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Satisfaction and quality of life in women who undergo breast surgery: A qualitative study Klassen, Anne F; Pusic, Andrea L; Scott, Amie; Klok, Jennifer; Cano, Stefan J May 1, 2009

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ralssBioMed CentBMC Women's HealthOpen AcceResearch articleSatisfaction and quality of life in women who undergo breast surgery: A qualitative studyAnne F Klassen*1, Andrea L Pusic2, Amie Scott2, Jennifer Klok3 and Stefan J Cano4Address: 1Department of Pediatrics, McMaster University, 3A 1200 Main Street W, Hamilton, ON, L8N 3Z5, Canada , 2Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA, 3University of British Columbia, Vancouver, BC, Canada and 4Neurological Outcomes Measures Unit, Institute of Neurology, University College London, London, Queen Square, London, WC1N 3BG, England, UKEmail: Anne F Klassen* - aklass@mcmaster.ca; Andrea L Pusic - PusicA@mskcc.org; Amie Scott - scotta@mskcc.org; Jennifer Klok - jklok@interchange.ubc.ca; Stefan J Cano - s.cano@ion.ucl.ac.uk* Corresponding author    AbstractBackground: In cosmetic and reconstructive breast surgery, measurement of patient-reportedoutcomes has become increasingly important to research efforts and clinical care. We aimed todescribe how breast conditions and breast surgery impact on patient satisfaction and quality of life.Methods: We conducted qualitative, in-depth interviews with 48 women who had undergoneeither breast reduction (n = 15), breast augmentation (n = 12), or breast reconstruction (n = 21)surgery in order to begin to build a theoretical understanding of patient satisfaction and quality oflife in breast surgery patients. Interviews were audio-taped, transcribed verbatim and analyzedthematically.Results: The patient interviews revealed that breast conditions and breast surgery impact womenin the following six main areas: satisfaction with breasts; satisfaction with overall outcome;psychosocial well-being; sexual well-being; physical well-being; and satisfaction with the process ofcare. We used these six themes to form the basis of a conceptual framework of patient satisfactionand quality of life in women who undergo breast surgery.Conclusion: Our conceptual framework establishes the main issues of concern for breast surgerypatients. This new framework can be used to help develop local guidelines for future clinicalassessment, management and measurement, establish the validity of the current managementstrategies, and develop evidence-based guidance for the development of new patient reportedoutcome measures for future outcomes research.BackgroundIn the United States, over 500,000 women undergo breastsurgery procedures each year [1]. Understanding the wideresearch endeavors and surgical quality improvementefforts [2]. Traditional surgical outcomes, centered onmorbidity and mortality, remain important but are noPublished: 1 May 2009BMC Women's Health 2009, 9:11 doi:10.1186/1472-6874-9-11Received: 17 July 2008Accepted: 1 May 2009This article is available from: http://www.biomedcentral.com/1472-6874/9/11© 2009 Klassen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 8(page number not for citation purposes)reaching impact of cosmetic and reconstructive breast sur-gery has thus become increasingly important for clinicallonger sufficient on their own. Thus, patient's perceptionsof the impact of disease and treatment are increasinglyBMC Women's Health 2009, 9:11 http://www.biomedcentral.com/1472-6874/9/11being considered as integral to understanding health out-comes [3-7].Breast conditions and their associated surgical interven-tions have a major impact on quality of life. In fact, in spe-cialties such as breast surgery, it has been suggested that"quality of life must be the major if not the only endpoint" [4]. Despite this, relatively little is known about theextent to which quality of life is impacted in breast surgerypopulations. There are a number of reasons for this. First,there is a lack of detailed qualitative research, based oninductive research methods, and a paucity of quantitativeresearch, using valid, reliable, and responsive instrumentsto measure patient-reported outcomes in cosmetic andreconstructive breast surgery [8]. Second, few researchershave tried to understand exactly what having breast con-ditions means to women, and what impact surgery thenhas on these perceptions. Third, breast conditions are var-ied and are associated with complex symptomologiesspanning the continuum of impact from physical func-tioning through to social interaction. As such, womenwith different conditions may experience the impact ofthese conditions differently.It is clear that a thorough evaluation of the impact ofbreast conditions and their surgical treatment is required.Therefore, in this study we have adopted a qualitativeapproach [5,9] that involves in-depth interviews