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Breast-Related Quality of Life in Young Reduction Mammaplasty Patients: A Long-Term Follow-Up Using the BREAST-Q

Krucoff, Kate B. M.D.; Carlson, Anna R. M.D.; Shammas, Ronnie L. M.D.; Mundy, Lily R. M.D.; Lee, Hui-Jie Ph.D.; Georgiade, Gregory S. M.D.

Plastic and Reconstructive Surgery: November 2019 - Volume 144 - Issue 5 - p 743e-750e
doi: 10.1097/PRS.0000000000006117
Breast: Original Articles
Free
SDC
Outcomes: Patient-Reported Health
Press Release

Background: Reduction mammaplasty is the most effective means of improving symptoms of macromastia. Although studies have shown lasting benefits in adult patients, there is a paucity of data that explore this topic in young patients. In this study, the long-term satisfaction and well-being of young reduction mammaplasty patients was assessed.

Methods: A retrospective review was performed for all female patients younger than 25 years who underwent reduction mammaplasty performed by a single surgeon from 1980 to 2003. Demographic characteristics, comorbidities, surgical details, and length of follow-up were recorded. Participants completed the postoperative version of the BREAST-Q Reduction module. Responses were scored on a scale of 0 to 100. Scores were summarized with descriptive statistics and compared to normative values.

Results: Thirty-seven of 52 eligible participants completed the survey (response rate, 71.2 percent). Median age at surgery was 21 years (range, 12.4 to 24.6 years), and median follow-up was 21.4 years (range, 11.4 to 32.4 years). Overall, participants demonstrated high satisfaction and well-being. Mean Q-Scores for Satisfaction with Breasts and Sexual Well-being were significantly higher than normative values (p = 0.0012 and p < 0.0001, respectively), and were as follows: Satisfaction with Breasts, 66.6 ± 16.5 (normative, 57 ± 16); Psychosocial Well-being, 75.9 ± 21.3 (normative, 68 ± 1 9); Sexual Well-being, 72 ± 18.2 (normative, 55 ± 19); and Physical Well-being, 81.1 ± 13.6 (normative, 76 ± 11).

Conclusions: Young reduction mammaplasty patients experience excellent breast-related quality of life decades after surgery. Compared with normative values, young reduction mammaplasty patients reported higher satisfaction with breasts and sexual well-being. Surgeons and third-party payers should be aware of these data and advocate for young patients to gain access to care.

Durham, N.C.

From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, and the Department of Biostatistics and Bioinformatics, Duke University Medical Center.

Received for publication June 3, 2018; accepted February 7, 2019.

Evidence-Based Outcomes Article.

Disclosure:The authors have no financial disclosures. No funding was received for this article.

Related digital media are available in the full-text version of the article on www.PRSJournal.com.

Kate B. Krucoff, M.D., 40 Duke Medicine Circle, M150, Green Zone, DUMC 2824, Durham, N.C. 27710, kate.buretta@duke.edu, Instagram: @dukeplasticsurgery

Women with macromastia are known to experience a variety of physical and psychological challenges. These may include neck, back, and shoulder discomfort, in addition to poor body image, low self-esteem, and a lack of confidence in social interactions. Multiple studies have shown that regardless of surgical technique, reduction mammaplasty is associated with improved physical and psychological well-being in adult women with macromastia.1–5

In addition to affecting adult women, macromastia is also seen in adolescent patients and may be associated with endocrine changes, childhood obesity, and juvenile hypertrophy of the breast.6 Although young patients experience many of the same symptoms as adults, controversy exists around performing reduction mammaplasty in a young patient population.6–8 This is mainly because of concerns around postoperative complications that may include changes in nipple sensation, the ability to breastfeed, alterations in breast morphology after pregnancy,9–11 and the potential need for revision operations in the future.8 However, data on long-term satisfaction and quality of life are lacking in this young patient population.

