Obesity and complications in breast reduction surgery: are restrictions justified?

Predictors of extended length of stay following outpatient reduction mammaplasty

PURPOSE

Reduction mammaplasty has transitioned into a largely outpatient procedure in the United States. Following planned outpatient procedures, patients may still be admitted for additional inpatient care, incurring clinical and economic burden. Prior literature has not explored the preoperative and perioperative determinants of extended lengths of stay (LOS) after breast reduction surgery.

METHODS

Patients who underwent scheduled outpatient reduction mammaplasty were identified via current procedural terminology code from the 2013 to 2021 National Surgical Quality Improvement Program databases. The primary outcome was extended LOS, defined as an LOS greater than 1 day. The most significant predictor variables were identified through bivariate association, and a binary logistic regression model was used to characterize predictive associations (p < 0.05).

RESULTS

In this study, 33,924 patients were included in the final cohort of planned outpatient reduction mammaplasty cases. Among them 325 (1.0%) patients had extended LOS. Concurrent liposuction, body contouring, and increased operative time were the most significant predictors of extended LOS (p < 0.001), followed by older age, higher body mass index, bleeding disorder, history of diabetes, higher American Society of Anesthesiologists class, and White race (p < 0.05). When adjusted for other confounding variables, extended LOS was also a significant predictor of increased risk of postoperative complications after discharge (OR: 1.85, 95% confidence intervals: 1.27-2.69, p = 0.0012).

CONCLUSION

Extended LOS after planned outpatient reduction mammaplasty is associated with specific comorbidities, and is a significant predictor of postoperative complications following hospital discharge.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are publicly available.

Understanding Hematoma Risk: Study of Patient and Perioperative Factors in a Large Cohort of Young Women Undergoing Reduction Mammaplasty

BACKGROUND

Despite high satisfaction rates, reduction mammaplasty can have complications such as hematoma. Factors such as age, tobacco use, and comorbidities are known contributors, whereas the influence of race, BMI, certain medications, and blood pressure (BP) remain contentious. This study investigates hematoma risk factors in young women undergoing reduction mammaplasty.

STUDY DESIGN

A retrospective review was conducted including all female patients who underwent bilateral reduction mammaplasty at a single institution between 2012 and 2022. Data on demographics, BMI, medical comorbidities, surgical techniques, medications, and perioperative BP were collected. Differences between patients who developed a hematoma and those who did not were assessed using chi-square, Fisher's exact, and t -tests. The relationship between perioperative BP and hematoma formation was assessed using logistic regression.

RESULTS

Of 1,754 consecutive patients, 3% developed postoperative hematoma of any kind, with 1.8% returning to the operating room. Age (odds ratio [OR] 1.14, p = 0.01) and ketorolac use (OR 3.93, p = 0.01) were associated with hematoma development. Controlling for baseline BP, each 10 mmHg incremental increase in peak intraoperative BP (systolic BP [SBP]: OR 1.24, p = 0.03; mean arterial pressure: OR 1.24, p = 0.01) and postoperative BP (SBP: OR 1.41, p = 0.01; mean arterial pressure: OR 1.49, p = 0.01) escalated the odds of hematoma. Postoperative SBP variability also incrementally increased hematoma odds (OR 1.48, p < 0.01). Other factors, including race and surgical technique, were not significantly influential.

CONCLUSIONS

Age, ketorolac use, and intra- and postoperative BP peaks and variability are risk factors for hematoma in reduction mammaplasty. This emphasizes the importance of perioperative BP management and optimizing pain management protocols.

Superior Pedicle Breast Reduction: Multivariate Analysis of Complication Risk Factors and Building a Predictive Score in 1306 Patients

BACKGROUND

Breast reduction surgery for hypertrophy is one of the most commonly performed procedures in plastic surgery. This surgery exposes patients to complications that are well-documented in the literature. The objective of this study is to identify risk factors to establish an estimate of the risk of developing complications. The authors propose the first predictive score of postoperative complications, including continuous preoperative variables such as body mass index (BMI) and suprasternal notch-to-nipple distance (SSN:N).

METHODS

An analytic observational retrospective cohort study was conducted including 1306 patients who underwent superior pedicle reduction mammaplasty at the Rennes University Hospital (France) between January 1, 2011, and December 31, 2016. The primary endpoint was to study the association between known preoperative risk factors and occurrence of any complications using multivariable logistic regression to identify independent risk factors. A secondary endpoint was to establish a score to estimate a probability of occurrence of complications.

RESULTS

A total of 1306 patients were analyzed. Multivariable logistic regression showed three independent risk factors: active smoking [OR, 6.10 (95% CI: 4.23, 8.78); P < 0.0001], BMI [OR, 1.16 (95% CI: 1.11, 1.22); P < 0.0001], and SSN:N [OR, 1.14 (95% CI: 1.08, 1.21); P < 0.0001]. The Rennes Plastic Surgery Score estimating the occurrence of postoperative complications was determined, integrating regression coefficients of each risk factor.

CONCLUSIONS

Active smoking, BMI, and SSN:N distance are independent preoperative risk factors for the occurrence of breast reduction complications. The Rennes Plastic Surgery Score including the continuous values of BMI and SSN:N allows us to provide our patients with a reliable estimation of the risk of occurrence of these complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Risk Factors and Complications in Reduction Mammaplasty: A Systematic Review and Meta-analysis

BACKGROUND

Reduction mammaplasty (RM) has become established as the standard effective method for treating macromastia, but reports on the risk factors that predispose to postoperative complications have been conflicting. This meta-analysis aimed to pool the available data to identify predictors of complications following RM.

METHODS

The PubMed, Web of Science, Embase, and Cochrane databases were screened from inception to 1 Jan 2022, and studies were included based on predefined criteria. The perioperative risk factors BMI, smoking, age, diabetes, radiation therapy, and tissue resection weight were extracted and their correlation with complications assessed.

RESULTS

A total of 40 studies comprising of 5908 patients were included. BMI ≥ 30kg/m2 (OR = 1.65, 95% CI 1.35-2.02; p < 0.01) and ≥ 40 kg/m2 (OR = 1.97, 95% CI 1.26-3.08; p < 0.01), smoking (OR = 2.57, 95% CI 2.01-3.28; p < 0.01), diabetes (OR = 2.21, 95% CI 1.19-4.07; p < 0.05), a unilateral resection weight ≥ 1000 g (OR = 1.76, 95% CI 1.02-3.05; p < 0.05), and radiation therapy (OR = 11.11, 95% CI 2.01-3.28; p < 0.01) were associated with higher rates of postoperative complications. Obese patients (BMI ≥ 30 kg/m2) were more likely to experience fat necrosis (OR = 3.00, 95% CI 1.37-6.57; p < 0.01) and infection (OR = 1.66, 95% CI 1.15-2.40; p < 0.05). Smokers had a 2.03 times higher risk of infection (95% CI 1.24-3.31; p < 0.01) and 2.34 times higher risk of dehiscence (95% CI 1.38-3.98; p < 0.01). No association between complication occurrence and age 40 or 50 years or total tissue resection weight ≥ 1000 g was identified.

