An Outcomes Analysis of 2142 Breast Reduction Procedures

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.

Exploring Complication Rates: A Comparative Study of Breast Reduction and Combined Breast Reduction with Abdominoplasty

BACKGROUND

Despite a trend towards combining abdominoplasty with breast reduction surgery, so called "mommy makeovers", the safety of this combined approach has been the subject of debate, with previous research yielding conflicting results. We evaluated the risk for complications and revision associated with adding abdominoplasty to bilateral breast reduction surgery.

METHODS

We conducted a 10-year single-center retrospective chart review of bilateral breast reduction patients in Nova Scotia. Univariate and multivariate analyses were performed to compare the risk for complication and revision in patients with bilateral breast reduction to those with a concomitant abdominoplasty.

RESULTS

Of the 1871 patients initially screened, 738 were included. 44 underwent a concomitant abdominoplasty procedure. Compared to the breast reduction alone group, patients with concomitant abdominoplasty were significantly older (47.5±9.9 vs. 42.8±13.2, p=0.004), had a higher BMI (28.1±4.4 vs. 25.8±3.1, p<0.001), and experienced longer operating room times (226±6 vs. 115±3 mins, p<0.001). In multivariate analysis, concomitant abdominoplasty did not increase the risk for breast-related (OR: 0.86 95%CI 0.43-1.7, p=0.668) or total complications (OR: 1.63, 95%CI 0.83-3.19, p=0.154). However, there was a trend towards an increased risk of breast revision (OR: 2.684, 95%CI 0.95-7.6, p=0.062) and a significantly increased risk of total revision (OR: 6.624, 95%CI 2.7-16.1, p<0.001). Moreover, patients with concomitant abdominoplasty experienced more follow-up visits (median: 4 vs. 3 visits, p=0.042).

CONCLUSION

In our single-center retrospective analysis, combining abdominoplasty with bilateral breast reduction did not increase the risk for breast, or total complications; however, it did increase the risk for total revisions.

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.

Reviewing Outcomes and Complications with the Use of Mesh in Breast Reduction Surgery

INTRODUCTION

Reduction mammoplasty is a common reconstructive and esthetic procedure with variable long-term outcomes regarding breast shape, projection, and nipple-areolar complex. One common complaint is recurrent breast ptosis, which may be mitigated by sufficient support of the inferior pole. This review will look at the effects of mesh in mitigating postoperative ptosis following reduction mammoplasty.

METHODS

A comprehensive review of the literature was performed using the PubMed database. Manuscripts that provided data with respect to the effects of mesh on cosmetic outcomes, patient-reported outcomes, complications, and surveillance were utilized.

RESULTS

Six studies with a total of 634 patients were included in this review. There is limited evidence to support a cosmetic benefit with the use of mesh in reduction mammoplasty patients. While subjective satisfaction was demonstrated in one paper, few others had objective measurements of the impact of mesh. Complications included infection, skin necrosis, and loss of nipple sensation. Mammography was found to not be affected by mesh placement.

DISCUSSION

The use of mesh during reduction mammoplasty is a relatively modern innovation that does not appear to have a significantly different risk profile than that of traditional reduction procedures. There is limited cosmetic value based on currently available data. More objective future analysis is necessary in order to justify the use of mesh in reduction mammoplasty for its claimed cosmetic benefits.

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 Table of Contents or online Instructions to Authors www.springer.com/00266.

[Breast restoration by the lipomodeling technique after breast sequelae following complications of reduction mammoplasty]

BACKGROUND

Complications of reduction mammoplasty can lead to aesthetic sequelae, which are known to be difficult and delicate to treat, and only a few articles deal with this subject.

PURPOSE

The objective of this article is to present and analyze our experience of lipomodeling for the secondary management of aesthetic sequelae occurring after a complication of reduction mammoplasty.

MATERIAL AND METHODS

An uniform and consecutive series of 22 female patients, operated with the lipomodeling technique from December 2003 to March 2019 by the last author, to correct aesthetic sequelae after secondary complications of reduction mammoplasty was studied analyzing the efficiency and the tolerance of this technique.

RESULTS

The results showed 86.4% of very good results and 13.6% of good results. Seventeen patients (77.3%) were highly satisfied with the postoperative outcome, and 5 patients were satisfied (22.7%). The number of procedures varied from 1 to 3: 15 patients (68.2%) underwent only one session of lipomodeling, 5 patients (22.7%) underwent two sessions, and 2 patients (9.1%) underwent three sessions. The mean time between two interventions was 4 months (3-12). No patient of this series initiates any medico-legal proceeding towards the first surgeon.

