Aesth Plast Surg (2023) 47:2295–2303

https://doi.org/10.1007/s00266-023-03642-2

ORIGINAL ARTICLES BREAST SURGERY

BREAST-Q-Based Survey of the Satisfaction and Health Status

of Patients with Breast Reconstruction
Lina Jiang1 • Xiaohui Ji2 • Wei Liu3 • Chuanchuan Qi3 • Xiaomei Zhai1

Received: 2 June 2023 / Accepted: 24 August 2023 / Published online: 11 September 2023
Ó The Author(s) 2023

Abstract submucosa (SIS) matrix (b = 0.13, P = 0.044) were inde-

Aims To explore the patients’ satisfaction and health-re- pendent risk factors influencing the HRQOL scores.
lated quality of life (HRQOL) of patients who received Conclusion Age, the surgical procedure, and the use of
reconstruction after breast cancer surgery using the matrix were associated with the satisfaction degree and
BREAST-Q questionnaire and further investigate the HRQOL after breast reconstruction in patients receiving
influencing risk factors. mastectomy.
Methods This cross-sectional study enrolled patients who Level of Evidence II This journal requires that authors
underwent first-ever breast reconstruction after unilateral assign a level of evidence to each article. For a full
or bilateral mastectomy at the Breast Surgery Department description of these Evidence-Based Medicine ratings,
of First Affiliated Hospital of Zhengzhou University or please refer to the Table of Contents or the online
People’s Hospital of Zhengzhou between January 2016 and Instructions to Authors www.springer.com/00266.
December 2021. Multivariable linear regression analysis
was used to analyze the risk factors. Keywords Breast cancer
Quality of life
Mastectomy

Results A total of 202 participants were included. Age of Reconstructive surgical procedures
Patient satisfaction

[45 years (vs.B35 years, b = - 3.74, P \ 0.001) was an Health status
independent risk factor influencing the satisfaction degree
score. Age between 36 and 45 years (vs. B35 years,
b = - 0.26, P \ 0.001), age of [45 years (vs. B35 years, Introduction
b = - 0.45, P \ 0.001), nipple-preserving mastectomy
(NSM)/ skin-preserving mastectomy (SSM) ? sentinel Breast cancer is the most common malignancy diagnosed
lymph node dissection ? prosthesis implantation ? con- in women worldwide, with estimated new cases of
tralateral breast augmentation (vs. NSM/SSM ? sentinel 2,261,419 in 2020 [1, 2]. Early or resectable breast cancer,
lymph node dissection ? prosthesis implantation, which is considered potentially curable, includes stage
b = - 0.16, P=0.012), and the use of small intestinal I-IIB and some stage IIIA cancers, specifically T3, N1
tumors [3]. The prognosis of breast cancer is generally
satisfying, with a 5-year survival rate of 99 and 85% for
& Xiaomei Zhai patients with localized disease and regional spread,
34405917@qq.com; zhaixiaomei@zzu.edu.cn respectively [2]. Surgery is the mainstay treatment of breast
1
Deparment of Plastic Surgery, The first affiliated hospital of
cancer, but it will inevitably lead to cosmetic breast defects
zhengzhou university, No. 1 East Construction Road, Jinshui or missing breasts [4]. The breast is essential to body image
District, Zhengzhou 450052, China for women, and many of them would have to live their
2
Department of Pathology, The people’s Hospital of entire life with an impaired body image [5, 6]. Hence,
Zhengzhou, Zhengzhou, China breast reconstruction surgery is an option to correct the
3
Department of Breast Surgery, The people’s Hospital of shape of the breast after lumpectomy or reconstruct a breast
Zhengzhou, Zhengzhou, China after mastectomy [4, 7].