CONCLUSIONS

This meta-analysis provides evidence that obesity, smoking, diabetes, unilateral resection weight ≥ 1000 g, and preoperative radiation therapy predispose to complication occurrence in RM. This information can optimize the ability of surgeons to provide preoperative patient education, perioperative assessment, and postoperative care planning.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Underused Superomedial Pedicle Reduction Mammaplasty: Safe and Effective Outcomes

BACKGROUND

The superomedial pedicle for reduction mammaplasty remains less commonly performed than the inferior pedicle. This study seeks to delineate the complication profiles and outcomes for reduction mammaplasty using a superomedial pedicle technique in a large series.

METHODS

A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. All consecutive superomedial pedicle reduction mammaplasty cases for benign symptomatic macromastia were included.

RESULTS

A total of 462 breasts were analyzed. Mean age was 38.3 ± 13.38 years, mean body mass index was 28.5 ± 4.95, and mean reduction weight was 644.4 ± 299.16 g. Regarding surgical technique, a superomedial pedicle was used in all cases; Wise-pattern incision was used in 81.4%, and short-scar incision was used in 18.6%. The mean sternal notch-to-nipple measurement was 31.2 ± 4.54 cm. There was a 19.7% rate of any complication, the majority of which were minor in nature, including any wound healing complications treated with local wound care (7.5%) and scarring with intervention in the office (8.6%). There was no statistically significant difference in breast reduction complications and outcomes using the superomedial pedicle, regardless of sternal notch-to-nipple distance. Body mass index ( P = 0.029) and breast reduction specimen operative weight ( P = 0.004) were the only significant risk factors for a surgical complication, and with each additional gram of reduction weight, the odds of a surgical complication increased by 1.001. Mean follow-up time was 40.5 ± 7.1 months.

CONCLUSION

The superomedial pedicle is an excellent option for reduction mammaplasty, portending a favorable complication profile and long-term outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Macromastia and Reduction Mammaplasty: Analysis of Outpatient Cost of Care and Opioid Consumption at 5 Years Postoperatively

BACKGROUND

Macromastia is associated with increased opioid consumption, which could potentially be the initial exposure for patients with an opioid use disorder amid an escalating opioid crisis in the United States.

OBJECTIVES

The purpose of this study was to evaluate outpatient cost of care and opioid consumption in patients with macromastia and compare those who underwent reduction mammaplasty vs those who did not have surgery.

METHODS

PearlDiver, a database encompassing a national cohort of private payers with 153 million unique patients, was queried. The study cohort included patients diagnosed with macromastia who did or did not undergo reduction mammaplasty utilizing both ICD-9 and ICD-10 and CPT codes. Outpatient cost of care and morphine milligram equivalents (MME) were calculated up to 5 years postoperatively for both cohorts.

RESULTS

At 1 to 3 years postoperatively, there was no statistically significant difference in outpatient cost of care between cohorts. At every follow-up thereafter, outpatient cost of care was higher among macromastia patients who did not undergo reduction mammaplasty, with cohort differences of US$240.68 and US$349.90 at 4 years and 5 years, respectively (P < .05). MME consumption was greater in patients who underwent reduction mammaplasty up to 30 days postoperatively (P < .01). Beyond that, there was no significant difference in MME consumption between cohorts. However, patients who did not undergo surgery had opioid consumption levels above 50 MME/day until 3 years after diagnosis of macromastia.

CONCLUSIONS

Patients with macromastia who undergo reduction mammaplasty have lower outpatient care costs than patients who do not undergo reduction mammaplasty, with safer long-term opioid consumption in alignment with current Centers for Disease Control and Prevention guidelines.

Patient-Reported Outcomes After Reduction Mammoplasty Using BREAST-Q: A Systematic Review and Meta-Analysis

BACKGROUND

The BREAST-Q questionnaire reduction module is an established tool for outcomes after reduction mammoplasty.

OBJECTIVES

This systematic review and meta-analysis assess key parameters affecting pre- and postoperative scores, with specific foci on patient characteristics and tissue resection weights.

METHODS

This study was conducted per PRISMA guidelines. PUBMED (National Institutes of Health; Bethesda, MD), Google Scholar (Google; Mountain View, CA), and Web of Science (Clarivate Analytics; Philadelphia, PA) were searched. All studies published before August 1, 2021, were assessed for eligibility by 2 independent reviewers. Inclusion criteria were prospective or retrospective studies in 6 languages that reported quality of life after reduction mammoplasty employing the BREAST-Q questionnaire reduction module. Quality of included studies was assessed employing the Newcastle-Ottawa-Scale. Analysis was performed per Cochrane Collaboration and the Quality of Reporting of Meta-analyses guidelines.

RESULTS

A total of 28 papers were included in the systematic review, 13 for preoperative meta-analysis, and 17 for postoperative meta-analysis. Postoperative scores in all 3 quality of life domains (psychosocial, physical, and sexual well-being) and satisfaction with breasts increased significantly after reduction mammoplasty compared with preoperative scores. Satisfaction with breasts showed the greatest improvement, from 22.9 to 73.0. Preoperative scores were lower than normative data, with improvement to comparable scores as the healthy population postoperatively. Improvements in BREAST-Q scores did not correlate with patient comorbidities, complication rates, or amount of breast tissue resected.

CONCLUSIONS

Reduction mammoplasty provides marked improvement in BREAST-Q patient-reported quality of life as well established in literature. However, these improvements do not correlate with tissue resection weights, warranting further inquiry of insurance-defined resection requirements.

LEVEL OF EVIDENCE: 3

Perioperative Outcomes and Risk Profile of 4730 Cosmetic Breast Surgery Cases in Academic Institutions: An ACS-NSQIP Analysis

BACKGROUND

Cosmetic breast surgery (CBS) can be subdivided into augmentation, mastopexy, reduction, and reconstruction.

OBJECTIVES

The aim of this study was to retrospectively analyze a multi-institutional national database to investigate the outcomes of CBS and identify clinical patterns to optimize care.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2008-2020) was reviewed to identify female patients who underwent CBS. Postoperative outcomes (30-day surgical and medical complications, reoperation, readmission, and mortality) and risk factors for complications were assessed.

RESULTS

In total, 4733 patients were identified (mean age, 40 [13] years; mean BMI, 24 [4.5] kg/m2) with augmentation accounting for 54% of cases. There were complications in 2.0% of cases. Age >65 years (P = .002), obesity (P < .0001), setting (P < .0001), and diabetes (P = .04) were risk factors for any complication. Age >65 years (P = .02), obesity (P = .03), diabetes (P = .01), history of chronic obstructive pulmonary disease (COPD) (P = .002) and congestive heart failure (P < .0001), smoking in the past year (P = .003), setting (P = .007), and increased American Society of Anesthesiology score (P < .0001) were predictors of surgical complications such as dehiscence and infection. Multivariable analysis confirmed that chronic obstructive pulmonary disease, obesity Class 1 and 3, and inpatient status were independent risk factors for occurrence of any complication (P = .0005, .0003, < .0001 and <.0001, respectively). Additionally, multiple procedures (P = .02) and smoking (P = .005) were found to be risk factors for surgical complications.

