Improving the Evaluation of Aesthetic Outcomes in DIEP Flap Breast Reconstruction: Validation of the Aesthetic Grading Tool

Introduction: This study aimed to develop and validate an aesthetic grading tool (AGT) for bilateral DIEP flap breast reconstruction and investigate the correlation of BREAST-Q scores with perceived aesthetic outcomes.

Methods: The AGT utilized a Likert scale to rate aesthetic outcomes based on photographs of post-reconstruction breasts. The validation involved iterative testing with healthcare providers and patients. A two-way mixed effects model estimated the intraclass correlation coefficients (ICC) to assess intra-rater and inter-rater reliability. Pearson Correlation Coefficients explored the relationship between aesthetic ratings and BREAST-Q Satisfaction with Breasts scores.

Results: The AGT demonstrated substantial intra-rater reliability (ICC = 0.74, 95% CI: 0.64-0.79) and moderate to very strong inter-rater reliability across respondents after iterative revisions (ICC = 0.75, 95% CI: 0.59-0.91). Pearson Correlation analysis revealed no significant relationship between AGT scores and BREAST-Q scores when surveying healthcare providers (mean = 0.145, 95% CI: [-0.35, 0.32], p = 0.94) (median = 0.06, 95% CI: [-0.28, 0.87], p = 0.73) or patients (mean = 0.15, 95% CI: [-0.19, 0.46], p = 0.41) (median = 0.17, 95% CI: [-0.17, 0.48], p = 0.32).

Conclusion: The AGT provides a validated, reliable measure for assessing aesthetic outcomes in bilateral DIEP flap reconstruction. The lack of correlation with BREAST-Q scores indicates that BREAST-Q may not be a reliable proxy for assessing aesthetic outcomes.