Reduction Mammaplasty for Macromastia in Adolescents

A Systematic Review and Pooled Analysis

Alexandra S. Hudson, M.D., H.B.Sc.; Alexander D. Morzycki, M.D., M.Sc.; Regan Guilfoyle, F.R.C.S.C.

Plast Reconstr Surg. 2021;148(1):31-43.

Abstract and Introduction

Abstract

Background: Reduction mammaplasty for macromastia is one of the most common operations performed by plastic surgeons. There remains hesitancy in operating on adolescents, as there is ongoing debate about breast regrowth and potential impact on breastfeeding. The goal of this study was to analyze these concerns by reviewing the current literature.

Methods: A systematic review of MEDLINE, Scopus, and Google Scholar was conducted using the following terms: "breast reduction" or "mammaplasty" or "breast reconstruction" and "adolescent" or "youth" or "pediatric" or "child" or "teen." Primary outcomes were success of breastfeeding after the procedure and procedure-related complications.

Results: Twenty-three studies (87 percent retrospective), consisting of 2926 patients with preoperative cup sizes of C to KK (mean, DDD), met inclusion criteria. Mean age at the time of surgery ranged from 16 to 21 years, with the youngest patient being 12 years old. The overall complication rate was 27.3 percent (95 percent CI, 14.4 to 42.5 percent). Minor complications (22.8 percent; 95 percent CI, 10.2 to 38.5 percent) were more common than major (4.2 percent; 95 percent CI, 1.6 to 7.9 percent). Eighteen percent of patients (95 percent CI, 2.2 to 43.8 percent) reported regrowth of their breast tissue postoperatively, with 2.7 percent (95 percent CI, 0.9 to 5.5 percent) undergoing a second revision mammaplasty. Fifty-three percent of patients (95 percent CI, 36.0 to 69.3 percent) did not attempt breastfeeding. Of those who attempted, 55.1 percent (95 percent CI, 34.4 to 74.9 percent) were successful.

Conclusions: Prospective data are lacking. Patient counseling should focus on encouraging a trial of breastfeeding, despite surgical history. One-fifth of adolescent patients may notice breast regrowth postoperatively; however, the amount of regrowth is likely small and unlikely to reexacerbate symptoms, as the rate of revision surgery is small.

Introduction

Macromastia, or benign breast hypertrophy, often leads to symptoms that can be debilitating for individuals. These include pain, intertriginous dermatitis, restrictive respiratory effort, self-esteem issues, limitations on activity participation, and others.^[1] Preoperatively, patients with macromastia have been shown to have a significantly worse health-related quality of life compared to the normal population.^[1] Bilateral reduction mammaplasty is a very common plastic surgery procedure undergone for macromastia.^[2,3] It is known to reduce symptoms and improve quality of life, and can often be done as an outpatient procedure.^[4,5] In 2018, it was the eighth most common procedure performed by plastic surgeons around the world. The number of these operations performed is also increasing over time, with an increase in 8.5 percent worldwide from 2017 to 2018, and by almost 20 percent from 2014 to 2018.^[3]

There is ongoing hesitancy when it comes to offering this surgery to adolescent patients, as there are concerns about the risk of significant breast regrowth requiring repeated revision surgery in the future, as breast development is often not complete until age 18 years. There are also concerns about the potential negative impact of surgery on nipple sensation and future breastfeeding, as the majority of adolescent patients will not yet have had children. The primary aim of this review was to summarize the literature to date on the success of breastfeeding after reduction and develop a comprehensive safety profile for this procedure in adolescent patients.

