Quality of life and aesthetic results after mastectomy and mammary reconstruction
Qualidade de vida e resultado estético após mastectomia e reconstrução mamária

INTRODUCTION

According to the National Cancer Institute, breast cancer is the second most common type of cancer among women in Brazil and worldwide, after non-melanoma skin cancer. Approximately 25% of all new cancer cases registered every year are breast cancers, and around 57,960 new cases of breast cancer registered in Brazil were expected in 2016. In 2013, 14,388 Brazilians, including 14,206 women, died from the disease¹.

Owing to the increased incidence of breast cancer, the demand for breast reconstruction is also growing, along with concerns regarding the satisfaction and quality of life of patients.

Mastectomy, even when accompanied by immediate breast reconstruction, can be a traumatic experience for women and may be perceived as a mutilation, significantly impacting their self-esteem and emotional stability. In addition, after the surgery, patients may present with symptoms such as pain or discomfort in the breast area, changes in tactile sensation, and impaired upper limb functionality after dissection of the axillary lymph nodes, among others, all of which affect their quality of life².

Given this scenario, breast reconstruction can be an important means of regaining a positive body image, re-establishing social engagement, and improving quality of life³.

The techniques used in breast reconstruction include the use of silicone prosthesis and tissue expanders and may be carried out immediately after mastectomy or may be delayed.

The silicone gel breast prosthesis was developed in 1961 by Cronin, Gerow, and Dow Corning Corp. and introduced in 1963, significantly advancing the field of breast reconstruction. In France, Arion introduced the first tissue expander in 1965, but it was not until 1982 that Radovan described its use in breast reconstruction. In 1984, Becker developed a definitive tissue expander. Techniques that have developed in tandem with the use of these alloplastic materials have improved patients’ quality of life, reducing the impact of perceived mutilation and surgical time, with the advantages of a shorter hospital stay, absence of donor area, and reduced risk of complications⁴,⁵.

The most effective way to evaluate quality of life is by means of validated questionnaires that focus on the treatment in question⁶,⁷. The BREAST-Q® questionnaire has been validated and specifically developed to assess pre- and postoperative quality of life related to breast reconstruction^7,8.

OBJECTIVE

The main objective of this study was to evaluate patients’ quality of life and satisfaction with the aesthetic result following breast reconstruction with implants via comparison between the pre-reconstruction and post-reconstruction periods.

MATERIALS AND METHODS

This was a retrospective longitudinal observational study conducted by reviewing the medical records of patients who underwent breast reconstruction using silicone implants or tissue expanders from January 2014 to December 2016, in association with a cross-sectional study of the application of the BREAST-Q^® questionnaire and evaluation of aesthetic results based on an analysis of pre-and postoperative photographs.

The research project followed the legal procedures determined by resolution 196/96 of the National Health Council regarding research involving human beings and was conducted in accordance with the principles of the Declaration of Helsinki.

All surgeries were performed by the same plastic surgeon in 5 hospitals located in the city of Brasilia (DF).

The variables evaluated were age, body mass index (BMI), comorbidities, type of breast reconstruction performed, the result of the histopathological study of lesion biopsy, laterality, time of breast reconstruction (immediate or delayed), symmetrization, preservation of the nipple-areola complex (NAC) upon mastectomy, postoperative complications, chemotherapy (CT), and radiotherapy (RT), as well as whether all stages of breast reconstruction were completed.

The inclusion criteria set for the study were:

The exclusion criteria were:

RESULTS

A total of 74 patients who underwent breast reconstruction with implants were selected: 59 (79.72%) with a silicone prosthesis and 15 (20.27%) with an expander (Table 1). The age of the patients ranged from 24 to 81 years, with an average of 55 years and a median of 54 years. The BMI ranged from 17.95 to 36.98, with an average of 24.50.

Table 1 - Breast Reconstruction Data.

Among the 74 breast reconstructions, 71 (95.94%) were performed at the same time as mastectomy and classified as immediate breast reconstruction. Only 3 (4.05%) reconstructions were late reconstructions. In terms of laterality, 50% were unilateral and 50% were bilateral (Table 1).

In 30 (40.54%) of the breast reconstructions performed, the NAC was spared. In addition, 48 (64.86%) patients underwent a second operation for breast symmetrization (Table 1).

Of the 74 patients undergoing breast reconstruction, 45 (60.81%) received complementary CT after mastectomy, 24 (53.33%) underwent adjuvant CT (ADJ), and 21 (46.67%) underwent neoadjuvant CT (NEO). Twenty-nine (39.18%) patients did not undergo any type of CT. RT was required in 24 (32.43%) patients (Table 1).

In terms of comorbidities, 17 (22.97%) of the patients who underwent breast reconstruction had none. In contrast, 16 (21.62%) patients were hypertensive, 15 (20.27%) presented with dyslipidemia, 13 (17.57%) had hypothyroidism, 8 (10.81%) reported being treated for depression, 6 (8.11%) had diabetes type II, 3 (4.05%) had arrhythmia and/or other cardiac disorders, 1 (1.35%) had multiple myeloma, 1 (1.35%) had thrombophilia, and 1 (1.35%) was a carrier of a genetic mutation for thrombosis. In addition, 5 (6.76%) patients were smokers and 15 (20.27%) reported being ex-smokers. Many patients had more than one comorbidity.

