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Satisfaction with the outcome of breast reconstruction
However, a flaw with much of this research into satisfaction is that women usually have no personal experience of alternative procedures, yet researchers use their results to extol the virtues of either reconstruction over mastectomy alone or one reconstructive technique over another. For example, Al-Ghazal et al. (2000) found that 63 of 83 (76%) delayed reconstruction patients would, looking back, prefer to have undergone an immediate procedure. However, these women were making an inappropriate comparison as the experience of immediate reconstruction (including post-operative pain and speed of recovery) is fundamentally different to that of undergoing separate procedures involving the inconvenience of two hospital admissions and periods of recovery. In addition, their decision may be influenced by biased and selective recall of their own experiences.
Reported satisfaction is also likely to depend upon the timing of assessment. Rowland et al. (1993) conducted a prospective study of 152 women who had sought consultation for delayed reconstruction of whom 117 (77%) proceeded with surgery. A longer delay between mastectomy and reconstruction was associated with greater satisfaction with the outcome of surgery however, they also found that women became more critical of the results of delayed procedures as the time since reconstruction increased. Longitudinal, prospective research is needed to investigate the changing nature of satisfaction over time.
Body image and breast reconstruction
Body image is closely linked with self-concept, attractiveness, self-confidence, sexuality and self-esteem, thereby complicating its assessment (Hopwood 1993). As no gold-standard of body image currently exists, researchers often develop their own assessment tools, making comparisons between studies problematic. For example, Filiberti et al. (1994) asked participants to draw a human figure and considered a more detailed drawing to represent a better body image. Although this identified a significant improvement in body image following reconstructive surgery, the subjective nature of this assessment makes replication difficult and the conclusions tenuous.
Al-Ghazal et al.'s (2000) retrospective study used a body image scale designed specifically for women who have undergone surgery following diagnosis of breast cancer (P. Hopwood -- personal communication). Women who had undergone immediate reconstruction reported significantly superior body image scores than those who underwent delayed reconstruction. However, no comparison was made with women who had undergone mastectomy without reconstruction. Furthermore the period between reconstructive surgery and assessment ranged from 6 months to 9 years. As the final cosmetic results of any reconstructive surgery are not evident for some time, and because time is also implicated in adjustment a new body image, this wide variation in the point of follow-up is likely to have influenced Al-Ghazal et al.'s findings.
Coping and breast reconstruction
In a rare prospective study, Rowland et al. (1993) reported a reduction in self-esteem following reconstructive surgery, reflecting women's use of defensive coping strategies prior to reconstruction in order to cope with the diagnosis and mastectomy.
An early retrospective study (Clifford 1979) found that around one-quarter of women used denial or avoidance whilst navigating through the process of reconstruction. Seeking surgery was seen as a sign of adjustment and coping rather than an indication of being unable to cope with the diagnosis or mastectomy. Women also perceived the offer of reconstructive surgery as a positive indication that medical staff did not anticipate recurrence of their cancer to be a significant problem. Clifford assessed coping by way of semi-structured interviews, thereby avoiding the problems inherent in using recognized coping checklists (Coyne & Gottlieb 1996).
Other studies have used checklists to assess coping in this context. Gross et al. (1996) used a disease-specific measure (the Reaction to Diagnosis of Cancer Questionnaire) with Lazarus & Folkman's model of coping in a study of 36 mastectomy or immediate reconstruction patients. Reconstruction patients reported a significant improvement in psychological well-being between two assessments, 2 and 30 days postmastectomy. In accordance with Clifford's findings, Gross et al. concluded that women elect reconstruction as a way of coping with the mastectomy and cancer diagnosis.
Using the Ways of Coping Questionnaire, Anderson and Kaczmarek (1996) found that women employed problem-solving strategies, including the decision to undergo reconstruction, in an attempt to cope with the mastectomy. Little use was made of avoidance or wishful thinking, whilst social support was widely used.
In contrast, Reaby (1998b) conducted semi-structured interviews to identify coping strategies used whilst making a decision about reconstruction. Whilst vigilance and satisfying (choosing a suboptimal option that is merely `good enough') were associated with higher quality decision-making, complacency and defensive avoidance were linked with lower quality decision-making.
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