CONCLUSIONS

This study confirms the positive safety profile of CBS. Healthy BMI is a protective factor, while complications were more likely among inpatient procedures. A correlation between multiple procedures and increased surgical complications was identified. Awareness of these risk factors can assist surgeons to further refine their perioperative protocols.

The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory.

OBJECTIVES

The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures.

METHODS

We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes.

RESULTS

Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction.

CONCLUSIONS

Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.

Helium Plasma-Assisted Breast Reduction: A Pilot Study

Background

Reduction mammaplasty and mastopexy are currently some of the most performed breast procedures. Techniques typically involve deepithelialization of the nipple-areola complex (NAC) pedicle. Traditionally scalpel or scissor dissection is performed below the basal skin layer to remove the germinal epithelium but above the subcutis to preserve the subdermal vascular plexus. Deepithelialization thus leaves a strong dermal ‘leash’ for the pedicle while preserving the subdermal blood supply. This process is time intensive and bloody, and often an assistant is required for counter-traction. Prior authors have described laser-assisted breast reduction surgery as an alternative to traditional cold-knife techniques. The advent of helium plasma generators offers another option for deepithelialization. This study is a preliminary assessment of the safety and efficacy of this application.

Objective

We performed a prospective pilot study of 10 patients who underwent outpatient, inferior pedicle, breast reduction mammaplasty or mastopexy surgery by a single surgeon. Outcomes were assessed for safety and efficacy. Representative tissue samples were evaluated by an independent pathology group.

Methods

All patients received standard outpatient perioperative care. Deepithelialization was performed using the Renuvion helium plasma device (Apyx Medical, Clearwater, FL), and standard breast reduction or mastopexy was performed.

Results

No major complications occurred in our series. Minor complications occurred in 1 patient (10%). No inclusion cysts were recorded in any patients.

Conclusions

Helium plasma energy for deepithelialization in breast reduction was found to be safe, efficient, and effective. Decreased operating room (OR) time and blood loss suggest that helium plasma is a potential alternative for surgeons who have access to this technology.

The Effect of Dermal Suspension on Early Complications After Vertical Reduction Mammoplasty

BACKGROUND

Reduction mammoplasty is frequently performed in plastic surgery clinics. The vertical technique can be performed using several different pedicles, including superior, superomedial, medial, and lateral. For patients with large breasts, using a medial pedicle is recommended as a safer approach. Superficial wound dehiscence is common with all breast reduction techniques.

METHODS

The present study compared early complications in patients who underwent reduction mammoplasty with superior pedicle, medial pedicle, or medial pedicle with dermal suspension performed by the same surgeon. The patients were evaluated in terms of age, weight, height, pedicle type and technique used for vertical reduction mammoplasty, resected tissue mass, suprasternal notch (SSN) to nipple-areola complex (NAC) distance, NAC transposition distance, and drain duration.

RESULTS

Pairwise comparisons revealed that wound dehiscence along the inframammary fold (IMF) was significantly less frequent in the superior pedicle group than the medial pedicle without suspension group (p = 0.018). Although not statistically significant, using the suspension method in medial pedicle procedures reduced the rate of IMF wound dehiscence from 32.4 to 25%. Delayed IMF wound healing was associated with the amount of resected tissue (p = 0.004) but not with age, BMI, SSN-to-NAC distance, NAC transposition distance, or drain duration.

CONCLUSION

Suspending the medial pedicle from the chest wall reduced the rate of IMF wound dehiscence.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Predictive Patient Characteristics and Surgical Variables That Influence Postoperative Complications following Bilateral Reduction Mammoplasty

Breast hypertrophy is known to be a source of both physical and psychosocial health deficits. Therefore, the ability to relieve these symptoms with surgical treatment is an important consideration for patients. The primary objective of this study was to assess the impact of patient body mass index (BMI) on postoperation complications. The secondary objective of this study was to assess patient demographics, surgical techniques, and patient comorbidities for their impact on specific postoperative complications.

Methods

A retrospective chart review of all patients who received bilateral breast reduction surgery in Nova Scotia over the past 10 years was performed. A total of 1022 patients met the inclusion criteria of the study. Logistic regression modeling was performed to identify demographic factors, surgical techniques, and patient comorbidities that impact the risk of developing specific postoperative complications.

Results

Our study population had a total complication incidence of 37.7%. BMI was not significantly different between patients who developed complications and those who did not. Logistic regression modeling showed a significant relationship that with each unit increase in BMI above the mean (25.9 kg/m2) the relative risk of patient-reported postoperative asymmetry increased by 6%.

Conclusions

The findings of this study suggest that BMI has several nonsignificant relationships to postoperative complications following bilateral breast reduction. These trends do not translate to significantly increased complaints of asymmetry, scarring' or revision surgeries. This study also provides valuable information on the timeline of postoperative complications and when they can commonly be identified.

Using the Modified Frailty Index to Predict Complications in Breast Reduction: A National Surgical Quality Improvement Program Study of 14,160 Cases

BACKGROUND

Breast reduction is a generally well-tolerated procedure with high patient satisfaction and low risk of surgical site infection and other complications. While age, obesity and comorbidities have historically been used as surgical risk proxies, recent literature suggests 'frailty' measures, such as the modified 5-item frailty index (mFI-5), may be a superior predictor.

OBJECTIVES

To investigate if mFI-5 can predict the likelihood and magnitude of 30-day complications resulting from breast reductions.

METHODS

A retrospective review was performed using the National Surgical Quality Improvement Program (NSQIP) database of patients who underwent breast reduction without other concurrent procedures, from 2013 to 2019. mFI-5 scores were calculated for each patient, and complication data were gathered. Age, BMI, number of major comorbidities, ASA class, smoking status, diabetes, steroid use and mFI-5 score were compared as predictors of all-cause 30-day complications, 30-day surgical site complications of any kind, length of stay, and aggregate Clavien-Dindo complication severity score. Univariate logistic, linear regressions and multivariate logistic regression analyses were performed to evaluate predictive value. Statistical significance was set at p < 0.05.

RESULTS

A total of 14,160 patients were analyzed. The overall complication rate was 5.6%. The mFI-5 score significantly predicted overall 30-day complications, surgical site complications, complication severity, overnight stay and likelihood of readmission (all p < 0.0001).

CONCLUSIONS

The mFI-5 is a statistically significant predictor for adverse outcomes in breast reduction surgery. The mFI-5 is a simple and reliable tool that can be efficiently used to conduct a preoperative evaluation of patients requesting breast reductions.

Twenty Years of Breast Reduction Surgery at a Veterans Affairs Medical Center

Background

Breast reduction surgery has a high patient satisfaction rate for the treatment of symptomatic macromastia. However, complications from the surgery can significantly disrupt a woman's life due to time in the hospital, clinic appointments, wound care, time off work, and poor aesthetic outcome. Beginning July 2007, the Malcom Randall Veterans Affairs Medical Center (MRVAMC) Plastic Surgery Service in Gainesville, Florida, started using a preoperative screening protocol to help patients achieve a healthier and more favorable risk profile.

