Keywords
breast reconstruction - autologous breast reconstruction - abdominally based breast
reconstruction
Introduction
Breast cancer is one of the most common malignancies in female population around the
world, affecting women in every country at any age after puberty.[1] Its treatment many times involves complete excision of the mammary gland, resulting
in mutilation of the breast mound.
For many years, these patients had little or no options for reconstruction. Sequelae
from a mastectomy or lumpectomy with adjuvant radiotherapy were permanent and served
as a constant reminder of their battle against breast cancer.[2] However, these days, breast reconstruction is considered as one more step in the
global treatment of this malignancy. It has evolved from an initial seek of merely
covering and restoring the chest wall to the actual possibility of reproducing a naturally
looking breast with a nipple–areola complex (NAC), searching for symmetry to the contralateral
healthy mammary gland.[3]
In this sense, autologous reconstruction, particularly the one using abdominal tissue
(deep inferior epigastric perforator flap [DIEP]), has become the gold standard in breast reconstructive surgery. As for any other kind of reconstruction, the plastic
surgeon will aim to achieve the best possible results in the reconstructed region
(breast) with the minimal donor site (abdomen) violation. This involves trying to
attain optimal breast shape, volume, texture, and symmetry, caring at the same time
about the aesthetics of the imprints we leave behind on the abdomen.
However, in some cases, patients' anatomical characteristics, conditioning factors
derived from previous surgeries, or others limit our possibilities, forcing us to
prioritize some of the above-mentioned aspects over others. In order to decide which
of these aesthetic goals we should prioritize and which could be somehow neglected,
it appears reasonable to investigate what women's aesthetic aspirations are when they
decide to subject themselves to reconstructive breast surgery. Indeed, a revision
of the published literature will bring us to numerous studies on patient-reported
outcomes (PROMs)[2]
[4] following breast reconstruction; however, there is little or no evidence on their
aesthetic preferences. With the intention to build a value scale that could guide
our decisions when performing autologous breast reconstruction, we decided to move
our focus from the moment “after” (PROMs) to the one “before” reconstruction, changing
our question from “what do you think about the result of your surgery?” to “what do
you want to achieve for your breast with this surgery?”.
Materials and Methods
Using the platform QuestionPro, we built a survey that was telematically distributed to three groups of participants:
patients, residents/fellows, and plastic surgery specialists. The survey was composed
by a number of preliminary questions on demographic data (different for each group),
followed by one main question evaluating 10 aspects of autologous breast reconstruction,
which were asked to be rated from 1 to 10 according to their relevance for the interrogated
subject:
-
Breast volume.
-
Breast shape.
-
Symmetry to the contralateral breast.
-
Sensitivity of the reconstructed breast.
-
Breast texture.
-
Scars on the reconstructed breast.
-
Scars on donor site (abdomen).
-
Aspect of the transposed umbilicus.
-
Reconstruction of the NAC.
-
Similarity to the original breast (prior to mastectomy).
In order for each item to be correctly understood, especially for the case of patients,
they were each accompanied by a short explanation clarifying exactly what we were
referring to, as well as a simple self-made drawing to help them visualize what was
being asked. Also, “sensitivity” was explained to patients as “the ability to notice
tactile stimuli on the reconstructed breast, rather than the presence of erogenous
sensation.” This aimed to ensure a consistent understanding of the functional nature
of sensitivity.
Although the questionnaire did not undergo formal psychometric validation, several
strategies were implemented to ensure clarity and consistency — particularly for patient
respondents. These included pilot testing with a small group of postoperative patients,
iterative feedback from clinical colleagues, and the incorporation of explanatory
text and schematic illustrations for each item, facilitating comprehension by patient
respondents. ([Appendix 1] [available in the online version]).
Medical records from patients reconstructed by our unit during the last 10 years were
reviewed. Patients were contacted by telephone and asked to participate by sharing
their e-mail directions, to which an online link for the survey would be sent for
them to fill out anonymously. Spanish and English versions of the survey were also
distributed amongst national and international specialist surgeons and surgeons in
training. Colleagues were contacted via social media or messaging platforms. They
were informed about the nature of the study and asked to participate anonymously.