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2296 Aesth Plast Surg (2023) 47:2295–2303

Depression is a major threat to the quality of life (QOL) The inclusion criteria were: (1) age of C 18 years; (2)
of women with breast cancer since it deteriorates the diagnosed with primary breast cancer according to the
patients’ somatic symptoms, decreases general functioning, Guidelines of the Chinese Society of Clinical Oncology on
and can even compromise adherence to treatments [8]. The Breast Cancer (2021 version) [18] and received surgery; (3)
proportion of women with breast cancer and depression underwent reconstruction after breast cancer surgeries,
was estimated at 11–20% [9]. Patients who did not undergo using implantation materials (TE/Imp), latissimus dorsi
plastic surgery after mastectomy can have higher levels of flap, or transverse rectus abdominis myocutaneous flap
depression and loneliness as well as poorer physical, social, (TRAM); (4) volunteered to participate in this study and
and emotional functioning [10–12]. Breast reconstruction complete the questionnaire survey. The exclusion criteria
has been shown to improve mental health, stress, loneli- were: (1) prosthesis-related infections or ischemic necrosis
ness, and anxiety, but at the cost of higher physical dis- of the flap; (2) tumor relapse or distal metastasis; or (3)
comfort and perceived physical distress [13]. A meta- incomplete baseline clinical data or follow-up.
analysis also concluded the uncertainty of the actual ben-
efits brought by breast reconstruction to women [14]. Questionnaire
Therefore, additional studies are necessary to find out
the actual impact of breast reconstruction on the mental The questionnaire was self-designed by the investigators
and physical health outcomes of women. The BREAST-Q after reviewing relevant studies and the medical records of
is a patient-reported outcome tool that can be used to patients. The questionnaire collected demographic charac-
quantify the impact and effectiveness of breast surgery, teristics and disease-related information. The demographic
including a questionnaire specific to reconstruction characteristics included age of disease onset, marital status,
[15, 16]. A meta-analysis also supported the value of the family income, and body mass index (BMI). The disease-
BREAST-Q in measuring patients’ satisfaction and health- related information included other underlying diseases
related QOL (HRQOL) after oncoplastic surgeries [17]. (e.g., hypertension and thyroid diseases), radiotherapy,
Furthermore, it is crucial to investigate the acceptance and chemotherapy, targeted therapy, endocrine therapy, axil-
postoperative satisfaction of patients, particularly regarding lary lymph node dissection, tumor stage, molecular clas-
prosthesis reconstruction, in regions with high incidence of sification, surgical mode, breast volume, and timing of
breast cancer and with conservative ideology. By under- reconstruction. The breast cancer-related clinical informa-
standing the specific factors that influence satisfaction and tion was collected by reviewing the medical records of the
HRQOL, clinicians can work toward improving the popu- patients to guarantee the accuracy of the data.
larity and effectiveness of prosthesis reconstruction in
patients who have received breast mastectomy.
Hence, this study aimed to explore the satisfaction and BREAST-Q scale
health status of patients who received reconstruction after
breast cancer surgery using the BREAST-Q questionnaire The BREAST-Q is a validated patient-reported scale that
and further investigate the factors influencing the patients’ assesses the HRQOL and satisfaction degree of patients
satisfaction and HRQOL. The results could help improve before and after breast reconstruction and plastic surgery
the management of women with breast cancer. [15]. The satisfaction degree part includes the satisfaction
degrees regarding the breast, information, and medical
team. The HRQOL part includes social psychological
Subjects and methods health, body health of the chest and upper limbs, and sexual
health. The scoring system of BREAST-Q ranges from 0 to
Study design and participants 100 points according to the performances of patients in
different dimensions, and higher scores indicate higher
This cross-sectional study enrolled patients who underwent HRQOL or satisfaction degree. The Chinese version
first-ever breast reconstruction after unilateral or bilateral BREAST-Q scale was used in this study, of which the
mastectomy between January 2016 and December 2021 at overall internal consistency coefficient of the five modules
the Breast Surgery Department of First Affiliated Hospital was 0.912–0.980, and the internal consistency coefficient
of Zhengzhou University or People’s Hospital of Zhengz- of a single dimension in each module was 0.741–0.978,
hou. The study was approved by the Ethics Committees of indicating its high validity and reliability [19]. The ques-
the First Affiliated Hospital of Zhengzhou University or tionnaires with less than 2/3 of the questions completed, or
People’s Hospital of Zhengzhou. Written informed consent all the questions that were replied to by the same choice,
was obtained from all participants. were considered invalid and excluded.