With regard to surgical complications after breast reconstruction surgery, 33 (44.59%) patients did not experience any type of complication. However, there were 14 (18.92%) cases of seroma, 7 (9.46%) cases of slight necrosis in the NAC region, 6 (8.11%) cases of slight dehiscence in the T region, 5 (6.76%) cases of hematoma, 3 (4.05%) cases of breast asymmetry, and 3 (4.05%) cases of capsular contracture. Three other complications were observed, including infection (2 cases) and late venous thrombosis. Some patients had more than one complication (Table 2).

Table 2 - Postoperative Complications.

Of the 74 patients selected, 52 (70.27%) answered the pre-reconstruction questionnaire, while 48 (64.86%) answered the post-reconstruction questionnaire. The responses of 4 patients who did not answer the post-reconstruction questionnaire were excluded from the study. In addition, the responses of 3 more patients were excluded because they were incomplete, yielding a total of 45 (60.81%) patients with responses. Statistical analysis of the pre- and post-reconstruction responses was performed.

In terms of the breast satisfaction domain, statistical significance in the comparison of the pre- and post-reconstruction responses was found for the following two questions: “How you look in the mirror clothed?” and “Being able to wear clothing that is more fitted?”, with p = 0.00121 and p = 0.0249, respectively (Figures 1 and 2).

Figure 1 - How you look in the mirror clothed .

Figure 1 - How you look in the mirror clothed .

Figure 2 - Ability to wear clothing that is more fitted.

Figure 2 - Ability to wear clothing that is more fitted.

Tables 3, 4, and 5 show the number of answers, in percentages, for each question in the pre- and post-reconstruction questionnaires. In addition, they display the p values obtained by statistical analysis. Table 3 refers to the psychosocial well-being domain, Table 4 refers to the physical well-being domain, and Table 5 refers to the sexual well-being domain. Statistical significance was shown for 4 questions in the physical well-being domain, as shown in Table 4, but not for the psychosocial well-being and sexual well-being domains.

Table 3 - Psychosocial Well-Being (Pre- and Post-Reconstruction).

Table 4 - Physical well-being (pre- and post-reconstruction).

Table 5 - Sexual well-being (pre- and post-reconstruction).

Table 6 presents the descriptive statistics of the results obtained from the Q-Score®, as well as the statistical analysis comparing the responses of patients for the pre-reconstruction period with those for the post-reconstruction period.

Table 6 - Q Score^® Pre and Post-Reconstruction.

Among 74 patients, breast reconstruction with symmetrization and reconstruction of the NAC was achieved in 40 (54.05%) patients, whose cases were analyzed by an experienced plastic surgeon without correlation with the proposed work. The majority of cases were rated as excellent by the external evaluator, and only 1 case was rated as poor. In total, 37 (92.5%) cases were considered satisfactory and 3 (7.5%) unsatisfactory. (Figure 3)

Figure 3 - Aesthetic result.

Figure 3 - Aesthetic result.

DISCUSSION

Breast cancer is the most prevalent cancer in women and often leads to a significant decrease in the ability to have a normal life¹. The beneficial effects of breast reconstruction on quality of life and psychosocial well-being are well documented. In a variety of studies, women who underwent reconstruction after mastectomy showed improvements in self-image, sexuality, and decreased rates of depression⁹-¹².

Plastic surgery is a specialty in which results are evaluated mainly by patient satisfaction¹³. Therefore, studies with the main objective of evaluating quality of life and aesthetic outcome satisfaction in patients undergoing breast reconstruction are critical.

Innumerable breast reconstruction techniques are available, and the selection of which technique will be used in each patient is influenced by several factors, including BMI, comorbidities, presence of donor areas for autologous reconstruction, patient preference, expectation as to the results, lifestyle factors, staging, need for radiotherapy, type of mastectomy, laterality (unilateral or bilateral), and others¹⁴.

Breast reconstructions with prostheses and/or tissue expanders are widely performed throughout the world and continue to be an excellent alternative for patients with contraindications for autologous reconstruction, those who cannot be subjected to extensive surgery, and those not wanting a prolonged postoperative recovery or a scar in the donor area¹⁵.

A total of 74 women between 24 and 81 years of age were selected for the present study. According to the National Cancer Institute (INCA), breast tumors in women aged less than 35 years are relatively rare, and the incidence rises progressively from that age onward, especially after 50 years of age¹⁶. In our study, with the exception of one 24-year-old patient, all the patients were aged over 35 years.

The mean BMI presented in this study was 24.5 kg/m², which is higher than that in previously published data that indicated an average BMI of 22.0 kg/m² in breast reconstruction patients¹⁷.

In our study, the complication rate was 55.4%, with the majority being slight seroma formation (18.92%) and slight necrosis in the NAC region (9.46%). The overall incidence of any type of complication in this study was comparable with published studies that reported a complication rate ranging from 4% to 58%¹⁸-²².