CONCLUSION

After this study, lipomodeling, in association with ancillary procedures, seems to be an effective and safe solution to correct aesthetic sequelae following secondary complications of reduction mammoplasty. It should have a key role for the correction of these sequelae. An effective and appropriate care of these patients leads to good results and patients' final satisfaction, and manages to avoid any medico-legal proceeding, always badly lived as much for the patient as for the first surgeon.

Central Mound Technique in Oncoplastic Surgery: A Valuable Technique to Save Your Bacon

INTRODUCTION

Breast-conserving surgery (BCS) is a valid method for the reconstruction of partial breast defects, however, there is a great variety of final aesthetic outcomes depending on the location of the tumor in the breast and also on the initial breast volume and the degree of ptosis. Specifically, defects affecting the upper inner/central quadrant represent a reconstructive challenge with not always satisfactory final results. For this purpose, the authors investigated the use of the central mound technique in breast-conserving surgery. The aim of the study was to apply the central mound as an oncoplastic technique and assess the satisfaction rate of the patients.

MATERIALS AND METHODS

This was a retrospective study that involved 40 patients (80 breast) underwent breast conserving surgery and contextual bilateral breast remodeling with central mound technique. A pre- and postoperative Breast-Q questionnaire (breast conserving therapy module) was given to all the patients before the surgery, 3 months and 9 months after. The statistical analysis with chi-square test was performed.

RESULTS

After 9 months the author found a major increase of all BREAST-Q parameters; the most valuable increments concerned the "Satisfaction with breast" and "Psychosocial well-being." None of the patients experienced a decreased in the quality of life related to the surgical procedure.

CONCLUSION

The authors believe that this technique has useful functional and aesthetic results particularly appreciated by patients with upper pole lesion who have a slightly or moderately breast ptosis and a small cup size.

Is Preoperative Asymmetry a Predictor of Postoperative Asymmetry in Patients Undergoing Breast Reduction?

Plastic surgeons aim to achieve symmetry in breast surgeries, which is the main determinant of chest aesthetics. The aim of this study was to verify if preoperative breast asymmetry is a predictor of postoperative asymmetry in women undergoing breast reduction. In this prospective study, we enrolled 71 women (the mean age 37 years, SD 10 years) with breast hypertrophy who underwent reduction mammaplasty. We collected clinical data including age, height, weight, weight of the resected tissues, and performed pre and postoperative photographic documentation. The following measurements of both breasts were analyzed: volumes (vol), nipple-sternal notch distance (A-sn), difference between nipples' levels (A-A'), nipple-midline distance (A-ml), difference between inframammary folds levels (IF-IF'), distance between inframammary fold and nipple (IF-A), distance between inframammary fold apex and midline (IF-ml). All measurements were performed preoperatively and 6 months after the surgery and asymmetries of all variables were calculated (asy-vol, A-A', asyA-sn, asyA-ml, IF-IF', asyIF-A, asyIF-ml). Postoperative asymmetry of breast volumes and nipples position was not associated with any of the analyzed clinical variables. Postoperative asymmetry of nipples' level was associated with preoperative asymmetry of IF-ml; however, logistic regression did not detect any preoperative measurement influencing postoperative volume and nipples' level asymmetry. Moreover, we found that preoperative asyIF-ml increased the risk of postoperative volume asymmetry, which is above the average (52 cc) (OR = 2.04). Postoperative breast asymmetry after breast reduction is not related neither to preoperative asymmetries nor clinical variables; however, asymmetry of inframammary fold apex to the midline may be the factor affecting postoperative volumetric asymmetry.

