BACKGROUND: Patient-reported outcome measures (PROMs) have become an integral part of the evaluation of reconstruction surgery outcomes. However, there are limitations in current PROMs when it comes to the assessment of well-being during inpatient stay, patient perception of health, relationship with partner, and vitality (i.e., mood and ability to work and pursue hobbies, carry out daily tasks, and sleep) following breast reconstructive surgery. The aim was to develop a novel set of measures to compare patient satisfaction and health-related quality of life following different types of postmastectomy breast reconstruction. METHODS: A novel questionnaire was created and refined through cognitive interviews with patients and expert feedback. A field test study was conducted, including patients who had undergone delayed postmastectomy breast reconstruction with implant, autologous tissue, or combination of implant and autologous tissue. Based on the results, confirmatory factor analysis and examination of reliability of the questionnaire were conducted. Results of patient responses were analyzed using Chi-square test, Kruskal-Wallis test, and Mann-Whitney U test. RESULTS: Confirmatory factor analysis showed good model fit, and Cronbach's alpha indicated high internal consistency of the questionnaire. Besides that, patients with combination reconstruction reported significantly lower vitality than patients with implant and autologous reconstruction (p = 0.048). CONCLUSIONS: This novel questionnaire expands the current knowledge base of postmastectomy breast reconstruction PROMs. Results of the field test study showed that combination reconstruction was associated with lower patient vitality than other reconstruction types. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Department of Plastic Surgery 3rd Faculty of Medicine and University Hospital Kralovske Vinohrady Charles University Prague Srobarova 50 10034 Prague 10 Czech Republic

Division of Plastic and Reconstructive Surgery Department of Surgery Stanford University School of Medicine 1651 Page Mill Road Palo Alto CA 94304 USA

Comment In

Aesthetic Plast Surg. 2022 Aug;46(4):1600-1601. doi: 10.1007/s00266-022-02993-6. PubMed

See more in PubMed

Fasse L, Flahault C, Vioulac C, Lamore K, Van Wersch A, Quintard B, Untas A (2017) The decision-making process for breast reconstruction after cancer surgery: representations of heterosexual couples in long-standing relationships. Br J Health Psychol 22:254–269 PubMed DOI

Cheng JYJ, Wong BWZ, Chin YH, Ong ZH, Ng CH, Tham HY, Samarasekera DD, Devi KM, Chong CS (2021) Preoperative concerns of patients undergoing general surgery. Patient Educ Couns 104:1467–1473 PubMed DOI

Makkar N, Jain K, Siddharth V, Sarkar S (2019) Patient involvement in decision-making: an important parameter for better patient experience—an observational study (STROBE Compliant). J Patient Exp 6:231–237 PubMed DOI

Somogyi RB, Ziolkowski N, Osman F, Ginty A, Brown M (2018) Breast reconstruction: updated overview for primary care physicians. Can Fam Physician 64:424–432 PubMed PMC

Cano SJ, Browne JP, Lamping DL (2004) Patient-based measures of outcome in plastic surgery: current approaches and future directions. Br J Plast Surg 57:1–11 PubMed DOI

Pusic AL, McCarthy C, Cano SJ, Klassen AF, Kerrigan CL (2008) Clinical research in breast surgery: reduction and postmastectomy reconstruction. Clin Plast Surg 35:215–226 PubMed DOI

Bojic D, Bodger K, Travis S (2017) Patient reported outcome measures PROMs in inflammatory bowel disease: new data. J Crohns Colitis 11(supp1–2):576–585

Borg S, Eeg-Olofsson K, Palaszewski B, Svedbo Engström M, Gerdtham UG, Gudbjörnsdottir S (2019) Patient-reported outcome and experience measures for diabetes: development of scale models, differences between patient groups and relationships with cardiovascular and diabetes complication risk factors, in a combined registry and survey study in Sweden. BMJ Open 9:025033 DOI

