Outcomes of Breast Reduction Surgery Using the BREAST-Q

A Prospective Study and Comparison With Normative Data

Tamara A. Crittenden, B.Sc.(Hons.); David I. Watson, M.D., Ph.D.; Julie Ratcliffe, Ph.D., M.Sc.; Philip A. Griffin, M.B.B.S.; Nicola R. Dean, M.B.Ch.B., Ph.D.

Disclosures

Plast Reconstr Surg. 2019;144(5):1034-1044. 

In This Article

Discussion

Health-related quality-of-life outcome studies reported from the patient's perspective provide an important measure of the impact of a health condition and the success of surgical interventions.[30] Research studies using generic health-related quality-of-life instruments such as the 36-Item Short-Form Health Survey have highlighted that breast reduction surgery is of significant benefit to women with breast hypertrophy, providing relief of symptoms and improved quality of life, often to a level greater than that of the general population.[1,4–7,31–34] However, it has been found that although generic instruments play an important complementary role in patient-reported outcome studies, they may not be sensitive or responsive enough to detect changes as a result of surgery or to capture all aspects of outcome after breast surgery.[35] The development of validated condition-specific patient-reported outcome instruments such as the BREAST-Q have facilitated outcome studies exploring the unique outcomes of breast surgery from the patient's perspective.[16]

Previous outcome studies have used the BREAST-Q Reduction module to explore patient satisfaction and health-related quality of life in women with breast hypertrophy. In the largest retrospective study to date, Cogliandro et al. used the BREAST-Q to report high levels of patient satisfaction and well-being following breast reduction surgery.[19] However, retrospective studies such as this are limited by their inability to provide preoperative health-related quality-of-life levels and therefore assume that all respondents had an approximately equal baseline level of satisfaction and well-being before surgery.[21,36–38] Furthermore, the broad range of time since surgery could have affected patient responses in these studies. Although several prospective studies demonstrate a statistically significant improvement in BREAST-Q scores following reduction mammaplasty, most are limited by a relatively small sample size, and in some studies there was minimal overlap in patients who completed the BREAST-Q at each study time point.[17,20]

Reduction mammaplasty is a common procedure in plastic surgery and is one of the most frequently performed breast operations worldwide. However, indications for surgery are increasingly subjected to restrictions or denials by health care funders in many jurisdictions; these are commonly centered on body mass index or a minimum reduction weight.[4,5,9–13,39] Within the Australian public hospital system, access to surgery is ultimately reliant on state and local policies: in some states, it is an excluded procedure, whereas in others, there are eligibility criteria, including body mass index requirements.[40–45] Although there is currently no known magnitude to establish a minimal clinically important difference for the change in BREAST-Q Reduction module scores following surgical intervention, a rule of thumb of a 10-point change on a 100-point quality-of-life scale[46] or 0.5 SD has been suggested as a default value for patient-perceived important change on health-related quality-of-life measures.[47,48] Accordingly, results from this study demonstrate that reduction mammaplasty is of significant health benefit to women with symptomatic breast hypertrophy and provides a clinically important improvement in all areas of patient satisfaction and health-related quality of life. The significant long-term improvement in physical well-being and relief of painful symptoms promotes the provision of insurance coverage for surgery as a functional rather than cosmetic procedure. Furthermore, our study provides evidence that the considerable health benefits of reduction mammaplasty are comprehensive and the marked improvement in health-related quality of life is experienced by patients regardless of characteristics, including body mass index, age, or a minimum resection. In addition, patients with a higher body mass index and older women who may be ineligible for surgery according to restrictions in some jurisdictions were found to have an even greater level of improvement in satisfaction with breasts, physical well-being, and psychosocial well-being than their respective comparison groups. Our surgical cohort were not biased by restrictions that previous studies have reported based on body mass index or resection weight and therefore includes a broad spectrum across these variables.[1,18,49–53] No differences were found in improvement in quality of life between those patients meeting traditional insurance cutoffs including Schnur sliding scale and the 500-g per breast minimum rule and those who did not. Our study supports previous findings that there is no evidence or rationale to justify any policy that restricts funding for reduction mammaplasty based on arbitrary cutoffs for body mass index or a minimum weight of reduction.[7,12,39,49,54–57]

Despite a surgical complication rate of 34 percent, there were no differences in either the change in scores in all four BREAST-Q scales or with the overall Satisfaction with Outcome of surgery between those patients who experienced a postoperative complication and those who did not. This finding highlights that the overall health benefits and long-term improvement in quality of life gained by women following breast reduction surgery appear to compensate for the negative impact of postoperative complications following surgery.

