation due to a heterogenous constellation of symptoms referred to as “breast implant illness” (BII). Although BII has no clear medical definition, pathophysiological explanation or diagnostic testing, a subset of patients report symptomatic improvement after explantation. Although several studies have attempted to clarify and better define this phenomenon, none have considered patient satisfaction and quality of life following implant removal. This study aims to assess patient reported satisfaction with the removal of implants through the use of the BREAST-Q. METHODS: Patients who underwent breast implant removal due to concerns for BII were asked to complete the augmentation BREAST-Q. Additionally, a survey was administered that queried 35 different BII-related symptoms and their response to implant removal. Questions specifically referencing the implants were removed because they were not applicable to this cohort. Consistent with scoring guidelines, missing data were replaced with the mean of remaining scores as long as 50% of questions were still completed. Outcomes in this cohort were compared with normative data for all modules this information was available for. Furthermore, satisfaction for patients who underwent explantation alone was compared with those who pursued explantation with cosmetic reconstruction. RESULTS: Of the 29 patients who underwent implant removal for BII, 16 patients (55.2%) completed the BREAST-Q and symptom survey. Mean age was 49.1 ± 10.8, and mean BMI was 25.1 ± 8. Interestingly, all patients were Whites. En bloc capsulectomy was requested by patients and performed in 100% of cases. The average time between augmentation and implant removal was 11.3 ± 6.2 months. Only 11 patients (68.8%) underwent implant removal and the other five underwent a cosmetic procedure (either autologous reconstruction or mastopexy) in addition to implant removal. Subjects report on average a total of 13.1 symptoms with brain fog, fatigue, chest discomfort, and anxiety being the most common. On average, symptoms of 14.9% of patients did not improve, those of 48.1% partially improved, and those of 37.0% were completely resolved. Compared with normative data, BII patients with implant removal alone had scores comparable to those of normative BREAST-Q data in the psychosocial well-being (P = 0.928), sexual well-being (P = 0.819), and satisfaction with breast modules (P = 0.529). They had lower scores for physical well-being (17 versus 86, P < 0.001). Upon subgroup analysis, implant removal with cosmetic procedures had a higher score in the satisfaction with breast module when compared with implant removal alone (76 versus 48, P = 0.022), though no other differences were seen. CONCLUSIONS: Concurrent with previous literature, patients with BII report some degree of symptomatic improvement after removal of implants. Patient-reported outcomes are similar to normative data in recently augmented patients. However, despite reported improvement of symptoms, physical well-being remains lower for patients with breast implant illness even after implant removal. Implant removal may be combined with cosmetic procedures to improve satisfaction with breasts. These results may aid in preoperative patient counseling.

Nipple-Sparing Mastectomy versus Skin-Sparing Mastectomy: Does Saving the Nipple Impact Short- and Long-Term Patient Satisfaction?

Nipple-sparing mastectomy (NSM) is an oncologically safe alternative to skin-sparing mastectomy (SSM). This study evaluated whether NSM patients were more satisfied than SSM patients in short- and long-term follow-up. Women who underwent NSM or SSM between 2009 and 2019 completed a postoperative BREAST-Q survey at least 1 year after surgery and patient characteristics were compared. Patient satisfaction at 1-5years and 6-10years after NSM and SSM were analyzed. Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10years prior to BREAST-Q survey completion. SSM patients were older, had higher body mass index (BMI), larger breast weight, and more hypertension than NSM patients, but oncologic treatments were similar between groups. BREAST-Q Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in NSM patients compared with SSM patients in the 1-5years cohort; however, scores attenuated in the 6-10years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5years cohort (p=0.056), but no different in the 6-10years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts. Women who are not candidates for NSM should be reassured that long-term qualify of life is not significantly different between SSM and NSM. Dissatisfaction with reconstructed breasts is linked with other factors (besides the nipple), which patients should be made aware of at the time of surgical decision making.

Donor Site Morbidity after Lumbar Artery Perforator Flap Breast Reconstruction.