Return to Work after Breast Reduction: A Comparative Study

(1) Background: Breast hypertrophy is a prevalent condition among women worldwide, which can affect different aspects of their quality of life. Uncertainty exists in the medical literature about recommendations for return to work after reduction mammaplasty procedures. The aim of this study was to assess the return to work after reduction mammaplasty for women with breast hypertrophy. (2) Methods: A retrospective cohort study composed of chart review of all reduction mammaplasties performed at a single institution due to breast hypertrophy was considered. Patients not in working life were excluded. Patients were divided into two groups based on the sick leave duration: normal versus prolonged. Prolonged sick leave time was defined as times greater than the 75th percentile for the respective sample data. Demographic and comorbidity data were secondary predictor variables. The primary outcome measure was the occurrence of prolonged sick leave. Secondary endpoints were specific wound healing complications and late complications. We further compare postoperative complications between patients who received a sick leave of 3 weeks versus the other patient cohort. (3) Results: From a total of 490 patients, 407 of them were employed at intake. Mean time to working return after reduction mammaplasty was 4.0 ± 0.9 weeks. Prolonged sick leave occurred in 77 patients and its mean duration was 5.5 ± 0.9 weeks. No differences in age, preoperative BMI, smoking, comorbidities, number of children or use of herbal supplements were detected. Significantly increased intraoperative blood loss occurred in the group who received prolonged sick leave (328.3 mL vs. 279.2 mL, p = 0.031). Postoperative complications were significantly higher in the group who experienced a prolonged sick leave (26.5% vs. 11.2%, p < 0.001), particularly infections and wound dehiscence incidences. No differences in late complications were detected (>30 days, 6.5% vs. 7.6%, p = 0.729). When comparing patients who received a 3 week sick leave with the rest of cohort, blood loss was significantly higher in the group who had a longer sick leave (230.9 mL vs. 303.7 mL, p < 0.001). (4) Conclusions: The occurrence of postoperative complications increased the patients’ return to work time. Comorbidities and preoperative parameters did not affect the length of sick leave. It appears reasonable to suggest a recovery period of approximately 3 weeks, subject to individual variations. An increased intraoperative blood loss might predict a prolonged sick leave.

Nationally Validated Scoring System to Predict Unplanned Reoperation and Readmission after Breast Reduction

BACKGROUND

Reduction mammoplasty continues to be a commonly sought procedure with complication rates ranging from 4.3 to 8.2%. In the current study, we sought to identify the clinical and preoperative risk factors for unplanned reoperation and readmission within the first postoperative month on a national scale.

METHODS

Patients who underwent reduction mammoplasty from the ACS-NSQIP 2012-2019 database were analyzed to determine rates of reoperation and readmission within 30 days of the initial breast surgery. The cohort was divided into 60 and 40% random testing and validation samples. A multivariable logistic regression analysis was then performed to isolate independent factors of unplanned readmission and reoperation using the testing sample (n = 22,743). The predictors were weighted according to beta coefficients to develop an integer-based clinical risk score predictive of complications. This system was then validated using receiver operating characteristics (ROC) analysis of the validation sample (n = 15,162).

RESULTS

A total of 37,905 reduction mammoplasties were analyzed. 1.3% of patients had an unplanned readmission. Independent risk factors for unplanned readmission included age older than the median of 44 years (p < 0.01), inpatient procedure (p < 0.01), smoking (p < 0.01), hypertension (p = 0.01), COPD (p < 0.05), BMI ≥ 35 (p < 0.01), and operation time greater than the median of 142 minutes ( p < 0.01). The factors were integrated into a scoring system, ranging from 0 to 36, and an ROC analysis revealed an area under the curve of 0.66. 1.9% of patients underwent unplanned reoperation. Independent risk factors for unplanned reoperation in this population included age older than the median of 44 years (p < 0.01), inpatient status (p < 0.01), and a history of bleeding disorders (p < 0.05). The factors were integrated into a scoring system, ranging from 0 to 25, and the ROC analysis revealed an area under the curve of 0.61.

CONCLUSIONS

We present a validated scoring system to better inform patients about their risk for unplanned reoperation and readmission following reduction mammoplasty. This system will enable surgeons to optimize patient selection and interventions in order to decrease morbidity and unnecessary health-care expenditure.

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.

A Simplified Approach to Breast Reduction Using the Medial Pedicle

Background

Breast reduction is a common procedure for plastic surgery. We have adopted a modified technique using the medial pedicle, with markings using a 15-9-9 framework and a methodical step wise approach.

Objectives

This study introduces the 15-9-9 framework as a design for medial pedicle breast reductions that is easy to perform and teach, with favourable outcomes.

Methods

Markings using the 15-9-9 framework was used, describing the mosque dome and medial pedicle length and width. The technique was performed in day surgery under general anesthesia. Patients were followed up to 1 year, with photographs taken at each visit and complications recorded. A retrospective review of 80 patients between November 2013 and July 2019 was completed in a single surgeon’s practice.