This study found that women reported high scores for Satisfaction with Outcome following surgery. This BREAST-Q scale is important because it represents the overall level of patient satisfaction with the results of surgery. Postoperative Satisfaction with Outcome was found to be greater in participants with a higher body mass index and in older women than in their respective comparison groups. In contrast, eligibility by traditional insurance requirements including the Schnur sliding scale or 500-g minimum rule was not found to be predictive of satisfaction with outcome. These findings strongly refute the validity of traditional selection criteria for coverage by insurance providers or restrictions on access to surgery based on body mass index and a minimum resection weight.

Overall patient Satisfaction with Outcome following surgery was found to be strongly correlated with Satisfaction with Surgeon, Satisfaction with Breasts, and Satisfaction with Information scales. Conversely, only weak associations were observed with remaining BREAST-Q scales. These findings highlight the central importance of the doctor-patient relationship and managing patient expectations.[58] Our findings confirm those of Coriddi et al., who reported that satisfaction with outcome is strongly correlated with satisfaction with breast appearance.[17]

In this study, we have also generated normative BREAST-Q data from an Australian population to comprehensively investigate the health burden associated with breast hypertrophy and the health benefits of reduction mammaplasty. Within the normative study, participants aged 40 years and older were found to have higher scores than those aged younger than 40 years in Satisfaction with Breasts, Psychosocial Well-being, and Physical Well-being. Furthermore, a larger body mass index and presence of a chronic health condition was found to be associated with lower scores in all BREAST-Q scales of participant satisfaction and quality of life. These findings are in agreement with the study by Mundy et al.[3] Conversely, an interesting finding was that sizable differences were found in mean BREAST-Q scores when comparing our generated norms to previously published U.S. norms (in particular, for Psychosocial Well-being). This finding highlights the importance of using country-specific norms for health-related quality-of-life studies wherever possible, as potentially important differences do exist between populations.

The comparison of generated norms to BREAST-Q data from participants in the surgical cohort confirmed that breast hypertrophy represents a significant health impairment to women, with preoperative scores significantly lower in all areas of satisfaction and health-related quality of life. At 1 year after reduction mammaplasty, mean scores increased significantly across all BREAST-Q scales to levels at least equivalent to the norm. This finding demonstrates the long-term health benefits and success of breast reduction surgery in bringing satisfaction and quality of life to levels of the general female population. This study facilitated the comparison of normative BREAST-Q data to a prospective study of women undergoing reduction surgery and therefore addresses previous gaps in the literature.[3]

A potential limitation of our study is the administration of the BREAST-Q questionnaire to the surgical cohort at a postoperative time point of 12 months. Although this has affirmed the long-term benefits of breast reduction surgery on patient satisfaction and health-related quality of life, for comparative purposes, the addition of a shorter postoperative time point may also have been informative. In addition, the process of participant recruitment in the normative study may not have necessarily provided a representation of the general Australian population. The Pureprofile panel consists exclusively of members of the public who voluntarily enrol to complete surveys, and this might introduce an element of selection bias.

Strengths of our study include the prospective design and relatively large sample size for the surgical cohort. To the best of our knowledge, this study is the largest peer-reviewed prospective study to date using the BREAST-Q Reduction module to assess outcomes following reduction mammaplasty in women with breast hypertrophy. The postoperative outcomes described were at 12 months, beyond the convalescence period following surgery, and therefore represent an appropriate measure of long-term outcomes for comparison to population norms. Furthermore, the generation of corresponding population-specific normative BREAST-Q data enabled an accurate comparison for the interpretation of health-related quality of life between surgical patients and population norms. Finally, given that the BREAST-Q is the most widely used patient-reported outcome measure in breast surgery, this study is valuable because it provides normative BREAST-Q Reduction data from a second, diverse population set, and highlights that within this context potentially important differences exist in health-related quality of life between populations.

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