Spector DJ, Mayer DK, Knafl K, Pusic A (2011) Women’s recovery experiences after breast cancer reconstruction surgery. J Psychosoc Oncol 29:664–676 PubMed DOI

Faria FS, Guthrie E, Bradbury E, Brain AN (1999) Psychosocial outcome and patient satisfaction following breast reduction surgery. Br J Plast Surg 52:448–452 PubMed DOI

Reaby LL, Hort LK, Vandervord J (1994) Body image, self-concept, and self-esteem in women who had a mastectomy and either wore an external breast prosthesis or had breast reconstruction and women who had not experienced mastectomy. Health Care Women Int 15:361–375 PubMed DOI

Imran M, Al-Wassia R, Alkhayyat SS, Baig M, Al-Saati BA (2019) Assessment of quality of life (QoL) in breast cancer patients by using EORTC QLQ-C30 and BR-23 questionnaires: a tertiary care center survey in the western region of Saudi Arabia. PLoS One 14:e0219093 PubMed DOI PMC

Cheung YB, Luo N, Ng R, Lee CF (2014) Mapping the functional assessment of cancer therapy-breast (FACT-B) to the 5-level EuroQoL Group’s 5-dimension questionnaire (EQ-5D-5L) utility index in a multi-ethnic Asian population. Health Qual Life Outcomes 12:180 PubMed DOI PMC

Baker JL, Dizon DS, Wenziger CM, Streja E, Thompson CK, Lee MK, DiNome ML, Ataai DJ (2021) “Going flat” after mastectomy: patient-reported outcomes by online survey. Ann Surg Oncol 28:2493–2505 PubMed DOI

Stanton AL, Krishnan L, Collins CA (2001) Form or function? part 1. Subjective cosmetic and functional correlates of quality of life in women treated with breast-conserving surgical procedures and radiotherapy. Cancer 91:2273–2281 PubMed DOI

Cohen M, Evanoff B, George LT, Brandt KE (2005) A subjective rating scale for evaluating the appearance outcome of autologous breast reconstruction. Plast Reconstr Surg 116:440–449 PubMed DOI

Baxter NN, Goodwin PJ, McLeod RS, Dion R, Devins G, Bombardier C (2006) Reliability and validity of the body image after breast cancer questionnaire. Breast J 12:221–232 PubMed DOI

Temple-Oberle CF, Cook EF, Bettger-Hahn M, Mychailyshyn N, Naeem H, Macdermid J (2012) Development of a breast reconstruction satisfaction questionnaire (BRECON-31): principal components analysis and clinimetric properties. J Surg Oncol 106:799–806 PubMed DOI

Wilkins EG, Cederna PS, Lowery JC, Davis JA, Kim HM, Roth RS, Goldfarb S, Izenberg PH, Houin HP, Shaheen KW (2000) Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the michigan breast reconstruction outcome study. Plast Reconstr Surg 106:1014–25. Discussion 1026–7

Liu LQ, Branford OA, Mehigan S (2018) BREAST-Q measurement of the patient perspective in oncoplastic breast surgery: a systematic review. Plast Reconstr Surg Glob Open 6:e1904 PubMed DOI PMC

Liu T, Freijs C, Klein HJ, Feinbaum A, Svee A, Lorenzo AR, Liss A, Acosta R, Mani M (2018) Patients with abdominal-based free flap breast reconstruction a decade after surgery: a comprehensive long-term follow-up study. J Plast Reconstr Aesthet Surg 71:1301–1309 PubMed DOI

Cohen WA, Mundy LR, Ballard TN, Klassen A, Cano SJ, Browne J, Pusic AL (2016) The breast-Q in surgical research: a review of the literature 2009–2015. J Plast Reconstr Aesthet Surg 69:149–162 PubMed DOI

Cano SJ, Klassen AF, Scott AM, Pusic AL (2013) A closer look at the BREAST-Q(©). Clin Plast Surg 40:287–296 PubMed DOI