Methods

A retrospective chart review was conducted on all breast reduction surgeries performed at the MRVAMC from July 1, 2000 to June 30, 2020. Medical records were queried for all primary breast reduction surgeries performed for symptomatic macromastia. Potentially modifiable or predictable risk factors for wound complications were recorded: nicotine status, body mass index (BMI), diabetes mellitus (DM) status, skin incision pattern, and pedicle location. Records were reviewed for 3 months after surgery for local wound complications that included: hematoma, infection, wound breakdown, skin and nipple necrosis. Major complications required an unplanned hospital admission or operation.

Results

Over the 20-year period, 115 bilateral breast reduction surgeries were performed. There were 48 wound complications (41.7%) and 8 major complications (7%). Most complications were identified in the first 7 years of the study. BMI > 32 (P = .03) and active nicotine use (P = .004) were found to be statistically significant risk factors for wound complications. DM status (P = .22), skin incision pattern (P = .25), and pedicle location (P = .13), were not predictors of wound complications.

Conclusions

Breast reduction surgery has a high wound complication rate, which can be predicted and improved upon so that patients can receive their indicated surgery with minimal inconvenience and downtime. This review confirms that preoperative weight loss and nicotine cessation were the appropriate focus of the MRVAMC Plastic Surgery service's efforts to achieve a safer surgical experience.

Age and Body Mass Index Affect Patient Satisfaction Following Reduction Mammoplasty: A Multicenter Study Using BREAST-Q

BACKGROUND

Reduction mammoplasty effectively improves quality of life for women with macromastia. However, little is known whether surgical- or patient-related factors affect satisfaction.

OBJECTIVE

The authors sought to investigate factors associated with altered patient satisfaction following reduction mammoplasty.

METHODS

A cross-section study was performed by sending the BREAST-Q Reduction module to all patients who had undergone reduction mammoplasty between January 2009 and December 2018 at 2 tertiary Danish hospitals. Demographics and pre-, peri-, and postoperative details were gathered from electronic medical records.

RESULTS

A total of 393 patients returned the questionnaire and were eligible for the study. Increasing age at the time of surgery was associated with higher satisfaction with breasts nipples, headache, psychosocial well-being, and outcome. Increased body mass index at the time of surgery negatively affected satisfaction with breasts and psychosocial well-being. Increase in body mass index after surgery was further associated with lower satisfaction with breasts, nipples, sexual well-being, and more pain in the breast area. Postoperative scar revision and wound infection was more common following inferior pedicle technique than superomedial technique and negatively affected satisfaction with outcome and pain in the breast area.

CONCLUSIONS

Patients should be motivated to optimize their weight prior to reduction mammoplasty to achieve optimal satisfaction. Age was associated with improved patient satisfaction, which should considered when operating on younger patients. Postoperative complications affect patient satisfaction, and the superomedial technique seems to be a better choice than the inferior pedicle technique in medium-large breasts.

LEVEL OF EVIDENCE: 4

[Factors influencing drainage productivity in breast reduction: A retrospective study of 222 breasts]

INTRODUCTION

The objective of this study is to highlight the factors that influence drain productivity in reduction mastoplasty.

MATERIALS AND METHODS

We have retrospectively referenced from November 2015 to November 2017 all breast reduction performed in the plastic surgery, reconstructive and esthetic surgery department of the University Hospital of Nancy. A total of 222 breasts were analyzed by listing age, weight, height, Body Mass Index (BMI), smoking status, surgeon, technical used, hospitalization stay, breast volume removed, type and size of drain and their productivity. Multivariate analysis were realised.

RESULTS

118 patients were included with an average age of 42.2 years. The average productivity of drains was 50 millilitres (ml). There was a significant difference in productivity of drainage according to the operator with a median ranging from 10ml to 60ml (P<0.0001). The median was 20ml for 10 Redon-Jost drains versus 50ml for the 16 Redon-Jost drains (P<0.0001). Multivariate analysis of the various factors influencing the total productivity of postoperative drainage showed a relative risk of 1.16 for smokers, 0.24 for one surgeon, 1.68 for the Skoog technique, and 1.000 for breast volume removed.

CONCLUSION

The drain productivity is not predictable before a breast reduction. Indeed, none of the characteristics studied have sufficient influence on the productivity of the drains.

Breast Reduction with Deskinning of a Superomedial Pedicle: A Retrospective Cohort Study

BACKGROUND

In most breast reduction techniques, the pedicle of the nipple-areola complex (NAC) is de-epithelialized to preserve the subdermal plexus, thereby decreasing the risk of NAC necrosis. However, deskinning the pedicle is faster and makes it more pliable, which potentially improves the aesthetic outcome. There is no scientific evidence regarding the beneficial effects of de-epithelialization. In this study, we present data from patients undergoing breast reduction with deskinning of a superomedial pedicle.

METHODS

In the period June 2013 to March 2019, a single surgeon performed all breast reductions using a superomedial glandular pedicle. The patients were included retrospectively and data were collected by reviewing the medical records. The NAC necrosis rate was compared with data from the literature through a systematic review.

RESULTS

The cohort consisted of 142 consecutive patients. The median resection weight was 287 g (interquartile range (IQR), 197-399) per breast. No complete NAC necroses occurred during the follow-up period, but two patients (1.4%) developed partial NAC necrosis. In the literature, the rate of NAC necrosis (complete or partial) was 1.5% of patients undergoing breast reduction with de-epithelialization.

CONCLUSION

The rate of NAC necrosis after breast reduction with deskinning of the pedicle was comparable with breast reductions with de-epithelialization that has been reported in the literature. Our findings support that the pedicle in breast reduction surgery can be deskinned safely in patients with low resection weights.

Nipple-Areola Complex Ischemia or Necrosis in Freestyle Perforator Flap Reduction Mammoplasty Operations

BACKGROUND

Necrosis of the nipple-areolar complex (NAC) is one of the most devastating complications of reduction mammoplasty. A variable, asymmetrical pattern of blood supply from the main sources was found in the same individual. To solve this problem, we present a method to be sure that the blood supply to the NAC is contained within the designed pedicle during reduction mammoplasty. This is done using the colored duplex scan and handheld Doppler to perform freestyle perforator flap reduction mammoplasty.

METHODS

This is a prospective randomized study that has been performed on 105 patients in the period between January 2014 and 2019 at the Plastic and Reconstructive Surgery Department, Tanta University Hospitals. Freestyle perforator flaps were performed for all cases after perforator detection using handheld Doppler and confirmed by colored duplex scan.

RESULTS

The procedure was performed as freestyle on medial perforators in 35 (33.3%) cases, on lateral perforators in 20 (19%) cases, on combined medial and lateral perforators, as a bipedicle in 30 (28.7%) cases, on upper pole perforators in 12 (11.4%) cases, and on lower pole perforators in 8 (7.6%) cases.

