Abstract
Background:
While postmastectomy breast reconstruction is commonly offered to improve quality of life, its long-term psychological impact by reconstruction type remains poorly understood. This study aimed to evaluate the long-term risk of clinically diagnosed mental disorders following autologous reconstruction (AR) vs. implant-based reconstruction (IBR) in breast cancer patients undergoing mastectomy.
Materials and Methods:
We conducted a target trial emulation using a nationwide population-based cohort from the Korean National Health Insurance Service (2015–2023), with follow-up up to 9 years after reconstruction. Women newly diagnosed with breast cancer and underwent total mastectomy followed by breast reconstruction were included (N = 24 930). Outcomes were compared by reconstruction type, categorized as AR or IBR. A 1:3 propensity score matching compared 5113 patients undergoing AR and 14 738 receiving IBR. The primary outcome was time to the first diagnosis of any mental disorder, identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes for anxiety, depression, bipolar disorder, post-traumatic stress disorder, sleep disorders, and substance use. Cox proportional hazards models estimated hazard ratios and 95% confidence intervals (CIs), adjusting for demographic and clinical covariates.
Results:
In the matched cohort (mean age 48.7 years), the incidence of any mental disorder was higher in the AR group than in the IBR group [adjusted hazard ratio (aHR) 1.13; 95% CI, 1.07–1.19]. The association was more pronounced in patients aged ≥50 years (aHR 1.16; 95% CI, 1.07–1.26). Time-stratified analyses showed increasing risk over time, persisting through 5 years. Among younger patients (<50 years), delayed AR was associated with lower psychiatric risk (aHR 0.79; 95% CI, 0.57–1.11; interaction P = 0.021). Validation analysis confirmed higher psychiatric risk with radiotherapy, supporting robustness of outcome definitions.
Conclusions:
AR was associated with an elevated long-term risk of mental disorders, particularly among older patients. These findings underscore the need for age-specific, psychologically informed counseling when discussing reconstruction options in survivorship care.
Keywords: autologous reconstruction, breast cancer, breast reconstruction, implant-based reconstruction, mental disorders, psychological outcomes
HIGHLIGHTS
Autologous breast reconstruction was associated with a higher long-term risk of clinically diagnosed mental disorders compared with implant-based reconstruction.
The increased psychiatric risk was particularly evident in patients aged ≥50 years and persisted for up to 5 years after reconstruction.
Among younger patients (<50 years), delayed autologous reconstruction was associated with a lower risk of mental disorders.
Introduction
With improving survival rates among breast cancer patients, attention has increasingly shifted toward survivorship care and long-term quality of life[1]. Among these, postmastectomy breast reconstruction has become an integral part of comprehensive breast cancer treatment[2,3]. Reconstruction offers physical restoration and also provides potential psychosocial benefits and is now routinely considered as part of standard surgical planning[2,3]. Reconstruction techniques are broadly categorized into two main types, implant-based reconstruction (IBR) and autologous reconstruction (AR)[4].
IBR, the more commonly performed technique, involves the insertion of saline or silicone implants and is typically associated with shorter operative times, reduced recovery periods, and less surgical morbidity[5,6]. In contrast, AR uses the patient’s own tissue, including that from the abdomen, back, or thighs to reconstruct the breast, often resulting in a more natural appearance and feel. This has led to the perception that AR yields higher patient satisfaction, particularly in terms of aesthetic and sensory outcomes[7]. Despite these perceived benefits, AR requires more extensive surgery, involves a longer recovery period, and carries risks related to donor site morbidity that may contribute to long-term psychosocial burden[8]. Moreover, patients who undergo AR face a significantly higher risk of postoperative complications compared with those receiving IBR, such as flap necrosis or total flap loss, may adversely affect mental well-being in the years following surgery[9]. As a consequence, a recent systematic review found no consensus on whether one method provides superior psychological outcomes[5].
