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Complications and Quality of Life following Reduction Mammaplasty in Adolescents and Young Women

Nuzzi, Laura C. B.A.; Firriolo, Joseph M. M.D.; Pike, Carolyn M. M.S.N., M.P.H.; DiVasta, Amy D. M.D., M.M.Sc.; Labow, Brian I. M.D.

Plastic and Reconstructive Surgery: September 2019 - Volume 144 - Issue 3 - p 572-581
doi: 10.1097/PRS.0000000000005907
Breast: Original Articles
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Outcomes: Patient-Reported Health
Coding Perspective
Patient Safety CME
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Background: Adolescent reduction mammaplasty remains controversial because of concerns of postoperative breast growth, complications, and the effect on well-being. The authors sought to prospectively quantify early and late complications following reduction mammaplasty in adolescents and young women, and examine the intersection of surgical complications and postoperative health-related quality of life.

Methods: From 2008 to 2017, female patients aged 12 to 21 years undergoing reduction mammaplasty were asked to complete the 36-Item Short-Form Health Survey (version 2), the Rosenberg Self-Esteem Scale, the Breast-Related Symptoms Questionnaire, and the Eating-Attitudes Test-26 preoperatively and postoperatively at 6 months and 1, 3, 5, and 7 years. Clinical evaluations using standardized forms assessed baseline and postoperative symptomatology, complications, and surgical outcomes.

Results: In the authors’ sample of 512 participants, the most common complications included hypertrophic scarring (20.0 percent) and altered sensation of the nipple (8.4 percent) or breast (7.8 percent). Patient age, body mass index category, and amount of tissue resected did not significantly increase the odds of developing a complication. Significant postoperative improvements on the Rosenberg Self-Esteem Scale, the Breast-Related Symptoms Questionnaire, the Eating-Attitudes Test-26, and in all 36-Item Short-Form Health Survey domains (i.e., physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health) were largely seen irrespective of whether complications occurred.

Conclusions: Although complications following reduction mammaplasty were common, the vast majority were minor. Patients had significant postoperative improvements in their physical and psychosocial well-being regardless of whether they experienced a complication. Concerns for potential complication, especially in younger and overweight or obese patients, should not preclude otherwise healthy adolescents and young women from the benefits of reduction mammaplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Coding Perspective for this Article is on Page 579.Patient Safety CME.Evidence-Based Outcomes Article.

Boston, Mass.

From the Adolescent Breast Clinic, the Department of Plastic and Oral Surgery, and the Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital and Harvard Medical School.

Received for publication September 10, 2018; accepted January 25, 2019.

Presented at the 63rd Annual Meeting of the Plastic Surgery Research Council, in Birmingham, Alabama, May 17 through 20, 2018; the 19th Annual Meeting of the American Society of Breast Surgeons, in Orlando, Florida, May 2 through 6, 2018; Plastic Surgery The Meeting 2018, Annual Meeting of the American Society of Plastic Surgeons, in Chicago, Illinois, September 28 through October 1, 2018; and the 35th Annual Meeting of the Northeastern Society of Plastic Surgeons, in Boston, Massachusetts, October 25 through 28, 2018.

Disclosure:None of the authors has a financial interest in any of the products or devices or drugs mentioned in this article.

By reading this article, you are entitled to claim one (1) hour of Category 2 Patient Safety Credit. ASPS members can claim this credit by logging in to PlasticSurgery.org Dashboard, clicking “Submit CME,” and completing the form.

A “Hot Topic Video” by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to PRSJournal.com and click on “Plastic Surgery Hot Topics” in the “Digital Media” tab to watch.

This work was supported by THE PLASTIC SURGERY FOUNDATION.

Disclosure: Dr. Janevicius (janeviciusray@comcast.net) is the president of JCC, a firm specializing in coding consulting services for surgeons, government agencies, attorneys, and other entities.