CONCLUSIONS

The use of handheld Doppler and the confirmation by duplex scan are mandatory to decrease the incidence of NAC necrosis or ischemia.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

BMI and specimen weight: impact on personalized risk profiling for optimized informed consent in breast reduction surgery?

We aimed to evaluate the interaction between individual risk factors and institutional complication rates after reduction mammaplasties to develop a chart for a personalized written patient informed consent. We retrospectively reviewed charts of 804 patients who underwent bilateral breast reduction between 2005 and 2015. The Clavien-Dindo classification was used to classify postoperative complications. Relevant predictors were found by applying a stepwise variable selection procedure. Multilevel predictors were assessed through chi-square tests on the respective deviance reductions. 486 patients were included. The most common complications were wound healing problems (n = 270/56%), foreign body reactions (n = 58/12%), wound infections (n = 45/9, 3%) and fat tissue necrosis (n = 41/8%). The risk factors for the personalized patient chart for the most common complications influencing the preoperative informed consent were: smoking, operative technique, resection weight for wound healing problems; body mass index and allergies for wound infections; and patients’ age, resection weight for fat tissue necrosis. The resultant chart of institutionally encountered most common complications based on individual risk factors is a graphical template for obtaining patient informed consent in the future. Whether this approach influences patient information retainment, incidence of filed lawsuits or behavioral change needs to be prospectively tested in future studies.

A 12-year review of patient-reported outcomes after reduction mammoplasty in patients with high body mass index

Patients with increased body mass index (BMI) are often denied reduction mammoplasty due to concern for high morbidity. There is a paucity of evidence identifying high BMI as a predictor of poor long-term outcomes in reduction mammoplasty. In this study, we investigated the influence of BMI on long-term patient satisfaction following reduction mammoplasty.All patients undergoing reduction mammoplasty over a 12-year period at a single institution were included in the study. A retrospective chart review was conducted to extract demographics, operative data, and postoperative course including complications. Patients were classified into 4 categories based on BMI (normal (<25), overweight (25-29.9), obese (30-39.9), and morbidly obese (≥40)). Patient satisfaction was assessed using a customized survey which was administered over the phone. Only patients with complete medical records who participated in the survey were included.The 70 patients met the inclusion criteria for the study. Median time from surgery to survey was 6 years. Overall satisfaction after reduction mammoplasty was high, 5 on a 5-point Likert scale. The amount of breast tissue resected correlated with patient BMI (P <.01). There was no statistical difference in satisfaction across BMI classes. Furthermore, high BMI (obese, and morbidly obese) was not associated with higher postoperative complications (P = .70). Those with a high overall satisfaction score had a significantly greater self-reported aesthetic score compared to those with low and mid satisfied scores (P <.01).Following reduction mammoplasty, patients report high satisfaction which is sustained over several years. Obesity is not associated with a higher incidence of complications or lower satisfaction. Our data suggest that patients with a high BMI should not be denied reduction mammoplasty out of concern for higher complication rate or reduced patient satisfaction due to BMI alone, but reduction mammoplasty should be considered in the setting of overall health counseling.

Effect of Obesity on Complications in Short-Scar Breast Reduction: A Retrospective Study of 236 Consecutive Patients

Background

Prior studies have examined the relationship between obesity and adverse outcomes after reduction mammaplasty, suggesting a correlation between increasing body mass index (BMI) and postoperative complications. However, there is little data published regarding such correlation with respect to short-scar technique.

Methods

A total of 236 patients underwent short-scar mammaplasty with a superomedial pedicle from 2008 to 2014. The procedure was performed by a single surgeon at an academic medical center. Adverse outcomes included delayed healing, major wounds, nipple necrosis, fat necrosis, seroma, hematoma, infection, revision, and dog ear deformities. Univariate and multivariate logistic regression analyses were used to calculate crude and adjusted odds ratios for the association of BMI category with the development of any adverse outcome.

Results

Patients were grouped by the following BMI categories: <25 kg/m² (n = 27), 25 to <30 kg/m² (n = 71), 30 to <35 kg/m² (n = 73), 35 to <40 kg/m² (n = 45), and >40 kg/m² (n = 20). The mean follow-up period was 260 days. The total complication rate in each group was 22.2%, 23.9%, 27.4%, 33.3%, and 45.0%, respectively. Although the proportion of patients experiencing at least 1 adverse outcome increased across the ascending BMI categories (P trend = .145), there was no statistically significant difference between the groups.

Conclusion

This study of 236 patients who underwent short-scar reduction mammaplasty found a positive trend in the incidence of adverse outcomes as BMI increased. However, this was not statistically significant.

Predictors of complications following breast reduction surgery: A National Surgical Quality Improvement Program study of 16,812 cases

BACKGROUND

Breast reduction is one of the most common procedures performed by plastic surgeons. Despite good outcomes and high patient satisfaction, there are little national data on the predictors that lead to complications in this patient population. We accessed a national outcomes database to examine these factors.

METHODS

This is a retrospective study examining the National Surgical Quality Improvement Program database from 2006 to 2015. Patients who underwent primary breast reduction were identified. Patients who underwent any cancer-related procedures were excluded. We identified patient-related and procedure-related factors for analysis. Univariate and multivariate logistic regression analyses were used to identify independent predictors of complications.

RESULTS

In total, 16,812 individual cases were identified. The overall complication rate for the cohort was 6.2%, and the major complication rate was 3.0%. Diabetes, bleeding disorder, hypertension, obesity, smoking, steroid use, and prolonged operative time were associated with increased risk of complications (p < 0.05). Concurrent body contouring was a predictor of increased major complications; however, liposuction was not.

CONCLUSIONS

Common surgical risk factors are associated with complications in breast reduction surgery. Although liposuction is not an independent risk factor, concurrent body contouring is associated with increased complications. Surgeons should be aware of these associations when discussing breast reduction with patients.

Oncological Outcomes of Nipple-Sparing Mastectomy: A Single-Center Experience of 1989 Patients

BACKGROUND

Nipple-sparing mastectomy (NSM) is increasingly used in women with breast cancer who are not eligible for conservative surgery, but extensive outcome data are lacking and indications have not been established.

OBJECTIVE

The aim of this study was to assess the oncological outcomes of NSM in a large series of patients with invasive or in situ breast cancer treated at a single center.

METHODS

We analyzed 1989 consecutive women who had an NSM in 2003-2011, for invasive (1711 patients) or in situ cancer (278 patients) at the European Institute of Oncology, Italy, and followed-up to December 2016. Endpoints were local recurrences, recurrences in the nipple-areola complex (NAC), NAC necrosis, and overall survival (OS).

RESULTS

After a median follow-up of 94 months (interquartile range 70-117), 91/1711 (5.3%) patients with invasive cancer had local recurrence (4.8% invasive disease, 0.5% in situ disease), and 11/278 (4.0%) patients with in situ disease had local recurrence (1.8% invasive disease, 2.2% in situ disease). Thirty-six (1.8%) patients had NAC recurrence, 9 with in situ disease (4 invasive and 5 in situ recurrences), and 27 with invasive disease (18 invasive and 9 in situ recurrences). NAC loss for necrosis occurred in 66 (3.3%) patients. There were 131 (6.6%) deaths, 109 (5.5%) as a result of breast cancer. OS at 5 years was 96.1% in women with invasive cancer and 99.2% in women with in situ disease.