The inconsistency across prior studies likely stems from several key limitations. First, many have focused primarily on short-term outcomes, such as aesthetic satisfaction or early psychological adaptation, often within the first 12 months post-surgery[10]. Second, few have examined clinically diagnosed mental disorders as long-term outcomes[11]. Third, prior analyses often lacked rigorous control for baseline mental health conditions[12,13]. Lastly, existing literature tends to be limited to single-center or small cohort studies, raising concerns about generalizability. To address these gaps, we conducted a target trial emulation using a nationwide administrative database to compare long-term mental outcomes between AR and IBR recipients. We hypothesized that AR would be associated with a higher long-term risk of clinically diagnosed mental disorders compared with IBR at 1, 5, and up to 9 years after reconstruction.
Methods
Study design and study population
This was a target trial emulation study using the Korean National Health Insurance Service (K-NHIS) database from 2015 to 2023, with follow-up up to 9 years after reconstruction to assess the long-term psychological impacts of AR and IBR following mastectomy (Supplemental Digital Content Table S1, available at: http://links.lww.com/JS9/F252). The K-NHIS database represents the entire population of Korea[14], and all citizens are continuously enrolled unless they become ineligible due to emigration or death.
The study included newly diagnosed female breast cancer patients who underwent total mastectomy followed by breast reconstruction classified into two types using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) procedure codes: ARs were coded from N7140 to N7147, and IBRs were coded from N7148 to N7151 (N = 31 727) (Supplemental Digital Content Tables S1 and S2, available at: http://links.lww.com/JS9/F252). Exclusions applied to individuals who received cosmetic breast surgery such as augmentation prior to mastectomy (N = 54), and those diagnosed with mental disorders within 1 year prior to surgery (N = 6743). Among 24 930 eligible participants, a total of 5113 patients who underwent AR and 14 738 who underwent IBR were included in the final analytic cohort after propensity-score matching (Supplemental Digital Content Fig. S1, available at: http://links.lww.com/JS9/F252). This study was approved by the Institutional Review Board (IRB) of our institute (IRB no. 2024-04-061). Informed consent was waived as de-identified data were used. The study protocol was registered at ClinicalTrials.gov. This cohort study has been reported in line with the STROCSS guidelines[15].
Data collection
Mental disorders were identified from diagnostic records according to ICD-10 codes, from either outpatient visits or hospitalization. The primary endpoint was a composite of major mental disorders newly diagnosed during the follow-up period, including anxiety disorders (F40 and F41), bipolar disorder (F30, F31, and F34.0), depressive disorders (F32 and F33), sleep disorders (G47.0 and F51.0), obsessive-compulsive disorder (F42), post-traumatic stress disorder (F43.1), substance use disorders (F10–F19), and any other psychiatric disorders at 1 year, 5 years, and up to 9 years following reconstruction (Supplemental Digital Content Tables S1 and S2, available at: http://links.lww.com/JS9/F252). South Korea’s healthcare system ensures that diagnostic codes are likely assigned following evaluations by mental health specialists. Previous studies in South Korea have demonstrated the reliability and specificity of claims-based definitions of mental illnesses using physician-assigned diagnostic codes[16,17].
Covariates
Age, sex, comorbidities, income, and residential area at baseline were included as covariates. Comorbidities during the year before baseline were obtained from claims data defined using the ICD-10 codes. We included hypertension (with medication), which was defined as the presence of at least one I10–I13 or I15 code during the year prior to baseline. Income data at the time of the first screening were obtained from the insurance eligibility database. Income level was categorized by percentile groups (≤30th, 31st–70th, and >70th percentiles).
For sensitivity analysis, we restricted the analysis to patients who underwent health screening within 2 years prior to baseline, and used body mass index, alcohol consumption, smoking, and exercise data from the screening examination.
Statistical analysis
Trial sets were created monthly for the first 6 months postmastectomy to align the timing of reconstruction between the AR and IBR groups and every 6 months thereafter. To minimize this bias, we implemented a 1:3 propensity score (PS) nearest-neighbor matching with a caliper of 0.1 on the PS scale[18]. PS was used based on age, income, residential area, comorbidities, and treatment modalities to ensure comparability between the groups. Differences in baseline covariates between the two groups were evaluated using an absolute standardized difference with a value of >0.25 indicating a significant difference[18]. Analyses were stratified by age group (<50 and ≥50 years) to assess potential age-related differences in psychiatric risk, as older age is a known risk factor for mental disorders independent of surgical intervention. The cutoff of 50 years was selected based on epidemiological evidence indicating that the mean age at natural menopause among Korean women is approximately 49–50 years[19], a period characterized by hormonal changes and increased vulnerability to psychological distress.