Brian I. Labow, M.D., Department of Plastic and Oral Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Boston, Mass. 02115, brian.labow@childrens.harvard.edu

Reduction mammaplasty is one of the most common operations performed by plastic surgeons.1 Patients report reduced musculoskeletal pain and improvements in physical and psychosocial well-being.2–25

Although reduction mammaplasty is a relatively safe procedure, postoperative complications are common. It is estimated that 14 to 53 percent of all adult reduction mammaplasties will yield a postoperative complication.26–30 Complications include wound dehiscence, scarring, hematoma/seroma, infection, and altered breast/nipple sensation. Although complications following reduction mammaplasty have been well-documented in adults,26–45 few studies have explored complication and regrowth rates in adolescents and young adults, with most relying on retrospective data or small sample sizes.17–19,23,24,46,47 As such, operating on young patients remains controversial despite current literature elucidating the associated postoperative health-related quality-of-life benefits.16–25

This longitudinal series is the first of its kind to prospectively explore the intersection of surgeon and patient-reported outcomes in adolescents and young women following reduction mammaplasty using a robust sample size, standardized clinical reporting, and previously validated health-related quality-of-life surveys.

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PATIENTS AND METHODS

After obtaining approval from the Boston Children’s Hospital Committee on Clinical Investigation (protocol number IRB- X08-10-0492) for this prospective study, written informed consent was obtained from all subjects and a parent/guardian, as applicable. Female patients aged 12 to 21 years undergoing bilateral reduction mammaplasty for macromastia were prospectively enrolled during initial consultation at Boston Children’s Hospital from 2008 through 2017. All patients were evaluated by a pediatric plastic surgeon, and diagnosis was made using symptomatology, physical examination, and modified Schnur criteria.48,49

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Clinical Presentation and Demographics

Clinical staff administered standardized assessment forms detailing symptomatology and patient satisfaction at baseline and postoperatively at the following time points: early outcomes (≤1 month postoperatively), intermediate outcomes (3 to 6 months postoperatively), and late outcomes (1 year postoperatively and annually thereafter). Postoperative forms assessed complications and resolution of baseline symptoms. Complications were defined as outlined in Table 1.

Table 1. - Classification of Postoperative Complications by Severity and Timing
Severity
Timing Minor Major
Early Surgical-site infection
 Requiring oral antibiotics Wound dehiscence
 Open wound at the T junction (point where the vertical/horizontal incisions meet), requiring clinical monitoring and dressing changes for less than 6 wk
Seroma/hematoma
 Requiring drainage in clinic
Surgical-site infection

Requiring intravenous antibiotics
Wound dehiscence

Open wound at the T junction (point where the vertical/horizontal incisions meet), requiring dressing changes for 6 or more wk or reoperation
Seroma/hematoma

Requiring evacuation in the operating room
Deep vein thrombosis
Pulmonary embolism
Late Altered breast/nipple sensation
 Patient reported altered sensation to light touch, persisting beyond the first postoperative year
Inverted nipple
 Persisting beyond the first postoperative year
Altered nipple pigmentation
 Distressing to the patient, and persisting beyond the first postoperative year
Hypertrophic scarring
 Persisting beyond the first postoperative year
Keloids
 Persisting beyond the first postoperative year
Scar concerns
 Expected scarring distressing to the patient, and persisting beyond the first postoperative year
Bottoming out
 Pseudoptosis (nipple-to–inframammary fold distance lengthening) distressing to the patient, and persisting beyond the first postoperative year
Breast/nipple cyst
 Persisting beyond the first postoperative year
Postoperative breast growth
 Noticeable to the patient, and persisting beyond the first postoperative year
Breast asymmetry
 Noticeable to the patient, and persisting beyond the first postoperative year

Height and weight were measured at each clinical encounter. For subjects aged 20 years or older, body mass index category was determined using the Centers for Disease Control and Prevention adult body mass index calculator and body mass index classifications.50 For participants younger than 20 years, body mass index–for-age percentiles and body mass index category were derived using the Centers for Disease Control and Prevention child and teen body mass index calculator and classifications, accounting for both age and sex.51

