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

Laura C. Nuzzi, B.A.; Joseph M. Firriolo, M.D.; Carolyn M. Pike, M.S.N., M.P.H.; Amy D. DiVasta, M.D., M.M.Sc.; Brian I. Labow, M.D.


Plast Reconstr Surg. 2019;144(3):572-581. 

In This Article

Patients and Methods

After obtaining approval from the Boston Children's Hospital Committee on Clinical Investigation (protocol number IRB- X08-10-0492) for this prospective study, written informed consent was obtained from all subjects and a parent/guardian, as applicable. Female patients aged 12 to 21 years undergoing bilateral reduction mammaplasty for macromastia were prospectively enrolled during initial consultation at Boston Children's Hospital from 2008 through 2017. All patients were evaluated by a pediatric plastic surgeon, and diagnosis was made using symptomatology, physical examination, and modified Schnur criteria.[48,49]

Clinical Presentation and Demographics

Clinical staff administered standardized assessment forms detailing symptomatology and patient satisfaction at baseline and postoperatively at the following time points: early outcomes (≤1 month postoperatively), intermediate outcomes (3 to 6 months postoperatively), and late outcomes (1 year postoperatively and annually thereafter). Postoperative forms assessed complications and resolution of baseline symptoms. Complications were defined as outlined in Table 1.

Height and weight were measured at each clinical encounter. For subjects aged 20 years or older, body mass index category was determined using the Centers for Disease Control and Prevention adult body mass index calculator and body mass index classifications.[50] For participants younger than 20 years, body mass index–for-age percentiles and body mass index category were derived using the Centers for Disease Control and Prevention child and teen body mass index calculator and classifications, accounting for both age and sex.[51]

Survey Measures

Subjects completed the following self-administered surveys, selected for their previous use in adolescents and adults with macromastia:[8,9,13,25,45,46,52–54] the 36-Item Short-Form Health Survey (version 2),[55] the Rosenberg Self-Esteem Scale,[56] the Breast-Related Symptoms Questionnaire,[53] and the Eating Attitudes Test-26.[57] The 36-Item Short-Form Health Survey assesses health-related quality of life across eight domains: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Domain scores are transformed to a scale of 0 to 100.[55] The Rosenberg Self-Esteem Scale measures self-esteem,[56] with scores ranging from 10 to 40.[58] The Breast-Related Symptoms Questionnaire quantifies breast symptomatology.[53,59] The Eating-Attitudes Test-26 scale assesses eating and body image attitudes and behaviors, with scores greater than or equal to 20 indicative of disordered eating thoughts and behaviors.[57] Higher scores are more favorable for the 36-Item Short-Form Health Survey, the Rosenberg Self-Esteem Scale, and the Breast-Related Symptoms Questionnaire; the inverse is true for the Eating-Attitudes Test-26. Subjects completed surveys once at baseline and again postoperatively at 6 months and at 1, 3, 5, and 7 years. Each participant's baseline and most recent follow-up survey scores were included in analyses.

Data Management and Statistical Methods

Data were collected and managed using the secure, Web-based application REDCap (Research Electronic Data Capture)[60] hosted at Boston Children's Hospital with support through Harvard Catalyst. Statistical analyses were performed using IBM SPSS Version 23 (IBM Corp., Armonk, N.Y.). The scores for the 36-Item Short-Form Health Survey domains, Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26 were generated according to algorithms developed by Ware,[55,61] Rosenberg,[56] Collins et al. and Kerrigan et al.,[13,54] and Garner et al.,[57] respectively. Except where otherwise noted, the following were stratified into dichotomous variables: age at surgery (younger than 18 years or 18 years or older), body mass index category (healthy weight or overweight/obese), total tissue mass resected (<1000 g or ≥1000 g), and complication status (no complication or one or more complication). Associations between demographics and complication status were assessed using Pearson chi-square or Fisher's exact test, and odds ratios were calculated. Within-subject baseline to postoperative comparisons for survey scores were analyzed for the total cohort and stratified by complication status, and the Cohen d was used to report effect size. Independent samples t tests were used to assess differences in postoperative survey scores by complication status. A threshold of 20 percent missing complications data was used. Patients who did not complete both baseline and follow-up surveys were excluded from health-related quality-of-life analyses. A value of p <0.05 was considered statistically significant for all analyses.