Hazard ratios and adjusted hazard ratios (aHR) were calculated to compare the incidence of mental disorders between the groups, using IBR as the reference. In a sensitivity analysis to account for the potential influence of late implant failure or revision surgery on mental health outcomes, we additionally censored follow-up at the time of any breast reoperation after the index reconstruction. To confirm the validity of our approach, we performed an exploratory analysis as a positive control, to assess whether the expected direction of association matched prior evidence linking radiotherapy to psychological distress, using the same outcome definitions and model structure.
We conducted additional analyses to test the robustness of our findings. First, in a sensitivity analysis, follow-up was censored at the time of any breast reoperation to account for the potential psychological impact of implant revision or replacement. Second, we conducted time-stratified analyses to evaluate whether the association between reconstruction type and mental outcomes persisted over both short-term and long-term follow-up. Specifically, we estimated aHR for mental disorders at predefined follow-up intervals, including up to 5 years post-reconstruction. Third, to account for the potential influence of acute psychological distress related to cancer surgery and treatment, a 1-year landmark analysis was conducted. For this analysis, we restricted the cohort to patients who survived at least 12 months after the date of breast reconstruction.
All analyses were two-sided, and P-values < 0.05 were considered statistically significant. All statistical analyses were performed using R version 4.0.3 (R Foundation for Statistical Computing, Vienna, Austria).
Results
Baseline characteristics were well balanced after matching, with a standardized mean difference of less than 0.01 for age, income, residential area, and comorbidities including diabetes, hypertension, and dyslipidemia (Table 1).
Table 1.
Characteristics of study participants
| Characteristics | Before matching | After matchinga | ||||
|---|---|---|---|---|---|---|
| AR (N = 6074) | IBR (N = 18 856) | SMD | AR (N = 5113) | IBR (N = 14 738) | SMD | |
| Age, year | 48.28 ± 7.58 | 47.45 ± 8.40 | 0.104 | 48.76 ± 7.35 | 48.70 ± 7.70 | 0.009 |
| Age group | ||||||
| ≤39 | 674 (11.1) | 2964 (15.7) | −0.136 | 421 (8.2) | 1236 (8.4) | −0.006 |
| 40–49 | 2937 (48.4) | 9054 (48.0) | 0.007 | 2551 (49.9) | 7458 (50.6) | −0.014 |
| 50–59 | 1964 (32.3) | 5116 (27.1) | 0.114 | 1700 (33.2) | 4701 (31.9) | 0.029 |
| ≥60 | 499 (8.2) | 1722 (9.1) | −0.033 | 441 (8.6) | 1343 (9.1) | −0.017 |
| Income | ||||||
| Medical aid | 60 (1.0) | 167 (0.9) | 0.011 | 49 (1.0) | 135 (0.9) | 0.004 |
| ≤30th | 1384 (22.8) | 4541 (24.1) | −0.032 | 1213 (23.7) | 3549 (24.1) | −0.008 |
| 31st–70th | 2082 (34.3) | 6323 (33.5) | 0.015 | 1805 (35.3) | 5091 (34.5) | 0.016 |
| >70th | 2391 (39.4) | 7308 (38.8) | 0.011 | 2046 (40.0) | 5963 (40.5) | −0.009 |
| Unknown | 157 (2.6) | 517 (2.7) | NA | 0 | 0 | NA |
| Residential area | 0.005 | |||||
| Metropolitan | 5741 (94.5) | 17 801 (94.4) | NA | 4836 (94.6) | 13 915 (94.4) | 0.007 |
| Rural | 333 (5.5) | 1055 (5.6) | NA | 277 (5.4) | 823 (5.6) | NA |
| Comorbidities | ||||||
| Diabetes mellitus, yes | 1235 (20.3) | 3920 (20.8) | 0.011 | 1052 (20.6) | 3089 (21.0) | 0.009 |
| Hypertension, yes | 1258 (20.7) | 3532 (18.7) | 0.050 | 1068 (20.9) | 3008 (20.4) | 0.012 |
| Dyslipidemia, yes | 3187 (52.5) | 10 366 (55.0) | 0.050 | 2719 (53.2) | 7947 (53.9) | 0.015 |
| Treatment modality | ||||||
| Radiotherapy | 1515 (24.9) | 2588 (13.7) | 0.287 | 1193 (23.3) | 1860 (12.6) | 0.282 |
| Chemotherapy | 4255 (70.1) | 12 855 (68.2) | 0.041 | 3492 (68.3) | 9841 (66.8) | 0.033 |
| Hormone therapy | 2108 (34.7) | 7957 (42.2) | 0.154 | 1713 (33.5) | 5949 (40.4) | 0.143 |
| Timing of breast reconstruction | 0.205 | 0.126 | ||||
| Immediate | 5511 (90.7) | 18 069 (95.8) | NA | 4835 (94.6) | 14 307 (97.1) | NA |
| Delayed | 563 (9.3) | 787 (4.2) | NA | 278 (5.4) | 431 (2.9) | NA |
Values were presented n (%) or mean ± AR, autologous tissue reconstruction; IBR, implant-based reconstruction; SD; SD, standard deviation; SMD, standard mean difference.