The purpose of this study was to use a validated patient-reported outcomes tool to report the long-term satisfaction and well-being in patients who underwent reduction mammaplasty at a young age (younger than 25 years). In addition, specific factors associated with long-term satisfaction and well-being were assessed. The authors hypothesized that years after surgery, young reduction mammaplasty patients experience excellent breast-related quality of life in long-term follow-up, comparable to established normative values.12

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PATIENTS AND METHODS

Study Population and Recruitment

A 33-year retrospective case review was performed for all female patients younger than 25 years who underwent reduction mammaplasty performed by a single surgeon (G.S.G.) at Duke University Medical Center (n = 134) from January 1, 1980, to December 31, 2003. These dates were selected to ensure that all included patients had a surgical follow-up time of at least 10 years. Current contact information could be identified for 53 patients, of which 48 consented to participate. Those who consented to the study were mailed the postoperative version of the BREAST-Q Reduction module (described below). The study methods and design were approved by the Institutional Review Board of Duke University Medical Center.

The decision to operate on girls as young as 12 to 13 years was based on clinical presentation and an assessment of the degree of physical and emotional distress experienced, akin to data from previously published studies.13,14 These young patients were often diagnosed with either juvenile gigantomastia or adolescent macromastia, experiencing rapid growth of their breast within a period of 6 months to 1 year. They were thought to be appropriate candidates for a reduction mammaplasty given the possibility for significant improvement in quality of life following the procedure. Before the procedure, the patients and their parents were counseled regarding the likelihood of needing future revision procedures and the potential effects reduction mammaplasty may have on future breastfeeding potential.

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Preoperative and Operative Data

Preoperative and operative data were obtained from the medical charts of all participants who consented to the study and returned a survey. Preoperative data included demographic characteristics such as age at the time of surgery, race, body mass index, and medical comorbidities. Operative details were also obtained, including date of surgery, reduction mammaplasty technique used, and total weight of breast tissue removed.

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Postoperative Data: BREAST-Q Reduction Module

Consented participants were sent the postoperative version of the BREAST-Q Reduction module. The BREAST-Q is a validated, patient-reported outcomes tool that has been used to study over 22,000 women undergoing various types of breast surgery.12,15,16 The BREAST-Q has separate preoperative and postoperative modules for each type of major breast surgery, including reduction mammaplasty. Each module consists of a set of scale items that address participant satisfaction and well-being specific to the type of surgery. In the postoperative version of the Reduction module, scales correspond to four satisfaction domains: Satisfaction with Breasts, Satisfaction with Nipples, Satisfaction with Outcome, and Satisfaction with Care. The Satisfaction with Care domain includes separate scales for Satisfaction with Information, Satisfaction with Plastic Surgeon, Satisfaction with Medical Team, and Satisfaction with Office Staff. In addition, three well-being domains are assessed that include Psychosocial Well-being, Sexual Well-being, and Physical Well-being.12 Answers to the scales are converted to a number from 0 (worst) to 100 (best) using the Q-Score program.17 As each scale is designed to function independently, research participants can be asked to complete some or all of a module’s scales.

The analysis focused on the four scales for which normative data were available for comparison: Satisfaction with Breasts, Psychosocial Well-being, Sexual Well-being, and Physical Well-being. The normative data were compiled from 1205 female participants from the Army of Women, an online community of women organized with the goal of connecting researchers to women both with and without breast cancer. An electronic survey was sent to members. Respondents were included in the study if they met the following criteria: age older than 18 years, no personal history of breast cancer or breast surgery, and the ability to complete the questionnaire in English. Participants completed the preoperative version of the Reduction module. The average age of the study population was 55 years. Mean body mass index was 27 kg/m2. Ninety-one percent of participants identified as white, and 2.3 percent identified as black. Fifty percent reported having a chronic health condition. Nearly 40 percent reported a bra cup size of D or larger.12