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Aesth Plast Surg (2023) 47:2295–2303 2297

Statistical analysis (P \ 0.001), ‘‘Psychosocial Well-being’’ (P \ 0.001),

‘‘Physical Well-being: Chest’’ (P \ 0.001), ‘‘Sexual Well-
SPSS 26.0 (IBM, Armonk, NY, USA) was used for sta- being’’ (P \ 0.001), ‘‘Satisfaction with the surgeons’’
tistical analysis. The continuous data were all with normal (P \ 0.001), ‘‘Satisfaction with the medical team’’
distribution according to Kolmogorov–Smirnov test; they (P \ 0.001), ‘‘Satisfaction with papilla’’ (P = 0.040),
were described as means ± standard deviations and com- ‘‘Satisfaction with the information’’ (P = 0.006), and
pared using analysis of variances (ANOVA). Categorical ‘‘Satisfaction with the other medical staff’’ (P = 0.001)
data were described as numbers and percentages. Paired- were significantly different among the three subgroups,
sample t test was used in the comparison between before except for ‘‘Satisfaction with the prosthesis’’ (P = 0.073).
and after surgery. Data among the three age subgroups
were compared using one-way ANOVA test. For the Multivariable analysis of satisfaction degree
multivariable linear regression analysis, satisfaction degree and HRQOL
and HRQOL were used as the dependent variables, and the
baseline characteristics with statistical significance were Age of [ 45 years (vs. B35 years, b = - 3.74,
used as the independent variables. Two-sided P-values P \ 0.001) was an independent risk factor influencing the
\0.05 were considered statistically significant. satisfaction degree score (Table 2). Age between 36 and 45
years (vs. B35 years, b = - 0.26, P \ 0.001), age of [ 45
years (vs. B35 years, b = - 0.45, P \ 0.001), NSM/SSM
Results ? sentinel lymph node dissection ? prosthesis implanta-
tion ? contralateral breast augmentation (vs. NSM/SSM ?
Characteristics of the participants sentinel lymph node dissection ? prosthesis implantation,
b = - 0.16, P = 0.012), and the use of an SIS matrix
A total of 213 participants were enrolled. One patient was (b = 0.13, P = 0.044) were independent risk factors influ-
excluded for prosthesis-related infection, one for flap encing the HRQOL score (Table 3).
ischemia, and nine for invalid questionnaires. The baseline
characteristics, satisfaction degree, and HRQOL are shown
in Table 1. The satisfaction degree of the participants was Discussion
significantly lower with increasing age (P \ 0.001),
increasing BMI (P = 0.001), higher TNM stages This study showed that age of [ 45 years was associated
(P \ 0.001), with radiotherapy (P \ 0.001), with with lower satisfaction degree score, while age of C36
chemotherapy (P \ 0.001), without neoadjuvant years, NSM/SSM ? sentinel lymph node dissection ?
chemotherapy (P = 0.001), and different surgical approach prosthesis implantation ? contralateral breast augmenta-
(P = 0.027) (Table 1). The HRQOL was significantly tion, and the use of SIS matrix were independent factors
lower with increasing age groups (P \ 0.001), higher TNM influencing the HRQOL scores. These results indicated
stages (P = 0.012), without radiotherapy (P \ 0.001), with which patients were more likely to achieve a better
neoadjuvant chemotherapy (P \ 0.001), with different HRQOL after breast reconstruction and could help improve
surgical approaches (P = 0.034), longer scars (P = 0.019), the management of women with breast cancer.
without flap harvesting (P = 0.014), and the use of small In this study, age was the only factor related to both
intestinal submucosa (SIS) matrix (TiLOOP Product, Pfm satisfaction and HRQOL, with older women being less
medical titanium gmbh, Germany) (P = 0.004) (Table 1). satisfied with their reconstruction. Complications become
The comparison of satisfaction degree score between more frequent with age, and complications were negatively
before and after surgery and among the age subgroups was associated with the mental health score [20]. Still, age
presented in supplementary Table 1 and 2. ‘‘Satisfaction should not be a contraindication to breast reconstruction
with Breasts,’’ ‘‘Psychosocial Well-being,’’ ‘‘Satisfaction [20]. Girotto et al. [21] also reported that breast recon-
with papilla,’’ and ‘‘Sexual Well-being’’ showed significant struction in older women could help maintain HRQOL but
decrease after surgery compared to that before surgery as HRQOL could be affected in older women by various
well as in all age subgroups (all P \ 0.001). ‘‘Physical physical limitations and comorbidities, while the older
Well-being: Chest’’ significantly increased after surgery women scored better than younger ones regarding the
than that before surgery in all age subgroups (all mental outcomes. Ritter et al. [22] also found out that age
P \ 0.001). ‘‘Satisfaction with Breasts,’’ ‘‘Psychosocial had a significant impact on QOL after reconstruction but
Well-being,’’ and ‘‘Sexual Well-being’’ before surgery was not a contraindication. Indeed, younger patients have
were significantly different among the three age subgroups worse QOL outcomes in the social domain because they
(all P \ 0.001). After surgery, ‘‘Satisfaction with Breasts’’ are often more concerned with their physical appearance