withwomen who had undergone breast surgery (i.e., breastreconstruction, breast reduction, breast augmentation) inorder to collect data about their personal experience ofbreast surgery. This descriptive data was used to develop atheoretical understanding of patient satisfaction and qual-ity of life in breast surgery patients. In particular, we haveused detailed analysis [10] to compare and contrast theexperiences of these women in order to develop a concep-tual framework [11-13] with the view to improving ourunderstanding of the impact of breast conditions andtheir surgical interventions.MethodsParticipantsThe sample was recruited from the patients of four plasticsurgeons practicing in Vancouver, Canada. These surgeonsidentified a pool of 120 women who had undergone threeforms of breast surgery (i.e., reconstruction, augmenta-tion, reduction). A letter and consent form was sent toeach woman from their plastic surgeon inviting her to par-ticipate in an in-depth semi-structured interview. Sixty-two women (51.7%) returned a signed consent. Table 1shows sample characteristics for 48 women (from the 62)that formed the final study sample.of how their breast condition and subsequent surgery hadimpacted their life. A reminder letter and replacementconsent form was sent to non-respondents approximatelyTable 1: Characteristics of the study sampleCharacteristics N %Operation typeReductionAugmentationReconstruction15122131.325.043.8Type of reconstructionImplant 12 57.1Tram 7 33.3Unilateral implant and tram 2 9.5Timing of reconstructionDelayed 9 42.9Immediate 11 52.4Unilateral immediate and delayed 1 4.8Time since surgery< 12 months12 to 24 months> 24 months8301016.762.520.8Age20 – 2930 – 3940 – 4950 – 7531413176.429.827.736.2Marital StatusMarriedCommon-lawDivorcedWidowedSingle214521643.88.310.44.233.3EthnicityCaucasianEthnic minority42687.512.5Main ActivityWorkingHomemakerStudentRetiredUnemployed33533270.210.66.46.46.4Page 2 of 8(page number not for citation purposes)We obtained local institutional ethics review boardapproval for this study. Women were invited by mail toparticipate in an interview where they could tell the storythree weeks after the first mailing. A one-page topic list,developed from a literature review of breast surgery out-come instruments [8], was developed to guide the inter-BMC Women's Health 2009, 9:11 http://www.biomedcentral.com/1472-6874/9/11views (see Table 2). This topic list was revised throughoutthe course of the study, with the findings from earlierinterviews influencing and shaping its content. Interviewswere initiated by having the participant discuss the cir-cumstances that led to her decision to have surgery. Partic-ipants were thereafter encouraged to tell their story ascompletely as possible in their own words. The researcherconsulted the interview guide and asked questions only asnecessary to ensure that all topics had been discussed.Interviews were conducted by a trained interviewer (JK)either in the patients' home or a preferred location. Allinterviews were audio-taped and transcribed verbatim bya professional transcription service.Data analysisData collection and analysis took place concurrently. Theiterative interaction between data collection and analysisis the essence of attaining reliability and validity [14] andmakes it possible for researchers to pursue emerging ave-nues of inquiry in further depth [10]. Each transcript wasread carefully in order to gain an overview of the mainissues of importance to participants. Transcripts were thenexamined in detail in order to identify basic patterns andrecurrent themes using line-by-line coding to examine,compare and begin to develop conceptual categories. Cat-egories were developed inductively using the constantcomparison method [10]. Comparing each item with therest of the data to create analytical categories and thengrouping categories together made it possible to identifykey themes [10]. All coding was done by one team mem-ber (JK) with the study investigators (AP, AK, SC) meetingregularly to discuss the coding results. Interviews wereconducted until no new themes were identified throughthe data analysis. To enhance the accuracy of the accountof our research, after completing data analysis, as a formof member-checking [15], we took our ideas back toresearch participants for their confirmation, holding twofocus groups with a total of six women in each group whohad undergone breast surgery. Focus groups were led by atrained facilitator who asked participants to discuss theextent to which the important themes that we had identi-fied through our analysis of the interview transcriptsreflected their subjective experience.ResultsOur interview findings with 48 breast surgery patientsindicate that breast surgery procedures can clearly affect awoman in multiple spheres of function and quality of life.Table 2: Interview guidePre-operation process: