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.

Disclosures

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

In This Article

Discussion

Reduction mammaplasty has been shown to alleviate physical and psychosocial symptoms.[2–25] Although 80 percent of these patients have been symptomatic since their teen years,[18] the majority of women undergoing reduction mammaplasty are aged between 40 and 60 years.[26–35,37,38,40–46] Historically, reduction mammaplasty in adolescents and young women has been controversial.[16–20] Surgeons and parents share concerns that young patients may experience postoperative breast growth and lack the emotional maturity to adapt to potential complications and postoperative changes in their body. This study prospectively followed a cohort of adolescents and young women undergoing reduction mammaplasty to determine whether surgical complications impacted patient-reported outcomes. Surgical and health-related quality-of-life outcomes were collected using standardized clinical assessments and previously validated surveys.

Early Complications

Concordant with previous studies, approximately one-third of subjects experienced at least one postoperative complication.[26–30] No patient in our sample experienced a pulmonary embolism, deep vein thrombosis, or major infection. Less than 3 percent of patients developed a minor infection, hematoma/seroma, or delayed wound healing requiring greater than 6 weeks of dressing changes. These rates are considerably lower than those observed in the adult population.[26–29,33,34,40–43] It is also likely that our surgical-site infection rates are inflated, given the observation that many patients presented to outside providers for suspected surgical-site infection, and were possibly treated with oral antibiotics for expected inflammatory responses or reactions to adhesives.

The low rates of both major and early complications in our sample may reflect the generally healthy nature of adolescents and young adults. Despite the majority of our sample being overweight/obese, our cohort did not have the decades of metabolic burden commonly seen in older patients who are overweight/obese. As such, younger patients may be at an advantage with respect to lower surgical-site infection, major complication, and wound healing complication rates.

Effect of Obesity and Resection Mass on Early Complications

Macromastia is commonly associated with obesity, and many surgeons and third-party payors require considerable weight loss before surgery. Although the association between obesity, surgical-site infection, and overall complication status has been well documented in adult studies,[28,30,31,35,37,40,42,62–68] obesity in our young cohort did not significantly increase the odds of developing a complication, including surgical-site infection and hematoma/seroma. Although obesity may be a significant risk factor for developing postoperative complications in older women, it may not play a considerable role in younger patients. Similarly, unlike previous adult studies,[27,30,68] total tissue resection mass in our cohort was not associated with developing a complication. Although weight loss should be strongly encouraged for overweight/obese patients, body mass index status may not portend poorer outcomes in otherwise healthy, young patients undergoing reduction mammaplasty.

Postoperative Breast Growth

The potential for breast growth after surgery is a reasonable concern when considering reduction mammaplasty in adolescents. In fact, 5 percent of our cohort exhibited postoperative breast growth, and roughly half of these patients had a return of baseline breast-related symptoms. Age, amount of tissue resected, and body mass index category were not associated with postoperative growth. As reported previously, body mass index category remained stable from baseline to most recent follow-up,[69] even in patients who experienced postoperative breast growth. This suggests that postoperative breast growth in adolescents is not simply a function of weight gain. However, it should also be noted that potential changes in body mass index category may be muted, as roughly one-third of our subjects hit the artificial body mass index ceiling of obese at baseline. The somewhat surprising observation that age was not associated with additional breast growth may reflect the natural variation in thelarche and menarche. Rather than using age as a criterion for surgery, time since these biological time points may be more appropriate. Further research is needed to precisely pinpoint the appropriate time to perform surgery within the individual to mitigate the risk of additional growth.

Scarring

Although keloids were rare in our series, roughly 40 percent of patients experienced hypertrophic scarring or expressed some concern about scarring at or beyond 1 year following surgery. This rate is considerably higher than that observed in similar adolescent studies.[17,24,47] This may reflect poorer wound healing in our series or broader inclusion criteria for scar concerns. Our clinical practice is to query all patients 1 year after surgery regarding any worrisome skin or scar concerns at every office visit, and proactively offer medical or surgical treatment when appropriate. Intralesional corticosteroid therapy or scar revisions are performed in the office using local anesthesia.

Persistent Altered Breast and Nipple Sensation

Fewer than 9 percent of patients experienced breast or nipple hypesthesia persisting beyond the first postoperative year, and no patient experienced breast/nipple anesthesia, in line with previous adolescent and adult studies.[17,42] It should be acknowledged that sensory data were not recorded preoperatively and were only qualitatively assessed postoperatively in response to examiner light touch. No validated tools or methodologies were used to quantify degree of sensation across all patients.

Effect of Complications on Postoperative Health-related Quality of Life

Consistent with the literature,[2–25] our cohort had significant postoperative improvements in health-related quality of life. In particular, gains in physical well-being, bodily pain, psychosocial functioning, self-esteem, and breast-related symptoms were observed. Overall, patients who experienced a complication largely derived the same postoperative health-related quality-of-life improvements as those who did not have a complication, performing comparably to or more favorably than those with no complication. Interestingly, patients who experienced a complication reported having less bodily pain than those patients without any complication. It is possible that having a potentially painful complication early in the postoperative course puts the patient's overall postoperative musculoskeletal pain reduction into greater perspective. It should be noted that complications were largely minor in our cohort of otherwise healthy, young women.

Major complications such as hematoma requiring surgical evacuation or pulmonary embolus were either too rare to statistically analyze, or simply did not occur. However, late complications such as hypertrophic scarring or sensory changes were observed with some frequency. Subanalysis in patients with late complications largely failed to show any decrement in health-related quality-of-life gains as compared to those patients without complications. Of importance, 5 percent of our sample experienced postoperative breast growth, of which half developed recurrent baseline symptoms. Subanalyses revealed that patients with postoperative breast growth did not enjoy the same postoperative health-related quality-of-life improvements as the rest of our cohort. Although postoperative breast growth is uncommon, surgeons treating these patients should be aware of the ramifications of this potential complication and advise patients and parents accordingly. For the overwhelming majority, concern for potential complications should not overshadow the benefits that reduction mammaplasty can provide young patients.

Limitations in this study must be acknowledged. Although the health-related quality-of-life surveys used in this study have been validated for a variety of populations, they have not been validated specifically for young adolescents. The minimal clinically important difference for our health-related quality-of-life measures could not be reported, as further research is needed to derive them for adolescents with breast conditions. Results may not be generalizable, as subjects were recruited from a single, large tertiary care facility. Additional studies are needed to measure longer term outcomes, specifically with respect to additional breath growth and future breastfeeding ability. To date, no study has examined breastfeeding after reduction mammaplasty using a validated survey and control group, both of which are necessary to properly assess the effect of reduction mammaplasty on lactation and breastfeeding performance.

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