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Table 1. Summary of the 23 Included Studies Assessing Adolescent Patients Who Underwent Bilateral Reduction Mammaplasty for Macromastia
Reference	Study Type and Years Included	MINORS Criteria	Sample Size	Ages of Inclusion (yr)	Age at Time of Surgery (yr)	Follow-Up Time (yr)	Primary Outcomes (measures used)	Outcome Results
Krucoff et al., 2019⁷	Retrospective case series, 1980–2003	12	37	<25	Median, 21 (SD, NR); range, 12.4–24.6	Median, 21.4 (SD, NR); range, 11.4–32.4	To report long-term satisfaction and well-being (BREAST-Q)	For Satisfaction with Breasts and Sexual Well-being, young reduction mammaplasty patients were significantly more satisfied as compared to normative data (p = 0.0012 and p < 0.0001). There was no statistically significant difference in the BREAST-Q between those with a BMI <25 kg/m² and those with a BMI >25 kg/m². Age at the time of surgery, the amount of tissue removed, BMI <25 or ≥25 kg/m², and race were not significantly associated with BREAST-Q scores.
Kulkarni et al., 2019⁸	Retrospective cohort, 2011–2017	20	60	NR	Mean, 16.7 (SD, 1.7); range, NR	Mean, 3.3 (patient satisfaction); mean 0.5, (all other variables) (SD and range NR)	Comparing demographics, surgical outcomes, patient satisfaction (BREAST-Q), and aesthetic outcomes (ABNSW) between Wise and vertical reduction techniques	Patients who reported preoperative pain (Wise, 95.9%; vertical, 72.7%; p = 0.039) were more likely to undergo Wise reduction. Adolescents undergoing Wise incision demonstrated statistically significant improvement in NAC contour (Wise, 61%; vertical, 47%; p = 0.028) and overall aesthetic outcome (Wise, 25%; vertical, 17%; p = 0.008) with scarring not being a negative factor (Wise, −16%; vertical, −35%; p = 0.004). Patient satisfaction and complications did not differ.
Nuzzi et al., 2019⁹	Prospective case series, 2018–2017	12	512	12–21	Mean, 17.8 (SD, 1.9); range, NR	Median, 1.5 (SD, NR); range 1–7.5 (complications), median, 1.6 (SD, NR); range, 1–8.9 (HRQOL)	To identify complications and how they relate to postoperative health-related quality of life (BREAST-Q, EAT-26, RSES, SF-36)	The most common complications included hypertrophic scarring, and altered sensation of the nipple/breast. Patient age, BMI, and amount of tissue resected did not significantly increase the odds of developing a complication. Significant postoperative improvements on all scales were largely seen irrespective of complications. A strong correlation between increasing BMI and a higher total weight of resection (r = 0.79). A significant difference in average total resection weight (p = 0.033) between group 1 (major complications) and group 3 (no complications); however, BMI was not significant (p = 0.061). There was no significant statistical difference in average BMI (0.879) or average resection weight (0.542) between group 2 (minor complications) and group 3 (no complications).
Tapp et al., 2019¹⁰	Retrospective case series, 2010–2015	12	51	<19	Mean, 16.8 (SD, NR); range, NR	Mean, 0.5 (SD, NR); range, NR	To identify risk factors associated with complications, resolution of symptoms, and specific surgical techniques used
Wirthmann et al., 2018¹¹	Retrospective case series, 2005–2015	12	67	<21	Mean, 18.1 (SD, NR); range, 15–20	Mean, 0.5 (SD, NR); range 1 wk–3.5 yr	To analyze whether there is a statistically significant difference in perioperative risk for complications between adolescents and elderly patients when performing reduction mammaplasty	A slightly increased risk in performing reduction mammaplasty on elderly (age ≥60 yr), because of increased comorbidities (70% vs. 7.5%) and BMI (29 kg/m² vs. 24 kg/m²) compared to adolescents.
Nuzzi et al., 2017¹²	Prospective cohort, 2008–2015	19	102 (and 84 controls)	12–21	Mean, 17.6 (SD, 1.7); range, NR	Mean, 2.6 (SD, NR; range, 0.5–7.5	To measure changes in health-related quality of life and breast-related symptoms	Patients with macromastia demonstrated significant score improvements postoperatively from baseline on the RSES, BRSQ, and in 7 of 8 SF-36 domains: physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health (p < 0.001 for all). By the 6-mo follow-up visit, postoperative subjects scored similarly to or more favorably than controls on the RSES, BRSQ, EAT-26, and SF-36; these benefits persisted for at least 5 yr and were not significantly affected by BMI category or age.
Lopez et al., 2016¹³	Retrospective case series, 2005–2013	12	49	<26	Mean, 19.9 (SD, NR); range, 14-–25	Mean, 0.7 (SD, NR); range, 0.3–1.8	To determine whether the timing of surgery relative to the menstrual cycle plays a role in surgical complications following bilateral reduction mammaplasty	Undergoing surgery during the postovulatory phase was associated with development of wound dehiscence and hypertrophic scarring (p < 0.005). Surgery in the preovulatory or postovulatory phase did not affect hematoma, seroma, wound infection, or nipple-areola complex necrosis rates (p > 0.05). Age, race/ethnicity, body mass index, large resection mass, and medical comorbidities did not affect wound dehiscence or scar hypertrophy rates (p > 0.05).
Wiser et al., 2015¹⁴	Prospective case series, 2006–2011	11	26	13–18	Mean, 16.9 (SD, 1.1); range 13.2–18.3	NR	To evaluate the intraoperative dynamics of pulmonary function	Improvement in lung compliance was observed in 24 patients (92.3%; p < 0.0001). Mean intraoperative lung compliance improvement was 23.92% (95% CI, 8.3–37%; p= 0.001).
Pike et al., 2015¹⁵	Retrospective case series, 2007–2013	12	80	12–21	Mean, 17.6 (SD, 1.7); range, 13.1–21.4	Mean, 2 (SD, 1); range, 1–6.2	To measure body mass index changes after surgery	Mean postoperative BMI did not differ significantly from mean preoperative BMI (27.8 ± 7.1 kg/m² vs. 27.3 ± 6.4 kg/m²). For overweight and obese patients, a significant gain in preoperative to postoperative BMI was observed, on average (p = 0.019).
Soleimani et al., 2015¹⁶	Retrospective case series, 2000–2009	8	1345	<21	Mean, 18 (SD, NR); range, 12–20	NR	To document epidemiology, and complications; to identify factors associated with complications and length of stay	The majority of patients were white (64%), from a zip code with greatest income (36%), and had private insurance (75%). Duration of stay was associated with race, income quartile, insurance type, having complications, and hospital type. African American race, Medicaid, lower income, and private-investor owned hospitals were predictive of greater hospital charges.