Results

Patients were an average of 49 years (18-72 years) with a BMI of 28 (23-32). The average postoperative sternal notch to areola distance was 22 cm (19-26 cm) and sternal notch to nipple distance was 24 cm (21-28). The average duration of the surgical procedure was 3.4 hours. An average of 464 g (90-1210 g) was removed from each breast. Complication rates were low with minor fat necrosis (14%), T junction breakdown (10%), hematoma (3.8%), dog ear formation (3.8%), junctional necrosis (2.5%), and partial nipple loss (1.3%). One patient had a cerebrovascular accident in the late postoperative period. Aesthetically pleasing results were achieved postoperatively.

Conclusions

This technique using the 15-9-9 framework is simple to learn, perform and teach with overall aesthetically pleasing outcomes.

American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline Revision: Reduction Mammaplasty

SUMMARY

A multidisciplinary work group involving stakeholders from various backgrounds and societies convened to revise the guideline for reduction mammaplasty. The goal was to develop evidence-based patient care recommendations using the new American Society of Plastic Surgeons guideline methodology. The work group prioritized reviewing the evidence around the need for surgery as first-line treatment, regardless of resection weight or volume. Other factors evaluated included the need for drains, the need for postoperative oral antibiotics, risk factors that increase complications, a comparison in outcomes between the two most popular techniques (inferior and superomedial), the impact of local anesthetic on narcotic use and other nonnarcotic pain management strategies, the use of epinephrine, and the need for specimen pathology. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development and Evaluation methodology). Evidence-based recommendations were made and strength was determined based on the level of evidence and the assessment of benefits and harms.

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.

A Matched Comparison of the Benefits of Breast Reduction on Health-Related Quality of Life

BACKGROUND

Breast reduction surgery has consistently fallen within the top 10 surgical procedures performed by plastic surgeons. This is because of its capability to relieve the physical and psychological impact of macromastia. Although numerous women pursue consultation, many never undergo the procedure. The authors aim to quantify the impact of breast reduction surgery on quality of life by comparing patients who underwent breast reduction surgery with those who did not.

METHODS

Patients seeking breast reduction surgery between 2016 and 2019 were identified. As standard-of-care, patients are surveyed during the consultation visit and postoperative visits using the BREAST-Q. The preoperative survey was readministered a second time for those who did not undergo breast reduction surgery. Propensity score matching, based on patient demographics, comorbidities, and breast examination, was used to balance baseline characteristics.

RESULTS

A total of 100 propensity-matched patients were identified (operative, n = 78; nonoperative, n = 22). Mean participant age was 39.5 ± 25 years and mean body mass index was 31.1 ± 7.4 kg/m2. Quality of life significantly improved in each domain for those in the operative group (p < 0.05). Those who did not undergo breast reduction surgery realized no improvement in quality of life and had a downward trend in quality of life across two of the four domains.

CONCLUSIONS

Breast reduction surgery offers a significant improvement in quality of life for macromastia. This matched study demonstrates that patients who are able to undergo breast reduction surgery have a statistically significant improvement in all aspects of quality of life, whereas nonsurgical patients experience no benefit with time, with a trend toward deterioration in specific domains.

Is Time a Factor in Quality of Life Improvement Following Breast Reduction?

BACKGROUND

Macromastia (breast hypertrophy) has a significant influence on patients' quality of life (QoL), and surgical treatment therefore offers clear medical benefits.Rapid improvements in musculoskeletal complaints are being reported long before final aesthetic results are traditionally evaluated.

OBJECTIVES

The aim of this study was to use the RAND Health Status Survey, in modified validated Short Form 36 (SF-36), to analyze patient QoL after breast reduction, and examine whether QoL changes as a function of postoperative time.

METHODS

This cross-sectional study included 50 consecutive selected female patients who underwent breast reduction surgery by the same technique performed by a single surgeon between January 2016 and December 2019. Changes in QoL were reported based on a modified SF-36 survey, with scores standardized according to the mean of the general population. Time intervals between the operations and surveys were recorded.

RESULTS

The patients were divided into 3 categories according to time since their operation (<3 months, 3-12 months, and >12 months), and assessed pre- and postoperatively. The mean [standard deviation] weight of breast tissue removed was 479.97 [159.38] g per breast. Mean follow-up time was 15.02 [14.3] months. All patients were satisfied with the shape of their new breasts and none reported to have suffered major complications postoperatively. For all 3 groups, patients' scores in the SF-36 survey post- compared with preoperation indicated improvement unrelated to time elapsed since operation.

CONCLUSIONS

Breast reduction improves symptoms and well-being, unrelated to amount of tissue removed or to time elapsed postsurgery. This improvement is rapid and may lead to better coverage from medical insurance providers.