timing; influence/opinion/perceptions of partner, friends, and/or family; reason for operation; motivation; type of operation chosen; information seeking; Internet; decision-makingPre/post operation perceptions: feelings going into the operation; concerns about complications/surgery process; expectations for recovery process; pre-op expectations for results; immediate feelings after operationPost-op symptoms: pain; itchiness; discomfort; mobility problems; fatigue; complications; capsular contracture; rippling; numbness; swelling; movement of the arm; tightness in abdominal areaFunctional ability and role performance: work and normal activities; interference in social activities; interference in family function; ability to participate in sports/fitness/activities; change in level of comfort; energy and vitalityAesthetic outcome: size; shape; appearance of scar; symmetry; cleavage; appearance of nipple/areola complex; difference in fit of clothing; change in style of clothing; ability to wear desired clothes and styles; body wholeness/harmony; proportionate; feel to touch; breast-self exams; naturalPsychological well-being and self-concept: changes in mood; changes in confidence level; emotional distress resulting from teasing, comments, or stares prior to or after operation; body image issues; feelings clothed and unclothed; self-consciousness; self-esteem; feelings of femininity; cancer worry; closure to emotions surrounding disease; feelings of normalcyRelationships with friends and family: reactions of friends and family; difference in treatment or attitude; marital relationship; family relationships; strain of physical or emotional problems on relationships; avoidance behavior; more or less outgoing; feelings in a social setting; undressing in public placesSexual life: satisfaction with sex life; partner's satisfaction; change in frequency of sex; feelings of sexual attractiveness; degree of sensation in breasts; undressing in front of partnerSurgical care: satisfaction with care; satisfaction with information provided; comfort with surgeon; confidence in surgeon; surgical setting; clinic; staff; follow-up care; information about scar healing; massagingExpectations: fulfillment of expectations; willingness to repeat and/or recommend procedure; satisfaction with overall appearance; regrets; Page 3 of 8(page number not for citation purposes)outcome better or worse than expected; process better or worse than expectedBMC Women's Health 2009, 9:11 http://www.biomedcentral.com/1472-6874/9/11The analysis revealed the following six key themes thatformed the basis of our conceptual framework of patientsatisfaction 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 careSatisfaction with breastsThis theme relates to women's satisfaction with theirbreasts. Women in all three surgical groups described sat-isfaction, or lack thereof, with reference to breast size,shape, symmetry, cleavage, scars, positioning, how natu-ral their breasts look and feel, and how their breasts fit inproportion to the rest of the body. A woman who under-went breast augmentation shared:I have really nice voluptuous rounded normal-sizedperky breasts and I am sooo happy with them. Soohappy.Comments that expressed some dissatisfaction weresometimes qualified by the recognition that although theoutcome wasn't perfect, breast appearance was vastlyimproved by surgery. A reconstructive patient expressed:So shape-wise, I mean, you know, it's the best it can begiven 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 brasand clothes. Women in all three surgical groups describedhow surgery made it possible for them to wear lower cutor tighter fitting tops, and that they now had much morechoice in terms of the type of bras, lingerie and swimsuitsthey could wear. As several women, each in a different sur-gical group, described:Some things are much more fun to put on, and thestuff that I used to wear looks way better–I am surethey looked good before, too–but I just fill in a bitmore, look a bit more busty in them (Augmentation).I can fit into regular-sized clothes now, which is a hugedifference (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 theylook much better (Reconstruction).For breast augmentation and reconstruction patients,issues related to the appearance of their implants were dis-cussed, such as rippling and how hard or soft the implantsfelt to the touch. Specific to reduction and reconstructionpatients were issues to do with nipple appearance. Areconstructive patient shared:I can wear T shirts and because of the nipples, actually,that has been an amazing thing for me, is that I havenipples that show through the T shirt. It just feels nor-malizing.Another woman, who underwent breast reduction, stated:I have one nipple that is sort of misshapen comparedto the other one. They aren't exactly the same.Satisfaction with overall outcomeThis theme relates