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Survey Measures

Subjects completed the following self-administered surveys, selected for their previous use in adolescents and adults with macromastia8,9,13,25,45,46,52–54: the 36-Item Short-Form Health Survey (version 2),55 the Rosenberg Self-Esteem Scale,56 the Breast-Related Symptoms Questionnaire,53 and the Eating Attitudes Test-26.57 The 36-Item Short-Form Health Survey assesses health-related quality of life across eight domains: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Domain scores are transformed to a scale of 0 to 100.55 The Rosenberg Self-Esteem Scale measures self-esteem,56 with scores ranging from 10 to 40.58 The Breast-Related Symptoms Questionnaire quantifies breast symptomatology.53,59 The Eating-Attitudes Test-26 scale assesses eating and body image attitudes and behaviors, with scores greater than or equal to 20 indicative of disordered eating thoughts and behaviors.57 Higher scores are more favorable for the 36-Item Short-Form Health Survey, the Rosenberg Self-Esteem Scale, and the Breast-Related Symptoms Questionnaire; the inverse is true for the Eating-Attitudes Test-26. Subjects completed surveys once at baseline and again postoperatively at 6 months and at 1, 3, 5, and 7 years. Each participant’s baseline and most recent follow-up survey scores were included in analyses.

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Data Management and Statistical Methods

Data were collected and managed using the secure, Web-based application REDCap (Research Electronic Data Capture)60 hosted at Boston Children’s Hospital with support through Harvard Catalyst. Statistical analyses were performed using IBM SPSS Version 23 (IBM Corp., Armonk, N.Y.). The scores for the 36-Item Short-Form Health Survey domains, Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26 were generated according to algorithms developed by Ware,55,61 Rosenberg,56 Collins et al. and Kerrigan et al.,13,54 and Garner et al.,57 respectively. Except where otherwise noted, the following were stratified into dichotomous variables: age at surgery (younger than 18 years or 18 years or older), body mass index category (healthy weight or overweight/obese), total tissue mass resected (<1000 g or ≥1000 g), and complication status (no complication or one or more complication). Associations between demographics and complication status were assessed using Pearson chi-square or Fisher’s exact test, and odds ratios were calculated. Within-subject baseline to postoperative comparisons for survey scores were analyzed for the total cohort and stratified by complication status, and the Cohen d was used to report effect size. Independent samples t tests were used to assess differences in postoperative survey scores by complication status. A threshold of 20 percent missing complications data was used. Patients who did not complete both baseline and follow-up surveys were excluded from health-related quality-of-life analyses. A value of p <0.05 was considered statistically significant for all analyses.

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RESULTS

Baseline Demographics and Operative Information

A total of 512 subjects participated in our study. The mean age at surgery was 17.8 ± 1.9 years (Table 2). Our sample’s mean right and left sternal notch–to-nipple distances were 29.5 ± 4.1 cm and 29.7 ± 4.6 cm, respectively. Most subjects were overweight or obese [n = 354 (69.1 percent)]. All patients underwent reduction mammaplasty using an inferior pedicle technique with Wise-pattern skin excision; median total tissue resection mass was 1394 g.

Table 2. - Macromastia Subjects’ Demographic and Operative Information
Value (%)
No. of patients 512
Mean age at surgery ± SD, yr 17.8 ± 1.9
Total tissue mass resected, g
 Median 1394
 IQR 680
Baseline BMI category
 Healthy 158 (30.9)
 Overweight 167 (32.6)
 Obese 187 (36.5)
Racial category
 White 279 (54.5)
 Black/African American 63 (12.3)
 Hispanic 40 (7.8)
 Asian 3 (0.6)
 Other 20 (3.9)
 Unknown 107 (20.9)
I
QR, interquartile range; BMI, body mass index.

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Early Postoperative Complications

Early complications were assessed within the first postoperative month, and data were available for all subjects (Table 3). No patient in our sample experienced deep vein thrombosis, pulmonary embolism, or major infection. The most common early complications included open wounds at the T junction [n = 20 (3.9 percent)], minor surgical-site infection [n = 12 (2.3 percent)], and seroma/hematoma [n = 12 (2.3 percent)]. The majority of patients with T-junction wounds [n = 17 of 20 (85.0 percent)] achieved complete wound closure in fewer than 6 weeks with dressing changes. Of those with delayed T-junction healing lasting 6 weeks or longer [n = 3 of 20 (15.0 percent)], two patients were managed with close monitoring and dressing changes, and one patient required débridement of necrotic tissue in clinic. All patients who developed a surgical-site infection were successfully treated with oral antibiotics. There was no association between surgical-site infection and obesity status (OR, 1.76; 95 percent CI, 0.56 to 5.55; p = 0.33). All patients with seroma/hematoma underwent successful drainage in the clinic [n = 7 of 12 (58.3 percent)] or the operating room [n = 5 of 12 (41.7 percent)]. There was no association between hematoma/seroma and obesity status (OR 1.25, 95 percent CI, 0.39 to 3.99; p = 0.71).

