Breast cancer is one of the most common diagnosed types of cancer among women, with an estimated 3.8 million survivors in the United States currently [1]. Because of the medical advances made in the past decade, survivorship rates have increased dramatically [1], allowing researchers to focus on helping improve psychosocial outcomes among survivors.
Studies suggest that among women with breast cancer, changes in physical appearance affect anywhere from 31%-67% of survivors [2] and is a significant cause of distress [3]. Body-image distress reflects “a direct personal perception and self-appraisal of one’s physical appearance, whereby negative thoughts and feelings related to one’s body indicate a disturbance of body-image and lead to dissatisfaction with one’s self [4].” The ramifications of body-image distress can be complex and cover a wide range of areas: identity and sexual functioning, perceived stigma, and fear of cancer recurrence [5–8].
While body-image distress is a prominent concern following surgical treatment, there is currently no consensus as to how each type of surgical treatment impacts body-image distress during long-term survivorship [9]. Thus, studies suggest that individual patient factors, such as appearance investment, satisfaction with decision, and cosmetic expectation discrepancy should also be evaluated in terms of predicting level of body-image distress [10–13]. Appearance investment refers to the value or importance placed by an individual on their appearance. Survivors’ satisfaction with decision is reflected by their perceived role in the decision-making process throughout treatment and whether they felt satisfied with that role and the decisions they made. Cosmetic expectation discrepancy occurs when survivors feel that the cosmetic outcomes following surgery/treatment do not match what they originally expected. When survivors are presented with examples of surgical outcomes, they are often shown images of optimal results and their surgical experience does not always match these ideal cosmetic outcomes.
For instance, appearance investment is associated with body-image distress if an incongruent perception exists between the real and ideal self [13]. Keating et al. (2002) [12] found that 64% of survivors desired a collaborative role in the decision-making process about their surgery. Overall, only 49% of survivors reported having a role that matched their desired role and were significantly more satisfied with treatment choice [12]. Type of treatment was not significantly associated with satisfaction with that treatment, but concordance between desired and actual role in decision making was associated with satisfaction [12]. Likewise, discrepancy in expectations, including expectations concerning cosmetic outcomes, can lead to dissatisfaction [14].
A survivors’ subjective evaluation of treatment outcomes extends beyond the preservation, restoration, or enhancement of physical appearance [11]—their role in the decision-making process is an important predictor for psychosocial outcomes [10]. All of these factors involve a concordance between an ideal and realistic perceived outcome and impact on patient satisfaction. Body-image distress indicates a “disturbance” or incongruence in how one perceives themselves aesthetically, which leads to patient dissatisfaction [4]. Therefore, a comprehensive assessment of how these factors relate to body-image distress in individuals may help us develop patient-centered psycho-educational interventions.
Overall, the literature suggests that body-image distress seems to put survivors at higher risk for developing depression or anxiety, and that body-image distress, anxiety, and depression reduce overall quality of life and hinder adjustment to breast cancer treatments among survivors [10, 15–17]. Research also suggests that survivors who were satisfied with their body-image exhibit a stronger belief in their ability to cope with breast cancer and associated treatments [17–19]. Therefore, alleviating body-image distress in breast cancer survivors is a priority given its chronic nature, incidence, and the substantial psychosocial consequences for survivors [9, 20].
Research expanding on our knowledge of body-image distress as a multi-dimensional construct and its relationship with psychosocial outcomes is still needed [11]. Additionally, research concerning complementary cosmetic interventions is warranted considering the varied results when examining breast reconstruction as a cosmetic intervention to mitigate body-image distress and poor mental health symptoms [9–11, 16]. Body-image distress is not only tied to physical, cosmetic outcomes, but to individual factors such as patient expectations, role in decision making, and identity [11].
Medical tattooing in this context can signify a women’s agency to reclaim their body and refine concepts of the self, such as self-expression, identity, femininity, sexuality, healing, and transformation [21, 22]. It can also serve to help survivors address any cosmetic complications (e.g., scarring, necrosis, etc.) or lingering needs following surgery [22]. Medical tattooing involves a patient-centered approach that allows survivors the opportunity to work directly with the medical tattoo artist to express their desires and expectations.
Medical Tattooing
Medical tattooing can serve as a complementary cosmetic intervention after breast cancer surgery, both in conjunction with reconstruction and as a standalone procedure. Specifically, subjective reports from patients suggest enhanced cosmetic satisfaction, improved body-image, and benefits to mental health [22, 23]. Yet, empirical research integrating standardized measures to assess benefits to body-image distress and mental health are needed.
