The plastic and reconstructive surgeon may meet the woman with breast cancer early in her experience (particularly if immediate reconstruction is a consideration) or may not, unfortunately, meet her until she has completed her initial ablative surgery and adjunct therapies. Clearly, the opinion of the author is that an early meeting (prior to a surgical decision being made) with a plastic and reconstructive specialist leaves the woman best placed to be a true partner in the informed decision making process, as well as best placed to have her psychosocial issues addressed and supported by the full range of specialists with whom she will work over her time of breast cancer treatment and recovery.

Women who are in a clinical position to be a partner in the choice between breast-conserving surgery, mastectomy alone, or mastectomy with either immediate or delayed reconstruction have much to consider. Breast centers, in which each woman is seen by a variety of specialists before choices are finalized, can be a real aid to a woman moving through her decision making process as there is the expectation that many members of the breast center team will review the best options for the woman and that breast reconstruction will receive a “fair hearing” early in the decision making process. This can be so both in breast centers where practitioners are located in one setting and in colloquially named “breast centers without walls” in which a group of breast cancer specialists work in separate private practices, but who come together at multidisciplinary treatment planning meetings. Even in settings without a designated breast center, solid collegial and collaborative relationships between breast cancer surgeons and their plastic and reconstructive surgery colleagues can help secure the inclusion of the reconstruction option early on.

Research regarding the benefits and limitations of breast reconstruction has been less prolific than research seeking to understand women’s emotional and psychological reactions to breast cancer, to breast cancer surgery, and to the impact of psychosocial interventions that can mitigate the emotional burdens women frequently endure. Nevertheless, there is a body of literature that aids in understanding the psychological issues related to the breast reconstruction experience and in helping to inform plastic and reconstructive surgeons regarding how to enhance the positive effect of their role as women seek to make the best decision for themselves.

Seeking to understand the “psychosocial and psychopathological” outcome for women with breast reconstruction, Rubino et al. [8] studied women with mastectomy alone, women with breast reconstruction, and healthy women and, interestingly, found no difference in social, sexual, relationship, and quality-of-life issues at 1 year between the group with breast reconstruction and healthy women. Although anxiety was not different between the women with mastectomy alone and the women with breast reconstruction, importantly, depression in the reconstruction group was less than for those women who had mastectomy alone. Evaluating satisfaction as a worthy emotional end point, one prospective study of women who underwent delayed reconstruction found that preoperative expectations were met in 90 % of the patients, with a hearty majority stating their satisfaction with the outcome [9]. Negative to psychological peace after reconstruction for some women is the experience of “decision regret.” While seeking to understand the effect of information satisfaction and personal variables on regret, one study found that most women in the study reported no decision regret but that for those who did experience mild to moderate or strong regret it was associated with low satisfaction with preparatory information [10]. The value of meeting and speaking with the reconstructive specialist before surgery was clearly reinforced in the findings.

Emphasizing that there are psychological/psychosocial benefits for breast reconstruction, Hasen et al. [11] noted in an evaluation of the overall role of plastic surgery as a component of comprehensive care of cancer patients that “the most convincing data for improved psychosocial well being through plastic surgery is in the setting of breast reconstruction after mastectomy.” Yet the evidence in the research literature is mixed. Evidence for the value of breast reconstruction can be seen in a study comparing women with breast reconstruction with women with breast conservation which found no difference between the two groups in overall psychosocial adjustment to illness, body image, or satisfaction with relationships or sexual life [12]. However, some studies have shown no difference in psychosocial parameters between women with and women without reconstruction following mastectomy. Seeking to broaden the comparison, many authors have sought psychological comparison between those with breast conservation, those with mastectomy alone, and those with mastectomy with reconstruction [13–16]. Two studies comparing the three groups found that the groups did not differ significantly in the psychosocial domains measured [13, 14]. The general capacity for women, irrespective of the surgical option, to adjust and return to a good quality of life was further supported by the prospective study of Parker et al. [15] in which those three groups showed differences in adjustment and adaptation at different time points along the study’s trajectory, with no significant differences in psychosocial adjustment by the study’s end. Likewise, Collins et al. [16] found there were differences between groups at different points along the trajectory of the study, with women with breast reconstruction faring less well on body image than those women having breast-conserving surgery at “time 2.” However, by the end of the study (2 years) there were no significant differences in body image for the different surgery types between any of the groups. Although it is good news that a statistically significant number of women, independent of which surgery they choose, will return to a good psychosocial state within a reasonable period after surgery, none of this research seems to show that breast reconstruction offers a better return to psychological health than mastectomy alone. If left without further studies, one could postulate that women who do not feel the need for reconstruction are in some measure emotionally prepared to live without a breast, whereas those women who choose breast reconstruction know the need they feel for this enhancement and would do less well psychologically were it not available to them. In clinical practice, this author has certainly experienced those distinctions. One study does lend credence to this theory as the researchers sought to isolate the psychological outcome for those with and without good cosmetic outcomes and did find a significant correlation between good cosmetic scores and good psychological adjustment [14]. Also of note is one recent study evaluating patient satisfaction and health-related quality of life specifically for those women whose breast reconstruction was conducted as autologous tissue reconstruction [17]. Using the newly available BREAST-Q research tool and validating the results with the findings of two other frequently used tools (Hospital Anxiety and Depression Scale and Impact of Event Scale), the authors found that these women enjoyed significantly higher scores on measures of psychosocial well-being, satisfaction with the breast, and sexual well-being as early as 3 weeks after surgery compared with their baselines on these measures.

