Quality of life and aesthetic results after mastectomy and mammary reconstruction

1 Hospital Daher Lago Sul, Brasília, DF, Brazil. 2 Hospital de Base do Distrito Federal, Brasília, DF, Brazil. Conflicts of interest: none. Introduction: Due to the increased incidence of breast cancer, the demand for breast reconstruction has been increasing, along with concerns regarding the satisfaction and quality of life of the patients. Mastectomy can be a traumatic experience, especially when it is perceived as a mutilation, which can impact self-esteem and emotional stability. The BREAST-Q® questionnaire was internationally validated and formulated for the preand postoperative assessment of quality of life related to breast reconstruction. This study aimed to evaluate quality of life and aesthetic result satisfaction in patients who underwent breast reconstruction with implants by comparing the period after breast reconstruction with the period before. Method: A retrospective longitudinal observational study was carried out by reviewing the charts of patients who underwent breast reconstruction using silicone or tissue expander implants from January 2014 to December 2016, in association with a cross-sectional study of the Breast-Q® questionnaire and an evaluation of aesthetic results based on photographic analysis before and after surgery. Results: We selected 74 patients who underwent breast reconstruction with implants (79.7% with silicone prostheses and 20.3% with expanders); 95.94% of the reconstructions were immediate, and no particular laterality predominated. We obtained statistical significance in the domains of both breast satisfaction and physical well-being. Most cases were considered satisfactory by the external evaluator. Conclusion: The patients’ quality of life in the period after breast reconstruction with breast implants was superior to that in the period prior to the procedure. ■ ABSTRACT

Introduction: Due to the increased incidence of breast cancer, the demand for breast reconstruction has been increasing, along with concerns regarding the satisfaction and quality of life of the patients.Mastectomy can be a traumatic experience, especially when it is perceived as a mutilation, which can impact self-esteem and emotional stability.The BREAST-Q® questionnaire was internationally validated and formulated for the pre-and postoperative assessment of quality of life related to breast reconstruction.This study aimed to evaluate quality of life and aesthetic result satisfaction in patients who underwent breast reconstruction with implants by comparing the period after breast reconstruction with the period before.Method: A retrospective longitudinal observational study was carried out by reviewing the charts of patients who underwent breast reconstruction using silicone or tissue expander implants from January 2014 to December 2016, in association with a cross-sectional study of the Breast-Q® questionnaire and an evaluation of aesthetic results based on photographic analysis before and after surgery.Results: We selected 74 patients who underwent breast reconstruction with implants (79.7% with silicone prostheses and 20.3% with expanders); 95.94% of the reconstructions were immediate, and no particular laterality predominated.We obtained statistical significance in the domains of both breast satisfaction and physical well-being.Most cases were considered satisfactory by the external evaluator.Conclusion: The patients' quality of life in the period after breast reconstruction with breast implants was superior to that in the period prior to the procedure.
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 complications 4,5 .
The most effective way to evaluate quality of life is by means of validated questionnaires that focus on the treatment in question 6,7 .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 postreconstruction 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: 1. Patients undergoing total mastectomy due to breast cancer or for prophylactic reasons; 2. Patients undergoing breast reconstruction by techniques involving a breast prosthesis or tissue expander; 3. Patients who agreed to the free and informed consent terms, authorizing the use of their records and their photographs for scientific purposes.The exclusion criteria were: 1. Patients who underwent other breast reconstruction techniques; 2. Patients who did not answer the pre-and postoperative BREAST-Q questionnaire; 3. Patients who refused to participate in the study.

Questionnaire for assessing quality of life -BRE-AST-Q ®
Quality of life of patients was evaluated by the BREAST-Q ® , a questionnaire validated internationally for the development of scales to assess quality of life related to breast reconstruction from the patient's perspective 6,7 .It was developed based on the guidelines of the FDA (U.S. Food and Drug Administration/Guidance and Compliance Regulatory Information).The questionnaire is composed of 4 independent modules (reductive mammoplasty, breast augmentation, breast reconstruction, and mastectomy).Each of the modules includes a core of independent scales that assess 6 domains (satisfaction with breasts, satisfaction with outcome, psychosocial well-being, sexual well-being, physical well-being, and satisfaction with care).
The patients' responses to the items in each domain are transformed by the Q-Score ® scoring software to yield a total score (for each scale) ranging from 0 to 100.For all BREAST-Q ® scales, a higher score indicates greater satisfaction or a better quality of life 7,8 .
The questionnaire was translated into Portuguese without any change in the meaning of any sentence.Two versions of the questionnaire were used, one specific to the preoperative period and one for the postoperative period.For the preoperative questionnaire, 4 domains were used (satisfaction with breasts, psychosocial wellbeing, physical well-being, and sexual well-being).For the postoperative questionnaire, 5 domains were used (satisfaction with breasts, satisfaction with outcome, psychosocial well-being, sexual well-being, and physical well-being), plus one subdomain (satisfaction with nipple).