Although the use of implants facilitates faster and simpler breast reconstructions, it tends to be associated with specific complications, such as capsular contracture. The percentage of verified capsular contracture in this study was 4.05%, which is lower than the 10% to 56% rate reported in other studies¹⁸-²².

Bilateral reconstructions have been gaining ground in recent years, either for therapeutic reasons due to the characteristics of the tumor, for indications of prophylactic mastectomy due to genetic alterations that lead to a significant increase in the risk of cancer, or even by the decision of the patient to undergo prophylactic contralateral mastectomy.

According to some studies, there is a positive influence of bilateral breast reconstruction on breast satisfaction owing to the symmetry that is more easily achieved and the fact that concern about the risk of cancer in the contralateral breast can be reduced¹⁰. In our study, half of the cases underwent bilateral reconstruction and the other half underwent unilateral. Most of the cases considered optimal included bilateral reconstructions. However, in the 3 cases with asymmetry as a complication in our study, the breast reconstruction was bilateral.

The majority of patients underwent immediate reconstruction (95.94%). According to previous reports, the majority of women opt for this form of breast reconstruction in an attempt to lessen the negative feelings triggered by the disease and its treatment, as well as to improve self-esteem, resolve the lack of a breast, and facilitate greater freedom in clothing options. After mastectomy, the absence of the breast alters a woman’s body image, potentially generating a sensation of mutilation and the loss of femininity and sensuality²³. There are published reports demonstrating better social interaction, higher levels of professional satisfaction and fulfillment, and a lower frequency of depression at one year after surgery among women who underwent mastectomy associated with immediate reconstruction²⁴,²⁵.

The treatment of breast cancer is guided by the characteristics of the tumor, and radiotherapy and chemotherapy are complementary to mastectomy. While radiotherapy decreases the incidence of local recurrence and improves the survival of patients, it can affect breast symmetry, impair aesthetics, and decrease quality of life. In previous studies on patients who underwent breast reconstruction with implants and radiotherapy, radiotherapy was found to negatively impact their quality of life and breast satisfaction²⁶,²⁷. Of the 74 patients undergoing breast reconstruction in our study, 45 (60.81%) underwent chemotherapy (CT) and 24 (32.43%) underwent radiotherapy. Of the 29 cases considered optimal by the external evaluator, 9 (31.033%) underwent radiotherapy. Of the 8 cases considered good, 3 (37.5%) received radiotherapy. Moreover, of the 3 cases considered fair and poor, 2 (66.67%) received radiotherapy.

Factors related to quality of life and aesthetic outcomes of breast reconstructions performed with implants were evaluated by means of the BREAST-Q® questionnaire, which was developed and validated as a specific measure of quality of life.

In 2016, Kuroda et al²⁸. used the BREAST-Q® to evaluate aesthetic results and quality of life outcomes in Brazilian patients who underwent immediate breast reconstruction using implants and demonstrated that breast reconstruction leads to satisfactory quality of life outcomes.

In the present study, we observed that breast reconstruction, despite the complications inherent to the procedure, facilitates enhanced quality of life and patient satisfaction. In the domains of satisfaction with breasts, psychosocial well-being, physical well-being, and sexual well-being, the scores were higher scores in the postoperative questionnaire than in the preoperative questionnaire quantified by Q-Score®. In particular, a significant result in the domain of “psychosocial well-being” was found (p = 0.005).

In a 2014 retrospective study, Ng et al²⁹. evaluated 143 mastectomized patients (79 with reconstruction and 64 without) using the BREAST-Q^® questionnaire. The reconstruction group showed higher BREAST-Q® scores in the domains of “satisfaction with breasts”, “psychosocial well-being”, and “sexual well-being” and also showed improved self-esteem, increased clothing options, and a greater sense of overcoming the cancer.

In 2013, Zhong et al. evaluated 29 mastectomized patients before and after breast reconstruction with the BREAST-Q^® questionnaire and observed improvements in satisfaction with breasts and psychosocial and sexual well-being.

In terms of the statistical analysis comparing the responses of the two groups for each question, statistical significance was found for the following 6 questions: “How you look in the mirror clothed?” (p = 0.00121); “Being able to wear clothing that is more fitted?” (p = 0.0249); “How often do you feel pain in the arms?” (p = 0.0396); “How often do you feel pain in the ribs?” (p = 0.0007); “How often do you have difficulty sleeping due to discomfort in the breast area?” (p = 0.0257); and “How often do you feel sharp pain in the breasts?” (p = 0.0121).

It is interesting to highlight the positive responses to the questions in the physical well-being domain, as more physical symptom complaints were expected after the surgical procedure. In 2013, Eltahir et al³⁰. assessed the quality of life of women following breast reconstruction in comparison with those of patients who underwent mastectomy, using the BREAST-Q^® questionnaire, and observed that women showed less pain and fewer limitations after reconstruction (p = 0.007).

CONCLUSION

The quality of life of patients in the period after breast reconstruction with silicone prostheses or tissue expanders was higher than that in the pre-reconstruction period.

Despite the feeling of mutilation and trauma incurred by the mastectomy procedure, breast reconstruction, when carefully executed by a well-trained and specialized team, can yield excellent aesthetic results.