to an overall sense of satisfaction withthe outcome of surgery that women have after goingthrough the process of breast surgery. Women who weresatisfied with their surgery overall, expressed how they feltwith comments such as:If I had to do it again, I would do it again (Augmenta-tion).There is not one day that goes by that I am not sopleased 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 isthinking about it (Reduction).I am very happy and I don't have any regrets abouthaving the surgery, no matter what. (Reduction)Psychosocial well-beingThis theme relates to the way that women described theeffects of breast surgery on their psychosocial well-being.Women in the three groups talked about how, with sur-gery, they felt better about themselves in many ways. Acommon theme was to mention feeling less embarrassed,more confident in a social setting and about their body,Page 4 of 8(page number not for citation purposes)and more self-assured.BMC Women's Health 2009, 9:11 http://www.biomedcentral.com/1472-6874/9/11A breast augmentation patient expressed:For me it's a confidence thing, to walk into a room andthe way my clothes fit now, you know, it's just cause Ifeel like the rest of my body is proportionate, its howI look in my gym clothes...overall, it has been really,really good...I just feel so much more confident, myself esteem and everything.A woman who underwent breast reconstruction surgeryhad the following to say with respect to her outcome:I have greater self-esteem having been through all thisand again because I could come through it and gothrough the big surgery and come out whole with twobreasts...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, femi-nine, good about themselves and normal or like otherwomen. Breast surgery was also seen as a way to bring thebody in line with what was perceived to be the "norm" fora woman's body. A number of women who underwentbreast reduction, for instance, talked about feelingdeformed, or not like other women before surgery. How-ever, with surgery, as one woman expressed:I feel like a normal person instead of like a freak.Another breast reduction patient expressed how she feltalmost too feminine because of the size of her breasts andhow people treated her because of her large breasts. Shedescribed feeling:...almost too feminine when I had big breasts, andthat's all people really saw me as.Women who had undergone reconstruction surgery forbreast cancer often expressed how reconstruction was away to get back what was lost and to move on from thecancer experience. As one woman described:I think once I had this surgery...it was just closure. It'sreally like that part of my life didn't happen. It's notdenial. I mean I still have to be vigilant and everythingits just I got my life back, I really did.Finally, a breast augmentation summed up her experienceas follows:My confidence level, my self esteem, my self respect,my self worth, everything...it has affected everything. Iam just so much more solid, grounded. I feel like I ama whole woman now.Sexual well-beingThis theme deals with the way that a woman's breast con-dition and surgery impacts on her sexual life. Negativefeelings about ones breasts may interfere with how sexu-ally attractive a woman feels as well as with her sexualfunctioning and sexual pleasure. With surgery, manywomen commented that they felt more sexually attractiveboth when they were clothed and unclothed, more confi-dent sexually, and more satisfied with their sex life. As onebreast reduction patient said:Yes it's better because when they were larger I didn'tfeel sexy.And a breast augmentation patient said the following:What I find now is that I am sensual, which I didn'tfeel before.Following surgery, some women expressed concern aboutchanges in their nipple sensation and how this affectedsexual pleasure. For instance, one woman shared:I do really miss my real nipples, because they werereally an important part of my sexuality. They are anessential part, and they are something I enjoy.Physical well-beingThis theme mainly relates to issues surrounding chest andupper body symptoms and how these impact on physicalfunction and participation in activities before and afterbreast surgery. This theme was discussed in much greaterdetail by breast reduction and reconstruction patientsthan augmentation patients.Reconstruction and reduction patients described a rangeof 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 breastconditions caused activity limitations, such as difficultylifting or moving their arms and difficulty doing vigorousactivities such as running, playing sports, or exercising, aswell as doing everyday household chores. A patient whounderwent breast reduction stated:Putting things into the dishwasher and taking themout has become a totally different experience for me.Page 5 of 8(page number not for citation purposes)BMC Women's Health 2009, 9:11 