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Statistical Analysis

Basic descriptive statistics were determined, including the mean, median, interquartile range, standard deviation, range, and 95 percent confidence interval for continuous variables. Percentages were calculated for categorical variables. The Wilcoxon rank sum test was used to compare the scores between participants with a body mass index less than 25 kg/m2 and participants with a body mass index of 25 kg/m2 or greater at the time of reduction mammaplasty. The primary aim of this study was to compare this study population’s BREAST-Q postoperative Reduction module scores with published normative scores.12 Each of the four scales focused on for analysis were compared using the two-sample t test. To adjust for an inflated type I error rate because of simultaneously conducting multiple tests, the familywise error rate was controlled using the Bonferroni correction. The Bonferroni adjusted significance level is 0.0125. The secondary aim of this study was to identify predictors of decreased patient satisfaction and well-being. Ordinary linear regressions were used to examine which, if any, collected variables were independently associated with BREAST-Q scores. Candidate variables included age at the time of surgery, total amount of tissue removed (in grams), body mass index less than 25 kg/m2 versus greater than or equal to 25 kg/m2, and race. Variables that were not significant predictors after adjustment for other covariates (p < 0.1) were removed in a backward selection process. All statistical analyses were performed in R (R Core Team, 2016, Vienna, Austria).

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RESULTS

Forty-eight of 53 eligible participants consented to participation. Five participants refused to participate. Of the 48 consented participants, 37 completed the survey (response rate, 71.2 percent). Demographic characteristics of the study cohort are summarized in Table 1. The median age at the time of surgery was 21 years (interquartile range, 18.4 to 22 years; range, 12.4 to 24.6 years). Eleven patients were 18 years of age or younger at the time of surgery. The median time from surgery to survey was 21.4 years (interquartile range, 15.9 to 26.8 years; range, 11.4 to 32.4 years). Seventeen participants (45.9 percent) were Caucasian, and 15 participants (40.5 percent) were African American. The median body mass index at the time of surgery was 27.8 kg/m2 (interquartile range, 23.6 to 33.2 kg/m2). Medical comorbidities at the time of surgery included diabetes (n = 1) and hypertension (n = 1). All patients underwent reduction mammaplasty performed by the same surgeon (G.S.G.) with an inferior pedicle Wise pattern reduction technique. The median reduction volume was 1705 g (interquartile range, 1160 to 2345 g; range, 220 to 3464 g).

Table 1. - Demographic Characteristics of Young Reduction Mammaplasty Cohort*
Characteristic Value (%)
Age at the time of surgery, yr (n = 35)
 Mean ± SD 20.3 ± 2.7
 Median 21
 IQR 18.4–22
Years since surgery (n = 35)
 Mean ± SD 21.1 ± 6.4
 Median 21.4
 IQR 15.9–26.8
Race
 African American 15 (40.5)
 Caucasian 17 (45.9)
 Others or unknown 5 (13.5)
BMI, kg/m2 (n = 33)
 Mean ± SD 29.2 ± 7.1
 Median 27.8
 IQR 23.6–33.2
Diabetes (n = 33)
 No 32 (86.5)
 Yes 1 (2.7)
Hypertension (n = 33)
 No 32 (86.5)
 Yes 1 (2.7)
I
QR, interquartile range; BMI, body mass index.
*
n = 37.

Summary statistics for the four scales focused on in this study are presented in Table 2. The distribution of Q-Scores for the Satisfaction with Breasts and Physical Well-being scales were roughly symmetric, with some participants reporting a score of 100. In contrast, the Psychosocial Well-being and Sexual Well-being scales were skewed. The mean of the Psychosocial Well-being scale was 75.9 ± 21.3, whereas the median was higher at 80 (interquartile range, 62 to 100). Among the remaining six scales measured in the postoperative version of the BREAST-Q Reduction module, mean scores were highest for Satisfaction with Medical Team, Satisfaction with Office Staff, and Satisfaction with Plastic Surgeon. (See Table, Supplemental Digital Content 1, which shows additional summary statistics for BREAST-Q Reduction module scores for the young reduction mammaplasty cohort, http://links.lww.com/PRS/D732.)