The lumbar artery perforator flap is a second-choice flap in autologous breast reconstruction whenever a deep inferior epigastric artery perforator (DIEP) flap is not possible. Ideal candidates are pear-shaped women who do not have enough bulk on the abdomen or thighs. Patient-reported "satisfaction with breasts" is excellent but we were curious about the donor site morbidity. We performed a retrospective study of all lumbar flap breast reconstructions performed between 2010 and 2019. Patients were invited by e-mail and telephone to take part in a BREAST-Q survey. One hundred fifty-four flaps were performed in 110 patients. Sixty-three patients filled out the BREAST-Q questionnaire. The most frequently observed donor site complications are seroma (35.1%), dehiscence (8.4%), and hematoma (3.2%). Correction of the donor site scar was performed in 31.8% of patients, lipofilling of the donor flank in 5.2%, and liposuction of the contralateral flank in 18.3% of patients. Body mass index (BMI) was the only significant risk factor for donor site complications. Patient-reported "satisfaction with donor site appearance" was good but significantly lower for primary reconstructions compared with secondary and tertiary procedures. Flap weight significantly influences patient-reported "physical wellbeing of the donor site." Ninety-seven percent of patients would recommend the surgery to someone in a similar position and would do it all over. The lumbar artery perforator flap is a good alternative for breast reconstruction in selected patients. The donor site issues consist mainly of seromas, prolonged discomfort, and a scar that might be noticeable to others, but patient-reported satisfaction is very high.

Analysis of adolescent patient satisfaction and well-being following reduction mammaplasty using the BREAST-Q survey

Background: While functional breast reduction surgery has been shown to lead to increased quality of life in adult patients, the effects of this operation has not been investigated as thoroughly in adolescent patients. This study uses the BREAST-Q, a validated, surgery-specific questionnaire, to measure changes in adolescent patient well-being and satisfaction following reduction mammaplasty.Methods: All patients presenting for breast reduction consultation between February and December 2016 were asked to complete the BREAST-Q. Post-operative surveys were completed at three-month follow up. A matched control cohort was established using patients who completed a pre-operative survey and were deemed appropriate surgical candidates, but then were denied by insurance and did not undergo surgery.Results: Of the 28 adolescent patients who presented for breast reduction consultation, 15 met inclusion criteria; 11 patients underwent reduction mammaplasty, and 4 patients were included in the control cohort. When these groups were compared, statistically significant improvements were observed in all BREAST-Q categories except for sexual well-being. Overall patient satisfaction correlated most highly to satisfaction with information.Conclusions: This study examines quality of life outcomes in adolescent breast reduction patients using the BREAST-Q survey. Our findings indicate that adolescent patients have an improved quality of life following breast reduction, but that their satisfaction stems from different sources from those of adult patients. Further characterization of outcomes specific to young patients with surgically managed symptomatic macromastia will increase the practice of tailored, evidence-based medicine for adolescent patients.Level of Evidence: Treatment Study, Level III

Does timing of chemotherapy impact breast satisfaction after breast conservation therapy and mastectomy with immediate reconstruction?