http://www.biomedcentral.com/1472-6874/9/11Preoperatively, women in the breast reduction groupdescribed having painful gouges or grooves in their shoul-ders from their bra straps, rashes under their breasts, anddifficulty sleeping due to breast discomfort. Women inthis group were often motivated for surgery due to thesephysical symptoms, as well as for activity limitations theyexperienced due to the size of their breasts. A breast reduc-tion patient shared:Before, I didn't want to run anywhere. Even across thestreet if something happened I would not run. It waspainful and embarrassing.For women who had reconstructive surgery, pain andactivity limitations were often reported and tended to berelated to the type of reconstruction and extent of surgery.For example, a woman who underwent Transverse RectusMyocutaneous Flap (TRAM) surgery described experienc-ing abdomen weakness. She expressed:There is sort of a bit of a discomfort there, and I don'tfeel that I have a lot of strength in my abdomen...theway I used to. So I am pretty cautious about what I amdoing 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 carePatients in our interviews repeatedly reflected on their sat-isfaction with process of care issues. Satisfaction with theprocess of care was clearly an important area in patientsoverall assessment of the surgery and thus formed animportant domain in our conceptual framework. Thistheme was, however, broad and we identified three mainsubthemes: satisfaction with preoperative information;satisfaction with the care provided by the plastic surgeon;and satisfaction with the office staff and other members ofthe medical team.Satisfaction with information was discussed in terms ofgeneral issues applicable to all three surgical groups, suchas how the surgery was to be done, healing and recoverytime, possible complications that might occur, breastappearance, risks, and scarring. Information needsdescribed by women in our sample were surgery-specific(e.g., differences in types and complications associatedwith implants were relevant to reconstruction and aug-mentation but not breast reduction patients).Patients' relationship with their plastic surgeons was animportant aspect of process of care. Women talked abouttions, understood what they wanted, involved them in thedecision-making and provided adequate follow-up. Thephysician-patient relationship was sometimes mentionedas important in terms of giving the patient confidence togo ahead with surgery. As one woman shared:My doctor was terrific and I trusted her and I had a lotof confidence in her and it didn't seem like there werean awful lot of things to worry about.But another woman who underwent a reconstruction feltquite differently:I had these fears and I just did not feel comfortable dis-cussing them with her.How women were treated by the medical and office staffwas important in terms of satisfaction with the overallexperience of care. Women talked about the medical teamand the office staff in terms of whether they were profes-sional, treated them with respect, and was kind andfriendly. As one patient described:And once I came home, the home care, I don't knowwhat they called it, but the nurses would come roundand they were just excellent. They were all lovely peo-ple. They were very positive and very encouraging.Formation of the conceptual frameworkRelationships between the six main themes describedabove, which were developed through our detailed codingprocess, form a coherent and comprehensible conceptualframework of patient satisfaction and quality of life inbreast surgery patients. Our conceptual framework isshown in Figure 1.Discussion and conclusionResearch that seeks to understand the experiences of anyparticular patient group needs to employ inductive, qual-itative methods. Our goal was to understand issues relatedto patient satisfaction and quality of life in breast surgerypatients and to develop a conceptual framework to betterunderstand the wide reaching impact of breast conditionsand the surgical interventions used to treat them.The patient interviews revealed that breast conditions andbreast surgery impact women in six main areas: satisfac-tion with breasts; satisfaction with overall outcome; psy-chosocial well-being; sexual well-being; physical well-being; and satisfaction with the process of care. Thesethemes form the basis of a conceptual framework ofpatient satisfaction and quality of life in women undergo-ing breast surgery. Patient satisfaction with breast appear-Page 6 of 8(page number not for citation purposes)the extent to which their surgeon made them feel comfort-able, was caring and reassuring, answered all their ques-ance was without doubt the key theme and is a salientfactor in determining the success of breast surgery. How-BMC Women's Health 2009, 9:11 http://www.biomedcentral.com/1472-6874/9/11ever, other themes were also identified that related