Table 3. - Early Complications Occurring within the First Postoperative Month in Macromastia Subjects
Value (%)
No. of patients 512
Deep vein thrombosis 0 (0)
Pulmonary embolism 0 (0)
Minor infection 12 (2.3)
Major infection 0 (0)
Open T-junction wounds 20 (3.9)
≥6 wk to closure 3/20 (15.0)
Seroma/hematoma 12 (2.3)

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Late Postoperative Complications beyond the First Postoperative Year

Postoperative sensory and late complications were assessed after the first postoperative year. Late postoperative sensory information was available for 346 subjects, with a median follow-up time of 18.0 months (minimum, 12.0 months; maximum, 89.9 months; interquartile range, 13.1 months) for these subjects (Table 4). A total of 27 patients (7.8 percent) reported partial breast hypesthesia and 29 patients (8.4 percent) had reported partial nipple-areola hypesthesia persisting beyond the first postoperative year. No patients experienced persistent absent breast or nipple sensation (anesthesia). One patient (0.3 percent) experienced persistent breast pain likely caused by a neuroma.

Table 4. - Late Sensory Complications Persisting beyond the First Postoperative Year in Macromastia Subjects
Value (%)
No. of patients 346
Nipple hypesthesia 29 (8.4)
 Partial 29/29 (100)
 Bilateral 18/29 (62.1)
Nipple anesthesia 0 (0)
Breast hypesthesia 27 (7.8)
 Partial 27/27 (100)
 Bilateral 22/27 (81.5)
Breast anesthesia 0 (0)
Persistent breast pain 1 (0.3)

Late postoperative complication information was available for 225 subjects (Table 5). The most common wound healing complication after the first postoperative year was hypertrophic scarring [n = 45 (20.0 percent)]. Comparatively, keloids were less common in our sample [n = 11 (4.9 percent)]. A significantly higher proportion of black/African American patients developed at least one keloid compared with all other racial categories (p = 0.04). Of note, roughly 19 percent of patients with expected, normal scarring voiced concern with their scar appearance. As part of our standard of care, all patients with hypertrophic scarring, keloids, or scar concerns were offered treatment; of these, 51 of 93 patients (54.8 percent) underwent scar revision and 14 of 93 patients (15.1 percent) received steroidal injection.

Table 5. - Late Complications Persisting beyond the First Postoperative Year in Macromastia Subjects
Value (%)
No. of patients 225
Inverted nipple 4 (1.8)
 Bilateral 2/4 (50.0)
Altered nipple pigmentation 2 (0.9)
Postoperative asymmetry 9 (4.0)
Hypertrophic scarring 45 (20.0)
Keloids 11 (4.9)
Scar concerns 42 (18.7)
Bottoming-out 4 (1.8)
Breast or nipple cyst 2 (0.9)
Postoperative breast growth 12 (5.3)

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Postoperative Breast Growth

A total of 12 patients (5.3 percent) experienced postoperative breast growth that resulted in dissatisfaction or the reoccurrence of baseline macromastia-related symptomatology, or necessitated repeated reduction mammaplasty. Seven of our 12 patients (58.3 percent) experienced a return of baseline breast-related symptomatology, of which three patients underwent a secondary reduction mammaplasty and four patients were considering a second operation at the time of their last clinic visit. Five patients (41.7 percent) with postoperative breast growth remained asymptomatic but found the increased size aesthetically bothersome. Median amount of tissue resected, median age at surgery, and baseline body mass index category distribution did not vary significantly by regrowth status (p > 0.05, all). Within-subject analyses comparing baseline and most recent body mass index category found no significant postoperative change in body mass index category in patients who experienced postoperative growth (p = 0.99) and in those who did not (p = 0.22).