Answers were collected automatically through the survey's server (QuestionPro) and later exported to SPSS for statistical analysis. A Shapiro–Wilk test was first
performed, showing the lack of normality of our sample. Consequently, nonparametric
tests were applied. A Kruskal–Wallis test was used to compare means between the three
groups. Mann–Whitney U-tests were employed to perform intra-group comparisons (elder
vs. younger patients and more vs. less experienced surgeons).
Results
Our response rate was 68% for patients, 74% for specialist surgeons, and 60% for surgeons
in training, collecting in total 56 answers from patients, 26 from specialist surgeons
(Spanish and international), and 27 from surgeons in training (residents or fellows,
both Spanish and international). Patient, “specialist surgeon,” and “surgeon in training”
sample characteristics are summarized in [Supplementary Table S1] (available in the online version).
Our patient sample came entirely from Hospital La Fe in Valencia, Spain. Their average
age was 52.67 years, with a median of 52, indicating a generally middle-aged population.
They had all been already operated on at the time of response.
The group of specialist surgeons consisted of 26 individuals, 69.2% men and 30.8%
women. The majority were Spanish (76.9%), while the rest came from various other countries
(France, Czech Republic, United Kingdom, and United States). In terms of experience,
34.6% handled fewer than one case per month, 26.9% performed at least one case monthly,
and others had a higher frequency, with 15.4% performing more than one case weekly.
The total number of cases each surgeon had reconstructed varied widely, with 26.9%
having completed fewer than 10 cases, while 11.5% (3 out of 26) had completed more
than 300 cases.
Finally, for the group of surgeons in training, 27 responses were collected, consisting
of nearly equal numbers of men (51.9%) and women (48.1%), with a majority of Spanish
nationals (77.8%), while the remaining trainees came from various European countries
(France, Belgium, Austria, Italy, and the United Kingdom). Experience levels varied,
with the majority being third and fourth-year residents and only one fellow. Their
surgical experience was diverse. Cumulatively, nearly half of the trainees had assisted
in 20 to 50 cases, while smaller groups counted fewer than 10 or more than 50 cases
assisted.
There was congruence amongst all three groups for the highest-priority aspect of autologous
abdominally based breast reconstruction: symmetry. However, differences emerged between
patients and surgeons (both specialists and trainees) in relation to the item considered
lowest priority: patients ranked the umbilicus as least important, whereas surgeons
prioritized sensitivity lowest ([Tables 1]
[2]
[3]). Also, we noted statistically significant differences in the ratings patients or
surgeons gave to 3 of the 10 evaluated items ([Fig. 1]): sensitivity, reconstruction of the NAC, and similarity to the original breast
(prior to undergoing mastectomy).
Table 1
Patient results
Item
|
Mean evaluation (/10)
|
Volume
|
7.46
|
Shape
|
8.39
|
Texture
|
7.23
|
Sensitivity
|
6.77
|
Symmetry
|
9.14
|
Scars on recipient site (breast)
|
7.23
|
Scars on donor site (abdomen)
|
7.02
|
Belly-button
|
6.29
|
Nipple–areola complex (NAC)
|
8.18
|
Similarity to original breast (pre-mastectomy)
|
6.55
|
Table 2
Specialist surgeon results
Item
|
Mean evaluation (/10)
|
Volume
|
7.72
|
Shape
|
8.54
|
Texture
|
7.15
|
Sensitivity
|
4.50
|
Symmetry
|
9.35
|
Scars on recipient site (breast)
|
7.69
|
Scars on donor site (abdomen)
|
7.88
|
Belly-button
|
7.20
|
Nipple–areola complex (NAC)
|
7.12
|
Similarity to original breast (pre-mastectomy)
|
4.63
|
Table 3
Surgeon in training (resident/fellow) results
Item
|
Mean evaluation (/10)
|
Volume
|
6.78
|
Shape
|
8.93
|
Texture
|
6.33
|
Sensitivity
|
4.38
|
Symmetry
|
9.33
|
Scars on recipient site (breast)
|
7.59
|
Scars on donor site (abdomen)
|
7.26
|
Belly-button
|
6.93
|
Nipple–areola complex (NAC)
|
7.78
|
Similarity to original breast (pre-mastectomy)
|
4.89
|
Fig. 1 Comparison between patients, specialists, and surgeons in training.