Table 2. - Summary Statistics of BREAST-Q Postoperative Reduction Module Scores for the Young Reduction Mammaplasty Cohort*
Value
Satisfaction with Breasts
 Mean ± SD 66.6 ± 16.5
 Median 65
 IQR 56–75
Psychosocial Well-being
 Mean ± SD 75.9 ± 21.3
 Median 80
 IQR 62–100
Sexual Well-being
 Mean ± SD 72 ± 18.2
 Median 67
 IQR 59.8–84
Physical Well-being
 Mean ± SD 81.1 ± 13.6
 Median 79
 IQR 71–92
I
QR, interquartile range.
*
n = 37.

The study population’s scores were then compared to previously published normative values (Table 3).12 Young reduction mammaplasty patients generally reported higher scores across all four domains as compared to the normative data. Furthermore, within the domains of Satisfaction with Breasts and Sexual Well-being, young reduction mammaplasty patients were significantly more satisfied as compared to normative data (p = 0.0012 and p < 0.0001, respectively). This level of statistical significance was not met when comparing Psychosocial Well-being and Physical Well-being scores between the two groups (p = 0.0318 and p = 0.0305, respectively).

Table 3. - Comparison of the Postoperative Version of the BREAST-Q Reduction Module Scores between Young Reduction Mammaplasty Patients and Normative Data*
Young Reduction Mammaplasty Cohort Normative Data p
Satisfaction with Breasts
 No. 37 1205
 Mean ± SD 66.6 ± 16.5 57 ± 16 0.0012
Psychosocial Well-being
 No. 37 1205
 Mean ± SD 75.9 ± 21.3 68 ± 19 0.0318
Sexual Well-being
 No. 36 1024
 Mean ± SD 72.0 ± 18.2 55 ± 19 <0.0001
Physical Well-being
 No. 37 1205
 Mean ± SD 81.1 ± 13.6 76 ± 11 0.0305
*From Mundy LR, Homa K, Klassen AF, Pusic AL, Kerrigan CL. Understanding the health burden of macromastia: Normative data for the BREAST-Q reduction module.
Plast Reconstr Surg. 2017;139:846e–853e.

Mean BREAST-Q scores and 95 percent confidence intervals from this study’s cohort and the normative data are displayed in Figure 1. The Satisfaction with Breasts and Sexual Well-being scales were appreciably different from each other; however, there was no appreciable difference when analyzing the Psychosocial Well-being and Physical Well-being scales.

Fig. 1.

Fig. 1.

The four selected scales were compared between participants with body mass indexes less than 25 kg/m2 and participants with body mass indexes greater than or equal to 25 kg/m2 at the time of surgery (Table 4). There was no statistically significant difference in the BREAST-Q scale scores between these groups. After considering all candidate variables, results of multivariable analyses indicated that age at the time of surgery, the amount of tissue removed, body mass index less than 25 or greater than or equal to 25 kg/m2, and race were not significantly associated with the scores from any of the four selected scales.

Table 4. - Summary Statistics of BREAST-Q Postoperative Reduction Domains by Body Mass Index for Young Reduction Mammaplasty Cohort
BMI <25 kg/m2 BMI ≥25 kg/m2 Total p
No. 13 20 33
Satisfaction with Breasts 0.96
 Mean ± SD 65.7 ± 18.4 66.5 ± 16.9 66.2 ± 17.2
 Median 65 64 65
 IQR 54–79 56–72.8 56–75
Psychosocial Well-being 0.41
 Mean ± SD 71.8 ± 25 78.5 ± 19.8 75.9 ± 21.9
 Median 68 80 80
 IQR 51–92 68–100 62–100
Sexual Well-being 1
 Mean ± SD 71.5 ± 17.4 72.5 ± 20.3 72.1 ± 19
 Median 67 67 67
 IQR 63.2–79.5 59.8–91 59.8–85.8
Physical Well-being 0.74
 Mean ± SD 81.2 ± 14.1 79.5 ± 13.9 80.1 ± 13.8
 Median 79 78 79
 IQR 71–92 70.5–88.2 71–92
B
MI, body mass index; IQR, interquartile range.