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 Table 1 Characteristics of the patients
2298

Characteristic n (%) Satisfactory degree score P HRQOL P

123
Total score 206.5±18.6 73.6±10.6
Age \0.001 \0.001
B 35 years 65 (32.2) 214.3±13.9 78.2±11.4
36–45 years 84 (41.6) 207.1±18.9 73.6±9.4
[ 45 years 53 (26.2) 196.1±18.3 67.9±8.7
Educational level 0.190 0.098
Primary school or junior middle school 38 (18.8) 203.0±18.0 71.0±11.5
Senior middle school or higher 164 (81.2) 207.3±18.6 74.2±10.3
Marital status 0.117 0.203
Married 19 3 (95.5) 206.1±18.7 73.4±10.7
Unmarried 9 (4.5) 216.0±12.5 78.00±7.3
Residence 0.436 0.249
Towns or cities 116 (57.4) 207.4±20.3 74.34±10.9
Rural area 86 (42.6) 205.3±15.9 72.59±10.1
Body mass index 0.001 0.498
\ 18.5 kg/m2 5 (2.5) 215.8±6.7 79.00±14.3
18.5–24 kg/m2 143 (70.8) 209.3±16.3 73.58±9.9
[ 24 kg/m2 54 (26.7) 198.4±22.2 73.13±12.0
TNM stage \0.001 0.012
0–I 77 (38.1) 211.3±14.3 71.12±11.5
II 109 (54.0) 205.3±19.8 74.61±10.2
III–IV 16 (7.9) 191.7±20.1 78.56±5.1
Radiotherapy \0.001 \0.001
Yes 51 (25.2) 196.0±19.1 78.5±7.2
No 151 (74.8) 210.1±17.0 71.9±11.1
Chemotherapy \0.001 0.416
Yes 125 (61.9) 202.9±19.8 74.1±10.3
No 77 (38.1) 212.3±14.7 72.8±11.1
Endocrine therapy 0.579 0.425
Yes 135 (66.8) 207.0±16.8 74.0±10.0
No 67 (33.2) 205.5±21.7 72.8±11.7
Neoadjuvant chemotherapy 0.001 \0.001
Yes 47 (23.3) 198.4±20.4 78.5±9.3
No 155 (76.7) 209.0±17.3 72.1±10.6
Surgical approach 0.027 0.034
Aesth Plast Surg (2023) 47:2295–2303
 Table 1 continued
Characteristic n (%) Satisfactory degree score P HRQOL P