589 Background: Receipt of chemotherapy is associated with decreased postoperative breast satisfaction, but whether timing as neoadjuvant (NAC) versus adjuvant (AC) affects this outcome after breast conservation therapy (BCT) and mastectomy with immediate reconstruction (M-IR) is unclear. Methods: We retrospectively identified patients treated with chemotherapy and breast surgery (BCT and M-IR), from 1/2017-12/2019, who completed ≥ 1 BREAST-Q survey through 12/2020. Mean (standard deviation [SD]) Q-scores for satisfaction with breasts (SATBR) were compared between NAC versus AC groups in BCT and M-IR cohorts, respectively. Higher Q-scores on a 0-100 scale indicate superior satisfaction. A minimum 4-point difference was considered clinically important. Chemotherapy timing and significant covariates on univariate analyses were entered in multivariable linear regressions of 1- and 2-year SABTR. Results: 640 patients had BCT and 602 had M-IR; 210 (33%) BCT patients and 294 (49%) M-IR patients had NAC. Compared with M-IR, SATBR was higher after BCT in both NAC and AC groups, at all postoperative timepoints (Table). Following BCT, SABTR was highest in both NAC and AC groups at 6 months and returned to baseline in the NAC group by year 3. In the M-IR cohort, 331 (55%) patients had radiation and 120 (20%) had complications requiring re-operation or hospitalization. Compared with baseline, mean (SD) Q-scores were substantially lower at 6 months but improved to near baseline at 3 years in both NAC and AC groups. On multivariable analysis, radiation was associated with decreased SABTR at 1 year (Beta, -11; 95% CI, -17, -5.0; p&lt;0.001) and 2 years (Beta, -12; 95% CI, -19, -5.5; p&lt;0.001), as were complications at 1 year (Beta, -6.1; 95% CI, -12, -0.34; p=0.038) but not 2 years (Beta, -5.5; 95% CI, -12, 0.92; p=0.09). After multivariable adjustment, NAC was not significantly associated with 1- or 2-year SABTR after M-IR or BCT. Conclusions: SABTR was higher in BCT compared with M-IR cohorts, independent of chemotherapy timing. Following BCT, SABTR was lower in the NAC group at years 2-3 but remained at baseline or higher at all timepoints. In the M-IR cohort, both groups endorsed lower than baseline SABTR in years 0-2 but returned to near baseline at 3 years. Radiation and complications were independent predictors of decreased SABTR, but our findings suggest that patients who experience complications after M-IR can expect return to baseline breast satisfaction by 2 years.[Table: see text]

Patients with psychiatric illness report worse patient-reported outcomes and receive lower rates of autologous breast reconstruction.

Psychiatric well-being impacts on general satisfaction and quality of life. This study explored how the presence of psychiatric diagnoses affects patient-reported outcomes in breast reconstruction and on selection of reconstructive modality. Patients who received breast reconstruction at a tertiary hospital between 2013 and 2018 and completed the BREAST-Q survey were included. BREAST-Q module scores were compared between patients who had a psychiatric diagnosis at presentation and the remaining cohort using t tests. General linear models (GLMs) were used to control for confounding factors. A chi-squared test was used to assess the effect on reconstructive modality, and binary logistic regression was used to control for confounding factors. Of the 471 patients included, 93 (19.7%) had at least one psychiatric diagnosis. Cohorts did not differ significantly by age, BMI, race, ASA classification, or insurance status. Patients with a psychiatric diagnosis experienced a decrease in BREAST-Q scores for the Psychosocial Wellbeing (B=9.16, P=.001) and Sexual Wellbeing (B=9.29, P=.025) modules. On binary logistic regression, patients with a psychiatric diagnosis were less likely to receive autologous reconstruction compared with implant reconstruction (OR=0.489, P=.010). The presence of psychiatric diagnoses is an independent predictor of decreased BREAST-Q. Furthermore, there is a significant disparity in modality of reconstruction given to patients with psychiatric diagnoses. Further study is needed to evaluate interventions to improve satisfaction among at-risk populations and evaluate the reason for low autologous reconstruction in this population.

Prepectoral Two-Stage Implant-Based Breast Reconstruction with and without Acellular Dermal Matrix: Do We See a Difference?

Prepectoral implant-based breast reconstruction has gained popularity because of advantages over the subpectoral technique. Acellular dermal matrix use with implant-based breast reconstruction has become common because of its perceived superior aesthetic outcome. Matrices are expensive, however, and recent evidence has pointed to several potential complications. This article reports a series of prepectoral implant-based breast reconstructions with and without acellular dermal matrix and compared their outcomes. This is a single-surgeon retrospective review of patients who underwent staged prepectoral implant-based breast reconstruction following nipple-sparing mastectomy over two periods. Patients with well-perfused mastectomy skin flaps with a homogeneous thickness underwent reconstruction with acellular dermal matrix initially. On evolution of the practice, it was not used. Patient demographics, operative data, and complications were analyzed. Aesthetic outcome was measured by the BREAST-Q survey and the Aesthetic Item Scale. A cost analysis was also performed. Forty patients were included (acellular dermal matrix group, n = 19; non-acellular dermal matrix group, n = 21). The nonmatrix group had one case (5 percent) of seroma and one case (5 percent) with hematoma; there were none in the acellular dermal matrix group. Average BREAST-Q and Aesthetic Item Scale scores were 82.3 versus 81.6 (p = 0.954) and 20.98 versus 20.43 (p = 0.640) for the matrix and nonmatrix groups, respectively. The direct cost savings for the authors' institution over 1 year if matrix was not used in all cases of implant-based breast reconstruction would be estimated at $3,105,960 to $6,211,920 for unilateral and bilateral cases, respectively, for Medicare reimbursement. With adequate patient selection, acellular dermal matrix is not always required during two-stage prepectoral implant-based breast reconstruction for good aesthetic outcomes. The economic burden on patients and the health care system could be lessened with selective matrix use. Therapeutic, III.