Over the follow-up period (median 4.5, interquartile range 2–7 years), the incidence of any mental disorder was higher in the AR group than in the IBR group. In the fully adjusted model, AR was associated with a higher risk of any mental disorder [aHR, 1.13; 95% confidence interval (CI), 1.07–1.19]. In the sensitivity analysis censoring patients at the time of any reoperation, the results were consistent with the main analysis (aHR, 1.13; 95% CI, 1.07–1.20; Supplemental Digital Content Table S3, available at: http://links.lww.com/JS9/F252).
Specifically, the risk of anxiety disorder was significantly elevated (aHR, 1.25; 95% CI, 1.16–1.35), while the risks of depressive disorder (aHR, 1.09; 95% CI, 0.99–1.19) and sleep disorder (aHR, 1.04; 95% CI, 0.96–1.13) showed modest and nonsignificant trends (Supplemental Digital Content Table S4, Table S5, available at: http://links.lww.com/JS9/F252). In a validation check, as expected, patients who received radiotherapy exhibited higher risks of mental disorders compared with those who did not receive radiotherapy (Supplemental Digital Content Table S5, available at: http://links.lww.com/JS9/F252).
Subgroup analyses revealed that the increased risk was more pronounced in older patients (≥50 years), with an aHR of 1.16 (95% CI, 1.07–1.26) for any mental disorder, compared with 1.10 (95% CI, 1.02–1.19) among those aged < 50 years (Fig. 1, Table 2). While the elevated risk in the AR group was generally consistent across subgroups, the direction of association reversed for patients who underwent delayed reconstruction (aHR, 0.79; 95% CI, 0.57–1.11; P for interaction = 0.021; Supplemental Digital Content Table S6, available at: http://links.lww.com/JS9/F252), particularly among younger patients (Fig. 2).
Figure 1.
Kaplan-Meier curve for the incidence of mental disorder by types of reconstruction surgery in age <50 (A) and age ≥50 years old (B).
Table 2.
Incidence of mental disorder by types of implant
| Disorder | <50 (N = 11 666) | ≥50 (N = 8185) | ||||
|---|---|---|---|---|---|---|
| Number of events | IBR (reference) vs. AR | Number of events | IBR (reference) vs. AR | |||
| (100 persons year) | (100 persons year) | |||||
| AR (N = 2972) | IBR (N = 8694) | aHR (95% CI)a | AR (N = 2141) | IBR (N = 6044) | aHR (95% CI)a | |
| Any | 944 (7.92) | 2523 (7.71) | 1.10 (1.02, 1.19) | 795 (10.16) | 1930 (9.35) | 1.16 (1.07, 1.26) |
| Anxiety disorder | 541 (3.91) | 1322 (3.47) | 1.19 (1.07, 1.31) | 476 (5.10) | 998 (4.01) | 1.34 (1.20, 1.50) |
| Bipolar disorder | 46 (0.28) | 118 (0.27) | 1.04 (0.73, 1.47) | 27 (0.24) | 74 (0.26) | 0.94 (0.60, 1.47) |
| Depressive disorder | 384 (2.61) | 1062 (2.72) | 1.04 (0.92, 1.17) | 303 (2.97) | 730 (2.83) | 1.15 (1.00, 1.32) |
| Sleep disorder | 458 (3.19) | 1356 (3.58) | 0.97 (0.87, 1.08) | 427 (4.45) | 1052 (4.32) | 1.12 (1.00, 1.26) |
| Obsessive-compulsive disorder | 3 (0.02) | 25 (0.06) | 0.33 (0.10, 1.10) | 4 (0.03) | 6 (0.02) | 1.95 (0.53, 7.14) |
| Post-traumatic stress disorder | 6 (0.04) | 5 (0.01) | 3.18 (0.94, 10.77) | 4 (0.03) | 2 (0.01) | 4.73 (0.84, 26.50) |
| Substance use disorder | 13 (0.08) | 31 (0.07) | 1.15 (0.59, 2.24) | 5 (0.04) | 10 (0.03) | 1.13 (0.38, 3.39) |
AR, autologous reconstruction; IBR, implant-based reconstruction; aHR, adjusted hazard ratios; CI, confidence interval.
