Our interview findings with 48 breast surgery patients indicate that breast surgery procedures can clearly affect a woman in multiple spheres of function and quality of life. The analysis revealed the following six key themes that formed the basis of our conceptual framework of patient satisfaction and quality of life in breast surgery patients:
• Satisfaction with breasts
• Satisfaction with overall outcome
• Psychosocial well-being
• Sexual well-being
• Physical well-being
• Satisfaction with the process of care
Satisfaction with breasts
This theme relates to women's satisfaction with their breasts. Women in all three surgical groups described satisfaction, or lack thereof, with reference to breast size, shape, symmetry, cleavage, scars, positioning, how natural their breasts look and feel, and how their breasts fit in proportion to the rest of the body. A woman who underwent breast augmentation shared:
I have really nice voluptuous rounded normal-sized perky breasts and I am sooo happy with them. Soo happy.
Comments that expressed some dissatisfaction were sometimes qualified by the recognition that although the outcome wasn't perfect, breast appearance was vastly improved by surgery. A reconstructive patient expressed:
So shape-wise, I mean, you know, it's the best it can be given what we have to work with, let's put it that way, but it's not where I'd like it to be.
Women also talked about how their breasts look in bras and clothes. Women in all three surgical groups described how surgery made it possible for them to wear lower cut or tighter fitting tops, and that they now had much more choice in terms of the type of bras, lingerie and swimsuits they could wear. As several women, each in a different surgical group, described:
Some things are much more fun to put on, and the stuff that I used to wear looks way better–I am sure they looked good before, too–but I just fill in a bit more, look a bit more busty in them (Augmentation).
I can fit into regular-sized clothes now, which is a huge difference (Reduction).
I mean, they're not real breasts, and they never will be, but I can go out in a T shirt or buy clothes and they look much better (Reconstruction).
For breast augmentation and reconstruction patients, issues related to the appearance of their implants were discussed, such as rippling and how hard or soft the implants felt to the touch. Specific to reduction and reconstruction patients were issues to do with nipple appearance. A reconstructive patient shared:
I can wear T shirts and because of the nipples, actually, that has been an amazing thing for me, is that I have nipples that show through the T shirt. It just feels normalizing.
Another woman, who underwent breast reduction, stated:
I have one nipple that is sort of misshapen compared to the other one. They aren't exactly the same.
Satisfaction with overall outcome
This theme relates to an overall sense of satisfaction with the outcome of surgery that women have after going through the process of breast surgery. Women who were satisfied with their surgery overall, expressed how they felt with comments such as:
If I had to do it again, I would do it again (Augmentation).
There is not one day that goes by that I am not so pleased that I did it. (Augmentation)
The bottom line is I really am glad that I did this (Reconstruction).
It just made me feel like I had my body back again (Reconstruction)
I would highly recommend it to anybody who is thinking about it (Reduction).
I am very happy and I don't have any regrets about having the surgery, no matter what. (Reduction)
This theme relates to the way that women described the effects of breast surgery on their psychosocial well-being. Women in the three groups talked about how, with surgery, they felt better about themselves in many ways. A common theme was to mention feeling less embarrassed, more confident in a social setting and about their body, and more self-assured.
A breast augmentation patient expressed:
For me it's a confidence thing, to walk into a room and the way my clothes fit now, you know, it's just cause I feel like the rest of my body is proportionate, its how I look in my gym clothes...overall, it has been really, really good...I just feel so much more confident, my self esteem and everything.
A woman who underwent breast reconstruction surgery had the following to say with respect to her outcome:
I have greater self-esteem having been through all this and again because I could come through it and go through the big surgery and come out whole with two breasts...I think that has helped a great deal.
Thirdly, a breast reduction patient shared:
I'm not so embarrassed or trying to hide all the time. So in that way it's better.
Women also talked about feeling more attractive, feminine, good about themselves and normal or like other women. Breast surgery was also seen as a way to bring the body in line with what was perceived to be the "norm" for a woman's body. A number of women who underwent breast reduction, for instance, talked about feeling deformed, or not like other women before surgery. However, with surgery, as one woman expressed:
I feel like a normal person instead of like a freak.
Another breast reduction patient expressed how she felt almost too feminine because of the size of her breasts and how people treated her because of her large breasts. She described feeling:
...almost too feminine when I had big breasts, and that's all people really saw me as.
Women who had undergone reconstruction surgery for breast cancer often expressed how reconstruction was a way to get back what was lost and to move on from the cancer experience. As one woman described:
I think once I had this surgery...it was just closure. It's really like that part of my life didn't happen. It's not denial. I mean I still have to be vigilant and everything its just I got my life back, I really did.