For intra-group analysis, patients were divided into two groups placing the cut-off
point on the sample's median age (52). Mean ratings for the 10 evaluated items were
compared between both groups (over or under 52), finding no statistically significant
differences between them.
Analogous comparisons were made for the “specialist surgeon” sample, with an intention
to evaluate eventual disagreements among them depending on their experience. In this
case, the sample was divided into two groups based on the total amount of autologous
reconstructions performed by each. Those having operated less than 100 cases throughout
their careers were allocated to the first group (less experienced) and the ones having
performed 100 or more to the second group (more experienced). Differences were observed
only for “texture,” which more experienced surgeons valued with significantly higher
marks (8.67 vs. 6.70) than less experienced ones ([Supplementary Table S2] [available in the online version ]). Indeed, all surgeons having performed more
than 100 breast reconstructions rated “texture” with more than an 8/10, whereas for
the other group only 9/20 surgeons gave the mentioned item such importance ([Fig. 2]).
Fig. 2 Intragroup comparison (specialist surgeon).
Discussion
Mastectomy exerts a profound impact on women both physically and emotionally, as it
significantly affects body image, self-esteem, and overall quality of life.[5]
[6] This surgical procedure frequently presents psychological challenges, largely due
to the loss of a body part intrinsically linked to femininity and identity. Given
that breast cancer remains the most commonly diagnosed cancer among women worldwide,
with millions of new cases each year,[1] the necessity for effective treatment and comprehensive support strategies, including
reconstructive surgery options, cannot be overstated.
In this regard, breast reconstruction plays a pivotal role, as it not only restores
the shape and volume of the breast but also contributes to the patient's self-image
and psychological well-being. Among the available reconstructive techniques, autologous
breast reconstruction using abdominal tissue—DIEP flap—is widely acknowledged as the
gold standard.[3]
[7]
[8]
[9]
[10]
[11] This preference is supported by extensive clinical evidence demonstrating its superior
outcomes over alternative methods. Furthermore, the increasing focus on PROMs[2]
[4]
[12] has provided a more nuanced and comprehensive perspective on the advantages and
limitations associated with this technique. Despite the wealth of evidence,[13]
[14]
[15] a notable gap persists in understanding the specific aesthetic priorities that patients
value most when undergoing this procedure.
The present study seeks to address this gap by investigating patients' aesthetic concerns
and establishing a priority scale informed by their expectations and values. Such
an approach is crucial, as achieving all aesthetic goals may not always be feasible
due to anatomical or surgical limitations. Consequently, effective and personalized
surgical planning is often required to balance competing priorities and optimize outcomes.
Our findings underscore the paramount importance of achieving breast symmetry in autologous
reconstruction. This aspect was universally identified as the most critical parameter
by patients, specialist surgeons, and trainees alike. This consensus is consistent
with existing literature,[16] which highlights breast symmetry as a key determinant of aesthetic success and long-term
patient satisfaction.
However, opinions diverged significantly regarding the least important parameter.
While patients ranked the appearance of the umbilicus as the least significant, surgeons,
including specialists and trainees, considered sensitivity to be of lesser priority.
This discrepancy can be attributed to differing perspectives: surgeons' heightened
concern for abdominal aesthetics, shaped by their experience with procedures such
as lipoabdominoplasty, contrasts with patients' view of abdominal improvements as
a secondary benefit rather than a primary objective.
Conversely, patients placed greater importance on breast sensitivity, reflecting their
aspiration for reconstructed breasts to approximate natural characteristics, including
protective and, ideally, erogenous sensation. However, surgeons, cognizant of the
technical challenges and limitations in achieving such outcomes, often relegated this
aspect to a lower priority. Notably, advancements in flap reinnervation techniques
have shown promising potential for enhancing sensitivity outcomes.[17]
[18]
[19]
[20]
[21] This trend is reflected in our findings, which revealed that more experienced surgeons
assigned higher importance to sensitivity compared to their less experienced counterparts,
although with no statistical significance.
