Role of Appearance-Pain in breast surgery: Impact on patient's appearance perception of autologous and implant based breast reconstruction following mastectomy and analysis of possible predictive factors of satisfaction

Appearance is a part of a complex system whose components interact in multidimensional ways and follow general, local and circular rules with non-linear logic. App-Pain consists of the re-composed systematic view of the experimental indicators of suffering, linked to one of the dimensions of appearance. The use of reliable, valid, and responsive patient questionnaires is essential to provide information about appearance and body image in each patient. The breasts represent the fulcrum of female sexuality and are one of the central and most important points for all women. It has been well known for decades that mastectomy after the whole breast involves not only a physical demolition, but also results in psychological discomfort in a woman's social, relational, and sexual life. Over the decades, reconstructive surgery techniques have been increasingly refined in order to allow patients to have a high quality of life. The reconstructive technique must be chosen based on the characteristics of the patient, the therapies already performed or to be performed, and the tissue to be reconstructed. However, we can evaluate in the long term and with the same initial condition and therapy, what is the percentage of the body of women who have undergone mastectomy and who have been reconstructed with microsurgical flaps and breast implants. Patient-reported outcomes following breast reconstruction are one of the most important success parameters. In this systematic review and meta-analysis, we aimed to compare the two methods using the recognized BREAST-Q questionnaire. In the literature, there are already comparative and prospective studies concerning this topic, all of which conclude that microsurgical reconstructions lead to the best long-term results, with fewer secondary procedures and with a better quality of life. Many studies have been performed with generic evaluation scales, with ad hoc questionnaires, and others with specific questionnaires. BREAST-Q is currently the most complete questionnaire and is indicated as the best tool for post-operative evaluation of breast interventions. Few studies have used BREAST-Q. In Italy, there is no study that compares the two long-term reconstructive techniques using the BREAST-Q. For this reason, the purpose of this study is to determine if there is a better quality of life with one of the two techniques and if the results are in line with those already present in the literature. The hypothesis from which we started is to demonstrate that cancer patients who undergo a deep inferior epigastric perforator flap (DIEP) breast reconstruction surgery are more satisfied and have a higher level of quality of life compared to those subjected to an intervention of reconstruction with prosthesis. The other purpose of this study is to analyze, on a sample of patients who have undergone both autologous and prosthetic mastectomy and reconstruction, that all or only some of these factors can influence the perception of the body. The usefulness of these results is to consider predictive factors that may influence patients in order to prepare them for the type of path and perception they will have once undertaken. This is the first study performed on the Italian population that compares autologous surgical techniques with the implantation of breast implants. In this population, DIEP is considered the technique that leads to the highest satisfaction in all BREAST-Q scores. Each country should conduct a study on this topic because the perception of one's body could be influenced by cultural factors and it would be interesting to analyze the case history of each country that deals with this type of surgery. This study is the first that groups a large number of patients and analyzes predictive factors of long-term satisfaction of patients undergoing breast reconstruction. Other studies are needed to corroborate these data and can evaluate, with different cultural adaptations, this same topic. This can be regarded as a pilot study to raise the awareness of everyone's clinical practice to predict the attitude that patients have after surgery and to prepare them in the best possible way. In our study, none of the predictive factors influenced post-operative satisfaction except the type of mastectomy and the type of reconstruction performed. Patients undergoing nipple sparing mastectomy and DIEP flap reconstruction were the most satisfied, regardless of age, BMI, or type of cancer therapies performed.