LEVEL OF EVIDENCE: 4

Immediate fat and nanofat-enriched fat grafting in breast reduction for scar management

BACKGROUND

Reduction mammoplasty can be successful but surgical scars may continue to be a most undesirable and unavoidable outcome. Various medical and non-invasive methods are available to minimize scar formation but as yet no methods have been discovered to eliminate them. We hypothesize that immediate fat and nanofat-enriched fat graft transfer may improve the scar quality and optimize results.

MATERIALS AND METHODS

This prospective study comprised 45 superomedial pedicle wise-pattern breast reduction patients divided into three groups of 15 in a randomized fashion. The control group had no additional injections whereas the other two groups received injections of fat and nanofat-enriched fat grafts immediately under their surgery scars, respectively. Surgical scar formation was evaluated at six months and scars were scored using the Vancouver scar scale and a visual analogue scale.

RESULTS

Fat and nanofat-enriched fat graft-injected groups scored significantly better on all items of the Vancouver scar scale, except for scar height, compared to the control group (p < 0.05). Visual analogue scores were significantly lower in the fat and nanofat-enriched fat graft-injected groups compared to the control group (p < 0.05).

CONCLUSIONS

In breast reduction patients, simultaneous fat and nanofat-enriched fat grafting appears to be a safe and promising strategy for scar management.

Outcomes and Outcome Measures in Breast Reduction Mammaplasty: A Systematic Review

BACKGROUND

Reduction mammaplasty remains critical to the treatment of breast hypertrophy. No technique has been shown to be superior; however, comparison between studies is difficult due to variation in outcome reporting.

OBJECTIVES

The authors sought to identify a comprehensive list of outcomes and outcome measures in reduction mammaplasty.

METHODS

A comprehensive computerized search was performed. Included studies were randomized or nonrandomized controlled trials involving at least 100 cases of female breast hypertrophy and patients of all ages who underwent 1 or more defined reduction mammaplasty technique. Outcomes and outcome measures were extracted and tabulated.

RESULTS

A total 106 articles were eligible for inclusion; 57 unique outcomes and 16 outcome measures were identified. Frequency of patient-reported and author-reported outcomes were 44% and 88%, respectively. Postoperative complications were the most frequently reported outcome (82.2%). Quality-of-life outcomes were accounted for in 37.7% of studies. Outcome measures were either condition-specific or generic; frequencies were as low as 1% and as high as 5.6%. Five scales were formally assessed in the breast reduction populations. Clinical measures were defined in 15.1% of studies.

CONCLUSIONS

There is marked heterogeneity in reporting of outcomes and outcome measures in the literature. A standardized outcome set is needed to compare outcomes of various reduction mammaplasty techniques.

LEVEL OF EVIDENCE: 4

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

BACKGROUND

Adolescent reduction mammaplasty remains controversial because of concerns of postoperative breast growth, complications, and the effect on well-being. The authors sought to prospectively quantify early and late complications following reduction mammaplasty in adolescents and young women, and examine the intersection of surgical complications and postoperative health-related quality of life.

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Does lipofilling after oncologic breast surgery increase the amount of suspicious imaging and required biopsies?-A systematic meta-analysis

OBJECTIVE

The aim of our systematic meta-analysis was to find out if lipofilling to the breast alters follow-up imaging procedures and leads to an increased number of biopsies because of suspicious findings.

METHODS

We conducted a systematic meta-analysis of the literature including all prospective and retrospective studies focusing on imaging outcomes in patients with a history of breast cancer who have received one or more lipofilling procedures after oncologic surgery to the breast.

RESULTS

Twelve studies met the inclusion criteria, comprising 1711 patients and at least 2261 lipofilling procedures. 564 patients (33%) were followed up only with ultrasound, 735 patients (43%) only received mammography, 273 (16%) had a combination of ultrasound, mammography and MRI, and 37 patients (2.1%) were followed up via ultrasound and mammography. A collective of 102 patients making up a matched-cohort study received ultrasound, mammography, MRI, and PET/CT, while only 51 of them made up the investigation group who had autologous fat grafting (3%). Biopsy rates were 1%-24% with a medium of 6.5% over all groups. Medium follow-up was 18.8 months (range 6-50 months). The rate of local oncologic events among the patients with lipofilling procedures detected during the study periods was 0.7%.