Reduction Mammaplasty in Adolescents: A Comparison of Wise and Vertical Incision Patterns.

Background:Reduction mammaplasty was shown to ameliorate physical and psychological problems in adolescents suffering from macromastia. However, benefits of the Wise compared to the vertical incision pattern have not yet been established in this population. The aim of this study is to compare the outcomes of these 2 techniques in adolescents undergoing reduction mammaplasty.Methods:A retrospective study of adolescents undergoing breast reduction by a single surgeon between 2011 and 2017 was conducted. Wise and vertical reduction techniques were compared based on demographics, surgical outcomes, patient satisfaction, and aesthetic outcomes. Patient satisfaction was determined using the validated BREAST-Q survey, and aesthetic outcomes using the validated ABNSW system.Results:A total of 60 adolescents underwent reduction mammaplasty (Wise/inferior pedicle = 80.0%, Wise/superior medial pedicle = 1.7%, vertical/superior medial pedicle = 18.3%). Patients who reported preoperative pain (Wise = 95.9%, vertical = 72.7%, P = 0.039) were more likely to undergo Wise reduction. Patients with Wise reductions also were more likely to undergo bilateral reduction (Wise = 93.9%; vertical = 63.6%, P = 0.017). The major and minor complication rates were 1.7% (Wise = 2.0%, vertical = 0%, P = NS) and 23.3% (Wise = 20.4%, vertical = 36.4%, P = NS), respectively. Adolescents undergoing Wise incision demonstrated statistically significant improvement in NAC contour (Wise = 61%, vertical = 47%, P = 0.028) and overall aesthetic outcome (Wise = 25%, vertical = 17%, P = 0.008) with scarring not being a negative factor (Wise = −16%; vertical = −35%, P = 0.004). Patient satisfaction was comparable in both groups.Conclusions:Reduction mammaplasty is a safe, effective treatment for adolescent macromastia. The similarity in complication and satisfaction rates between Wise and vertical patterns suggests that both techniques can be safely performed in the adolescent population and allow for overall improvements in aesthetic outcomes.

Vertical Augmentation Mastopexy with Implant Isolation and Tension Management.

The increasingly popular vertical method of mastopexy is less commonly the technique of choice in augmentation mastopexy possibly due to concerns raised in the literature. The purpose of this report is to evaluate safety and satisfaction of the author's variation of the vertical method in this combination surgery. It includes unique tension management steps and total implant isolation from cut parenchyma. A retrospective analysis was done of 105 consecutive patients treated with the author's method over an 8 year 6 month period. Clinical outcomes were examined, and a Breast-Q survey and Spear's 2004 survey were mailed to all patients who agreed to it by phone. There were no hematomas or delayed healing but one pulmonary embolus treated as an outpatient and one infection appearing 6 weeks postoperatively. There were only 3 grade 3 or 4 capsular contractures. Sixty-seven patients consented to the survey and 36 were returned. With Breast-Q, there was a mean score of 82.78 for outcome satisfaction and 75.94 for satisfaction with breasts. Spear's survey confirmed high satisfaction with 90.9% indicating that they were satisfied or extremely satisfied. Comparison with Spear's own surgical results did not reach statistical significance. The author's specific adaptation of vertical augmentation mastopexy appears to be very safe and successfully addresses a variety of healing, tension, and exposure concerns mentioned in the literature. Implant isolation may decrease capsular contracture rate. Both Breast-Q survey and Spear's more specific survey indicate high patient satisfaction.

