Additional Benefits to Reduction Mammoplasty

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.

This article (full reference below) on the additional benefits an individual gains from having a reduction mammoplasty (RM) has been published online ahead of print.  The authors performed a systemic review of the literature focusing on functional outcomes after RM with regard to physical and psychological symptom improvement.

The authors performed a systematic review of the English literature using PUBMED for the period between 1977 to 2010. Studies were chosen that addressed the physical and psychological benefits of RM using a validated questionnaire.

The authors note that nearly eighty thousand breast reductions
were performed in 2009.  For insurance coverage in the United States a woman seeking breast reduction must have complaints of physical symptoms (ie neck pain, upper back pain, inframammary rashes, etc). 

The authors of this article choose to look at the other benefits a reduction mammoplasty can have:

Even less common are investigations on the effect of RM on weight loss, exercise, and eating behavior.  Women with large breasts often find exercising difficult due to public scrutiny and physical constraints. They may even develop eating disorders in an attempt to match their breast size to the rest of their body. ……..Women with macromastia often have
diminished self-esteem, poor psychosexual function, depression, and anxiety.

I want to applaud them for their article.  There are 52 article in their reference list.  Table I is a breakdown of 6 articles on physical symptoms/improvements.  Table II is a reference does the same for 8 articles on the effects of reduction mammoplasty on exercise, weight and eating behaviors.  Table III does the same for 5 articles on the effects of reduction mammoplasty on psyche.  Table IV summarizes 3 articles on the effects of reduction mammoplasty on appearance.

The results of their summary:

Women who undergo RM have a functional improvement in musculoskeletal pain, headaches, sleep, and breathing. Psychological benefits are vast and include improved self esteem, sexual function, and quality of life, as well as less anxiety and depression. Following RM, women appear to exercise more and have a reduction in eating disorders.

This is what I saw over my 21 years of practice in taking care of these women.
……
Related post: 
Reduction Mammoplasty (December 19, 2007)
……
REFERENCE

Additional Benefits to Reduction Mammaplasty: A Systemic Review of the Literature; Singh, Kimberly A.; Losken, Albert; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 15 November 2011; doi: 10.1097/PRS.0b013e31824129ee

Bariatric Surgery Should Come Before Breast Reduction

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

Many women with large breast and weight issues seek breast reduction.  I was taught to encourage them to lose weight first.  Now there is a very small study that backs this up  (full reference below).

The American Society of Plastic Surgeons issued a press release entitled “Breast Reduction and Bariatric Surgery—Which Should Be Done First?” and provided the answer “ Final Results May Be Better When Weight Loss Comes First.”  I agree, but find it odd that such a small study was published.  There should have been more patients included.

Jeffrey A. Gusenoff, MD, and colleagues reviewed two groups of patients who sought consultation for body contouring surgery August of 2008 and February of 2010 after massive weight loss (defined as a weight loss of greater than 50 pounds).

Group I (n=15) included any patients who underwent reduction mammoplasty for symptomatic macromastia before massive weight loss.  Group II (the control group, n=14) included any patients who did not undergo breast surgery before massive weight loss.

The patients were given a prospective phone survey to assess self-ratings of breast appearance before and after breast reduction and after massive weight loss, ability to exercise, which would have preferred to have first—massive weight loss or breast reduction surgery—and what they would recommend to a friend.

Of the 15 patients (7.9%) in group I, 14 completed the survey (93%). 

For group I, all patients felt the appearance of their breasts improved after reduction (p < 0.001) but felt appearance worsened or stayed the same after weight loss (p = 0.003).

Seventy-one percent of patients were able to exercise more and 64 percent were able to lose weight on their own because of their reduction. ……..

Ten patients (71 percent) would recommend that a friend lose weight before breast reduction surgery. …

For group II, 79 percent of patients felt the appearance of their breasts worsened or stayed the same after massive weight loss (p = 0.03). ……

All 14 patients (100 percent) would recommend losing weight before undergoing breast surgery.

Even though I tend to agree that patients should loss weight prior to breast surgery.  It is much easier to achieve the cosmetic goals of the patient if she is at or near her goal weight.  Otherwise, the surgeon and patient are left to guess at how her skin will retract with weight loss and how much deflation or loss of volume will occur.

I wish the study had ask how many of the Group I patients desired an augmentation as part of their revision. 

Eleven patients (79 percent) felt a secondary lift following massive weight loss should be covered by insurance, and seven patients (50 percent) plan on having revision breast surgery.

They noted it with Group II patients

Eleven patients (79 percent) wished their breasts currently appeared different, with eight (57 percent) desiring lifted breasts, seven (50 percent) desiring general reshaping, two (14 percent) desiring reduced breasts, and two (14 percent) desiring larger breasts.