CONCLUSIONS

The findings in this large series, with a median follow-up of nearly 8 years, indicate that NSM is oncologically safe for selected patients. The rate of NAC loss was acceptably low.

[Should surgeons keep performing drainage after breast reduction?]

OBJECTIVE

Despite the absence of "evidence-based medicine", the use of closed suction drainage in breast surgery is currently the standard practice. Its goal is to minimize the amount of fluid at the operation site, the dead space that can involve postoperative complications. The purpose of this study is to demonstrate that with or without drainage the complication rate is unchanged.

METHODS

We conducted a retrospective and comparative study of two groups of breast reduction with and without drainage. Every complication has been recorded and statistically analyzed: seroma and hematoma, infections, wound breakdown, skin flap or nipple-areola complex necrosis, fat necrosis and reoperation.

RESULTS

A total of 138 breast reductions were performed (37 drained patients and 32 non-drained). Data collection of complications was done on average 10months after the operation (1-15). There was no statistical difference between the two groups regarding the complication rate. Our results confirm the ones found in the literature.

CONCLUSION

Except for specific cases (e.g. gigantomasty), this study demonstrates that after breast reduction, drainage is not appropriate. Drains do not reduce postoperative complications and can increase hospitalization length of stay (inducing higher costs). Furthermore, it is often source of pain, anxiety and discomfort for patients.

Treatment of Gigantomastia Using a Medial-Lateral Bipedicle Reduction Mammoplasty: The Role of Doppler-Assisted Preoperative Perforator Identification

The purpose of this study is to introduce a breast reduction technique designed to reduce the incidence of postoperative nipple-areola complex ischemia and necrosis following reduction mammoplasty, while at the same time allowing all the other goals of breast reduction to be realized. This is achieved through preoperative detection of perforating vessels supplying the nipple-areola complex using a hand-held Doppler. The horizontally based parenchymal pedicle is designed to include these perforators whether originating from the internal mammary artery, lateral thoracic artery or both. This technique provides freedom in pedicle shaping and fixation to the pectoral fascia to achieve the best breast contour. The study included 50 patients equally divided into two groups: the study group (using preoperative Doppler for detection of perforators) and control group (without preoperative Doppler). The average body mass index of our patients was 32.4 and 29.8 for study and control groups, respectively. The average suprasternal notch to nipple distance was 40.8 cm in the study group and 38.9 cm in the control group. In all cases of the study group, both medial and lateral pedicles were used each of them containing one perforator. The average resection weight per side was 1433.6 g for the study group and 1173.2 g for the control group. None of the study group cases experienced NAC necrosis, while four cases of the control group experienced NAC necrosis (3 partial and 1 total). The horizontally based parenchymal pedicle constructed with the aid of preoperative perforator identification with a Doppler is an effective technique for breast reduction that results in a very low rate of postoperative ischemia and necrosis of the nipple-areola complex. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes analysis of breast reduction in Brazilian women using the BREAST-Q® questionnaire: a cross-sectional controlled study

OBJECTIVE

The aim of this study was to analyse patient-reported outcomes of reduction mammoplasty among Brazilian women.

METHODS

A total of 100 women were enrolled in this cross-sectional controlled study, 50 with breast hypertrophy (Hypertrophy Group) and 50 who had undergone breast reduction at least six and up to 12 months before (Mammoplasty Group). The Brazilian version of the BREAST-Q® was applied to assess patient-reported outcomes. The module reduction/mastopexy was used, and the preoperative and postoperative versions were applied to the hypertrophy and mammoplasty groups, respectively.

RESULTS

The mammoplasty group presented higher scores for the subscales satisfaction with breasts, psychosocial well-being, sexual well-being and physical well-being (p=0.0001 for all of these subscales).

CONCLUSION

These results suggest that patients submitted to reduction mammoplasty are satisfied with the outcomes and present better quality of life scores compared with women with breast hypertrophy.

Incisional Negative Pressure Wound Therapy for Prevention of Wound Healing Complications Following Reduction Mammaplasty

BACKGROUND

It has been proposed that negative pressure wound therapy (NPWT) applied prophylactically to a closed incision may decrease the incidence of wound complications. Patients undergoing reduction mammaplasty are at risk of wound complications such as delayed healing, infection, and dehiscence, and the bilateral nature of the surgery allows for a within-patient randomized study to evaluate incisional NPWT's effect in reducing healing complications.

METHODS

In this multicenter trial, 200 patients undergoing bilateral reduction mammaplasty were treated with PICO Single-Use NPWT System or standard wound-care dressings randomized to right or left breast for up to 14 days to enable within-patient comparison. Follow-up assessments were conducted to evaluate the difference in incision healing complications up to 21 days postsurgery. Healing complications (for the primary endpoint) were defined as delayed healing (incision not 100% closed by 7 days) and occurrence of dehiscence or infection within 21 days. Individual healing complications were assessed separately as secondary endpoints.

RESULTS

Significantly fewer healing complications (primary endpoint) were noted in NPWT-treated breasts [113 (56.8%)] versus standard care [123 (61.8%)]. The difference of 10 (5.0%) patients with fewer healing complications using NPWT was statistically significant (P = 0.004). NPWT also resulted in a significantly lower incidence of dehiscence (secondary endpoint) compared with standard care [32 patients (16.2%) versus 52 patients (26.4%)] by day 21, a relative reduction of 38% (P < 0.001).

CONCLUSIONS

This is the first major prospective, within-patient, randomized, controlled, multicenter study to provide evidence for an incisional NPWT strategy to reduce healing complications.

Overweight is Associated With Increased Incidence of Minor Complications After Reduction Mammoplasty: A Retrospective Analysis of 453 Consecutive Cases

Background and Aims:

Reduction mammoplasty alleviates macromastia symptoms and improves quality of life. We investigated a large series of consecutive reduction mammoplasties to assess various risk factors for both minor and major complications after the procedure.

Materials and Methods:

A retrospective analysis of 453 consecutive reduction mammoplasties was performed between 2007 and 2010 at an academic tertiary referral center to evaluate risk factors and complications.

Results:

The incidence of minor and major complications was 40.5% and 8.8%, respectively. Patients with minor complications had both a significantly higher mean body mass index (30.2 vs 28.0) and sternal notch to nipple distance (33.9 vs 32.4 cm) than patients who recovered without complications (p < 0.001 for both comparisons), as well as more visits to the outpatient clinic (p < 0.001). In the multivariate analysis, body mass index was found to be the only significant risk factor for minor complications (p < 0.001). Furthermore, patients with body mass index higher than 27 had a 2.6-fold greater risk of minor complications (p < 0.001). An increase of one unit in body mass index increased the probability of minor complications by 14.1% (p < 0.001). 22 (4.9%) patients developed a hematoma requiring evacuation in the operating room. The mean body mass index of patients who developed a hematoma was 26.4, a value lower than that of patients without this complication (mean 29.0; p = 0.003). This finding was significant also in the multivariate analysis (p = 0.002).

