Abstract
Incisional scarring is a factor of cosmetic appearance evaluated after breast reconstruction, along with the shape, position, and size of the breast. This study aimed to examine the effect of the incision scar location on patient satisfaction after breast reconstruction. Using the Japanese version of the SCAR‐Q, we assessed the scar appearance, symptoms and psychosocial effects. Plastic surgeons performed assessments using the Manchester Scar Scale. The patients were divided into two groups: those with scars on the margins of the breast (MB group) and those with scars in the breast area (IB group). The results revealed that patients in the MB group reported significantly higher satisfaction with the scar appearance and psychological impact than those in the IB group. However, assessments using the Manchester Scar Scale did not reveal any significant differences between the two groups. In conclusion, this study underscores the importance of patient‐reported outcomes in the evaluation of scar satisfaction after breast reconstruction. Patients tend to prefer and have higher satisfaction with scars along the breast margin, which offers valuable insights into surgical decisions. Further studies with larger and more diverse sample sizes are required for validation.
Keywords: breast reconstruction, incision, patient‐reported outcome, scar, SCAR‐Q
1. INTRODUCTION
In the cosmetic appearance of breast reconstruction, the incisional scar is one of the factors evaluated along with the shape, position, and size of the breast. Furthermore, for breast cancer patients, the incisional scar is a major issue that affects a patient's satisfaction. 1 However, no reports of satisfaction regarding the scar position exist. Various scales have been developed to evaluate surgical scars. However, most of them quantify objective evaluations by medical personnel, and very few have been subjective evaluations based on the patient's own report. 2 Furthermore, individual assessments of medical personnel and patients do not always coincide. In recent years, emphasis has been placed on patient‐reported outcomes (PROs), which strictly exclude the physician's evaluation.
The BREAST‐Q reconstruction module (BREAST‐Q) has been used as a measure of patient satisfaction in breast reconstruction after breast cancer surgery. 1 However, the BREAST‐Q evaluates only the reconstructed breast as a whole and does not focus on scars alone. Therefore, the BREAST‐Q is unable to assess patient satisfaction with respect to breast surgical scars.
The SCAR‐Q, 3 a questionnaire designed for patients with surgical and trauma scars that evaluates their appearance, symptoms and psychosocial impact, was published in 2018. The SCAR‐Q is designed to assess each aspect as a score on a separate scale. The SCAR‐Q is being translated into a number of non‐English languages, and a Japanese version of the SCAR‐Q (SCAR‐Q_J) was developed in 2022. 4 The SCAR‐Q_J uses the four steps of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR): (i) forward translation, (ii) back translation, (iii) back translation review, and (iv) patient interviews to translate the English version into Japanese.
Various incisions are used in breast cancer resection procedures. Hence, the aim of this study was to investigate whether the satisfaction differed depending on the incision location using the SCAR‐Q_J and to compare differences with the medical personnel‐rating scale using the Manchester Scar Scale (MSS).
2. MATERIALS AND METHODS
This was a prospective cohort study, and all data were obtained from medical charts. This study was approved by the Ethics Committee of Tokyo Medical University (TS2020‐0394), and consent was obtained from all patients.
The inclusion criteria were as follows: (1) consulted the breast reconstruction outpatient clinic between November 2022 and July 2023, (2) underwent total mastectomy for breast cancer at our institution, (3) underwent implant‐based breast reconstruction by inserting an artificial prosthesis under the pectoralis major muscle, and (4) were followed up for at least 1 to 5 years after reconstruction. The exclusion criteria were: (1) under 20 years of age, (2) did not provide consent, (3) had postoperative local recurrence, or (4) had distant metastasis.
With regard to the location of the surgical incisional scar, patients with incision lines along the breast margin, such as lateral inframammary fold and inframammary fold incisions, were categorised as having scars on the margins of the breast (i.e., the MB group), while patients with peri‐areolar, horizontal, or radial incisions and other incisions within the breast area were classified as having scars within the breast area (i.e., the IB group) (Figure 1).
FIGURE 1.
Typical incision sites for the IB and MB groups are shown.
Eligible patients were asked to complete an assessment of their postoperative scars using the SCAR‐Q_J, which was administered in person. Eligible patients subsequently sent their results by mail. Additionally, scars were assessed using the MSS 5 via a face‐to‐face assessment by two plastic surgeons specialising in breast reconstruction. Scars from NAC reconstruction were excluded in the evaluation.