Anterior pectoralis approach 10 (5.0) 193.9±15.8 80.5±6.4

Posterior pectoralis approach 192 (95.0) 207.2±18.5 73.2±10.7
Surgical mode 0.133 \0.001
NSM/ssm? sentinel lymph node dissection ? prosthesis implantation 128 (63.4) 208.5±16.8 72.5±10.4
NSM/ssm? axillary lymph node dissection ? prosthesis implantation 35 (17.3) 202.6±25.2 78.4±9.5
NSM/ssm? sentinel lymph node dissection ? prosthesis implantation 22 (10.9) 207.7±15.9 67.2±11.0
? contralateral breast augmentation
Latissimus dorsi flap 5 (2.5) 204.0±22.6 78.8±7.4
Aesth Plast Surg (2023) 47:2295–2303

Transverse rectus abdominis myocutaneous flap 12 (5.9) 195.9±13.0 81.1±6.3

Breast volume 0.166 0.940
B 200 mL 82 (40.6) 208.8±16.6 73.3±9.6
201–300 mL 102 (50.5) 205.8±20.2 73.8±11.6
[ 300 mL 18 (8.9) 200.1±16.1 73.7±9.3
Length of scar 0.116 0.019
[20 cm 185 (91.6) 207.3±18.6 73.0±10.7
10–20 cm 5 (2.5) 204.0±22.6 78.8±7.4
\10 cm 12 (5.9) 195.9±13.0 81.1±6.3
Time of breast reconstruction 0.814 0.549
B 1 year 48 (23.8) 207.1±15.9 72.8±10.9
2–3 years 154 (76.2) 206.3±19.3 73.8±10.5
Timing of reconstruction 0.277 0.261
Immediate reconstruction 198 (98.0) 206.7±18.6 73.5±10.6
2-phase reconstruction 4 (2.0) 196.5±10.3 79.5±6.6
Flap harvesting 0.068 0.014
Yes 16 (7.9) 198.6±16.5 79.9±6.3
No 185 (91.6) 207.4±18.5 73.1±10.7
Use of SIS matrix 0.128 0.004
Yes 4 (2.0) 220.5±8.2 88.8±5.9
No 198 (98.0) 206.2±18.6 73.3±10.5
NSM: nipple-preserving mastectomy; SSM: skin-preserving mastectomy; HRQOL, health-related quality of life; SIS, small intestinal submucosa.
2299

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Table 2 Multivariable analysis of the satisfaction degree

Variable Regression coefficient (B) Standardized regression coefficient (b) P

Age
B 35 years Ref
36–45 years - 4.694 - 0.125 0.086
[ 45 years - 15.746 - 3.74 \0.001
Body mass index
\ 18.5 kg/m2 Ref
18.5–24 kg/m2 - 3.129 - 0.077 0.676
[ 24 kg/m2 - 8.633 - 0.206 0.266
TNM stage
0–I Ref
II - 1.273 - 0.034 0.644
III–IV - 9.261 - 0.135 0.097
Radiotherapy - 8.589 - 0.202 0.062
Chemotherapy - 4.759 - 0.125 0.084
Neoadjuvant chemotherapy 2.742 0.063 0.538
Surgical approach
Anterior pectoralis approach Ref
Posterior pectoralis approach 1.999 0.023 0.722