Approximately one-third (n = 160) of all subjects experienced at least one postoperative complication. Complication status was not associated with age at surgery (OR, 1.21; 95 percent CI, 0.83 to 1.76; p = 0.33), body mass index category (OR, 0.73; 95 percent CI, 0.48 to 1.08; p = 0.12), or total tissue mass resected (OR, 0.78; 95 percent CI, 0.52 to 1.16; p = 0.22). White patients were 1.6 times more likely to develop a postoperative complication compared with all other racial categories (OR, 1.6; 95 percent CI, 1.10 to 2.36; p = 0.01).

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Postoperative Health-Related Quality of Life

A total of 207 subjects completed preoperative and postoperative health-related quality-of-life surveys, with a median follow-up time of 19.1 months (minimum, 12.0 months; maximum, 107.2 months; interquartile range, 30.6 months). When stratifying by complication status, patients with and without a complication had significant postoperative score improvements on the Rosenberg Self-Esteem Scale, the Breast-Related Symptoms Questionnaire, and in all eight 36-Item Short-Form Health Survey domains (p < 0.05, all) (Table 6). Patients who did not develop a complication had significant improvements in mean Eating-Attitudes Test-26 scores (baseline score, 10.7; postoperative score, 7.3; p = 0.001). The postoperative improvements in Eating-Attitudes Test-26 score for patients who developed a complication approached significance (baseline score, 8.5; postoperative score, 6.6; p = 0.05). It must be noted that both the preoperative and postoperative Eating-Attitudes Test-26 scores for both groups were considerably below the clinical threshold of 20, which would indicate disordered eating thoughts and behaviors.

Table 6. - Comparisons of Preoperative and Postoperative Survey Score by Complication Status
No Complication Group Complication Group
Mean Postoperative–Preoperative Difference (95% CI)* No. Cohen d p Mean Postoperative–Preoperative Difference* (95% CI) No. Cohen d p
SF-36 domains
 Physical Functioning 28.8 (24.2 to 33.3) 118 1.16 <0.001 23.7 (17.6 to 29.9) 79 0.86 <0.001
 Role-Physical 32.1 (27.1 to 37.1) 121 1.15 <0.001 26.3 (20.8 to 31.8) 82 1.05 <0.001
 Bodily Pain 33.7 (29.5 to 37.9) 119 1.45 <0.001 35.2 (29.6 to 40.7) 81 1.40 <0.001
 General Health 4.5 (1.0 to 7.9) 120 0.25 0.01 4.7 (1.1 to 8.3) 73 0.31 0.01
 Vitality 12.9 (9.6 to 16.2) 114 0.73 <0.001 14.9 (10.3 to 19.5) 79 0.73 <0.001
 Social Functioning 23.5 (18.1 to 29.0) 119 0.78 <0.001 26.5 (18.7 to 34.4) 81 0.75 <0.001
 Role-Emotional 17.0 (11.3 to 22.7) 119 0.54 <0.001 19.9 (12.6 to 27.2) 81 0.60 <0.001
 Mental Health 10.2 (6.3 to 14.1) 117 0.48 <0.001 13.1 (8.5 to 17.6) 80 0.64 <0.001
RSES 4.3 (3.1 to 5.5) 122 0.65 <0.001 3.9 (2.3 to 5.5) 82 0.52 <0.001
BRSQ 92.6 (90.0 to 95.2) 121 6.48 <0.001 92.4 (89.9 to 95.0) 82 7.98 <0.001
EAT-26 −3.4 (−5.4 to −1.5) 121 0.32 0.001 −2.0 (−3.9 to 0) 81 0.22 0.05
S
F-36, 36-Item Short-Form Health Survey (version 2); RSES, Rosenberg Self-Esteem Scale; BRSQ, Breast-Related Symptoms Questionnaire; EAT-26, Eating-Attitudes Test-26.
*
Mean difference between postoperative and preoperative survey scores for patients with and without a postoperative complication. Positive change indicates a preoperative to postoperative increase in survey score.
Cohen d, measure of effect size.
Paired samples t test.

When comparing postoperative survey scores by complication status, both groups performed comparably on all survey measures (p > 0.05, all) except the 36-Item Short-Form Health Survey domain for bodily pain. Patients with a complication experienced a more favorable mean bodily pain score than those without a complication (83.0 versus 78.8, respectively; p = 0.04).

