Patient-Reported Aesthetic Satisfaction with
Breast Reconstruction during the Long-Term
Emily S. Hu, M.D.
Andrea L. Pusic, M.D.
Jennifer F. Waljee, M.D.,
Latoya Kuhn, M.P.H.
Sarah T. Hawley, Ph.D.
Edwin Wilkins, M.D.
Amy K. Alderman, M.D.,
Ann Arbor, Mich.; and New York, N.Y.
Background: Expander/implant and autogenous tissue breast reconstructions
have different aging processes, and the time when these processes stabilize is
unclear. The authors’ goal was to evaluate long-term patient-reported aesthetic
satisfaction with expander/implant and autogenous breast reconstruction.
Methods: The authors surveyed a cross-section of University of Michigan
women who underwent postmastectomy breast reconstruction (response rate,
73 percent) between 1988 and 2006 [110 expander/implant and 109 transverse
rectus abdominis myocutaneous (TRAM) reconstructions]. Each group was
stratified into three postreconstructive periods: short term (?5 years), inter-
mediate (6 to 8 years), and long term (?8 years). Validated satisfaction items
negative responses. Logistic regression assessed satisfaction by procedure, while
controlling for sociodemographic and clinical variables.
Results: Mean follow-up time after reconstruction was 6.5 years (range, 1 to 18
years). Procedure type had no effect on short-term aesthetic satisfaction. How-
ever, in the long term, reconstruction type considerably affected satisfaction.
Although satisfaction with TRAM reconstruction remained relatively constant,
satisfaction with expander/implants was significantly less among those patients
in the long term. Patients who had undergone implant reconstruction more
than 8 years earlier, compared with those who undergone implant reconstruc-
tion less than 5 years earlier, were significantly less satisfied with breast appear-
ance (odds ratio, 0.10; 95% CI, 0.02 to 0.48), softness (odds ratio, 0.14; 95% CI,
0.03 to 0.64), and size (odds ratio, 0.13; 95% CI, 0.03 to 0.62).
Conclusions: In the long term, TRAM patients, compared with expander/
implant patients, appear to have significantly greater aesthetic satisfaction.
These long-term data have important implications for women’s health in the
survivorship period and will help women navigate the complex decision-making
process of breast reconstruction.(Plast. Reconstr. Surg. 124: 1, 2009.)
becoming increasingly important and will help
ore women are surviving breast cancer
than ever before.1Outcomes data on the
long-term impact of their treatment are
patients make educated healthcare decisions.
With the variety of surgical techniques available in
breast surgery, choosing the “right” operation can
be a daunting task, even for experienced surgeons
and highly educated patients. Patient-reported
outcomes measures, such as surgical satisfaction
and quality of life, can provide patients and phy-
sicians with important information to assist in this
decision-making process. These kinds of data can
From the Section of Plastic Surgery, Department of Surgery,
the Robert Wood Johnson Clinical Scholars Program and the
Department of Surgery, and the Division of General Medi-
cine, Department of Internal Medicine, The University of
Michigan Medical Center; the Plastic and Reconstructive
Surgical Service, Department of Surgery, Memorial Sloan-
Kettering Cancer Center; and the Veterans Affairs Center for
Practice Management and Outcomes Research, Ann Arbor
Veterans Affairs Health Care System.
Disclosure: This work was supported by the Robert
Wood Johnson Foundation. None of the authors has
a financial interest in any of the products or devices
mentioned in the article.
nipple-areola-preserving envelope mastectomy with immedi-
ate reconstruction. Plast Reconstr Surg. 2007;119:796–803.
5. Tykka E, Asko-Seljavaara S, Hietanen H. Patient satisfaction
with delayed breast reconstruction: A prospective study. Ann
Plast Surg. 2002;49:258–263.
with breast reconstruction and reduction mammaplasty.
Scand J Plast Reconstr Surg Hand Surg. 2001;35:399–405.
7. Kovacs L, Papadopulos NA, Ammar SA, et al. Clinical out-
come and patients’ satisfaction after simultaneous bilateral
breast reconstruction with free transverse rectus abdominis
muscle (TRAM) flap. Ann Plast Surg. 2004;53:199–204.
8. Ramon Y, Ullmann Y, Moscona R, et al. Aesthetic results and
patient satisfaction with immediate breast reconstruction us-
ing tissue expansion: A follow-up study. Plast Reconstr Surg.
9. Simon AM, Bouwense CL, McMillan S, et al. Comparison of
unipedicled and bipedicled TRAM flap breast reconstruc-
tions: Assessment of physical function and patient satisfac-
tion. Plast Reconstr Surg. 2004;113:136–140.
aesthetic results after pedicled transverse rectus abdominis
muscle flap for breast reconstruction. Ann Surg Oncol. 2006;
outcomes and the decision process in a population-based
sample of women with breast cancer. Health Serv Res. 2005;
12. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of
Plast Reconstr Surg. 2000;106:769–776.
13. Alderman AK, Kuhn LE, Lowery JC, et al. Does patient sat-
isfaction with breast reconstruction change over time? Two-
year results of the Michigan Breast Reconstruction Out-
comes Study. J Am Coll Surg. 2007;204:7–12.
14. Clough KB, O’Donoghue JM, Fitoussi AD, et al. Prospective
evaluation of late cosmetic results following breast recon-
struction: I. Implant reconstruction. Plast Reconstr Surg. 2001;
15. Spear SL, Onyewu C. Staged breast reconstruction with sa-
line-filled implants in the irradiated breast: Recent trends
and therapeutic implications. Plast Reconstr Surg. 2000;105:
16. Clough KB, O’Donoghue JM, Fitoussi AD, et al. Prospective
evaluation of late cosmetic results following breast recon-
struction: II. TRAM flap reconstruction. Plast Reconstr Surg.
17. Dillman D. Mail and Telephone Surveys: The Total Design
Method. New York: John Wiley and Sons, Inc.; 1978.
18. Pusic AL, Chen CM, Cano S, et al. Measuring quality of life
in cosmetic and reconstructive breast surgery: A systematic
review of patient-reported outcomes instruments. Plast Re-
constr Surg. 2007;120:823–837; discussion 838–839.
19. Cano S, Klassen A, Pusic A. The science of quality of life
measurement: A primer for plastic surgeons. Plast Reconstr
20. Pusic AL, Cano S, Klassen A, et al. Measuring Quality of Life in
Breast Surgery: Content Development of a New Modular System to
Capture Patient-Reported Outcomes (the BREAST-Q). Lisbon, Por-
Procedures, 2006. Available at: http://www.plasticsurgery.org/
Media/Statistics/2006_Statistics.html. Accessed August, 1, 2007.
22. Department of Labor. Women’s Health and Cancer Right’s
Act. Available at: http://www.dol.gov/ebsa/publications/
whcra.html. Accessed May 17, 2007.
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Plastic and Reconstructive Surgery • July 2009