CONCLUSION

Lipofilling to the breast after oncologic operations appears to be a safe procedure with overall low biopsy and local recurrence rate. Suspicious imaging occurs in most cases out of physiologic remodeling and inflammation processes at the operation site and needs to be distinguished from malignant focusses. The amount of required biopsies stands in relation to the used imaging method and the time to follow-up.

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.

[Unfavorable results of reduction mammoplasty: Causes, preventions and treatments]

Reduction mammoplasty is known to be a highly satisfactory surgery but complications and unfavorable results can occur. The objective was to describe the main unfavorable results, to specify their causes, preventions and treatments. We have analyzed articles from the last ten years regarding reduction mammoplasty complications as well as their main unfavorable results. The most common complications were wound dehiscence, hypertrophic scars, infections, fat necrosis, hematomas, and partial or total nipple-areolar complex necrosis. The most frequently reported unfavorable results were unaesthetic and retracted scars, asymmetry in breast size, abnormalities in shape, and malposition of the nipple-areolar complex. For each type of unfavorable outcomes, the possible causes, preventions and treatments were detailed.

Combined Breast Reduction Augmentation

BACKGROUND

Numerous methods have been designed to reduce breasts size and weight. The goal today is to not only to reduce size but also to create a pleasing shape. Breast reduction techniques do not obtain the desired upper pole fullness, and commonly recurrent ptosis develops. To improve and maintain breast shape in the late postoperative period, we combine breast reduction with implants.

METHODS

Three hundred and sixty-six patients who underwent combined breast reduction or mastopexy with implants from January 2014 to November 2017 at IM Clinic were retrospectively reviewed. We present the indications, surgical technique, and outcomes of these patients to determine the safety and efficacy of our technique.

RESULTS

No major complications were noted in an average of 2 years of follow-up (range 2 months to 4 years). Minor complications occurred in 61 patients, of whom 46 required revision surgery (12.6%). The most common tissue-related complications were dog ears (7.6%) and poor scarring (4.9%). The most common implant-related complication was capsular contracture (0.8%).

CONCLUSIONS

Breast reduction with implants is a reliable option to provide additional volume to the upper pole of the breast to improve long-term breast shape and avoid ptosis recurrence. Our study indicates that the procedure is safe and has complication and revision rates comparable to traditional breast reduction or augmentation mastopexy techniques.

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 .

A pictorial review: multimodality imaging of benign and suspicious features of fat necrosis in the breast

Fat necrosis of the breast is a well-described benign entity that can result in unnecessary biopsy of breast lesions. The pathogenesis of fat necrosis is a non-suppurative inflammatory process of adipose tissue, which may be seen after trauma, surgery, biopsy, post-breast reconstruction, post-fat grafting, post-radiotherapy, infection, and duct ectasia, among other conditions. Clinically, these patients may be asymptomatic or may present with a palpable lump, skin tethering, induration, and occasionally axillary lymphadenopathy. Depending on the time at which diagnostic imaging is performed, fat necrosis can have highly variable appearances on different modalities as it evolves. This is directly related to whether inflammation or fibrosis is predominating within the lesion, and correlation with clinical history is paramount in evaluating these patients. This review aims to analyze benign and suspicious imaging features of fat necrosis confirmed by tissue sampling. Knowledge of both benign and malignant-appearing features of fat necrosis on conventional modalities such as mammography and ultrasound, as well as newer applications including digital breast tomosynthesis, PET/CT, and MRI, should help the radiologist minimize the number of unnecessary biopsies.

Fat necrosis and polymicrobial wound infection caused partly by Raoultella ornithinolytica after reduction mammoplasty

Raoultella ornithinolytica is a rare opportunistic aerobic gram-negative bacillus that naturally exists in soil, water and plants. The pathogen has been described in association with diabetic foot infections, biliary infections, bacteraemia and native and prosthetic joint infections. Fat necrosis and wound infection following breast reduction surgery or other plastic surgeries caused by this pathogen have not been previously described. We present a case of bilateral fat necrosis, wound infection and dehiscence in a 24-year-old woman with no significant past medical problems. She initially had an uneventful early postoperative course but 3 weeks after surgery noticed pain and discharge from both nipple/areola area of both breasts which later developed into full-thickness fat necrosis and complete destruction of the nipple areolar complex. R. ornithinolytica, Escherichia coli and Enterococcus faecalis were identified from wound exudate cultures. She was treated with surgical debridement and 2 weeks of appropriate antibiotics with a favourable outcome.

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.