Sharma et al., 2014¹⁷	Retrospective case series, 1997–2009	11	36	<19	Mean, 17.4 (SD, NR); range, 14–19	Mean, 7 (SD, NR); range, 5–13	To review the indications, complications, and long-term outcomes	Primary mechanical symptoms included back/neck pain, difficulty sleeping, and intertrigo. The principal psychological complaints were increased self-consciousness, low self-esteem, depression, and bullying. Sixty-seven percent agreed there was an immediate resolution of mechanical symptoms, and 47% reported an improvement in psychological symptoms.
Xue et al., 2013¹⁸	Retrospective case series, 2006–2010	8	34;	<19	Mean, 16 (SD, NR); range, 13–18	Mean, 1.2 (SD, NR); range, NR	To describe indication and timing of surgery at one institution	Self-reported patient satisfaction was 97%. All patients described significant improvements in self body-image and participation in social activities.
Nguyen et al., 2013¹⁹	Retrospective case series, 1985–2005	12	99	<21	Mean, 19.1 (SD, NR); range, 16.2–20.9	Mean, 15.6 (SD, NR); range, 6–26.4	To report long-term outcomes and satisfaction	Sustained long-term symptom resolution was highest with shoulder pain (94.7%), breast pain (92.0%), and intertrigo (88.6%). Improvements in feeling uncomfortable (87.5%), finding clothes that fit (86.0%), sports participation (85.2%), and running (83.7%) were reported; 42.4% reported 100% success in treating the problems. Improved quality of life was reported by 88.7%. Subgroup analysis of patients aged <18 yr (n = 23; mean age, 17.3 yr) at the time of surgery revealed equivalent results.
Webb et al., 2012²⁰	Retrospective case series, 1997–2008	12	67	12–21	Mean, 17.1 (SD, 1.6); range, 13.3–20.4	Mean, 0.7 (SD, 0.5); range, NR	To review symptoms in obese and nonobese adolescent macromastia patients and describe early outcomes following surgery	Of patients with complications, obese patients reported a greater number than nonobese patients (p = 0.013). There were no differences in the type of complication or self-reported satisfaction between obese and nonobese patients.
Koltz et al., 2010²¹	Retrospective case series, 2002–2009	7	76	<18	Mean, 16.4 (SD, NR); range, 13–18	NR	To document one institution's experience with presenting symptoms, techniques, and both surgical and pathologic outcomes	Operative indications included neck, back, and/or shoulder pain (75%), intertrigo (8%), shoulder grooving (17%), difficulty finding bras (8%) and participating in sports (9%), and social distress (24%). Per breast reduction specimen, pathology internal costs and external costs by Medicare data averaged $65 and $118, respectively.
Losee et al., 2004²²	Retrospective case series, 1997–2003	12	4	<23	Mean, 18.5 (SD, NR); range, 15–22	Mean, 10.5 (SD, NR); range, 8–13	To evaluate the degree of long-term postoperative satisfaction and recovery from eating disorders	All patients maintained consistent recovery from their eating disorder. A statistically significant improvement in eating attitudes was found when comparing preoperative and postoperative EAT-26 data. Comparing body dissatisfaction, pain, and physical symptoms, there was consistent improvement in subjective scoring.
Lee et al., 2003²³	Retrospective case series, 1981–2000	10	17	<20	Mean, 16.1 (SD, NR); range, 12.5–18.9	Mean, 7 (SD, NR); range, 2–13	Demographics, short- and long-term outcomes and satisfaction	82% of patients reported resolution of their physical symptoms. Self-esteem was cited most commonly as a reason to recommend this procedure to other adolescent women. Nearly 65% of respondents would repeat their adolescent surgical experience, and 82.4% would recommend it.
Aillet et al., 2002²⁴	Retrospective case series, 1981–1997	11	65	15–17	Mean, 17 (SD, NR); range, 15.2–17.9	Mean, 8.1 (SD, NR); range, 3.1–12.1	To assess breastfeeding after reduction mammaplasty to identify surgical features influencing functional outcome	No relationship between breast feeding, degree of satisfaction, patient-assessed scar quality, or nipple disorders. Sixty-three percent of women stated they were not informed on breastfeeding.
Tarrado et al., 2002²⁵	Retrospective case series, 1990–1999	10	9	<19	Mean, 16 (SD, NR); range, 13–18	Mean, 0.8 (SD, NR); range, NR	To document the cause, associated pathology, surgical technique, and complications	Associated pathology: obesity (n= 3), psychiatric and behavior disorders (n = 3), scoliosis (n = 2), and one case of isosexual precocious puberty. The cosmetic results were good, except for 2 cases of hypertrophic scar. The only complication was a wound infection that healed well.
Aillet et al., 2001²⁶	Retrospective case series, 1981–1997	12	65	15–17	Mean, 17 (SD, NR); range, 15.2–17.9	Mean, 8.1 (SD, NR); range, 3–17	To report the long-term results of reduction mammaplasty and to assess their consequences	The psychological and functional complaints observed preoperatively disappeared in >90% of the cases. In over 80% of the cases, the patients were pleased or very pleased with the shape, the volume kept, and the symmetry. Scars were well accepted in 83% of the cases.
Kreipe et al., 1997²⁷	Retrospective case series, 1988–1995	12	5	<21	Mean, 18.5 (SD, 2.5); range, NR	Mean, 4 (SD, NR); range, NR	To determine the outcome of patients with bulimia nervosa and symptomatic breast hypertrophy (macromastia) who had reduction mammaplasty and to identify factors that were associated with positive outcomes	All patients experienced improvement in symptoms. Preoperative eating disorder habits were a dysfunctional attempt to achieve more "normal" body proportions; postoperatively, symptoms of an eating disorder were completely eliminated or greatly reduced.
McMahan et al., 1995²⁸	Retrospective case series, 1970–1990	11	48	<20	Mean, 17.8 (SD, NR); range, 15–19.9	Mean, 5.9 (SD, NR); range, 1.4–20.4	To study the long-term benefits and consequences of adolescents undergoing reduction mammaplasty	Improved symptoms in 73–96%; 73% were happy with the procedure.
Evans et al., 1994²⁹	Retrospective case series, 1980–2003	11	16	<21	Mean, 17.7 (SD, NR); range, 14–20	Mean, 3.5 (SD, NR); range, 1.8–7.5	To examine the results of reduction mammaplasty in the pubescent female	All patients' symptoms resolved.