Selimen D, Andsoy II (2011) The importance of a holistic approach during the perioperative period. AORN J 93:482–487, quiz 488-90

Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ (2009) Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg 124:345–353 PubMed DOI

Lai WS, Shu BC, Hou WL (2019) A qualitative exploration of the fear of recurrence among Taiwanese breast cancer survivors. Eur J Cancer Care (Engl) 28:e13113 DOI

Fekih-Romdhane F, Henchiri H, Ridha R, Labbane R, Cheour M (2019) Psychological distress and caregiving burden among spouses of women with breast cancer. Encephale 45:190–192 PubMed DOI

Andrzejczak E, Markocka-Mączka K, Lewandowski A (2013) Partner relationships after mastectomy in women not offered breast reconstruction. Psychooncology 22:1653–1657 PubMed DOI

Sergesketter AR, Thomas SM, Lane WO, Shammas RL, Greenup RA, Hollenbeck ST (2019) The Influence of Marital Status on Contemporary Patterns of Postmastectomy Breast Reconstruction. J Plast Reconstr Aesthet Surg 72:795–804 PubMed DOI

Duijts SF, van Egmond MP, Spelten E, van Muijen P, Anema JR, van der Beek AJ (2014) Physical and psychosocial problems in cancer survivors beyond return to work: a systematic review. Psychooncology 23:481–492 PubMed DOI

Hayes SC, Rye S, Battistutta D, DiSipio T, Newman B (2010) Upper-body morbidity following breast cancer treatment is common, may persist longer-term and adversely influences quality of life. Health Qual Life Outcomes 8:92 PubMed DOI PMC

Marsili C, Wilson CM, Gura N (2019) Prospective Surveillance Screenings to Identify Physical Therapy Needs During Breast Cancer Diagnosis and Surviviorship: A Case Report. Cureus 11:e5265 PubMed PMC

Blackburn NE, Mc Veigh JG, Mc Caughan EM, Kennedy RD, McIntosh SA, Wilson IM (2018) The musculoskeletal consequences of latissmus dorsi breast reconstruction in women following mastectomy for breast cancer. PLoS One 13:e0202859 PubMed DOI PMC

Lee KT, Mun GH (2014) A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer. Plast Reconstr Surg 134:303–314 PubMed DOI

Christensen BO, Overgaard J, Kettner LO, Damsgaard TE (2011) Long-term evaluation of postmastectomy breast reconstruction. Acta Oncol 50:1053–1061 PubMed DOI

Potter S, Harcourt D, Cawthorn S, Warr R, Mills N, Havercroft D, Blazeby J (2011) Assessment of cosmesis after breast reconstruction surgery: a systematic review. Ann Surg Oncol 18:813–823 PubMed DOI

Potter S, Brigic A, Whiting PF, Cawthorn SJ, Avery KN, Donovan JL, Blazeby JM (2011) Reporting clinical outcomes of breast reconstruction: a systematic review. J Natl Cancer Inst 103:31–46 PubMed DOI

Kuo NT, Kuo YL, Lai HW, Ko NY, Fang SY (2019) The influence of partner involvement in the decision-making process on body image and decision regret among women receiving breast reconstruction. Support Care Cancer 27:1721–1728 PubMed DOI

Streiner DL, Norman GR (2008) Health measurement scales: a practical guide to their development and use, 4th edn. Oxford University Press, New York DOI

Aaronson N, Alonso J, Burnam A, Lohr KN, Patrick DL, Perrin E, Stein RE (2002) Assessing health status and quality-of-life instruments: attributes and review criteria. Qual Life Res 11:193–205 PubMed DOI

Patrick DL, Burke LB, Gwaltney CJ, Leidy NK, Martin ML, Molsen E, Ring L (2011) Content validity—establishing and reporting the evidence in newly developed patient-reported outcomes (PRO) instruments for medical product evaluation: ISPOR PRO good research practices task force report: part 1—eliciting concepts for a new PRO instrument. Value Health 14:967–977 PubMed DOI