Inferior Pedicle Reduction Mammoplasty with or without Tourniquet: A Comparative Study

OBJECTIVE

To compare the perioperative findings of inferior pedicle reduction mammoplasty (IPRM) performed with or without a tourniquet.

METHODS

This study was carried out in the plastic and reconstructive surgery department at a tertiary care center on a total of 42 consecutive women scheduled for IPRM. Patients in Group I (n = 21) underwent surgery using a tourniquet, whereas patients in Group II (n = 21) were operated on without a tourniquet. Levels of hemoglobin (Hb), hematocrit (Hct), Hct/Hb ratio, and platelet counts were noted preoperatively and on postoperative 24th and 48th h. Numbers of surgical pads and gauze sponges completely used and dripping with blood were recorded. Duration of operation, the amount of breast tissue excised on both sides, and fluid collected in hemovac drains on 48th h after operation were documented.

RESULTS

In Group I, the operative time was significantly shorter (p < 0.001), and numbers of gauze sponges and surgical pads were fewer (p < 0.001 for both). Hemoglobin levels were significantly higher in Group I on postoperative 24th (p = 0.002) and 48th h (p = 0.007). Similarly, hematocrit levels in Group I were higher than those of Group II on postoperative 24th (p = 0.004) and 48th h (p = 0.009).

CONCLUSION

We determined that use of a tourniquet significantly reduced the operative time and blood loss during IPRM. Therefore, our preliminary results support that tourniquet usage is practical and safe, and it may also improve the cost-effectiveness of the procedure.

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 .

Aesthetic Breast Surgery and Concomitant Procedures: Incidence and Risk Factors for Major Complications in 73,608 Cases

Background

Major complications following aesthetic breast surgery are uncommon and thus assessment of risk factors is challenging.

Objectives

To determine the incidence and risk factors of major complications following aesthetic breast surgery and concomitant procedures.

Methods

A prospective cohort of patients who enrolled into the CosmetAssure (Birmingham, AL) insurance program and underwent aesthetic breast surgery between 2008 and 2013 was identified. Major complications (requiring reoperation, readmission, or emergency room visit) within 30 days of surgery were recorded. Risk factors including age, smoking, body mass index (BMI), diabetes, type of surgical facility, and combined procedures were evaluated.

Results

Among women, augmentation was the most common breast procedure (n = 41,651, 58.6%) followed by augmentation-mastopexy, mastopexy, and reduction. Overall, major complications occurred in 1.46% with hematoma (0.99%) and infection (0.25%) being most common. Augmentation-mastopexy had a higher risk of complications, particularly infection (relative risk [RR] 1.74, P < 0.01), than single breast procedures. Age was the only significant predictor for hematomas (RR 1.01, P < 0.01). Increasing age (RR 1.02, P = 0.03) and BMI (RR 1.09, P < 0.01) were risk factors for infection. Concomitant abdominoplasty was performed in 4162 (5.8%) female patients and was associated with increased risk of complications compared to breast procedures or abdominoplasty performed alone. Among men, correction of gynecomastia was the most common breast procedure (n = 1613, 64.6%) with a complication rate of 1.80% and smoking as a risk factor (RR 2.73, P = 0.03).

Conclusions

Incidence of major complications after breast cosmetic surgical procedures is low. Risk factors for major complications include increasing age and BMI. Combining abdominoplasty with any breast procedure increases the risk of major complications.

Level of Evidence

2.

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.

Clinical Evaluation of Hyaluronic Acid Sponge with Zinc versus Placebo for Scar Reduction after Breast Surgery

BACKGROUND

Scar formation is a major source of dissatisfaction among patients and surgeons. Individually, hyaluronan, or hyaluronic acid (HA), and zinc have been shown to reduce scarring. The authors evaluated the safety and efficacy of an HA sponge with zinc compared with placebo when applied to bilateral breast surgery scars; specifically, they evaluated whether the use of this product modulates inflammation and immediate scarring in treated patients after bilateral breast surgery.

METHODS

This double-blind, randomized, prospective study was approved by the local institutional review board. Bilateral breast surgery patients with right and left incision lines were randomly assigned to receive HA sponge with zinc or placebo within 2 to 4 days after their procedure. Participants were followed up at 6 weeks, 12 weeks, and 1 year and evaluated at 12 weeks. Three blinded evaluators reviewed photographs of the incision lines and assessed the scars using a visual analog scale, new scale, and a patient satisfaction survey.