and femininity. On the other hand, older patients often see a significant risk factor for lower ‘‘Psychosocial well-be-
their breast appearance as a less important aspect of their ing.’’ Another study from Dartmouth showed complication
QOL, but they tend to score lower in the physical well- and surgeon experience were the only independent pre-
being domains [23]. dictors of lesser improvement of the Satisfaction. A ret-
In this study, the procedure of NSM/SSM, sentinel rospective study showed that factors associated with lower
lymph node dissection, prosthesis implantation, and con- satisfaction included history of psychiatric diagnosis, pre-
tralateral breast augmentation was negatively associated operative radiotherapy, marital status (married), and higher
with HRQOL. This particular type of surgery involves BMI. The discrepancy among the above-related studies
several procedures that could together increase the mor- suggested the necessity of deeper exploration on the factors
bidity of the intervention and decrease HRQOL. A study associated with patients’ satisfaction.
showed a different conclusion that lumpectomy or mas- According to the supplementary tables, ‘‘Satisfaction
tectomy before reconstruction did not affect the HRQOL with Breasts,’’ ‘‘Psychosocial Well-being,’’ ‘‘Satisfaction
outcomes [24], but it did not consider all procedures with papilla,’’ and ‘‘Sexual Well-being’’ showed significant
regarding the lymph nodes and reconstruction. Additional decrease after surgery compared to that before surgery in
studies are necessary to further explore the association the overall population as well as in all age subgroups, so
between various surgery type and HRQOL. breast reconstruction might not bring additional benefits.
In this study, the use of SIS matrix was positively These findings collectively underscore the multifaceted
associated with HRQOL. The use of matrix aims to facil- nature of patient experiences and satisfaction in the context
itate one-stage breast reconstruction and create a more of breast surgery. The observed decreases in certain areas
natural-looking breast [25]. However, the previous study of well-being, such as ‘‘Satisfaction with Breasts’’ and
suggested that using acellular dermal matrix did not appear ‘‘Psychosocial Well-being,’’ might be attributed to post-
to affect the HRQOL after reconstruction [26]. Specifi- surgery adjustments and psychosocial challenges. On the
cally, several matrixes are currently available, and it other hand, the increase in ‘‘Physical Well-being: Chest’’
remains unknown which one could be associated with suggests a positive impact on physical comfort following
better outcomes. the surgical intervention. The variations in patient satis-
A study in Japanese indicated some different factors faction across different age groups highlight the impor-
from our study, such as higher BMI leading to lower tance of considering age-related factors when assessing and
‘‘Satisfaction with breasts,’’ and a bilateral procedure being addressing post-surgery well-being and satisfaction.

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Aesth Plast Surg (2023) 47:2295–2303 2301

Table 3 Multivariable analysis of the health-related quality of life

Variable Regression Standardized regression P
coefficient (B) coefficient (b)

Age
B 35 years Ref
36–45 years - 5.611 - 0.262 \0.001
[45 years - 10.796 - 0.451 \0.001
TNM stage
0–I Ref
II 6.75 0.032 0.657
III–IV - 2.300 - 0.059 0.487
Chemotherapy 4.544 1.87 0.090
Neoadjuvant chemotherapy 0.548 0.022 0.840
Surgical approach
Anterior pectoralis approach Ref
Posterior pectoralis approach 1.666 0.034 0.740
Surgical mode
NSM/SSM? sentinel lymph node dissection ? prosthesis implantation Ref
NSM/SSM? axillary lymph node dissection ? prosthesis implantation 1.590 0.057 0.480
NSM/SSM? sentinel lymph node dissection ? prosthesis implantation ? - 5.441 - 0.161 0.012
contralateral breast augmentation
Latissimus dorsi flap 13.540 0.200 0.228
Transverse rectus abdominis myocutaneous flap 15.390 0.346 0.118
Flap harvesting - 7.851 - 0.201 0.461
Use of SIS matrix 9.635 0.128 0.044
NSM: nipple-preserving mastectomy; SSM: skin-preserving mastectomy; SIS, small intestinal submucosa.