Abstract QS39: Patient Reported Satisfaction and Quality ofLife in Predominantly Minority Obese Patients: A Comparison Between Microsurgical and Prosthetic Implant Recipients

PURPOSE: Patients undergoing autologous breast reconstruction have higher rates of patient reported satisfaction as compared to patients undergoing prosthetic reconstruction. Obesity, defined as body mass index (BMI) ≥30 kg/m2, has been shown in microsurgical and implant reconstructions to increase postoperative complications making this population a great reconstructive challenge. With this challenge in mind, the purpose of this investigation was to evaluate the effects of microsurgical breast reconstruction and prosthetic breast reconstruction on patient reported outcomes and quality of life in obese patients. METHODS: After institutional review board approval was obtained, a retrospective review of patients who underwent breast reconstruction at Montefiore Medical Center from January of 2009 to December of 2015 was conducted. Patients with preoperative obesity were included for analysis. Patients were divided into two cohorts: those undergoing microsurgical reconstruction and prosthetic reconstruction. Patients were mailed a BREAST-Q survey for response. Additionally, the demographic information, complications, and need for revisionary procedures were analyzed in comparison. BREAST Q satisfaction was then analyzed using Q-Score software. RESULTS: 114 patients met the inclusion criteria: 41.2 percent (n=47) of patients underwent microsurgical breast reconstruction and 58.8 percent (n=67) underwent tissue expander/implant reconstruction. Patients in each cohort were similar in BMI, mean mastectomy specimen weight, indication for surgery, smoking status and postoperative complications. However, patients undergoing microsurgical breast reconstruction were younger (48.0 versus 53.0 years, p=0.02), more likely to have bilateral reconstruction (66.0 percent (n=31) versus 40.3 percent (n=27), p=0.007), and more likely to have delayed reconstruction (44.5 percent (n=28) versus 0.0 percent (n=0), p= 0.00001). Of those patients undergoing microsurgical reconstruction, 44.7% (n=21) responded to the BREAST-Q survey, whereas 38.8% (n=26) of patients with implant reconstruction were responders. BREAST-Q responses showed patients undergoing microsurgical breast reconstruction were more satisfied with their breasts (Q-score of 64.1 (25.3) versus 54.6 (21.0), p=0.04) and satisfaction with overall outcome (Q-score 73.5 (25.5) versus 63.5 (25.2), p=0.02). However, both cohorts had similar chest wall physical well-being, sexual well being, and psychosocial well being. Conclusions: Microsurgical breast reconstruction in obese patients yields higher satisfaction with breasts and overall outcomes as compared to implant based reconstruction. Despite increased postoperative complications associated with obese patients, microsurgical breast reconstruction appears to offer a superior reconstructive choice. This information will be important in preoperative patient discussions and counseling. G. Kamel: None. D. Nash: None. R. Berk: None. A. Rizzo: None. T. Benacquista: None. E. Garfein: None. K. Weichman: None.

Association of Fat Grafting With Patient-Reported Outcomes in Postmastectomy Breast Reconstruction

Fat grafting has proven to be a useful adjunct to breast reconstruction for the treatment of contour irregularities and volume deficits, but the proposed US Food and Drug Administration regulations may severely limit the ability of plastic surgeons to continue its use in this clinical context. To determine whether fat grafting is associated with patient-reported outcomes (PROs) in patients undergoing breast reconstruction. A longitudinal, multicenter, prospective cohort study was conducted between February 1, 2012, and July 31, 2016, at the 11 sites associated with the Mastectomy Reconstruction Outcomes Consortium Study. Eligible patients included women 18 years or older presenting for breast reconstruction after mastectomy with 2 years or more of follow-up. All primary procedure types (implant based and flap based) were eligible. Patients were excluded if they had not completed breast mound reconstruction by 1 year after starting reconstruction. Fat grafting as an adjunct to breast mound reconstruction. Primary end points were patient-reported outcome measures as assessed by the validated BREAST-Q survey, with higher scores on a 0- to 100-point scale indicating better health-related quality of life. Survey subscales included breast satisfaction, as well as psychosocial, physical, and sexual well-being. Patient-reported outcomes were compared between those who received and did not receive fat grafting. A total of 2048 women were included (mean [SD] age, 49.4 [10] years), with 165 (8.1%) undergoing fat grafting between years 1 and 2. One year postoperatively, patients who later underwent fat grafting reported significantly lower breast satisfaction (adjusted mean difference [AMD], -4.74; 95% CI, -8.21 to -1.28; P = .008), psychosocial well-being (AMD, -3.87; 95% CI, -7.33 to -0.40; P = .03), and sexual well-being (AMD, -5.59; 95% CI, -9.70 to -1.47; P = .008), compared with those who did not receive subsequent fat grafting. Following the procedure, the fat-grafted cohort reported similar breast satisfaction (AMD, -0.68; 95% CI, -4.42 to 3.06; P = .72), psychosocial well-being (AMD, -0.59; 95% CI, -3.92 to 2.74; P = .73), and sexual well-being (AMD, -2.94; 95% CI, -7.01 to 1.12; P = .15) 2 years postoperatively. Fat grafting may improve breast satisfaction, psychosocial well-being, and sexual well-being in patients undergoing breast reconstruction.