Conclusion:

A higher body mass index was strongly associated with an increased risk of minor complications after reduction mammoplasty. It is important to inform obese patients about the increased risk of complications and to encourage them to lose weight before surgery.

Antibiotic prophylaxis in breast reduction surgery: A systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness and harm of using antibiotic prophylaxis versus placebo or no intervention in patients undergoing breast reduction surgery to prevent surgical site infection.

MATERIALS AND METHODS

A search strategy was conducted in the MEDLINE, CENTRAL, EMBASE, and LILACS databases. Searches were also conducted in other databases and unpublished literature. Clinical trials were included without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. An analysis of fixed effects was conducted. The primary outcome was surgical site infection. The secondary outcomes were delayed wound healing and adverse effects. The measure of the effect was the risk difference (RD) with a 95% confidence interval (CI). The planned interventions were antibiotic prophylaxis versus placebo/no intervention.

RESULTS

Five articles were included in the qualitative and quantitative analysis. A total of 584 patients were included from the five studies. A low risk of bias was shown for most of the study items. The overall RD for surgical site infection was -0.08 (95% CI -0.14--0.03), favoring antibiotic prophylaxis compared with placebo.

CONCLUSION

Antibiotic prophylaxis lowers the incidence of surgical site infection in breast reduction surgery compared with placebo or no intervention.

Computed Tomographic Angiography-Based Characterization of Source Blood Vessels for Nipple-Areola Complex Perfusion in Hypertrophic Breasts

BACKGROUND

Current knowledge about the blood supply of the nipple-areola complex (NAC) has largely been derived from studies on cadavers or persons with breasts of normal size. The aim of this study was to identify and classify the NAC blood supply by computed tomographic angiography (CTA) examination in female volunteers with breast hypertrophy.

METHODS

CTA examination was performed on hypertrophic breasts of 23 female subjects. The main blood supplies were revealed through image data analyses. The dominant blood supply of the NAC and its vascular sources were identified and sorted. The detectable diameter threshold of blood vessels was set beyond 1.0 mm.

RESULTS

A total of 61 dominant blood vessels were identified. The source arteries were traced as the internal thoracic artery (ITA, 50.8%), lateral thoracic artery (LTA, 27.8%), thoracoacromial artery (TA, 14.8%), brachial artery (BA, 3.3%), and axillary artery (AA, 3.3%), and the corresponding reproducibility of these source vessels was 31, 37, 9, 4.3, and 4.3%, in all breasts. The intercostal artery (IA) was not identified as a dominant NAC supplying vessel in any CTA scan image. Twenty-six breasts had only one dominant artery, whereas 17 breasts showed multiple dominant blood supplies. Three breasts showed no dominant blood vessels of the NAC, with diameters greater than the detectable threshold of 1.0 mm, and 52.2% of the breasts demonstrated anatomically symmetrical patterns of blood supply for the NAC.

CONCLUSIONS

The ITA, LTA, and TA are likely to be the main vessel sources, whereas the IA is unlikely to be the dominant vessel for NAC perfusion, on the basis of the studied breasts. An asymmetrical pattern of bilateral breast blood supply was demonstrated in a considerable portion of the females with breast hypertrophy in this study.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Preoperative weight loss program targeting women with overweight and hypertrophy of the breast - a pilot study

Among women with hypertrophic breasts, the clear majority are overweight or obese. Owing to increased risk of complications, women with a body mass index (BMI) above 25 kg m ^-2 are precluded from reduction mammaplasty. The primary aim was to investigate if intensive weight loss could ready women with overweight for breast reduction surgery. Six women, all overweight [BMI 30.9 {28.5; 35.8} kg m ^-2 ] with symptomatic hypertrophy of the breast, were included a 12-week weight loss program. All women desired reduction mammaplasty and were motivated for preoperational weight loss. The first 8 weeks consisted of a formula-based diet supplying 800 kcal daily, in the subsequent 4 weeks regular foods were reintroduced increasing the intake to 1200 kcal daily. Five women completed the trial, and achieved a median (range) weight loss of 10.2 (6.5; 19) kg. Initial breast volume was 1100-2500 mL per breast, this was reduced by 300 (200; 500) mL after the intervention; equivalent to approximately 19%. Waist, hip, upper arm and thorax circumference were significantly reduced following weight loss. At end of study, all the women still suffered from symptomatic breast hypertrophy to substantiate reduction mammaplasty. Surgeries were performed 2 months thereafter. A 12-week intensive preoperative weight loss program enabled women with obesity for breast reduction surgery. Breast size was reduced proportionally more than total weight loss among women with hypertrophy.

Relationship Between Obesity and Surgical Complications After Reduction Mammaplasty: A Systematic Literature Review and Meta-Analysis

Background

Although many patients who undergo reduction mammaplasty are obese, reports on whether obesity is a risk factor for postoperative complications have been conflicting.

Objectives

This systematic literature review and meta-analysis aimed to evaluate the relationship between obesity and surgical complications after reduction mammaplasty.

Methods

The PubMed, Medline, and Embase databases were searched between 1998 and 2016 using the MeSH terms and keywords “reduction mammoplasty (mammaplasty),” “breast reduction,” “obesity,” “body weight,” “body mass index,” and “risk factor.”

Results

Among 26 studies that reported surgical complication risk and patient body weight, 11 concluded that obesity is not a risk factor and 15 reported that high body mass index increases surgical risk. On comparing obese and non-obese patients, we found that obese patients had a higher relative risk of surgical complications (1.38, 95% confidence interval 1.13-1.69), particularly skin and fat necrosis (2.01, 95% confidence interval 1.54-2.63). The pooled risk further increased with an increase in body mass index, and it was 1.71 for body mass index >35 kg/m2 and 2.05 for body mass index >40 kg/m2.

Conclusions

Our meta-analysis indicated that the risk of surgical complications and tissue necrosis after reduction mammaplasty is higher in obese patients than in non-obese patients and that the risk gradually increases with an increase in the severity of obesity. The findings of this study could form a basis for preoperative patient education, surgical method selection, and determination of the extent of postoperative care.

Standardizing the complication rate after breast reduction using the Clavien-Dindo classification

BACKGROUND

Published complication rates for breast reduction surgery, also known as reduction mammaplasty, vary between 4% and 54%. This wide range of complication rates could be attributable to the lack of a standardized classification of complications in plastic surgery. The aim of this study was to analyze our single-center complication rates after reduction mammaplasty using the Clavien-Dindo classification.

METHODS

We performed a retrospective chart review studying 804 patients between the ages of 18 and 81 years old who underwent breast reduction between 2005 and 2015 at our institution. Patients with a history of breast cancer, a previous breast operation, who did not undergo bilateral reduction mammaplasty, or who required systemic immunodeficiency/immunosuppressive drugs were excluded from our analysis. Complications were classified according to the Clavien-Dindo classification from Grades I to V.