Historically, breast reconstruction has been deemed the “gold standard” as a cosmetic intervention following breast cancer surgery [24]. Medical tattooing offers an additional option to further enhance cosmetic outcomes for women who choose various reconstructive approaches, including those who ‘go flat.’ Medical tattooing for breast cancer survivors can be applied to correct or simulate the nipple areola complex (NAC) (Fig. 1) or conceal scarring using decorative appliques (Fig. 2), in which the medical tattoo artists consults with the survivor to create a custom design that is often guided by the survivors’ values and motivations [22]. NAC tattooing has been found to achieve high cosmetic and survivor satisfaction, without serious complication (i.e., infection rates [3.2%] and fading over time), indicating the procedure is highly acceptable and suitable in this context [22, 23, 25, 26]. The authors affirm that patients pictured below in Figs. 1 and 2 signed informed consent regarding publishing their photographs and any identifying information was removed.
Medical tattooing can also be used to address complications associated with necrosis, excess scarring, asymmetrical nipple areolas, and complete or partial loss of the nipple due to flap or graft techniques during surgery [22]. It is often pursued by patients and survivors independent of their physicians and surgeons to improve cosmetic outcomes and regain a sense of empowerment [21, 22].
Despite the potential for medical tattooing to improve post-surgical cosmetic outcomes, acceptance of it as a reconstruction related-procedure covered by insurance is inconsistent. The Women’s Health and Cancer Rights Act (WHCRA) mandates insurance coverage for all stages of post-mastectomy breast reconstruction [27]. However, the law's language, requiring procedures to be "medically necessary," poses challenges, particularly regarding the coverage of medical tattooing [24]. This limitation and the ambiguity in the law create a loophole allowing insurance companies to deny coverage for NAC tattooing, a non-surgical option often considered post-mastectomy when traditional reconstruction is unfeasible. Breast reconstruction's eligibility varies based on the extent of disease and available tissue, making it unsuitable for all survivors. Therefore, in cases where surgical reconstruction is not feasible, non-surgical alternatives like medical tattooing become even more essential.
The WHCRA also mandates coverage for complications at all mastectomy stages [27]. Medical tattooing, both NAC and decorative, addresses surgical issues like necrosis, scarring, asymmetry, or loss of the nipple. The law, however, applies only to private group health insurance and individual policies, excluding federal or state programs like Medicare and Medicaid, which have limited coverage and specific requirements for nipple-areola tattooing. For example, coverage may only apply if the nipple-areola tattooing is performed by a physician rather than a credentialed tattoo artist [24, 27]. Variability in coverage across different companies and states further complicates the accessibility of medical tattooing. Empirical studies supporting the mental health benefits of medical tattooing among survivors is crucial to standardize coverage and promote its inclusion as a complementary intervention across insurance providers nationwide.
Research Approach
Despite advances in the effectiveness of breast cancer surgical procedures on mortality, cosmetic outcomes have not been studied as extensively in terms of survivor body-image distress and psychosocial functioning. Medical tattooing is a promising intervention that gives survivors additional options to enhance cosmetic outcomes following surgery. Nonetheless, the use of medical tattooing to reduce body-image distress and improve mental health symptoms deserves additional research. To our knowledge, the present study is the first to investigate the relationship between body-image distress and medical tattooing among survivors post-breast cancer surgery.
The primary aim of the study was to examine body-image distress and mental health symptoms in participants post-breast cancer surgery with and without medical tattooing. This was accomplished by comparing body-image distress, depression and anxiety symptoms, and perceived stress in two groups of participants: 1) those who received a post-surgical medical tattooing and 2) those who did not.
Secondary aims of the study were to: (a) evaluate the impact of the participant’s surgery type (i.e., breast conserving surgery [BCS], mastectomy, or BCS/mastectomy with reconstruction) on body-image distress, depression and anxiety symptoms, and perceived stress and (b) examine the relationship between body-image distress and related psychosocial factors such as appearance investment, satisfaction with decision, and cosmetic expectation discrepancy. Ultimately, we hope results will be useful in guiding breast cancer survivor’s decision making about cosmetic interventions and in helping standardize medical tattooing as an insurable complimentary cosmetic intervention following surgery.
Participants
Data was collected through a national online survey. Recruitment involved reaching out to national breast cancer-affiliated organizations and support groups to share an IRB-approved flyer and a Qualtrics link to the study. Chain referral sampling was also employed [36]. The online survey was constructed using the Qualtrics XM ® software and approved by the ethics committee of The University of Central Florida Institutional Review Board (IRB) as an exempt anonymous study (STUDY00004826). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Inclusion criteria were self-reported history of having undergone breast cancer surgery. Exclusion criteria included breast cancer survivors who had not undergone surgical treatment, adults unable to consent, individuals who were younger than 18 years or older than 65 years, pregnant women, and prisoners. Participants read an explanation of research and informed consent then provided consent electronically before they could attempt the survey.