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The Great Cosmetic Versus Reconstructive Debate: Public Perceptions On Breast Reconstruction As Compared To Breast Augmentation Andgynecomastiareduction
Helen Xun1, Erica Lee, BS1, Pooja Yesantharao, BS, MA1, Leen el Eter, BS2, Sarah Persing, MD1, Matthew Generoso, BS1, Justin Sacks, MD, FACS, MBA1.
1Johns Hopkins School of Medicine, Baltimore, MD, USA, 2St George's University of London, London, United Kingdom.

PURPOSE: The Agency for Healthcare Research and Quality reports that 40% of women who undergo a mastectomy have breast reconstruction surgery. Breast reconstruction is associated with significant quality of life benefits, including improvement in self-esteem, body image, and social life. Unfortunately for these breast cancer warriors, receiving breast reconstruction can be stigmatizing, as the public and patients continue to debate whether breast reconstruction is "vanity or life", or "cosmetic or reconstructive". While it is well received in the medical community that breast reconstruction serves well beyond aesthetic purposes, and is covered by insurance, the layperson's perceptions of this have not previously been studied. The purpose of our study is to compare public attitudes and perceptions towards breast reconstruction following mastectomies as compared to breast augmentations for cosmetic purposes, or the male counterpart of gynecomastia surgery.
METHODS: Surveys were administered through mTurks in an IRB exempt study. Demographic information was self-reported. Respondents were presented with before and after pictures of procedures with cosmetic or reconstructive cues. Procedures included breast augmentation or reconstruction, and gynecomastia reduction. Respondents were then asked whether this procedure is cosmetic or reconstructive, perceived attractiveness following procedure, likelihood of pursuing the procedure, procedure's impact on self-esteem, and insurance coverage. All statistical analyses were completed using Stata v. 13 (StatCorp, College Station, TX). Patient-level variables and survey responses were analyzed using two-tailed Student's t tests and chi square analyses.
RESULTS: The average age of the 459 completed surveys was 38.5 12.1, and 48.4% female. Surprisingly, more respondents indicated that reconstruction should be classified as cosmetic (71.1%) than for breast augmentations (54.6%, p<0.001). Respondents were more likely to pursue breast reconstruction than breast augmentation (p<0.001), and breast reconstruction was seen to have a higher impact on self-esteem than augmentation. Majority of respondents (73.1%) believed that breast reconstruction should be covered by insurance, compared to the 26.9% that believe that breast augmentation should be covered by insurance (p<0.0001). In contrast, gynecomastia reduction in men after being provided a reconstructive cue was appropriately classified as reconstructive. More individuals believed that insurance should cover gynecomastia for cosmetic purposes (59.6%) than breast augmentation (26.9%, p<0.0001).
CONCLUSION: The majority of respondents believed that breast reconstruction following lumpectomy was cosmetic. This misconception emphasizes the need for public education on the importance of breast reconstruction, and its psychological impact and reestablishment of quality of life. The difference between public perceptions of the female and male procedures suggest there may be residual social stigma involving plastic surgery female breast procedures. This may be due to gender biases that female breast procedures are perceived as more cosmetic, while male breast procedures are thought to be more restorative. This further emphasizes the need for continued research on the importance of breast reconstruction, and physician education to the patient and the community on the benefits of breast reconstruction.


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