Adjusted for age, residential area, income, body mass index, diabetes mellitus, hypertension and dyslipidemia, timing of breast reconstruction, radiotherapy, chemotherapy, and hormone therapy.
Figure 2.
Subgroup analysis for age <50 (A) and age ≥50 (B).
In time-stratified models, the elevated risk associated with AR persisted across both short-term and long-term follow-up. At 5 years, AR was associated with a higher risk of any mental disorder among both younger (aHR, 1.21; 95% CI, 1.12–1.31) and older patients (aHR, 1.25; 95% CI, 1.14–1.36; Table 3). The risk of anxiety disorder remained particularly elevated at 5 years (aHR, 1.40 in patients < 50 years; aHR, 1.49 in patients ≥ 50 years).
Table 3.
Incidence of mental disorder by types of implant
| <50 | ≥50 | |||
|---|---|---|---|---|
| Disorder | 1 yr | 5 yr | 1 yr | 5 yr |
| aHR (95% CI)a | aHR (95% CI)a | aHR (95% CI)a | aHR (95% CI)a | |
| Any | 1.10 (0.99, 1.22) | 1.21 (1.12, 1.31) | 1.12 (1.00, 1.25) | 1.25 (1.14, 1.36) |
| Anxiety disorder | 1.14 (0.98, 1.32) | 1.40 (1.26, 1.55) | 1.11 (0.94, 1.32) | 1.49 (1.33, 1.67) |
| Bipolar disorder | 0.83 (0.48, 1.44) | 1.22 (0.85, 1.76) | 1.06 (0.52, 2.15) | 1.13 (0.71, 1.80) |
| Depressive disorder | 1.14 (0.95, 1.37) | 1.22 (1.08, 1.38) | 1.10 (0.90, 1.35) | 1.36 (1.18, 1.57) |
| Sleep disorder | 1.05 (0.90, 1.23) | 1.09 (0.97, 1.21) | 0.99 (0.85, 1.16) | 1.25 (1.11, 1.41) |
| Obsessive-compulsive disorder | 0.03 (0.00, 5.60) | 0.48 (0.14, 1.65) | NA | 1.59 (0.39, 6.55) |
| Post-traumatic stress disorder | NA | 3.31 (0.91, 11.99) | NA | 6.10 (1.10, 33.97) |
| Substance use disorder | 0.00 (0.00, 0.01) | 1.07 (0.49, 2.34) | NA | 1.16 (0.35, 3.87) |
aHR, adjusted hazard ratios; CI, confidence interval.
Adjusted for age, residential area, income, body mass index, diabetes mellitus, hypertension and dyslipidemia, timing of breast reconstruction, radiotherapy, chemotherapy, and hormone therapy.
In a 1-year landmark analysis restricted to patients who survived at least 12 months after surgery, AR remained significantly associated with higher risk of mental outcomes, with an aHR of 1.12 (95% CI, 1.02–1.22) for any mental disorder and 1.13 (95% CI, 1.02–1.25) for anxiety disorder (Supplemental Digital Content Table S7, available at: http://links.lww.com/JS9/F252).