This study had several limitations. First, the sample size HRQOL, while the use of matrix was positively associated
was not calculated and convenience sampling was used. In with HRQOL after breast reconstruction in patients with
addition, the BREAST-Q can delve into intimate matters or breast cancer. More prospective studies are needed to
raise some emotions. Specifically, when reporting sex-re- explore the issues leading to the dissatisfaction of the
lated questions, Chinese women may be very shy and thus patients after breast reconstruction and thus to improve the
hesitate or avoid such questions. Therefore, the sex-related surgical mode and details.
answers in the BREAST-Q might be more or less accurate.
Patients feeling distressed when answering the questions
could also provide inaccurate answer. Furthermore, the Author’s Contributions LNJ and XMZ contributed to the study
conception and design. All authors collected the data and performed
numbers of patients treated using specific techniques for the data analysis. All authors contributed to the interpretation of the
breast surgery, lymph node sampling, and reconstruction data and the completion of figures and tables. All authors contributed
were relatively small, and thus the power of the corre- to the drafting of the article and final approval of the submitted
sponding subgroup analyses was low. Nevertheless, such version.
subgroup analyses can provide directions for future studies.
Funding This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit sectors.

Conclusion Declarations

Conflict of interest All the authors declare that they have no conflict
In conclusion, older age was associated with lower satis- of interest.
faction degree in patients receiving breast reconstruction.
Older age and the procedure of NSM/SSM, sentinel lymph Ethical Approval The study was approved by the Ethics Committees
node dissection, prosthesis implantation, and contralateral of the First Affiliated Hospital of Zhengzhou University or People’s
Hospital of Zhengzhou. All procedures performed in studies
breast augmentation were negatively associated with

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2302 Aesth Plast Surg (2023) 47:2295–2303

involving human participants were in accordance with the ethical 11. Trejo-Ochoa JL, Maffuz-Aziz A, Said-Lemus FM, Dominguez-
standards of the institutional and/or national research committee and Reyes CA, Hernández-Hernández B, Villegas-Carlos F et al
with the 1964 Helsinki Declaration and its later amendments or (2013) Impact on quality of life with breast reconstructive surgery
comparable ethical standards. Informed consent was obtained from all after mastectomy for breast cancer. Ginecol Obstet Mex
participants. 81(9):510–518
12. Marroquı́n B, Czamanski-Cohen J, Weihs KL, Stanton AL (2016)
Supplementary Information The online version contains Implicit loneliness, emotion regulation, and depressive symptoms
supplementary material available at https://doi.org/10.1007/s00266- in breast cancer survivors. J Behav Med 39(5):832–844. https://
023-03642-2. doi.org/10.1007/s10865-016-9751-9
13. Fanakidou I, Zyga S, Alikari V, Tsironi M, Stathoulis J, The-
Open Access This article is licensed under a Creative Commons ofilou P (2018) Mental health, loneliness, and illness perception
Attribution 4.0 International License, which permits use, sharing, outcomes in quality of life among young breast cancer patients
adaptation, distribution and reproduction in any medium or format, as after mastectomy: the role of breast reconstruction. Qual Life Res
long as you give appropriate credit to the original author(s) and the 27(2):539–543. https://doi.org/10.1007/s11136-017-1735-x
source, provide a link to the Creative Commons licence, and indicate 14. Saldanha IJ, Cao W, Broyles JM, Adam GP, Bhuma MR, Mehta
if changes were made. The images or other third party material in this S et al (2021) Breast reconstruction after mastectomy: a sys-
article are included in the article’s Creative Commons licence, unless tematic review and meta-analysis. AHRQ Comparative Effec-
indicated otherwise in a credit line to the material. If material is not tiveness Reviews, Rockville, MD
included in the article’s Creative Commons licence and your intended 15. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano
use is not permitted by statutory regulation or exceeds the permitted SJ (2009) Development of a new patient-reported outcome
use, you will need to obtain permission directly from the copyright measure for breast surgery: the BREAST-Q. Plast Reconstr Surg
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org/licenses/by/4.0/. 16. Seth I, Seth N, Bulloch G, Rozen WM, Hunter-Smith DJ (2021)
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