Research Article: Most women recover from psychological distress after postoperative complications following implant or DIEP flap breast reconstruction: A prospective long-term follow-up study

Date Published: March 27, 2017

Publisher: Public Library of Science

Author(s): Reinier Timman, Jessica P. Gopie, J. Nick Brinkman, Annelies Kleijne, Caroline Seynaeve, Marian B. E. Menke-Pluymers, Moniek M. ter Kuile, Aad Tibben, Marc A. M. Mureau, Dongmei Li.


Substantial complication rates after postmastectomy breast reconstruction (BR) in breast cancer patients have been reported. Few studies have reported on the resulting psychological distress (PD) and satisfaction with the aesthetic result in relation to postoperative complications after completion of implant or DIEP flap BR. The present study investigated whether women were able to recover from complication related distress in the long term.

PD was prospectively measured using questionnaires regarding anxiety, depression and cancer distress. Eligible patients completed questionnaires before BR (T0, n = 144), after one month (T1, n = 139) and after completion of BR, approximately 21 months after initial reconstructive surgery (T2, n = 119). Satisfaction with the aesthetic result was assessed 21 months after BR. Data concerning complications, subsequent additional surgery and total reconstruction failure up to T2 were collected from the medical records. Analyses were performed using multi-level regression analyses correcting for age.

One or more complications occurred in 61 patients (42%) and 50 women required subsequent surgery (35%). In time, mean PD significantly declined towards baseline scores independent of complications. However, a total reconstruction failure (n = 10) was significantly associated with a large temporary increase in depression scores. After additional surgery due to complications patients were less satisfied with aesthetic outcome, although patient satisfaction was independent of PD.

PD outcomes generally declined to normal levels after completion of the entire BR course. Patients experiencing a total reconstruction failure reported more depression after this loss, but in the long term recovered to the same level as women without complications. These findings indicate that women generally can cope efficiently with these serious adverse events, even if they were less satisfied with the aesthetic result.

Partial Text

Breast reconstruction (BR) after mastectomy for breast cancer is generally a well considered option in case of either therapeutic treatment or preventive surgery. BR is intended to improve body image and quality of life, however, there is a considerable risk of complications which can lead to adverse psychosocial effects [1,2,3,4]. Understandably, BR will be accompanied by psychological distress but it may be expected that, in the longer term, women with adequate psychosocial resources will recover from distress, even after experiencing complications or less satisfaction with aesthetic outcome than expected. Yet, clinical experience shows that a sub-group of women remains distressed and finds it difficult to resume their lives in the longer term. Identification of risk factors for psychological distress after BR, including complications and subsequent additional surgery, allows professionals to adequately inform their patients, and to offer support if necessary, in addition to routine medical care.

The present study prospectively investigated the relationship between complications, subsequent additional surgery as well as a total reconstruction failure with psychological distress and patient satisfaction, before and after completion of breast reconstruction (BR) with either an implant or DIEP flap. The overall complication rate after BR in this study was comparable to data of other studies [14,28,29]. As expected, our study confirmed our hypothesis (and clinical experience) as well as Lu’s findings [16] and our clinical experience that in the long term most women recover from psychological distress. Understandably, the occurrence of complications leading to subsequent surgery was associated with lower patient satisfaction with aesthetic outcome.




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