Patrick DL, Burke LB, Gwaltney CJ, Leidy NK, Martin ML, Molsen E, Ring L (2011) Content validity—establishing and reporting the evidence in newly developed patient-reported outcomes (PRO) instruments for medical product evaluation: ISPOR PRO Good Research Practices Task Force report: part 2—assessing respondent understanding. Value Health 14:978–988 PubMed DOI

Willis GB (2015) Analysis of the cognitive interview in questionnaire design: understanding qualitative research. Oxford University Press, Toronto

Opdenakker R (2006) Advantages and disadvantages of four interview techniques in qualitative research: Forum qualitative Sozialforschung/Forum. 7th vol Qualitative Social Research, doi.org/ https://doi.org/10.17169/fqs-7.4.175,2006/09/30

Cronbach LJ (1951) Coefficient alpha and the internal structure of tests. Psychometrika 16:297–334 DOI

Kline P (1993) The handbook of psychological testing. Routledge, London

Gliem A, Gliem R (2003) Calculating, interpreting, and reporting cronbach’s alpha reliability coefficient for likert-type scales. midwest research-to-practice conference in adult, continuing, and community education, The Ohio State University, Columbus, OH, October 2003/10/8-10

Zafar SN, Ellsworth WA 4th (2015) Reduction and mastopexy of the reconstructed breast: special considerations in free flap reconstruction. Semin Plast Surg 29:110–121 PubMed DOI PMC

Frey JD, Salibian AA, Karp NS, Choi M (2017) Examining Length of Hospital Stay after Microsurgical Breast Reconstruction: Evaluation in a Case-Control Study. Plast Reconstr Surg Glob Open 5:e1588 PubMed DOI PMC

Ludolph I, Horch RE, Harlander M, Arkudas A, Bach AD, Kneser U, Schmitz M, Taeger CD, Beier JP (2015) Is there a Rationale for Autologous Breast Reconstruction in Older Patients? A Retrospective Single Center Analysis of Quality of life, Complications and Comorbidities after DIEP or ms-TRAM Flap Using the BREAST-Q. Breast J 21:588–595 PubMed DOI

Campbell-Enns H, Woodgate R (2015) The psychosocial experiences of women with breast cancer across the lifespan: a systematic review protocol. JBI Database System Rev Implement Rep 13:112–121 PubMed DOI

Jabłoński MJ, Streb J, Mirucka B, Słowik AJ, Jach R (2018) The relationship between surgical treatment (mastectomy vs. breast conserving treatment) and body acceptance, manifesting femininity and experiencing an intimate relation with a partner in breast cancer patients. Psychiatr Pol 52: 859-872 [Article in English, Polish.]

Rowland JH, Meyerowitz BE, Crespi CM, Leedham B, Desmond K, Belin TR, Ganz PA (2009) Addressing intimacy and partner communication after breast cancer: a randomized controlled group intervention. Breast Cancer Res Treat 118:99–111 PubMed DOI PMC

Rowland E, Metcalfe A (2014) A systematic review of men’s experiences of their partner’s mastectomy: coping with altered bodies. Psychooncology 23:963–974 PubMed DOI

Archangelo SCV, Sabino Neto M, Veiga DF, Garcia EB, Ferreira LM (2019) Sexuality, depression and body image after breast reconstruction. Clinics (Sao Paulo) 74:e883 DOI

Tenna S, Salzillo R, Brunetti B, Morelli Coppola M, Barone M, Cagli B, Cogliandro A, Franceschi F, Persichetti P (2020) Effects of latissimus dorsi (LD) flap harvest on shoulder function in delayed breast reconstruction. A long-term analysis considering the acromiohumeral interval (AHI), the WOSI, and BREAST-Q questionnaires. J Plast Reconstr Aesthet Surg 73:1862–1870 PubMed DOI

Koh E, Watson DI, Dean NR (2018) Quality of life and shoulder function after latissimus dorsi breast reconstruction. J Plast Reconstr Aesthet Surg 71:1317–1323 PubMed DOI