Discussion
In this nationwide cohort study emulating a target trial, we found that patients undergoing AR had a significantly higher long-term risk of clinically diagnosed mental disorders compared with those undergoing IBR. This association persisted across age groups but was more pronounced in individuals aged ≥50 years and became more evident over longer follow-up.
Our finding that AR is associated with greater mental health morbidity contrasts with earlier studies reporting higher satisfaction with AR, particularly regarding breast aesthetics and tactile outcomes[6,12]. Several methodological differences may explain this discrepancy. First, many prior studies relied on subjective survey instruments, such as the BREAST-Q, which are prone to recall bias, social desirability bias, and subjective interpretation[20–22]. While the BREAST-Q is a validated tool widely used to assess patient-reported satisfaction and quality-of-life following breast reconstruction, it is not designed as a direct measure of clinical mental health outcomes[5]. In contrast, our study used clinically diagnosed mental disorders from longitudinal national claims data, offering an objective and more holistic assessment of mental health outcomes beyond aesthetic satisfaction. Second, although some prior studies have reported long-term outcomes, many were cross-sectional in design[23] or had substantial loss to follow-up[13]. In one frequently cited study with follow-up extending to 8 years, only 20% of participants had preoperative data, and just 7% were retained at the 8-year follow-up[13]. Such attrition may introduce bias, as patients who remain engaged in long-term surveys are often those who are more satisfied with their outcomes[24]. In contrast, our study leveraged a comprehensive national database with minimal loss to follow-up and excluded patients with a history of mental disorders, allowing for an unbiased evaluation of new-onset psychiatric morbidity after reconstruction. Third, prior studies have often been limited to single institutions or small regional cohorts, which may not account for variation in surgical quality and complication rates across hospitals[25]. In contrast, our study included patients treated at hospitals nationwide, which may explain some of the divergence in findings. Finally, the internal validity of our findings was supported by an exploratory validation analysis showing that radiotherapy, a known psychological stressor, was independently associated with higher rates of mental disorders. This consistency reinforces the robustness of our outcome definitions and analytic framework.
Beyond methodological considerations, several plausible mechanisms could explain the observation that AR is associated with greater mental health risks. AR involves more extensive surgery, longer recovery times, and both visible and non-visible scarring, potentially leading to physical and emotional distress[26]. Patients who choose AR often do so with high expectations for a natural appearance and feel, which may be unmet due to complications such as flap necrosis, asymmetry, or sensory loss[27,28]. These unmet expectations, combined with the greater financial and emotional investment required for AR, may amplify psychological distress over time[25,29,30]. In many real-world settings, reconstruction decisions are heavily influenced by physician preferences or institutional practices rather than by thorough, preference-sensitive discussions[27]. Patients may receive limited counseling about the long-term physical and psychological implications of AR, including donor site morbidity, delayed recovery, and functional limitations[30]. When patients are inadequately informed, subsequent regret or dissatisfaction may contribute to worsening mental health outcomes. These findings highlight the importance of comprehensive and balanced preoperative counseling that incorporates both physical risks and long-term psychosocial considerations, particularly for patients considering AR.
The more pronounced mental disorder risk observed in patients aged ≥50 years warrants further consideration. Older patients may have more comorbidities, slower recovery, and greater difficulty adjusting to postoperative functional limitations[31]. Additionally, body image concerns and coping mechanisms may differ by age, with older patients potentially more vulnerable to long-term psychosocial strain[32]. However, interestingly, we observed that among patients aged <50 years who underwent delayed reconstruction, the direction of association between AR and IBR was reversed in age- and timing-stratified subgroup analysis. This suggests that delayed reconstruction may allow for emotional processing and informed, preference-sensitive decision-making, potentially mitigating psychological distress. On the other hand, the older age group showed consistent results across timing groups, indicating that other age-related factors such as recovery capacity or comorbid burden may overshadow the influence of timing. Notably, most previous studies have not stratified psychological outcomes by age, underscoring the added value of our age-stratified, time-sensitive analysis. These findings suggest that AR may carry greater psychological risks in older populations, reinforcing the need for age-specific counseling and mental health support.