Patients with an early complication had significant postoperative score improvements across all measures (p < 0.05, all). Although patients with late complications had significant gains in seven 36-Item Short-Form Health Survey domains and on the Rosenberg Self-Esteem Scale, the Breast-Related Symptoms Questionnaire, and the Eating-Attitudes Test-26 (p < 0.05, all), they had no postoperative improvement in the general health domain of the 36-Item Short-Form Health Survey (p = 0.18). Patients with postoperative breast growth had significant postoperative improvement in the role-physical domain of the 36-Item Short-Form Health Survey (p = 0.03) and Breast-Related Symptoms Questionnaire (p = 0.02), but experienced no postoperative change in seven 36-Item Short-Form Health Survey domains (i.e., physical functioning, bodily pain, general health, vitality, social functioning, role-emotional, and mental health) and on the Rosenberg Self-Esteem Scale and Eating-Attitudes Test-26 (p > 0.05, all).

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DISCUSSION

Reduction mammaplasty has been shown to alleviate physical and psychosocial symptoms.2–25 Although 80 percent of these patients have been symptomatic since their teen years,18 the majority of women undergoing reduction mammaplasty are aged between 40 and 60 years.26–35,37,38,40–46 Historically, reduction mammaplasty in adolescents and young women has been controversial.16–20 Surgeons and parents share concerns that young patients may experience postoperative breast growth and lack the emotional maturity to adapt to potential complications and postoperative changes in their body. This study prospectively followed a cohort of adolescents and young women undergoing reduction mammaplasty to determine whether surgical complications impacted patient-reported outcomes. Surgical and health-related quality-of-life outcomes were collected using standardized clinical assessments and previously validated surveys.

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Early Complications

Concordant with previous studies, approximately one-third of subjects experienced at least one postoperative complication.26–30 No patient in our sample experienced a pulmonary embolism, deep vein thrombosis, or major infection. Less than 3 percent of patients developed a minor infection, hematoma/seroma, or delayed wound healing requiring greater than 6 weeks of dressing changes. These rates are considerably lower than those observed in the adult population.26–29,33,34,40–43 It is also likely that our surgical-site infection rates are inflated, given the observation that many patients presented to outside providers for suspected surgical-site infection, and were possibly treated with oral antibiotics for expected inflammatory responses or reactions to adhesives.

The low rates of both major and early complications in our sample may reflect the generally healthy nature of adolescents and young adults. Despite the majority of our sample being overweight/obese, our cohort did not have the decades of metabolic burden commonly seen in older patients who are overweight/obese. As such, younger patients may be at an advantage with respect to lower surgical-site infection, major complication, and wound healing complication rates.

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Effect of Obesity and Resection Mass on Early Complications

Macromastia is commonly associated with obesity, and many surgeons and third-party payors require considerable weight loss before surgery. Although the association between obesity, surgical-site infection, and overall complication status has been well documented in adult studies,28,30,31,35,37,40,42,62–68 obesity in our young cohort did not significantly increase the odds of developing a complication, including surgical-site infection and hematoma/seroma. Although obesity may be a significant risk factor for developing postoperative complications in older women, it may not play a considerable role in younger patients. Similarly, unlike previous adult studies,27,30,68 total tissue resection mass in our cohort was not associated with developing a complication. Although weight loss should be strongly encouraged for overweight/obese patients, body mass index status may not portend poorer outcomes in otherwise healthy, young patients undergoing reduction mammaplasty.

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Postoperative Breast Growth

The potential for breast growth after surgery is a reasonable concern when considering reduction mammaplasty in adolescents. In fact, 5 percent of our cohort exhibited postoperative breast growth, and roughly half of these patients had a return of baseline breast-related symptoms. Age, amount of tissue resected, and body mass index category were not associated with postoperative growth. As reported previously, body mass index category remained stable from baseline to most recent follow-up,69 even in patients who experienced postoperative breast growth. This suggests that postoperative breast growth in adolescents is not simply a function of weight gain. However, it should also be noted that potential changes in body mass index category may be muted, as roughly one-third of our subjects hit the artificial body mass index ceiling of obese at baseline. The somewhat surprising observation that age was not associated with additional breast growth may reflect the natural variation in thelarche and menarche. Rather than using age as a criterion for surgery, time since these biological time points may be more appropriate. Further research is needed to precisely pinpoint the appropriate time to perform surgery within the individual to mitigate the risk of additional growth.