Nelson JA, Lee IT, Disa JJ (2018) The functional impact of breast reconstruction: an overview and update. Plast Reconstr Surg Glob Open 6:e1640 PubMed DOI PMC

Steffenssen MCW, Kristiansen AH, Damsgaard TE (2019) A systematic review and meta-analysis of functional shoulder impairment after latissimus dorsi breast reconstruction. Ann Plast Surg 82:116–127 PubMed DOI

Eyjolfsdottir H, Haraldsdottir B, Ragnarsdottir M, Asgeirsson KS (2017) A prospective analysis on functional outcomes following extended latissimus dorsi flap breast reconstruction. Scand J Surg 106:152–157 PubMed DOI

Bruce J, Williamson E, Lait C, Richmond H, Betteley L, Lall R, Petrou S, Rees S, Withers EJ, Lamb SE, Thompson AM, PROSPER Study Group (2018) Randomised controlled trial of exercise to prevent shoulder problems in women undergoing breast cancer treatment: study protocol for the prevention of shoulder problems trial (UK PROSPER). BMJ Open 8:e019078 PubMed DOI PMC

Hamdi M, Salgarello M, Barone-Adesi L, Van Landuyt K (2008) Use of the thoracodorsal artery perforator (TDAP) flap with implant in breast reconstruction. Ann Plast Surg 61:143–146 PubMed DOI

Abdelrahman EM, Nawar AM, Balbaa MA, Shoulah AA, Shora AA, Kharoub MS (2019) Oncoplastic volume replacement for breast cancer: latissimus dorsi flap versus thoracodorsal artery perforator flap. Plast Reconstr Surg Glob Open 7:e2476 PubMed DOI PMC

Brambilla L, Parisi P, Gatto A, Codazzi D, Baronetto N, Gilardi R, Giovanazzi R, Marchesi A (2021) A retrospective comparative analysis of latissimus dorsi (LD) flap versus thoracodorsal artery perforator (TDAP) flap in total breast reconstruction with implants: a pilot study. J Reconstr Microsurg. Epub ahead of print

Rindom MB, Gunnarsson GL, Lautrup MD, Christensen RD, Tos T, Hölmich LR, Sørensen JA, Thomsen JB (2019) Shoulder-related donor site morbidity after delayed breast reconstruction with pedicled flaps from the back: An open label randomized controlled clinical trial. J Plast Reconstr Aesthet Surg 72:1942–1949 PubMed DOI

Thomsen JB, Gunnarsson GL (2014) The evolving breast reconstruction: from latissimus dorsi musculocutaneous flap to a propeller thoracodorsal fasciocutaneous flap. Gland Surg 3:151–154 PubMed PMC

El-Shebly AM, El-Hadidy MR, Shehabeldin SA, El Din AB, Zeina AM, Zayed AE, El Fahar MH (2021) Outcome comparison between thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap in axillary reconstruction after hidradenitis suppurativa excision. Microsurgery 42:143–149 PubMed DOI

Angrigiani C, Rancati A, Escudero E, Artero G (2015) Extended thoracodorsal artery perforator flap for breast reconstruction. Gland Surg 4:519–527 PubMed PMC

Youssif S, Hassan Y, Tohamy A, Eid S, Ashour T, Malahias M, Khalil H (2019) Pedicled local flaps: a reliable reconstructive tool for partial breast defects. Gland Surg 8:527–536 PubMed DOI PMC

Hekkert KD, Cihangir S, Kleefstra SM, van den Berg B, Kool RB (2009) Patient satisfaction revisited: a multilevel approach. Soc Sci Med 69:68–75 PubMed DOI

Chapin L, Ward K, Ryken T (2017) Preoperative depression, smoking, and employment status are significant factors in patient satisfaction after lumbar spine surgery. Clin Spine Surg 30:E725–E732 PubMed DOI