to thebroadened notion of quality of life, including conceptssuch as physical, psychological and sexual well-being.Recognition and examination of these themes confirmsfindings from existing research showing quality of lifebenefits following different forms of breast surgery [16-19].While the six identified themes were common to womenin all three groups, the specific issues for operative proce-dures that preserve or improve breast appearance varied inimportance by surgical group. For example, while physicalwell-being was of only limited importance to breast aug-mentation patients (only a few reported pain and discom-fort post-operatively), it was often the main motivationbehind breast reduction surgery (patients reported sub-stantial pain and activity limitations pre-operatively), andwas often a problem for women following breast recon-struction. Similarly, while women in the three surgicalgroups all identified the six themes as being important tothem, they expressed themselves differently. As an exam-ple, in terms of sexual well-being, an augmentationpatient may describe 'feeling sexy' while a reconstructionpatient may describe 'feeling normal'.An important theme within our conceptual frameworkwas that of satisfaction with the process of care. Patientsdiscussed at length the extent to which they had receivedinformation about the operation, and their thoughtsabout their plastic surgeon and his/her medical team andoffice staff. A clearer understanding of aspects of the proc-esses involved in breast surgery would be a useful additionfor quality improvement studies. Using such informationcould help to determine whether, for example, womenwho are well informed preoperatively about the surgery(e.g., complications, healing and recovery time, expectedresults) and feel comfortable with their surgeon, may alsoreport greater postoperative satisfaction and perceive bet-ter quality of life.building blocks of a conceptual framework to help under-stand pre- and post-surgical satisfaction and quality of lifein breast surgery patients. This new conceptual frameworkestablishes the main issues of concern for breast surgerypatients. With further development and input we envisagethat this new framework can be used to help develop localguidelines for future clinical assessment, managementand measurement, establish the validity of the currentmanagement strategies, and develop evidence-based guid-ance for the development of new patient reported out-come measures for future outcomes research.We have already taken this work forward by using the con-ceptual framework to develop a new patient-reported out-come measure. The new measure, which we have namedthe BREAST-Q©, consists of three procedure-specific mod-ules (Augmentation, Reconstruction and Reduction) witheach module functioning independently [20]. The itemsfor each module were developed directly from the inter-view data, and consisting only of items generated bypatients who had undergone that procedure. Whereverpossible, we maintained the exact wording used bypatients for the generation of questionnaire items andensured that all six themes identified as important towomen were captured in each module.We sought to incorporate patient input at each step in thedevelopment of the BREAST-Q©. Following the qualitativeinterviews, women were invited to be part of a focus groupwhere we presented the conceptual framework and ourdraft questionnaires for their feedback. We also obtainedfeedback in later phases of our study using one-on-onecognitive debriefing interviews to obtain feedback on ourpreliminary questionnaires as well as our item-reducedquestionnaires. Patient feedback was vital to refining theBreast-Q©.Our team combined our qualitative findings with state-of-the art quantitative psychometric methods that includedthe use of modern psychometrics (i.e., Rasch analysis) toselect the best items from the qualitative interviews forour scales. The use of Rasch analysis makes it possible toselect a range of items for each scale that differ in terms ofitem difficulty such that they "map out" the construct thatthey propose to measure. The combination of extensivedetailed qualitative research and modern psychometricmethods make it possible to measure constructs, such aspatient satisfaction, in a more clinically meaningful andscientifically robust way than has been done in the past inthis patient group.As described above, the new conceptual framework hasvalue beyond the role it has played in the development ofConceptual model of patient satisfaction and quality of life in breast surgery patientsFigure 1Conceptual model of patient satisfaction and quality of life in breast surgery patients.PsychosocialWell-beingPhysicalWell-beingSatisfactionWith OutcomeSatisfaction  With Breasts SatisfactionWith CareSexualWell-beingPage 7 of 8(page number not for citation purposes)We are proposing that the six themes identified throughpatient interviews in this study can be used as the initialthe BREAST-Q©. This framework establishes the mainissues of concern for breast surgery patients and as such,will be an important resource for healthcare providers andPublish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central BMC Women's Health 2009, 9:11 http://www.biomedcentral.com/1472-6874/9/11those involved in patient counseling. It may guide thedevelopment of patient education materials and facilitateshared-medical decision-making. As well, by conceptual-izing patient-perceptions of breast surgery outcomes, itmay inform advocacy efforts and future health-servicesresearch.