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Body Image And Race In Online Resources For Breast Reconstruction: What Do Our Patients See?
Erica Lee, MS, Pooja Yesantharao, MS, Chao Long, MD, Wilmina Landford, MD, Carisa M. Cooney, MPH, Justin Sacks, MD MBA, Kristen P. Broderick, MD.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background
Body image distress is common amongst women with breast cancer who undergo mastectomy and can persist for years, even after reconstruction. Although surgeons aim to provide comprehensive education on the journey from mastectomy to final reconstruction, patients often seek additional information online. However, there is a paucity of literature evaluating the extent to which readily available online patient resources and visual aids can prevent or mitigate body image distress. Racial minority patients suffer from poorer post-operative satisfaction and often face greater difficulties in accessing appropriate breast reconstruction resources. Thus, this study assessed 1) body image discussion in current United States online resources for breast reconstruction, and 2) racial demographics of the visual aids in these resources.
Methods
An online Google search using the key phrases "breast reconstruction" and "breast reconstruction [and] body image" was conducted. The first 10 institutional/academic websites and media/private websites for each phrase were identified and assessed for: presence of body image discussion and visual aids. Body image discussion was defined as an article or article section directly addressing body image and/or expectations. The first 200 Google Images for each phrase were selected for image analysis. The subject matter of each image was categorized as one of the following: "Before/After Reconstruction," "Surgical/Anatomical Diagram," "Step-by-Step," or "Complications." Patients in images were further classified by skin tone into "White" or "Non-White" using the Fitzpatrick scale and by body habitus. All statistical analysis was completed using two-tailed chi-squared tests.
Results
Sixty-percent of the 20 websites analyzed contained discussion of body image after breast reconstruction, only three of which appeared in the "breast reconstruction" search (p<0.05). Half of the websites included visual aids: predominantly "Before/After Reconstruction" photographs (67.1%), followed by Surgical/Anatomical (26.1%) and Step-by-Step (6.8%) illustrations. Including the Google Images, a total of 561 visual aids were assessed. The majority were of "White" skin tones (94.9%); significantly disparate from the current United States demographics (p<0.0001) and from women undergoing first-time breast reconstruction (p<0.0001). "Before/After" photographs were significantly more likely to show overweight/obese women and "Non-White" skin tones than "Surgical/Anatomical" and "Step-by-Step" illustrations (p<0.0001). Slender body types (e.g. waistline narrower than hips) were predominantly seen in all visual aids (85.6%). No images of complications were found.
Conclusions
Our findings demonstrate that breast reconstruction online resources lack information on body image. Patients who do not include "body image" within their online search may not be aware of resources to alleviate body image distress. Additionally, visual aids largely depict slender Caucasian subjects and do not reflect the demographics of breast reconstruction patients nor the United States' population. This disparity may contribute to inequalities in patient satisfaction and body image. "Before/After" photographs showcase a variety of women; however, they omit the numerous stages between mastectomy and final reconstructive outcome wherein body image distress can occur. By better representing the populations we serve in visual aids, online patient resources addressing body image concerns can provide more comprehensive information to patients and better frame their expectations regarding the reconstructive process, helping mitigate body image distress.


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