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A Prospective, Cohort Analysis of Satisfaction and Outcomes Following Breast Reconstruction: The Impact of Reconstruction Modality, Obesity and Age on Changes in Satisfaction
Jonathan R. Sarik, MD, Andrew R. Bauder, BA, Marten N. Basta, BA, Jonas A. Nelson, MD, Michael Chu, MD, Nancy Folsom, BSN, David B. Sarwer, PhD, Stephen J. Kovach, III, MD, Joseph M. Serletti, MD, Liza C. Wu, MD, John P. Fischer, MD.
University of Pennsylvania, Philadelphia, PA, USA.

BACKGROUND: Breast reconstruction represents a critical step in the physical and psychological recovery following breast cancer surgery. In this analysis, we report our early results for satisfaction and well-being in patients undergoing breast reconstruction enrolled in a prospective observation study. Furthermore, to identify factors associated with significant changes in satisfaction between the preoperative assessment and postoperative assessments we specifically assessed the impact of reconstruction modality, obesity and age on each domain at various time intervals.
METHODS: An ongoing prospective, observational cohort study (July 1st 2013 - Current) was designed to perform serial assessments of perioperative patient satisfaction and well-being before and after breast reconstruction using the Breast-Q© instrument. Patients enrolled in the study completed preoperative Breast-Q© surveys, as well serial post-operative surveys. Postoperative data was collected prospectively and reviewed retrospectively to assess outcomes such as minor complications, defined as those requiring only conservative treatment, and major complications, defined as flap or device loss or other complication requiring reoperation.
RESULTS: A total of 103 patients have enrolled in this prospective study as of April 1st, 2015. The average age and BMI were 50.3 +/- 10.3 years and 28.4 +/- 6.6 kg/m2, respectively. Currently 83 patients have undergone reconstruction including 61 (73%) autologous free flap reconstructions and 22 (27%) 2-stage implant based reconstructions. The average time from reconstruction to survey completion for the early and late postoperative surveys is 91.7 +/- 51.1 days and 367.6 +/- 139.6 days, respectively. For the overall cohort, significant improvements between preoperative and late-postoperative scores were noted in satisfaction with the breast (55.2 vs 69.1, p=0.001), psychosocial well-being (72.4 vs 80.6, p=0.010), and physical well-being of the abdomen (54.3 vs 63.4, p=0.001). Overall there was a decline in physical well-being of the chest between the preoperative and late-postoperative assessments (78.2 vs 72.7, respectively, p=0.029). In subgroup analysis, patients undergoing free flap reconstruction had significant improvements from the preoperative to the late-postoperative assessment in satisfaction with the breast (53.6 vs 69.8, respectively, p=0.002), psychosocial well-being (71.7 vs 80.3, respectively, p=0.011), and sexual well-being (53.3 vs 62.2, respectively, p=0.022). Patients undergoing implant based reconstruction did not show any significant changes in satisfaction across all domains. Non-obese patients had significant improvements in satisfaction with the breast (57.8 vs 71.6, respectively, p=0.002), psychosocial well-being (73.5 vs 82.8, respectively, p=0.043), and physical well-being of the abdomen (55.0 vs 64.7, respectively, p=0.030). Obese patients only showed significant improvement in physical well-being of the abdomen (50.1 vs 61.3, respectively, p=0.009). Patients younger than 60 years had significant improvements in satisfaction with the breast (57.6 vs 70.4, respectively, p=0.004) and physical well-being of the abdomen (54.8 vs 64.7, respectively, p=0.007). Patients older than 60 years had significant improvements in sexual well-being (44.0 vs 66.9, respectively, p=0.022).
CONCLUSIONS: Patient satisfaction following surgery is a critically important benchmark that surgeons must recognize, and continually aim to improve. Overall patient satisfaction appears to improve following breast reconstruction. Patients reconstructed using abdominal-based free flaps, the non-obese, and younger patients tend to have the greatest improvements compared to other patients.

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