title: Patient-subjective cosmetic outcomes following the varying stages of tissue expander breast reconstruction: the importance of completion.
abstract: BACKGROUND
  Tissue expander breast reconstruction consists of three major surgical steps: placement of the expander after mastectomy, exchange of the expander for an implant, and nipple-areola complex reconstruction. The evolution of patient satisfaction throughout this process has not been evaluated. Here we performed a stratified analysis of patient-subjective cosmetic outcomes during the stages of breast reconstruction.
  
  
  METHODS
  Twenty-eight consecutive tissue expander-implant reconstructions were performed by the senior author using human acellular dermis. Cosmetic outcomes were assessed after each reconstructive stage using a validated Breast Evaluation Questionnaire consisting of questions related to breast size, shape and firmness in three separate contexts: intimate or sexual activities, leisure or social activities, and professional or job-related activities.
  
  
  RESULTS
  Eighteen patients underwent unilateral reconstruction, while 10 underwent bilateral reconstruction. Satisfaction scores were statistically higher following Stage I and II procedures for bilateral reconstructions. For unilateral reconstructions, there was a statistically significant elevation in scores following Stage II. The addition of nipple-areola reconstruction resulted in the highest scores for both unilateral and bilateral reconstructions. These score elevations were significant (p < 0.05) in nearly every measured context for unilateral reconstructions and as such, the significant differences in scores between unilateral and bilateral cohorts after stages I and II were nearly eliminated after completion of the entire reconstructive process.
  
  
  CONCLUSIONS
  Satisfaction with tissue expander reconstruction is significantly affected by the patients' stage during the reconstructive process. Completion of all three stages, including nipple-areolar complex reconstruction, achieves maximal patient satisfaction. For unilateral reconstructions, completion of the entire reconstructive process, including contralateral symmetry procedures and nipple-areolar complex reconstruction, results in cosmesis scores that are similar to those in bilateral cases.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University, 675 North St Clair Street, Galter Suite 19-250, Chicago, IL 60611, United States.
authors.forename: Donald W
authors.initials: DW
authors.lastname: Buck
authors.forename: Deana
authors.initials: D
authors.lastname: Shenaq
authors.forename: Kamaldeep
authors.initials: K
authors.lastname: Heyer
authors.forename: Caroline
authors.initials: C
authors.lastname: Kato
authors.forename: John Y S
authors.initials: JY
authors.lastname: Kim
mesh_terms: D001940:Breast / Q000033:anatomy & histology / Q000601:surgery; D018427:Breast Implants; D020405:Dermis / Q000637:transplantation; D004954:Esthetics / Q000523:psychology*; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods* / Q000523:psychology*; D008875:Middle Aged; D009558:Nipples / Q000033:anatomy & histology / Q000601:surgery; D017060:Patient Satisfaction; D018709:Statistics, Nonparametric; D011795:Surveys and Questionnaires; D015625:Tissue Expansion Devices; D016896:Treatment Outcome