Relatively few investigators have sought to understand the possible psychological distinctions for women with immediate reconstruction versus those with delayed reconstruction. An early study by Wellisch et al. [18] found women with immediate breast reconstruction less often reporting “high distress” in recalling their mastectomy surgery (25 %) than those women with delayed reconstruction (60 %). Another early and small study found that those with immediate reconstruction experienced significant advantages that included a sense of freedom with attire as well as improved self-image as compared with women with delayed reconstruction [19]. Adding to these salutary findings on behalf of immediate breast reconstruction, a retrospective analysis of the psychological advantages of immediate reconstruction found that anxiety and depression were lower and body image, self-esteem, feeling sexually attractive, and satisfaction were higher for the immediate reconstruction group than for their delayed reconstruction counterparts [20]. Analyzing subjects from the Michigan Breast Reconstruction Outcomes Study, Roth et al. [21] identified that women awaiting their mastectomy with immediate reconstruction showed “higher prevalence of psychosocial and functional morbidity” (e.g., depressed emotional well-being and increased anxiety) compared with the women awaiting reconstruction for a previous mastectomy. It is important not to assume, however, that immediate reconstruction is a poor choice with regard to emotional outcome, but rather to await further studies in which those with immediate reconstruction could be assessed again at a time further distant from their receiving a diagnosis of breast cancer to assess whether their time for emotional adjustment to the cancer diagnosis would compensate for this reported finding. The authors noted that those awaiting surgery for a previous mastectomy had likely been through the adjustment to their breast cancer diagnosis, whereas those awaiting immediate reconstruction concurrent to their mastectomy were likely dealing with “the apprehension and fears related to a recent diagnosis of breast cancer.” Lending credibility to this theory are two other studies, one prior to the above-mentioned study and one later, following women from this same database that found that women with immediate reconstruction showed significant improvement on all of the psychosocial outcome subscales (the later study evaluating them further from their time of diagnosis) other than on body image (having come from intact breasts to surgically produced breasts), and that women with delayed reconstruction showed improvement only on the subscale for body image (having come from having no breast tissue to now having surgically produced breasts), but not on the other psychosocial measures (already having had time to adjust to psychosocial issues before their breast reconstruction) [22, 23]. The analysis by Wilkens et al. [22] and the later analysis by Atisha et al. [23] also showed little to no difference in psychosocial well-being for the different types of reconstruction procedure.

In addition to women for whom breast reconstruction is a follow-up to cancer-related mastectomy of the breast(s) scheduled for reconstruction are those women whose breast reconstruction follows a contralateral prophylactic mastectomy and those at “high risk” who chose a bilateral prophylactic mastectomy. Although the circumstances driving the need for reconstruction are different, there is an interesting body of literature to inform our understanding of the psychological issues for women with reconstruction after either contralateral or bilateral prophylactic mastectomy. McGaughey [24], in an integrative review of 13 studies evaluating the impact of prophylactic mastectomies on women’s body image and sexuality, found that up to half of the women experienced a negative impact on body image and sexuality. Unfortunately, many studies found likewise. Payne et al. [25] following women who had registered in the Memorial Sloan-Kettering Cancer Center National Prophylactic Mastectomy Registry found women reporting negative impact on body image and sexual function as well. Following in that tradition, a smaller and more recent study with a 93 % response rate found 75 % of the women after bilateral prophylactic mastectomy reporting that enjoyment of sex was negatively impacted [26]. Evaluating the experience of women with contralateral prophylactic mastectomy, Boughey et al. [27] found that the women in their study who had had contralateral prophylactic mastectomy on average 20 years earlier frequently noted a negative impact on sense of femininity, body appearance, and sexual relationships. Further validation of the impact on sexuality comes from a more recent prospective study evaluating the impact of bilateral prophylactic mastectomy on body image, sexuality, emotional reactions, and quality of life for “high-risk” women. Brandberg et al. [28] analyzed responses from women preoperatively, at 6 months postoperatively, and at 1 year postoperatively. Sexual pleasure decreased significantly from assessment preoperatively to assessment at 1 year postoperatively, although, interestingly, the frequency of sexual activity remained stable through all assessment points. Although the latter might seem counterintuitive in the face of the former, it is beyond the scope of this chapter to theorize, and I only note that this prospective work supports the findings of previous retrospective studies that these women do experience a negative impact on their sexuality. This frequently reported negative impact on sexuality is not difficult to understand given the change in body image and the loss of this part of a woman’s anatomy that is often pivotal to a woman’s experience of sexual pleasure.

One of the major drivers of the decision for bilateral prophylactic mastectomy is an anticipated decrease in anxiety [29]. Happily, this was born out in the prospective study of Brandberg et al. [28], with women reporting decreased anxiety over time. This was further supported by the findings in an early study that offered bilateral prophylactic mastectomy to 143 women considered to be high risk of breast cancer. [30

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