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Prospective Analysis of Psychosocial Outcomes in Breast Reconstruction: One-Year Postoperative Results from the Michigan Breast Reconstruction Outcome Study

Wilkins, Edwin G. M.D., M.S.; Cederna, Paul S. M.D.; Lowery, Julie C. Ph.D.; Davis, Jennifer A. M.H.S.A.; Kim, Hyungjin Myra Sc.D.; Roth, Randy S. Ph.D.; Goldfarb, Sherry M.P.H.; Izenberg, Paul H. M.D.; Houin, Herman P. M.D.; Shaheen, Kenneth W. M.D.

Plastic and Reconstructive Surgery: October 2000 - Volume 106 - Issue 5 - p 1014-1025

In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy. Although investigators have documented the psychological, social, emotional, and functional benefits of breast reconstruction, little research has evaluated the effects of procedure choice on these outcomes. The current study prospectively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction: tissue expander/implant, pedicle TRAM, and free TRAM techniques.

In a prospective cohort design, patients undergoing postmastectomy reconstruction for the first time with expander/implant, pedicle TRAM, or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada. Before reconstruction and at 1 year after reconstruction, patients were evaluated by a battery of questionnaires consisting of both generic and condition-specific surveys. Outcomes assessed included emotional well-being, vitality, general mental health, social functioning, functional well-being, social well-being, and body image. Baseline (preoperative) scores and the change in scores (the difference between postoperative and preoperative scores) were compared across procedure types using t tests and analysis of covariance.

Preoperative and 1-year postoperative surveys were obtained from 273 patients. Procedure type was reported in 250 patients, of whom 56 received implant reconstructions, 128 pedicle TRAM flaps, and 66 free TRAM flaps. A total of 161 immediate and 89 delayed reconstructions were performed. Among women receiving immediate reconstruction, significant improvements were observed in all psychosocial variables except body image. However, no significant effects of procedure type on these changes over time existed. Similarly, delayed reconstruction patients had significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image. Although the choice of reconstructive technique did not significantly impact most of these outcomes, significant differences existed among procedure types for three psychosocial subscales. Patients undergoing delayed expander/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures. By contrast, delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed expander-implant reconstruction.

The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients. Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction, our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction.

Ann Arbor, Ypsilanti, Detroit, and Troy, Mich.

From the Section of Plastic and Reconstructive Surgery, University of Michigan Health System; Veterans Affairs Center for Practice Management and Outcomes Research; the Departments of Biostatistics, Physical Medicine and Rehabilitation, and Anesthesiology, University of Michigan; the Section of Plastic and Reconstructive Surgery, St. Joseph Mercy Hospital; the Section of Plastic and Reconstructive Surgery, Henry Ford Health System; and the Section of Plastic and Reconstructive Surgery, William Beaumont Hospital.

Received for publication August 19, 1999;

revised January 18, 2000.

Edwin G. Wilkins, M.D., M.S. University of Michigan Health Systems Section of Plastic and Reconstructive Surgery 2130 Taubman Center 1500 East Medical Center Drive Ann Arbor, Mich. 48109-0340

Presented at the Annual Plastic Surgery Senior Residents Conference, Sacramento, California, April 16 through 20, 1997, where it won First Prize for Best Reconstruction/Burn Paper. Also presented at the Annual Scientific Meeting of the American Society of Plastic and Reconstructive Surgeons, San Francisco, California, September 20 through 24, 1997, and the Annual Clinical Congress of the American College of Surgeons, Chicago, Illinois, October 12 through 17, 1997.

©2000American Society of Plastic Surgeons