This study has several limitations. First, as this is an observational study, it cannot prove cause and effect; however, we used a target trial emulation framework with high-quality PS matching. Second, psychiatric outcomes were defined using an administrative claims database. In Korea, however, only board-certified psychiatrists can assign psychiatric diagnosis codes using diagnostic categories in the Diagnostic and Statistical Manual of Mental Disorders. This likely improves the validity of these results. Third, while this study accounted for numerous variables related to psychological and disease status, unmeasured confounding factors such as marital status, baseline psychosocial functioning, and survivorship factors (e.g., chronic pain, fatigue, and lymphedema support) may still exist. Nevertheless, as all patients underwent total mastectomy and reconstruction for breast cancer, it is likely that both groups experienced similar underlying psychological stressors at baseline, making it more plausible that the type of reconstruction independently influenced the observed associations. Fourth, reconstruction type was derived from procedure codes, which did not capture variations in surgical technique according to surgeon preference and comfort, or perioperative decisions that could affect long-term mental health. Lastly, as the Korean National Health Insurance Service database is specific to Korea, our findings may not be generalized to other populations with different healthcare systems, cultural viewpoints toward breast reconstruction, or socioeconomic states.
Conclusion
In conclusion, this nationwide study using a target trial emulation design found that AR was associated with a significantly higher long-term risk of clinically diagnosed mental disorders compared with IBR, particularly among patients aged ≥50 years. These findings highlight the need to consider long-term psychosocial consequences when counseling patients on reconstruction options. Integrating mental health screening and individualized, age-sensitive counseling into preoperative decision-making may help align surgical choices with both aesthetic preferences and long-term psychological well-being.
Acknowledgements
This study was supported by Trend Sensing and Risk Modeling Center, Institution of Quality of Life in Cancer, Samsung Medical Center, Seoul, Republic of Korea, and a grant from National Institute of Medical Device Safety Information in 2024. Artificial intelligence was not used in this research or manuscript development.
Footnotes
Danbee Kang, Woong Ki Park, and Chanwoo Park contributed equally to this work as co-first authors.
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.lww.com/international-journal-of-surgery.
Contributor Information
Danbee Kang, Email: dbee.kang@samsung.com.
Woong Ki Park, Email: woongki.park@samsung.com.
Chanwoo Park, Email: cwpcjp.park@samsung.com.
Juwon Park, Email: juwon2.park@samsung.com.
Jeong Eon Lee, Email: paojlus@hanmail.net.
Woo Jin Song, Email: pswjsong@gmail.com.
Subin Lim, Email: subin3314@gmail.com.
Jai Min Ryu, Email: sheol1981@naver.com.
Byung-Joon Jeon, Email: byungjoon.jeon@samsung.com.
Ethical approval
The Institutional Review Board of Samsung Medical Center approved the study.
Consent
The Institutional Review Board of Samsung Medical Center waived the requirement for informed consent because the K-NHIS data were de-identified (SMC 2024-04-061).
Sources of funding
The authors have received no specific funding for this study.
Author contributions
D.K., W.K.P., J.M.R., and B.J.J. contributed to the study design and conception. D.K., D.W.S., W.J.S., and J.P. contributed to the data acquisition and analysis. D.K. and W.K.P. drafted the manuscript. J.Y., J.E.L., W.J.S., S.L., J.M.R., and B.J.J. contributed to interpretation of data. D.K. and D.W.S. had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analyses. J.M.R. and B.J.J. are the manuscript’s guarantors. All authors read and approved of the final manuscript.
Conflicts of interest disclosure
The authors declare that they have no competing interests.
Research registration unique identifying number (UIN)
The study protocol was registered at ClinicalTrials.gov (NCT06981689).
Guarantor
J.M.R. and B.J.J. are the manuscript’s guarantors.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data availability statement
The data from Korean National Health Insurance Service (NHIS) could be accessed via the Health Insurance Data Service website (http://nhiss.nhis.or.kr). However, the researchers should submit a study proposal for acquiring approval from each institutional review board, which is also reviewed by the NHIS review committee to access the database. The raw data cannot be retrieved from the NHIS server.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data from Korean National Health Insurance Service (NHIS) could be accessed via the Health Insurance Data Service website (http://nhiss.nhis.or.kr). However, the researchers should submit a study proposal for acquiring approval from each institutional review board, which is also reviewed by the NHIS review committee to access the database. The raw data cannot be retrieved from the NHIS server.