Abstract: A Prospective Randomized Trial to Assess Perfusion and Patient Satisfaction in Nipple-Areola Skin Sparing Mastectomy with Immediate Reconstruction

BACKGROUND: Nipple-areola and skin sparing mastectomy (NASSM) is an accepted and sought after option for eligible patients, and the rate of women undergoing this operation continues to climb. The main advantage of the procedure is the ability utilize existing skin envelope and NAC for improved shape, fewer operations, and less psychological impact on patients. There are many possible incisions, each providing its own advantage from an oncologic or reconstructive perspective. Studies suggest that perfusion is received primarily from superior, medial, and lateral contributions. Therefore the lateral radial (LR) incision may lead to improved perfusion, however the mastectomy is more difficult via an inframammary (IMF) incision and this could lead to a higher complication rate. We aim to assess perfusion to nipple-areola complex in these two incision patterns and determine the impact of the incision type on overall outcomes, complications, and patient satisfaction. METHODS: Patients with age >18 with BMI 18–35, with estimated breast size 100-800g were included in this prospective study. Patients were randomized to receive either an IMF or LR incision unless one was given a strong preference by patient or surgeon. A BreastQ survey was administered preoperatively, and three-dimensional images of both breasts were captured. Mastectomies were performed by experienced breast surgical oncologists. Laser angiography (SPY system, Lifecell) was performed at 3 distinct time points: pre-operatively, post-NASSM, and post-reconstruction. Blood pressure was monitored closely throughout the operation. Patients were followed for at least 3 months after their permanent implant placement for complications. Three months post-operatively, the BreastQ survey was again administered and three-dimensional images were captured to measure aesthetic landmarks. Two-tailed Mann-Whitney U and Chi-squared tests were used to compare group medians and proportions with P<0.05 indicating significance. RESULTS: Fifty-five received an IMF incision, and twenty-four a LR incision. There was no difference in demographics, comorbidities, specimen weight, initial implant volume, or intraoperative blood pressure between groups. Similarly, there was no there a difference in distribution of breast perfusion pattern. The LR group did have a longer operative time (155 min vs 177 min, p=0.02). The decrease in perfusion to the whole breast did not differ between groups at each surgical stage. Patients with an IMF incision had significantly lower remaining perfusion to the inferior (21.94% vs 36.89%, p=0.001) and lateral portions of the flap (23.08% vs 40.70%, p=0.003) after reconstruction. Perfusion to the nipple was not significantly different (29.87% vs 40.03%, p=0.15) when adjusting for covariates. Rates of complications, including necrosis, infection, implant exposure or malposition, and explant did not differ between incision types. There was no difference in patient satisfaction based on BreastQ scores between incision types. Finally, there was no significant difference in mammographic measurements on three-dimensional imagining between groups. CONCLUSIONS: There is a significant decrease in blood flow to the inferior and lateral portions of the skin envelope using the IMF incision when compared to the LR incision, possibly due to differences in retraction and difficulty in technique. Despite this, there is no difference in complications, outcomes, or patient satisfaction with their surgical reconstruction over a 3 month period.