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsAK participated in the design of the study, data analysisand interpretation, manuscript writing and final approvalof the manuscript. AP conceived and designed the study,participated in collection and assembly of data, data anal-ysis and interpretation, manuscript writing and finalapproval of the manuscript. AS participated in collectionand assembly of data, data analysis and interpretation,manuscript writing and final approval of the manuscript.JK participated in collection and assembly of data, dataanalysis and interpretation, manuscript writing and finalapproval of the manuscript. SC participated in the designof the study, collection and assembly of data, data analysisand interpretation, manuscript writing and final approvalof the manuscript.AcknowledgementsThis study was funded by a grant from the Plastic Surgery Education Foun-dation. Anne Klassen is a recipient of Canadian Institute of Health Research career award.References1. American Society of Plastic Surgeons   [http://www.plasticsurgery.org/Media/stats/2008-US-cosmetic-reconstructive-plastic-surgery-minimally-invasive-statistics.pdf]2. Cano SJ, Klassen A, Pusic A: The science behind quality of lifemeasurement: a primer for plastic surgeons.  Plast Reconstr Surg2009, 123(3):98e-106e.3. Troidl H, Kusche J, Vestweber K, Eypasch E, Koeppen L, Bouillon B:Quality of life: An important endpoint both in surgical prac-tice and research.  J Chronic Diseases 1987, 40:523-528.4. Spilker G, Stark G: Quality of life considerations in plastic andreconstructive surgery.  Theor Surg 1991, 6:216-220.5. Pope C, Mays N: Qualitative Research: Reaching the partsother methods cannot reach: an introduction to qualitativemethods in health and health services research.  BMJ 1995,311:42-45.6. Scientific Advisory Committee of the Medical Outcomes Trust:Assessing health status and quality of life instruments:attributes and review criteria.  Qual Life Res 2002, 11:193-205.7. Revicki D: FDA draft guidance and health-outcomes research.Lancet 2007, 369:540-542.8. Pusic A, Chen CM, Cano S, Klassen A, McCarthy C, Collins ED, Cor-deiro PG: Measuring quality of life in cosmetic and recon-structive breast surgery: A systematic review of patient-reported outcome instruments.  Plast Reconstr Surg 2007,120:823-837.9. Britten N: Qualitative interviews in medical research.  BMJ1995, 311:251-253.10. Pope C, Ziebland S, Mays N: Qualitative research in health care.Analyzing qualitative data.  BMJ 2000, 320:114-116.11. Barofsky I: Health-related quality of life: methods of assess-12. Ware J, Sherbourne C: The MOS 36-item Short-Form HealthSurvey (SF-36): I. Conceptual Framework and item selec-tion.  Med Care 1992, 30:473-483.13. Hunt S: The problem of quality of life.  Qual Life Res 1997,6:205-212.14. Morse JM, Barrett M, Mayan M, Olson K, Spiers J: Verificationstrategies for establishing reliability and validity in qualita-tive research.  Int J Qual Methods 2002, 1:2.15. Cresswell JW: Qualitative inquiry & research design. Choosing among fiveapproaches 2nd edition. California: Sage Publication Inc; 2007. 16. Cook SA, Rosser R, Salmon P: Is cosmetic surgery an effectivepsychotherapeutic intervention? A systematic review of theevidence.  J Plast Reconstr Aesthet Surg 2006, 59:1133-1151.17. Klassen A, Jenkinson C, Fitzpatrick R, Goodacre T: Patients' healthrelated quality of life before and after aesthetic surgery.  Br JPlast Surg 1996, 49:433-438.18. Klassen A, Fitzpatrick R, Jenkinson C, Goodacre T: Should breastreduction surgery be rationed: a comparison of the healthstatus of patients before and after treatment: postal ques-tionnaire survey.  BMJ 1996, 313:454-457.19. Shakespeare V, Cole RP: Measuring patient-based outcomes ina plastic surgery service: breast reduction surgical patients.Br J Plast Surg 1997, 50:242-248.20. The BREAST-Q©   [http://www.breast-q.org/]Pre-publication historyThe pre-publication history for this paper can be accessedhere:http://www.biomedcentral.com/1472-6874/9/11/prepubyours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 8 of 8(page number not for citation purposes)ment.  Horm Res 2001, 56(Suppl 1):51-54.

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