Satisfaction and aesthetic result
A medical assessment of the aesthetic result was performed after analyzing pre-and postoperative photographs obtained from the medical records.The surgeon's satisfaction with the results achieved was classified as unsatisfactory in cases rated as poor or regular or satisfactory in cases rated as good or very good.Patient satisfaction was assessed by the BREAST-Q ® questionnaire.

Surgical technique
The same surgical technique was applied to both procedures: reconstruction using either a prosthesis or an extender.The choice between the two techniques was always made at the time of surgery when the pliancy of the muscle was tested through the placement of molds.In cases where it was not possible to achieve a proper size with direct implantation of the prosthesis, a tissue expander was used.
Initially, the patient was subjected to mastectomy under general anesthesia by a mastology team and the weight of the part removed was assessed.Thereafter, the plastic surgery team took charge, preparing a submuscular pocket after infiltration with 0.9% saline solution and epinephrine (1:300,000), using the greater pectoral muscle, rectus abdominis, and the fascia of the anterior serratus (when possible) or the muscle itself.Rigorous hemostasis was performed followed by testing with molds and implant placement, either a prosthesis or expander.Finally, the surgical pocket was closed, a Portovac drain was placed, and the skin flaps were adjusted followed by sutures.

Statistical analysis
The statistical analysis was performed using SPSS 22.0 (IBM-SPSS Inc., Armonk, New York) software.Categorical variables were analyzed with the chi-square test and Fisher's exact test.The results were considered statistically significant when p ≤ 0.05.

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.
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).
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).
Of the 74 patients selected, 52 (70.27%) answered the pre-reconstruction questionnaire, while 48 (64.86%) 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.
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)

DISCUSSION
Breast cancer is the most prevalent cancer in women and often leads to a significant decrease in the ability to have a normal life 1 .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 depression [9][10][11][12] .
Plastic surgery is a specialty in which results are evaluated mainly by patient satisfaction 13 .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 others 14 .
Breast reconstructions with prostheses and/or tissue expanders are widely performed throughout the world and continue to be an excellent alternative   In terms of the breast satisfaction domain, statistical significance in the comparison of the preand 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).
Tables 3, 4, and 5 show the number of answers, in percentages, for each question in the pre-and postreconstruction 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 6 presents the descriptive statistics of  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 area 15 .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 age 16 .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/m 2 , which is higher than that in previously published data that indicated an average BMI of 22.0 kg/m 2 in breast reconstruction patients 17    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][19][20][21][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 studies [18][19][20][21][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 reduced 10 .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 sensuality 23 .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 reconstruction 24,25 .
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 satisfaction 26,27 .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 al 28 .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 wellbeing, 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 al 29 .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 al 30 .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 prereconstruction period.
Despite the feeling of mutilation and trauma incurred by the mastectomy procedure, breast reconstruction, when carefully executed by a welltrained and specialized team, can yield excellent aesthetic results.

COLLABORATIONS MCC
Analysis and/or data interpretation, final manuscript approval, realization of operations and/or trials.

ACC
Conception and design study, writingreview & editing.

CADCF
Analysis and/or data interpretation, final manuscript approval, realization of operations and/or trials.

GCS
Conception and design study, writingreview & editing.

FTV
Formal analysis.

JCD
Final manuscript approval.

Figure 1 .
Figure 1.How you look in the mirror clothed .

Figure 2 .
Figure 2. Ability to wear clothing that is more fitted.answeredthe post-reconstruction questionnaire.The responses of 4 patients who did not answer the postreconstruction 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 preand 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 (Figures1 and 2).Tables3, 4, and 5 show the number of answers, in percentages, for each question in the pre-and post-

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