I have augmented four patients over my 21 years of practice who had previous breast reductions prior to losing weight (one was mine).  This should be included in the discussion as well as the high probability that a revision to reshape or re-lift the breasts will be needed if the reduction is done prior to the (massive) weight loss.

Related posts:
Reduction Mammoplasty (December 19, 2007)
Breast Reduction: Safe in the Morbidly Obese?—Article Review  (August 25, 2008)
Tennis Star Brings Breast Reduction Surgery into Press (June 4, 2009)
Impact of Obesity on Breast Surgery Complications – article review  (June 16, 2011)


REFERENCE

Reduction Mammaplasty, Obesity, and Massive Weight Loss: Temporal Relationships of Satisfaction with Breast Contour; Coriddi, Michelle; Koltz, Peter F.; Gusenoff, Jeffrey A.; Plastic & Reconstructive Surgery. 128(3):643-650, September 2011; doi: 10.1097/PRS.0b013e318221da6b

ASPS News on Breast Reductions

The ASPS News Brief section has two updates listed related to breast reductions regarding papers presented at last week’s American Society of Plastic Surgeons (ASPS) Plastic Surgery 2009 conference which I wasn’t able to attend.  According to ASPS statistics, nearly 89,000 breast reductions were performed in 2008, up 5 percent since 2000.

The first one is a pilot study conducted to “determine the extent to which reduction mammaplasty surgery produces a change in biomechanical stress of the spine and level of disability in women
with macromastia.” 

In the study,  eleven women (ages 27 to 71 yrs, mean age 44.18) who had been determined to need breast reduction surgery, participated in a biomechanical analysis/task that involved lifting a 5 lb. weight and responded to a questionnaire prior to and following their surgery (at one week and at 3 months).  

The biomechanical analysis included performance of 3-trials of a lifting task using a 5 lb. weight located 12 in. anterior to the feet and 16 in. above the ground. Concurrent kinematic and kinetic data from the task was collected using a 6-camera motion capture system (Vicon; Centennial, Co) and an in ground force-plate (AMTI; Watertown, MA).  A custom made application (Matlab: Natick, MA) was used to calculate the total compressive forces at the low back using an inverse dynamic approach based on Zatiorsky's anthropometric data. Functional analysis consisted of the completion of the standardized Function Rating Index (FRI) questionnaire to assess their self-reported ability to perform dynamic movements of the neck and back and/or withstand static positions.

The results of the study showed an average maximum low back compressive force during the lifting task decreased 35% post surgery.  The  scores on the functional rating index improved 76% .  The authors concluded “The results from this study combined with previous research demonstrate that women who undergo medically necessary reduction mammaplasty surgery may be at a decreased risk for disc degeneration and low back disorders.  These results warrant additional research to prospectively investigate these individuals.”

 

The  authors of the second one concluded that increased testing in breast reduction patients can help to identify patients at-risk of breast cancer, especially patients over 40.  The reported incidence of occult breast cancer in reduction mammoplasty patients (RMP) ranges from 0.06% to 4.6% in the literature.

The study authors state, “No standard pathology assessment for RMP exists.”   It is however standard that breast tissue be sent to pathology for testing regardless of the patient’s age.  Perhaps  our pathologist who blogs at Methodical Madness  could weigh in on the standard sampling. 

Two-hundred-two cases were evaluated over a 20-month period at a single institution.  None of these women had any lesions identified on their pre-operative mammograms.  Significant pathologic findings (SPF), i.e. carcinoma and atypical hyperplasia, were present in 12.4% of patients.  Of the 202 cases, 4% were found to have carcinoma.  When age of the patients was considered, the rate of carcinoma increased to 6.2% in patients over 40 years and to 7.9%  in those over 50 years of age.

The authors suggests “ indicating the need for thorough sampling of RMP specimens in patients older than 40.”  What would  thorough sampling be as they indicated that no standard exists?

 

 

 

REFERENCES

American Society of Plastic Surgeons News Brief (October 25, 2009)

"The Impact of Breast Reduction Surgery on the Low Back Compressive Forces and Function in Individuals with Macromastia" presented Sun., Oct. 25, 10:25 - 10:30AM PDT, at the Washington State Convention and Trade Center. (pdf file of abstract)

"Carcinoma and Aypical Hyperplasia in Reduction Mammaplasty: Increased Sampling Leads to Increased Detection: A Prospective Study"  presented Sun., Oct. 25, 10:30 -10:35AM PDT, at the Washington State Convention and Trade Center.