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New BREAST-Q module helps manage patients' anticipations of reconstructive surgery

NEW YORK — A new module of the BREAST-Q questionnaire enables plastic and reconstructive surgeons to gauge patient expectations related to reconstructive breast surgery.

Dr. Pusic
Andrea Pusic, M.D., M.H.S., F.R.C.S.C., says that when she initially consults with new patients, "I spend 45 minutes to an hour with them. During that consultation, I can easily spend 30 or more minutes talking about different surgical options and how the surgery will be done technically. Then I spend 10 or 15 minutes talking about everything that can go wrong." Dr. Pusic is an associate attending surgeon at Memorial Sloan-Kettering Cancer Center in New York and a plastic surgeon who specializes in post-cancer reconstruction.

As a result, she says patients can easily leave her office with a clear understanding of all the possible negative outcomes they may encounter. "But they may have almost no idea of what to expect if all goes well. That potentially sets me up for litigation," she says.

Dr. Pusic says if she operates on a patient who possesses unrealistically high expectations, "I've already failed before I've started. As an example, in my practice, I see a fair number of young women who will be undergoing prophylactic mastectomies. And very frequently, they come in expecting the outcome to be very similar to breast augmentation — that's their mental model for the outcome" of reconstructive breast surgery.

That's a fairly reasonable expectation, she explains, considering the frame of reference of females in their 20s, whose only exposure to breast surgery typically comes through knowledge of friends' augmentation procedures. The fact that post-mastectomy reconstruction often involves bilateral implant reconstruction with nipple-sparing techniques, and scars placed under the breast fold, further reinforces this notion, she says.

Dr. Pusic says that if she doesn't address this misconception, "It's a setup for disappointment, no matter how well the surgery goes."

Conversely, patients with low expectations may feel anxious because they assume their procedure will be disfiguring, she says, adding that it's critical to reassure patients whose expectations are lower than necessary.

To further understand patient expectations, Dr. Pusic and her research team performed in-depth interviews with 44 patients before and after surgery. In one case, a patient whose results Dr. Pusic considered unsatisfactory actually liked her results because all she expected was to look good when clothed.

Another patient wasn't prepared for loss of sensation after a nipple reconstruction procedure, perhaps because Dr. Pusic or her staff unintentionally omitted this element in presurgical counseling, she says. In another case, a patient who had received cohesive gel implants achieved good aesthetic results with no complications. However, the patient was dissatisfied because she believed the implants felt harder than normal breast tissue and didn't move as she expected them to.

"She's absolutely right — cohesive gel implants do feel firm, and they don't move naturally on the chest. I knew that going into the surgery, but (I)failed to communicate it to my patient," she says.

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