RESULTS

A total of 486 patients met the inclusion criteria for the analysis. Patients had an age (mean ± standard deviation) of 39 ± 13 years and a body mass index of 26 ± 4 kg/m². Median follow-up was 274 days (interquartile range: 90.5-378). The overall rate of complications of reduction mammaplasty was 63%, with the majority of those being Grades I (48%) and II (9%), comprising 92% of all the complications. Operative revisions were required in 6% (1% Grade IIIA and 5% Grade IIIB). There were no complications graded in categories IV and V.

CONCLUSION

Although complications occurred in more than half of the cases, the majority did not require operative reintervention. The Clavien-Dindo classification can classify the severity of complications and serve as a benchmark to compare complication rates between different practices. We believe that grading of complications should distinguish between those that do and do not require operative reinterventions.

Risk Factors for Complications after Reduction Mammoplasty: A Meta-Analysis

Background

Reduction mammoplasty (RM) is a proven method of treating macromastia, but the risk factors for postoperative complications have not been clearly identified. Through this meta-analysis, the authors aimed to identify the risk factors of RM complications.

Methods

An extensive search of the literature describing complications after RM was performed using the PubMed Central, Embase, and Cochrane databases. The following risk factors were extracted: age, body mass index (BMI), tissue resection weight per breast (TRW), smoking and radiation therapy. Odds ratios (OR) were pooled with 95% confidence intervals (CI) to evaluate the relationship between these risk factors and complications after RM.

Results

A total of 16 unique studies including 10 593 patients were included in the final analysis. It showed that there was a significant difference in complications in BMI ≥30 kg/m² (OR 0.73; 95% CI: 0.61–0.89, p = 0.001) and smoking (OR 1.56; 95% CI: 0.98–2.49, p = 0.06). Infection in those with BMI ≥30 kg/m² showed a significant difference (OR 0.68; 95% CI: 0.52–0.89, p = 0.004), as well as wound dehiscence in smokers (OR 2.73; 95% CI: 1.60–4.67, p = 0.0002) and infection in irradiated breasts (OR 20.38; 95% CI: 3.42–121.35, p = 0.0009). However, there was no significant difference in age ≥50 years (OR 0.96; 95% CI: 0.71–1.29, p = 0.78), combined TRW ≥1000 g (OR 1.04; 95% CI: 0.43–2.50, p = 0.93).

Conclusions

BMI ≥30 kg/m² and smoking increase the risk of complications. Persons who are obese or irradiated are more likely to develop infections, and smokers experienced a higher incidence of wound dehiscence than did nonsmokers. However, patients aged ≥50 years and TRW ≥1000 g are not associated with complications from RM.

Antibiotic prophylaxis in reduction mammaplasty: study protocol for a randomized controlled trial

Background

The role of antibiotics in surgical procedures where the risk of surgical site infection (SSI) is low remains uncertain. There is, to date, no evidence to justify the routine use of antibiotics in postoperative reduction mammaplasty. The aim of this study is to evaluate the effect of postoperative antibiotic treatment on the occurrence of SSI after breast reduction surgery.

Methods

This is a double-blind randomized clinical trial with 124 breast hypertrophy patients allocated to two treatment groups: antibiotic (n = 62) and placebo (n = 62). All patients will undergo reduction mammoplasty, performed by the same surgical team. The surgeons will raise the nipple-areola complex by the superomedial pedicle technique. The patients will receive antibiotics intravenously during anesthetic induction and every 6 hours thereafter during their 24-hour hospital stay. During discharge from the hospital, each patient will receive a numbered package containing either cephalexin or placebo capsules and will be directed to take one capsule every 6 hours for 7 days. Neither the surgery team nor the patients will know the contents of the capsules. Patients will be monitored for the occurrence of SSI once weekly during the first 30 days following hospital discharge by a single surgeon who is blinded to their treatment group. SSI will be evaluated based on the definition adopted by the Centers for Disease Control and Prevention.

Discussion

Due to the variety of risk factors for SSI and limited case studies, conclusions regarding the effect of antibiotics on the occurrence of SSIs following reduction mammaplasty are potentially biased. In recent studies, perioperative antibiotic prophylaxis was effective in preventing infection and is therefore recommended in clinical practice. However, antibiotic use in the postoperative period still remains controversial.

Trial registration

Clinicaltrials.gov Identifier: NCT02569866. Registered on 4 October 2015.

Triangular lipodermal flaps in Wise pattern reduction mammoplasty (superomedial pedicle): A novel technique to reduce T-junction necrosis

BACKGROUND

Although Wise pattern reduction mammoplasty is one of the most prevalent procedures providing satisfactory cutaneous reduction, it is at the expense of inevitable lengthier scars and wound complications, especially at the inverted T junction.

OBJECTIVE

To describe a novel technique providing tension-free closure at the T junction through performing triangular lipodermal flaps. The aim is to alleviate skin tension, thus reducing skin necrosis, dehiscence and excessive scarring at the T junction.

METHODS

One hundred seventy-three consecutive procedures were performed on 137 patients between 2009 and 2013. Data collected included demographics, perioperative morbidity and resected breast tissue weight. The follow-up period ranged from three to 30 months; early and late postoperative complications and patient satisfaction were recorded.

RESULTS

Superficial epidermolysis without T-junction dehiscence was experienced in eight (4.6%) procedures while five (2.9%) procedures developed full-thickness wound dehiscence. Ninety-four percent of patients were highly satisfied with the outcome.

CONCLUSIONS

The technique is safe, versatile and easy to execute, providing a tension-free zone and acting as internal dermal sling, thus providing better wound healing with more favourable aesthetic outcome and maintaining breast projection.

Bilateral Breast Reconstruction with Abdominal Free Flaps: A Single Centre, Single Surgeon Retrospective Review of 55 Consecutive Patients

Breast reconstruction using free tissue transfer is an increasingly utilised oncoplastic procedure. The aim was to review all bilateral breast reconstructions using abdominal free flaps by a single surgeon over an 11-year period (2003–2014). A retrospective review was performed on all patients who underwent bilateral breast reconstruction using abdominal free flaps between 2003 and 2014 by the senior author (DAM). Data analysed included patient demographics, indication for reconstruction, surgical details, and complications. Fifty-five female patients (mean 48.6 years [24–71 years]) had bilateral breast reconstruction. The majority (41, 74.5%) underwent immediate reconstruction and DIEP flaps were utilised on 41 (74.5%) occasions. Major surgical complications occurred in 6 (10.9%) patients, all of which were postoperative vascular compromise of the flap. Failure to salvage the reconstruction occurred on 3 (5.5%) occasions resulting in a total flap failure rate of 2.7%. Obesity (>30 kg/m²) and age > 60 years were shown to have a statistically increased risk of developing postoperative complications (P < 0.05). Our experience demonstrates that abdominal free flaps for bilateral breast reconstruction fares well, with a flap failure rate of 2.7%. Increased body mass index and patient age (>60 years) were associated with higher complication rates.