Finally, a breast augmentation summed up her experience as follows:
My confidence level, my self esteem, my self respect, my self worth, everything...it has affected everything. I am just so much more solid, grounded. I feel like I am a whole woman now.
This theme deals with the way that a woman's breast condition and surgery impacts on her sexual life. Negative feelings about ones breasts may interfere with how sexually attractive a woman feels as well as with her sexual functioning and sexual pleasure. With surgery, many women commented that they felt more sexually attractive both when they were clothed and unclothed, more confident sexually, and more satisfied with their sex life. As one breast reduction patient said:
Yes it's better because when they were larger I didn't feel sexy.
And a breast augmentation patient said the following:
What I find now is that I am sensual, which I didn't feel before.
Following surgery, some women expressed concern about changes in their nipple sensation and how this affected sexual pleasure. For instance, one woman shared:
I do really miss my real nipples, because they were really an important part of my sexuality. They are an essential part, and they are something I enjoy.
This theme mainly relates to issues surrounding chest and upper body symptoms and how these impact on physical function and participation in activities before and after breast surgery. This theme was discussed in much greater detail by breast reduction and reconstruction patients than augmentation patients.
Reconstruction and reduction patients described a range of chest and upper body symptoms such as arm, shoulder, neck, back and breast pain, as well as tenderness, pulling, discomfort. They also discussed ways in which their breast conditions caused activity limitations, such as difficulty lifting or moving their arms and difficulty doing vigorous activities such as running, playing sports, or exercising, as well as doing everyday household chores. A patient who underwent breast reduction stated:
Putting things into the dishwasher and taking them out has become a totally different experience for me.
Preoperatively, women in the breast reduction group described having painful gouges or grooves in their shoulders from their bra straps, rashes under their breasts, and difficulty sleeping due to breast discomfort. Women in this group were often motivated for surgery due to these physical symptoms, as well as for activity limitations they experienced due to the size of their breasts. A breast reduction patient shared:
Before, I didn't want to run anywhere. Even across the street if something happened I would not run. It was painful and embarrassing.
For women who had reconstructive surgery, pain and activity limitations were often reported and tended to be related to the type of reconstruction and extent of surgery. For example, a woman who underwent Transverse Rectus Myocutaneous Flap (TRAM) surgery described experiencing abdomen weakness. She expressed:
There is sort of a bit of a discomfort there, and I don't feel that I have a lot of strength in my abdomen...the way I used to. So I am pretty cautious about what I am doing exercise-wise.
Another breast reconstruction patient described:
This implant feels as if it is low and I get rib pain.
Satisfaction with the process of care
Patients in our interviews repeatedly reflected on their satisfaction with process of care issues. Satisfaction with the process of care was clearly an important area in patients overall assessment of the surgery and thus formed an important domain in our conceptual framework. This theme was, however, broad and we identified three main subthemes: satisfaction with preoperative information; satisfaction with the care provided by the plastic surgeon; and satisfaction with the office staff and other members of the medical team.
Satisfaction with information was discussed in terms of general issues applicable to all three surgical groups, such as how the surgery was to be done, healing and recovery time, possible complications that might occur, breast appearance, risks, and scarring. Information needs described by women in our sample were surgery-specific (e.g., differences in types and complications associated with implants were relevant to reconstruction and augmentation but not breast reduction patients).
Patients' relationship with their plastic surgeons was an important aspect of process of care. Women talked about the extent to which their surgeon made them feel comfortable, was caring and reassuring, answered all their questions, understood what they wanted, involved them in the decision-making and provided adequate follow-up. The physician-patient relationship was sometimes mentioned as important in terms of giving the patient confidence to go ahead with surgery. As one woman shared:
My doctor was terrific and I trusted her and I had a lot of confidence in her and it didn't seem like there were an awful lot of things to worry about.
But another woman who underwent a reconstruction felt quite differently:
I had these fears and I just did not feel comfortable discussing them with her.
How women were treated by the medical and office staff was important in terms of satisfaction with the overall experience of care. Women talked about the medical team and the office staff in terms of whether they were professional, treated them with respect, and was kind and friendly. As one patient described:
And once I came home, the home care, I don't know what they called it, but the nurses would come round and they were just excellent. They were all lovely people. They were very positive and very encouraging.
Formation of the conceptual framework
Relationships between the six main themes described above, which were developed through our detailed coding process, form a coherent and comprehensible conceptual framework of patient satisfaction and quality of life in breast surgery patients. Our conceptual framework is shown in Figure .
Conceptual model of patient satisfaction and quality of life in breast surgery patients.