The patient background information included the age at the time of the scar evaluation, body mass index (BMI) at the first visit to the plastic surgery clinic, volume of breast implants used for reconstruction, smoking history, chemotherapy/radiotherapy, ptosis after reconstruction, and postoperative follow‐up period. Ptosis was defined as a case in which the lower edge of the breast was below the IMF line. Statistical analyses were performed using SPSS ver. 28 (IBM, NY, USA) with a t‐test. Statistical significance was set at p < 0.05.
3. RESULTS
Of the 57 eligible patients, 50 responded to the SCAR‐Q_J, with a response rate of 87%, and 50 patients were assessed using the MSS. Of the 50 patients, 26 were in the MB group (24 lateral inframammary fold and 2 inframammary fold incisions) and 24 were in the IB group (1 peri‐areolar, 18 horizontal, 2 radial, and 3 other incisions).
Patient background factors were not significantly different between the two groups (Table 1). Patient satisfaction with scars according to the Scar Q_J was significantly higher in the MB group than in the IB group on the appearance and psychological scales. Furthermore, the MB group had a higher total satisfaction score than that of the IB group (Table 2). In contrast, the MSS assessment of the same patients showed no significant differences in both individual questions and total scores (Table 3).
TABLE 1.
Patient demographics.
| MB group (n = 26) | IB group (n = 24) | p‐value | |
|---|---|---|---|
| Age: years; average (SD) | 52.92 (9.389) | 52.92 (9.722) | 0.998 |
| BMI: kg/m2; average (SD) | 20.34 (2.823) | 21.189 (3.112) | 0.400 |
| Implant volume: cc, average (SD) | 237.1 (104.1) | 240.5 (69.4) | 0.895 |
| Smoking: cases | 9 | 5 | 0.530 |
| Chemotherapy: cases | 12 | 15 | 0.849 |
| Radiotherapy: cases | 5 | 4 | 0.523 |
| Ptosis: cases | 1 | 0 | 0.342 |
Abbreviations: BMI, body mass index; IB, scar within the breast area; MB, scar on the margins of the breast; SD, Standard deviations.
TABLE 2.
SCAR‐Q_J scores.
| MB group (n = 26) | IB group (n = 24) | p‐value | |
|---|---|---|---|
| Appearance (SD) | 84.62 (18.348) | 66.75 (26.405) | 0.007* |
| Symptom (SD) | 82.00 (13.014) | 77.79 (17.828) | 0.343 |
| Psychosocial Impact (SD) | 87.19 (15.791) | 71.13 (30.700) | 0.028* |
| Total (SD) | 253.81 (38.511) | 215.67 (66.504) | 0.016* |
Abbreviations: IB, scar within the breast area; MB, scar on the margins of the breast; SCAR‐Q_J, Japanese version of the SCAR‐Q; SD, Standard deviations.
p < 0.05, significant difference.
TABLE 3.
Manchester Scar Scale scores.
| EB group (n = 26) | IB group (n = 24) | p‐value | |
|---|---|---|---|
| Colour (SD) | 1.15 (0.456) | 1.42 (0.647) | 0.111 |
| Finish (SD) | 1.00 (0.000) | 1.04 (0.209) | 0.328 |
| Contour (SD) | 1.04 (0.192) | 1.08 (0.417) | 0.618 |
| Distortion (SD) | 1.00 (0.000) | 1.00 (0.000) | ‐ |
| Texture (SD) | 1.07 (0.385) | 1.08 (0.417) | 0.958 |
| Total (SD) | 5.26 (0.984) | 5.63 (1.502) | 0.319 |
Abbreviations: IB, scar within the breast area; MB, scar on the margins of the breast; SD, Standard deviations.
A comparison of MSS scores with the total appearance and symptom scores from the SCAR‐Q, excluding the psychosocial impact item, showed that the MB group scored predominantly higher on the SCAR‐Q_J, whereas, the two groups had no significant differences on the MSS. This shows that there was no similar trend in the assessment of the orderliness of medical personnel and patient satisfaction (Table 4).
TABLE 4.
Comparison of SCAR‐Q and Manchester Scar Scale scores.
| MB group (n = 27) | IB group (n = 23) | p‐value | |
|---|---|---|---|
| SCAR‐Q_J Appearance+Symptoms | 166.62 | 144.54 | 0.033* |
| MSS Total | 5.26 | 5.57 | 0.392 |
Abbreviations: IB, scar within the breast area; MB, scar on the margins of the breast; MSS, Manchester Scar Scale; SCAR‐Q_J, Japanese version of the SCAR‐Q_J.
p < 0.05, significant difference.
