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Chin et al. Plast Aesthet Res 2023;10:52 https://dx.doi.org/10.20517/2347-9264.2023.44 Page 9 of 14

[59]
often driven by the desire for a “normal” feminine appearance .” One patient explicitly described how “the
breast and shape do imply a femininity which I have always had,” demonstrating how breasts often serve as
a cultural symbol for femininity [18,25] . Thus, embodiment can often be a matter of societal adaptation to
gender norms and/or a negotiation of one’s femininity. Women are often situated between individual and
cultural perceptions of what it means to be a woman, which further complicates an individual’s negotiation
[60]
of their own sense of identity .
While many existing outcome evaluations of breast reconstruction focus on the “natural look” of the breasts
or how the breast physically “feels to touch” relative to preoperatively, the qualitative results from our
literature analysis highlight the patient’s feeling of how the implant/prosthesis “fills a void in her chest .”
[25]
From this perspective, the implant/prosthesis not only restores an empty space but also provides
[25]
psychological comfort in the face of this recent loss . Beyond the outward appearance of the breasts,
embodiment examines the deeper, inner function of the breast implant/prosthesis as filling a void and
fitting into one’s body representation.

This literature review offers insight into how “embodiment” allows for a more capacious understanding of
patients’ subjective experience of their bodies following reconstruction. These studies and this proposed
framework of breast embodiment provide a foundation for incorporating embodiment into existing
evaluations of patients’ quality of life post-reconstruction.

INCORPORATING EMBODIMENT INTO PATIENT-REPORTED OUTCOME MEASURES
The embodiment framework extends the scope beyond current breast reconstruction outcome measures
while still centering patients’ experiences and perspectives. In designing and implementing outcome
evaluations for breast reconstruction, capturing the first-person perception of the embodied experience is
critical to understanding reconstructive goals and the patient’s experience postoperatively. Traditionally,
evidence-based medical sciences have given primacy to quantitative data, which, in the case of subjective
[25]
matters, has given rise to a variety of “quality of life” scales . These quantitative tools are valuable for the
collection of large data samples to offer generalizable outcomes.

Within the field of breast reconstruction, the BREAST-Q is the gold standard patient-reported outcome
measurement instrument [11,61] . The BREAST-Q measures three quality of life domains (physical, sexual, and
psychosocial well-being) and three satisfaction domains (satisfaction with breasts, outcome, and care) .
[11]
The BREAST-Q questionnaire has demonstrated high reliability and has been independently validated [11,62] .

Since its inception in 2004, the BREAST-Q has evolved considerably, with the addition of multiple new
modules and scales to address identified gaps [12,63-65] . When the content validity was recently re-examined to
determine relevance and comprehensiveness, additional scales for breast sensation, cancer worry, fatigue,
[66]
work impact, and upper extremity lymphedema were developed . These changes reflect the increasing
trend in the literature on functional outcomes, in addition to the traditional paradigms in post-mastectomy
breast reconstruction focusing on aesthetic outcomes [38,67] .

As breast reconstruction techniques continue to advance, we believe that embodiment offers a helpful
framework for formulating additional questions that can capture patients’ values. The developments in
breast neurotization have already been paralleled with evolving sensation measures [12,35,36,67] . Previous focus
on breast sensory outcomes focused on symptomatic complications following surgery, such as pain,
burning, or tightness. Numbness, or loss of sensation, was largely overlooked in patient-reported outcome
scales. In 2021, the BREAST-Q incorporated new sensation modules to evaluate how the loss of sensation in