Moreover, statistically significant differences emerged between patients and surgeons
regarding the importance of sensitivity, the reconstruction of the NAC, and the resemblance
of the reconstructed breast to its pre-mastectomy appearance. Patients consistently
rated these aspects higher than surgeons. The lower priority assigned to NAC reconstruction
by specialists may be explained by their perception of this procedure as relatively
straightforward and noncritical. However, for patients, the emotional significance
of reconstructing the NAC is substantial. Similarly, the high value patients placed
on recreating the original appearance of their breasts underscores the emotional resonance
of this feature.
Interestingly, no age-related differences were observed among patients regarding their
priorities. However, surgeon experience significantly influenced the perceived importance
of breast texture. Experienced surgeons placed greater emphasis on achieving a supple
and natural breast texture, reflecting their refined skills and heightened expectations.
In contrast, less experienced surgeons appeared more forgiving of suboptimal textural
outcomes, possibly due to the challenges of detecting such deficiencies in before-and-after
photographs.
It is worth noting that patients uniformly assigned higher importance to all aspects
of reconstruction compared to surgeons, with average scores ranging from 6.29 to 9.14.
This finding suggests that patients perceive every aesthetic and functional feature
as meaningfully contributing to their overall satisfaction.
Remarkably, patients exhibited less concern about donor site scars, a preference that
could provide surgeons with greater flexibility in flap positioning. For example,
this flexibility might allow for the placement of the lower abdominal scar slightly
higher to facilitate a more reliable and manageable free flap and ensure safer donor
site closure.
While our study focused on preoperative priorities, existing PROMs such as the BREAST-Q
assess postoperative satisfaction. Several domains evaluated by BREAST-Q—such as symmetry,
nipple reconstruction, and sensation—align with our findings. Thus, our results complement
PROM-based research by offering insight into expectations that may shape satisfaction.
In conclusion, our findings indicate that surgeons are generally well aligned with
patients' priorities, particularly regarding the importance of breast symmetry. However,
surgeons could benefit from reevaluating the emphasis placed on other aspects, such
as sensitivity, to better address factors that contribute to long-term satisfaction.
These insights are invaluable for optimizing surgical procedures and managing patient
expectations more effectively.
Nevertheless, it is important to acknowledge the limitations of this study. First,
the patient population was derived from a single institution, which may limit the
generalizability of the findings. Surveying patients from multiple centers was not
feasible due to ethical and logistical constraints, including the need for local approvals
and controlled patient access. However, the surgeon sample included both national
and international participants—from countries such as France, Czech Republic, United
Kingdom, and the United States—offering a broader view of training backgrounds and
aesthetic values. Conversely, only 11% of the specialist sample could be classified
as highly specialized in autologous breast reconstruction, having performed over 300
cases. This low proportion may skew the findings toward less experienced perspectives,
which may not fully represent the practices and priorities of highly specialized surgeons.
Finally, and most importantly, a major limitation is the potential selection bias,
as only postoperative patients were surveyed, making their responses potentially influenced
by their satisfaction or dissatisfaction with their outcomes, despite efforts to focus
the survey on preoperative expectations. Future studies including preoperative assessments
could help validate these findings.
Conclusion
This study contributes to the field of autologous breast reconstruction by generating
evidence on patients' aesthetic priorities when they decide to undergo autologous
abdominally based breast reconstruction, aiming to support a more personalized and
patient-centered approach. Understanding these preferences can help surgeons better
align their surgical goals with patients' expectations, potentially improving satisfaction
with aesthetic outcomes. While all groups agree on symmetry as the most important
factor of the reconstruction, patients assign higher importance to a range of aspects,
among which sensitivity stands out. This priority, which currently receives less focus
from surgeons, suggests that a holistic approach to reconstruction is essential to
meet patient expectations. The fact that more experienced surgeons do adopt strategies
to sensitize the reconstructed breast proofs its significance. Our findings suggest
that incorporating a structured preoperative counseling session, explicitly addressing
functional outcomes such as sensitivity and aesthetic goals like symmetry and texture,
may improve patient satisfaction and alignment of expectations.