Monday, August 25, 2008

Breast Reduction: Safe in the Morbidly Obese?--Article Review

I found the article regarding breast reduction in the morbidly obese (reference #1) to be quite interesting. It does seem to be an important question with the increasing obese population and with the "never events" list being expanded. They give their reason for looking at the topic:

Background: With an increasing obese population, plastic surgeons are consulted by women requesting larger breast reductions, with body mass indices in the obese to morbidly obese range (30 to ≥40 kg/m2) and breasts considered gigantomastic (>2000 g resected from each breast). There have been few descriptions of outcomes in the morbidly obese population. Previous literature reports high complication rates in obese women and large-volume breast reductions.

The article is a retrospective review of 179 consecutive patients who had surgery at the University of Texas Medical Branch at Galveston during the time frame of June 1996 to April 2006. I hope they will do another review in a prospective manner and see how it compares.

... We obtained data points including height, weight, preoperative symptoms, medical history, smoking history, breast size, physical examination, type of reduction, amount of resection, and postoperative course including complications. All complications were recorded, and included hematoma, seroma, asymmetry requiring further surgery, stitch abscess, open wounds, cellulitis, fat necrosis, flap loss, changes in nipple sensation, nipple loss, nipple graft loss, and hypertrophic scarring. All were recorded, with no gradation as to severity. These were recorded throughout the patient's follow-up course, ranging from 1 month to 1 year.

The most common pedicle type was the inferior pedicle or central mound used in 134 patients. Free nipple grafts were done in 37 patients. There were 29 patients who had surgery for gigantomastia (more than 2000 gm per side). Six of these women had inferior pedicle/central mound reductions. The other 23 had breast amputations with free nipple grafting.

There patient population characteristics:

Average reduction mass -- 1259 gm per breast (117 - 4875 gm)

Average age -- 35 yrs (15 - 68 yrs)

Average body mass index -- 34 (range, 20.7 - 54.4)

World Health Organization: 18 to 24.9 kg/m2 (normal weight), 25 to 29.9 kg/m2 (overweight), 30 to 39.9 kg/m2 (obese), and greater than 40 kg/m2 (morbidly obese)

  • 93 women in the obese category
  • 34 women in the morbidly obese category

There were a total of 90 patients (out of 179) with complications, or an overall complication rate of 50 percent. The most common complication was delayed healing which accounted for 65% of the complications

The complications were broken down as follows:

Delayed wound healing -- 65%

Cellulitis -- 17.6%

Hypertrophic scarring -- 8%

Hematoma -- 3%

Seroma -- 3%

Fat necrosis -- 3%

Nipple graft loss -- 1%

Their Results:

The overall complication rate was 50 percent.

There was no statistical difference in the incidence of complications attributable to size of reduction, age, or body mass index (p = 0.37, p = 0.13, and p = 0.38, respectively).

Also, smoking status, method used (p = 0.65 and p = 0.17, and p = 0.48 and p = 0.1, respectively) and

comorbidities had no effect on complication rates (reduction size, p = 0.054; age, p = 0.12; and body mass index, p = 0.072).

There was no significant increase in the rate of complications for each body mass index group based on the reduction mass (p = 0.75, p = 0.89, p = 0.23, and p = 0.07).

They conclude that reduction mammoplasty is "a safe operation for patients regardless of their age, size of reduction, or body mass index." I don't insist that patient's loss weight prior to a breast reduction, but I do (and will continue to do so) tell them that they are at more risk of wound/healing issues.

REFERENCES

1. Breast Reduction: Safe in the Morbidly Obese?; Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 370-378; Roehl, Kendall M.D.; Craig, E Stirling M.D.; Gómez, Victoria B.A.; Phillips, Linda G. M.D.

2. A Comparison of Complication Rates in Large and Small Inferior Pedicle Reduction Mammoplasty; Plast. Reconstr. Surg. 115: 736, 2005; O'Grady, K. F., Thoma, A., and Dal Cin, A.

3. Analysis of Breast Reduction Complications Derived from the BRAVO Study; Plast. Reconstr. Surg. 115: 1597, 2005; Cunningham, B. L., Gear, A. J., Kerrigan, C. L., et al.

4 comments:

femail doc said...

Women are always so happy with the results of their breast reductions, even those who have complications. Still, a one in two chance of complications? But H cup to double D is quite a load of those shoulders...

Theresa said...

I know someone who wants a breast reduction. This information will be of interest to her and other patients, thank you for compiling it here!

Dreaming again said...

My surgeon was insistant (given my eating disorder history and 100 pound weight changes in just a few months time) that I PROMISE him, that I stay at a stable weight for at least a year post surgery. I was in treatment for the ED at the time. I had the ok from all doctors and treatment team ... all was a go ...
I was a 36 ii at the time, down to a 36 c (begged and begged for an a or b, but he wouldn't go for it) He said d, compromised with a small c)

When I came back in for my 6 week check up, 40 lbs smaller than I was at the date of surgery, he was less than impressed. (he's also not willing to operate on me again)

He has no problem with operating on women who are overweight .. on women with eating disorders that aren't stable ...not so much.

(there was more to that, on the eating disorder & treatment side, but the surgeon didn't know that)

DrCris said...

I was amazed that there wasn't an incrased complication rate with smoking. I mean, this is the classic poor healing scenario - fatty tissue, infections common etc. I would expect smoking to be a big factor.

Thanks for the summary. It was a very interesting article.