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Scarring

Although keloids were rare in our series, roughly 40 percent of patients experienced hypertrophic scarring or expressed some concern about scarring at or beyond 1 year following surgery. This rate is considerably higher than that observed in similar adolescent studies.17,24,47 This may reflect poorer wound healing in our series or broader inclusion criteria for scar concerns. Our clinical practice is to query all patients 1 year after surgery regarding any worrisome skin or scar concerns at every office visit, and proactively offer medical or surgical treatment when appropriate. Intralesional corticosteroid therapy or scar revisions are performed in the office using local anesthesia.

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Persistent Altered Breast and Nipple Sensation

Fewer than 9 percent of patients experienced breast or nipple hypesthesia persisting beyond the first postoperative year, and no patient experienced breast/nipple anesthesia, in line with previous adolescent and adult studies.17,42 It should be acknowledged that sensory data were not recorded preoperatively and were only qualitatively assessed postoperatively in response to examiner light touch. No validated tools or methodologies were used to quantify degree of sensation across all patients.

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Effect of Complications on Postoperative Health-Related Quality of Life

Consistent with the literature,2–25 our cohort had significant postoperative improvements in health-related quality of life. In particular, gains in physical well-being, bodily pain, psychosocial functioning, self-esteem, and breast-related symptoms were observed. Overall, patients who experienced a complication largely derived the same postoperative health-related quality-of-life improvements as those who did not have a complication, performing comparably to or more favorably than those with no complication. Interestingly, patients who experienced a complication reported having less bodily pain than those patients without any complication. It is possible that having a potentially painful complication early in the postoperative course puts the patient’s overall postoperative musculoskeletal pain reduction into greater perspective. It should be noted that complications were largely minor in our cohort of otherwise healthy, young women.

Major complications such as hematoma requiring surgical evacuation or pulmonary embolus were either too rare to statistically analyze, or simply did not occur. However, late complications such as hypertrophic scarring or sensory changes were observed with some frequency. Subanalysis in patients with late complications largely failed to show any decrement in health-related quality-of-life gains as compared to those patients without complications. Of importance, 5 percent of our sample experienced postoperative breast growth, of which half developed recurrent baseline symptoms. Subanalyses revealed that patients with postoperative breast growth did not enjoy the same postoperative health-related quality-of-life improvements as the rest of our cohort. Although postoperative breast growth is uncommon, surgeons treating these patients should be aware of the ramifications of this potential complication and advise patients and parents accordingly. For the overwhelming majority, concern for potential complications should not overshadow the benefits that reduction mammaplasty can provide young patients.

Limitations in this study must be acknowledged. Although the health-related quality-of-life surveys used in this study have been validated for a variety of populations, they have not been validated specifically for young adolescents. The minimal clinically important difference for our health-related quality-of-life measures could not be reported, as further research is needed to derive them for adolescents with breast conditions. Results may not be generalizable, as subjects were recruited from a single, large tertiary care facility. Additional studies are needed to measure longer term outcomes, specifically with respect to additional breath growth and future breastfeeding ability. To date, no study has examined breastfeeding after reduction mammaplasty using a validated survey and control group, both of which are necessary to properly assess the effect of reduction mammaplasty on lactation and breastfeeding performance.

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CONCLUSIONS

Reduction mammaplasty significantly improves the breast-related symptoms and physical and psychosocial well-being of adolescent and young adult patients. Although complications are common, most are minor and do not diminish patients’ marked gains in health-related quality of life. Patient age, body mass index category, and total resection mass did not increase the odds of developing a complication. Postoperative breast growth can occur in younger patients and may diminish the benefits of reduction mammaplasty. Providers, patients, and parents should be aware of the potential complications following reduction mammaplasty in this population Preoperative counseling should include the potential for persistent hypesthesia, scars necessitating treatment, and postoperative breast growth that may result in a return of baseline symptoms and require reoperation. However, fear of potential complications should not preclude otherwise healthy patients from the benefits that reduction mammaplasty can provide adolescents.

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ACKNOWLEDGMENT

This work was supported in part by the Plastic Surgery Foundation (grant no. 192776).

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