Introduction: Multiple studies have attempted to identify which of the three most commonly performed breast reconstructive procedures, transverse rectus abdominus myocutaneous flap (TRAM), latissimus dorsi flap (LD), or tissue expansion with implant replacement (TE), is superior. The majority of these studies have concluded the TRAM is superior due to its consistently good aesthetic outcome based on a surgeon’s assessment. However, no study has compared the three types of breast reconstructive procedures based on overall patient satisfaction. In this study we aim to quantify and compare patient satisfaction among the three breast reconstruction techniques, as well as identify any variables that possibly influenced their degree of satisfaction. Methods: 268 questionnaires were mailed at least six months after immediate breast reconstruction to a group of consecutive breast reconstruction patients operated on over a three year period. 172 (64%) patients completed and returned the questionnaire resulting in 90 TRAM, 25 LD, and 57 TE patient responses. The questionnaire, made up of 51 questions, addressed the patient’s overall degree of satisfaction with the procedure, and their peri-operative and recovery experiences. Also included were questions directed toward potential external influences such as the presence of support at home, young children at home, and professional demands. Results: TRAM patients reported a significantly longer hospital stay and recovery period as compared to LD and TE patients (p<0.05), and greater post-operative pain and longer narcotic use as compared to TE patients (p<0.05). “Overall satisfaction” was significantly greater in TRAM patients as compared to TE patients (p<0.05). However, the number of patients willing to “repeat their procedure” and “recommend their procedure to a friend” was similar among the three techniques. No significant differences in age, BMI, personal or professional demands, or reported complications was noted between the three groups. However, a significantly greater number of TE patients as compared to TRAM patients felt they had not received “sufficient information pre-operatively to make an educated decision” (p<0.05). [ A second questionnaire sent only to the TE patients revealed the majority felt “inadequately informed pre-operatively” about the need for repeat office visits during the expansion process, the pain associated with expansion and the final aesthetic outcome.] Conclusions: The TRAM flap resulted in the highest “overall patient satisfaction” despite the greater peri-operative pain and time to recovery reported by our patients. However, the lack of difference among the three procedure types with regard to patient willingness to “repeat their procedure” and “recommend it to a friend” suggests that all three groups were ultimately equally satisfied with their own personal choices. This was the case despite the TE group feeling “less informed pre-operatively” about certain aspects of the procedure as compared to the TRAM patients. In conclusion, we need to improve our ability to inform patients about the implications of their choice in breast reconstruction, especially the TE patients. These patients should be told they will most likely not be as satisfied with their overall reconstruction as the TRAM and latissimus patients. Many patients will continue to choose TE/implants in an effort to avoid scars and more extensive surgery. Being “less satisfied” is not wrong or bad, as long as it is known.
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