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DISCUSSION

Despite literature indicating that reduction mammaplasty is safe and effective in relieving the symptoms of macromastia,1–5,18 reluctance to pursue the surgery in young women still exists among plastic surgeons, referring physicians, and patients’ families.6–8 This study shows that decades after undergoing surgery, young reduction mammaplasty patients report greater satisfaction with their breasts and sexual well-being than women who never underwent breast surgery. Notably, this study represents one of the longest follow-ups of young reduction mammaplasty patients to date. In addition, this is the first study to use the validated BREAST-Q tool in this specific patient population and compare participants’ results to normative values.

These data are consistent with several previously published studies that demonstrated long-term overall satisfaction in young reduction mammaplasty patients. In 1994, Evans and Ryan published a retrospective review of 15 patients, younger than 20 years, who underwent reduction mammaplasty with an average follow-up of 42 months. Although no specific survey was administered, the authors noted that all patients reported being pleased with the results and would undergo the procedure again.9 Two similar studies by Webb et al. and Xue et al., looked at adolescent reduction mammaplasty patients and found that self-reported satisfaction was high (86.6 percent and 97 percent, respectively) at 34.4 weeks and 1.2 years postoperatively, respectively.13,19 In addition, McMahan et al. studied 48 reduction mammaplasty patients younger than 20 years and found that 94 percent reported that they would have the surgery again at a mean follow-up of 5.9 years.20

In 2003, Lee et al. published a review of 17 patients, younger than 18 years, who underwent reduction mammaplasty an average of 7 years before the survey. The authors used an ad hoc survey to evaluate satisfaction and resolution of symptoms. Eighty-two percent of participants reported resolution of preoperative symptoms, 65 percent responded that they would undergo the adolescent surgery again, and 82 percent responded that they would recommend the surgery to a friend. From these results, the authors concluded that the patients benefited significantly from the surgery and that long-term satisfaction was high.8 In one of the longest follow-ups of young adolescent reduction mammaplasty patients, Nguyen et al. performed a telephone survey of 99 female subjects, younger than 21 years at the time of reduction mammaplasty. More than 80 percent of patients reported long-term resolution of pain and intertrigo, along with improved clothing fit and sporting participation at a mean follow-up of 15.6 years. In addition, 95.9 percent stated that they would choose to undergo the surgery again.21

Although the results of the aforementioned outcomes studies are encouraging and are consistent with this study’s findings, these prior reports have several limitations. Namely, the authors did not use a validated, disease-specific outcomes tool to evaluate patient well-being and satisfaction. In addition, no normative data were available to make a comparison. The BREAST-Q modules are valuable clinical research tools because they quantify health-related qualitative patient experiences. The BREAST-Q Reduction module, in particular, provides researchers with reproducible, disease-specific data about the impact of macromastia symptoms and treatments aimed at relieving the symptoms. With the recent generation of population norms for the BREAST-Q Reduction module, researchers can interpret reduction mammaplasty scores in the context of a normal population and thus better assess the true effectiveness of surgical intervention.12 Given the length of this study’s follow-up, the findings of significantly higher Satisfaction with Breasts and Sexual Well-being are both surprising and encouraging. In addition, in the Physical Well-being and Psychological Well-being domains, this study’s cohort had higher raw scores, although these did not reach statistical significance. These findings suggest that, although many participants in the cohort likely underwent hormonal changes that affected breast size and morphology (e.g., pregnancy, lactation, weight gain, or menopause) in the decades after surgery, the benefits from reduction mammaplasty have endured. Thus, avoiding or delaying reduction mammaplasty in young patients may prevent them from achieving lasting improvements in satisfaction and well-being.