RESULTS

Nineteen bilateral breast surgery patients were enrolled in the study. Statistical analysis was performed on 14 patients who completed the follow-up. The mean visual analog scale score was lower for the side receiving the HA sponge with zinc (2.6) than for the side receiving placebo (3.0), indicating a better outcome (t test; P = 0.08). The HA sponge with zinc was found to have significant positive findings on a patient satisfaction survey (P = 0.01).

CONCLUSIONS

This is a preliminary study that shows zinc hyaluronan was associated with high patient satisfaction in achieving a better scar after bilateral breast surgery, irrespective of skin color. It seems to be safe and effective for early scars.

Safety of Aesthetic Surgery in the Overweight Patient: Analysis of 127,961 Patients

BACKGROUND

Nearly 70% of US adults are overweight or obese (body mass index, BMI ≥ 25 kg/m(2)), and more such patients are seeking aesthetic surgery. Previous studies have evaluated surgical risk in obese (BMI ≥ 30) or morbidly obese (BMI ≥ 40) patients, with mixed results.

OBJECTIVES

This study evaluates BMI 25 to 29.9 and BMI ≥ 30 as independent risk factors of major complications following aesthetic surgery in a large, prospective, multi-center database.

METHODS

A prospective cohort of patients undergoing aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database (Birmingham, AL). BMI was evaluated as a risk factor for major complications, defined as complications requiring an emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Multivariate analysis controlled for variables including age, gender, smoking, diabetes, combined procedures, and type of surgical facility.

RESULTS

Of the 127,961 patients, 36.2% had BMI ≥ 25. Overweight patients were more likely to be male (12.5%), diabetic (3.3%), nonsmokers (92.8%), or have multiple procedures (41%). Complication rate steadily increased with BMI: 1.4% (BMI < 18.5); 1.6% (18.5-24.9); 2.3% (25-29.9); 3.1% (30-39.9); 4.2% (≥40). Infection (0.8%), venous thromboembolism (VTE, 0.4%), and pulmonary dysfunction (0.2%) were twice as common among overweight patients. Incidence of hematoma was similar in the two groups (0.9%). Complications following abdominoplasty (3.5%), liposuction (0.9%), lower body lift (8.8%), or combined breast and body procedures (4.2%) were significantly higher in overweight patients. On multivariate analysis, being overweight (BMI 25-29.9) or obese (BMI ≥ 30) were independent predictors of any complication (Relative Risk, RR 1.17 and 1.51), especially infection (RR 1.63 and 2.73), and VTE (RR 1.67 and 2.56).

CONCLUSIONS

Overweight (BMI 25-29.9) and obesity (BMI ≥ 30) are both independent risk factors for post-operative infection and VTE in aesthetic surgery. LEVEL OF EVIDENCE 2: Risk.

Quality of Life and Alleviation of Symptoms After Breast Reduction for Macromastia in Obese Patients: Is Surgery Worth It?

BACKGROUND

Breast hypertrophy can cause a variety of symptoms and affect lifestyle and quality of life. Breast reduction, being the most effective treatment, is sometimes difficult to establish as standard treatment in obese patients (difficulties to differentiate symptoms from macromastia or from obesity, higher rate of complications).

AIM

To evaluate the effect of reduction mammaplasty (quality of life and symptoms) in obese patients comparing with non-obese.

METHODS

This is a prospective study of patients undergoing reduction mammaplasty. Patients were allocated in non-obese (BMI < 29) and obese (BMI > 30). Demographic data, comorbidities, specific symptoms questionnaire, data from the surgical procedure, Spanish version of the Health-Related Quality of Life (SF-36) questionnaire, complications and sequels were recorded and collected before the operation and at 1 month and 1 year after. Chi-square, Fisher's exact t test, McNemar, Mann-Whitney U and Kruskal-Wallis tests were used for statistical analysis.

RESULTS

One hundred twenty-one consecutive patients were operated on; 54 (44.6 %) obese and 67 (55.4 %) non-obese. The average age of patients was 40.7 (18-78), average volume of resected tissue was 1.784 g (401-5.790), and average hospital stay was 2.94 days (1-11). There were no differences between obese and normal BMI patients with regard to length of hospital stay, complications, sequels, or reoperations. Symptoms improved in both groups. Physical and mental components of the SF-36 improved at 1 year in both groups (p < 0.001). The mental health component improved at 1 month (p < 0.001) in both groups.

CONCLUSIONS

Obese patients should be considered for reduction mammaplasty surgery in the same way as women of normal weight.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.