4. DISCUSSION
For patients with breast cancer, scarring is the most important cosmetic concern, even before the shape and position. Anatomical considerations of the scar location have been reported; however, no postoperative follow‐up studies on the cosmetic appearance of the scar and comparisons with patient satisfaction exist. While the breast has been actively investigated using the Breast Q, scars have not been investigated with this scale. In situations where the incision location can be chosen, the SCAR‐Q may be useful in determining the preferred scar location.
PROs for scars have been published, including the Stony Brooks Scar Evaluation Scale in 2007, and the Scar Cosmesis Evaluating Scale in 2016; however, the SCAR‐Q has been the most recent and widely used. 3 The SCAR‐Q is used for children and adults aged 8 years and older with any type of surgical, traumatic, or burn scar. The SCAR‐Q has three independent functioning scales that measure the scar appearance, symptoms, and psychosocial impact.
The SCAR‐Q has been used before and after scar treatment. 6 In addition, the psychosocial impact score of the SCAR‐Q has been identified as a low factor in the desire for scar revision surgery. 7 Furthermore, the SCAR‐Q has been used before and after cosmetic surgery, and higher postoperative SCAR‐Q scores have been reported for facial and breast augmentation surgeries than for abdominoplasty. 8 Moreover, the score for breast augmentation incision lines was higher for IMF incisions than for peri‐areolar incisions. 9
The Harris Scale 10 and breast analysing tool (BAT) 11 have been used to assess scarring after breast cancer surgery. In contrast, the European Organisation for Research and Treatment of Cancer quality of life questionnaire (EORTC‐QLQ) has been used to assess patient satisfaction. When cosmetic items were assessed simultaneously by patients and medical personnel, medical personnel were more satisfied than patients. 12
Regarding incision scars in mastectomies, evaluations of the cosmetic appearance by medical personnel suggest that the hidden incision line (external to breast areas) is the most aesthetic in nipple‐sparing mastectomy (NSM) cases, while vertical scars are better than horizontal scars in skin‐sparing mastectomy (SSM). 13 The results reported for NSM are similar to our results.
The MSS used in the present study assessed the cosmetic appearance of the scar itself; therefore, assessing the location of the scar was not possible. This cannot be performed by existing medical personnel who report scar scales other than the MSS. In this respect, patient assessments using the PRO and SCAR‐Q included the location and condition of the surgical scar. Even if the scar quality assessment were not different, the SCAR‐Q results would have been significantly different.
In the present study, we found that incisions made on the breast margin were associated with higher patient satisfaction. Therefore, incisions on the margins of the breast area are preferable if oncological safety is ensured and the residual breast skin flap has no blood flow problems.
Patient satisfaction on the SCAR‐Q was significantly higher in the MB group than in the IB group. However, the MSS scores proved that both groups had similar scars. Thus, even with a similar scar quality, patient satisfaction was better for incisional scars outside the breast. Hence, when choosing the site of the incision line, considering a more esthetic scar location and placing the incision at a site with which the patient is satisfied is important. In a study comparing thigh and lower leg incisions in lower leg lengthening procedures, despite the shorter and cosmetically better lower leg scars, better patient satisfaction, based on PRO using a visual analogue scale, was reported for thigh scars, which can be easily concealed with clothing. 14 Therefore, the use of PRO is especially important for studies involving the location of surgical scars.
As for the limitations of this study, the total number of evaluated patients was small (n = 50). The location of the incisional scar was divided into only two groups; therefore, evaluating the difference between peri‐areolar and horizontal or radial incisions inside the breast area was not possible.
Based on the results of this study, the number of cases with incisions in the breast area will likely decrease in the future. However, incisions in the breast area may still be required due to various restrictions. Therefore, increasing the number of cases in future studies is necessary.
In conclusion, the Japanese version of the SCAR‐Q, developed by the coauthor in 2022, was used for the first time to assess patient scars after implant‐based breast cancer reconstruction. Patient satisfaction and medical personnel ratings did not show similar trends. Medical personnel rated the incisional scar, whether inside or on the margins of the breast area, as cosmetically pleasing, but the patient satisfaction was higher with scars in the breast area margins. Furthermore, PROs should be used to assess surgical scars.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest regarding this article.
ACKNOWLEDGEMENTS
We would like to thank Editage (www.editage.jp) for English language editing.
Suzuki M, Komiya T, Asai M, et al. Effectiveness of SCAR‐Q for assessment of incisional SCAR after implant‐based reconstruction in breast cancer patients: Can it be a tool for incision selection? Int Wound J. 2024;21(3):e14822. doi: 10.1111/iwj.14822
DATA AVAILABILITY STATEMENT
Data available on request due to privacy/ethical restrictions.
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Data Availability Statement
Data available on request due to privacy/ethical restrictions.