Similarly to other studies, the results of this study showed no correlation between body mass index at the time of surgery or amount of tissue removed and overall participant satisfaction or well-being. In 2012, Gonzalez et al. published results from a study of 600 reduction mammaplasty patients (average age, 43.6 years) who completed the postoperative version of the BREAST-Q Reduction module. The authors found no correlation between the amount of tissue removed and BREAST-Q Satisfaction with Outcome scores. Notably, the participants’ responses were not converted to a 0 to 100 scale using Q-Score, but were instead reported as an average of the responses on a scale of 1 to 3 (average score, 2.8).22 Additional studies in the adult female population had similar findings.1,5 In the young reduction mammaplasty patient population, Webb et al. examined the effect of obesity on early outcomes between obese and nonobese adolescents undergoing reduction mammaplasty. Satisfaction with the surgery was recorded by physicians during postoperative visits. The researchers found no significant difference in reported satisfaction between the groups, although the obese group had a higher complication rate.19 These studies in conjunction with the results of the current study suggest that there may be benefits from reduction mammaplasty that cannot be quantified by the amount of tissue removed. Notably, in a report on normative values for the BREAST-Q Reduction module, Mundy et al. found that preoperative scores for women presenting for reduction mammaplasty were significantly lower than normative scores for women with a large body mass index or breast cup size (at least size D), further supporting the idea that other factors may contribute to the burden of macromastia.12

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Study Limitations

The primary limitations of this study are its retrospective nature and small sample size. Given the limited size of this study’s cohort, a subgroup analysis of patients younger than 18 years was unable to be performed, and only a limited number of variables in regression analysis could be tested, as there was not sufficient statistical power to detect an association in multivariable regression models. Demographic data were not available for all of the patients considered for the study; therefore, there may be an element of selection bias among those who responded. In addition, patients were unable to complete a preoperative version of the BREAST-Q Reduction module. Therefore, this study could not provide a comparison of prereduction and postreduction scores. Finally, there are inherent limitations to the normative data used for comparison as detailed in the published work by Mundy et al.12 As noted by Mundy et al., responses from 4326 members of the Army of Women cohort were used to generate normative values for the BREAST-Q Reduction module. The cohort is composed primarily of Caucasian women from higher-than-average education and income backgrounds, with no personal history of breast surgery and/or breast cancer. Although the Army of Women cohort may not be fully representative of the general population, these are the only U.S. population-based normative and standardized values for the BREAST-Q Reduction modules. It is the opinion of the authors that the values still hold merit when assessing general trends in satisfaction with respect to the BREAST-Q scores. Future studies are needed to determine the specific generalizability of the normative values to different groups of women. Other directions for future research include prospective studies using both the preoperative and postoperative versions of the BREAST-Q Reduction module for young reduction mammaplasty patients and studies comparing the effects of different reduction techniques, age, relationship status, and complications on quality of life.

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CONCLUSIONS

This study evaluated long-term quality-of-life data in young reduction mammaplasty patients using the validated, disease-specific BREAST-Q Reduction module. By comparing the results to normative values, this study demonstrated that reduction mammaplasty patients experience excellent breast-related satisfaction and sexual well-being that endures for decades. Concerns over issues such as decreased nipple sensation, reduced ability to breastfeed, and recurrence of macromastia in the young reduction mammaplasty patient must be balanced by the potential to relieve the emotional and physical symptoms of macromastia. In the era of value-based care, studies such as this will guide physicians and third-party payers in improving the indications for reduction mammaplasty in young female patients.

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ACKNOWLEDGMENTS

Special thanks to Judith E. Hall and Deborah Lorbacher for expert assistance throughout the duration of this study.

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REFERENCES

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Supplemental Digital Content

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