MINORS, Methodological Index for Nonrandomized Studies; NR, not reported; BMI, body mass index; ABNSW, asymmetry, breast shape, nipple shape, skin condition, and wound scar; NAC, nipple-areola complex; HRQOL, Health-Related Quality of Life; EAT-26, 26-Item Eating Attitudes Test; RSES, Rosenberg Self-Esteem Scale; BRSQ, Breast-Related Symptoms Questionnaire; SF-36, 36-Item Short-Form Health Survey.

Table 2. Study Characteristics of the 23 Included Studies on Bilateral Reduction Mammaplasty for Macromastia in Adolescent Patients
Characteristic	Value (%)
Journal published in
Plastic and Reconstructive Surgery	3 (13)
Annals of Plastic Surgery	3 (13)
Journal of Plastic, Reconstructive, and Aesthetic Surgery	2 (9)
Journal of Adolescent Health	2 (9)
Plastic and Reconstructive Surgery Global Open	1 (4)
Plastic Surgery	1 (4)
Pediatrics	1 (4)
Surgery	1 (4)
Journal of Pediatric and Adolescent Gynecology	1 (4)
European Journal of Plastic Surgery	1 (4)
International Journal of Surgery	1 (4)
Journal of Craniofacial Surgery	1 (4)
Cirugia Pediatrica	1 (4)
Annales de Chirurgie Plastique Esthetique	1 (4)
Archives of Pediatric and Adolescent Medicine	1 (4)
Aesthetic Plastic Surgery	1 (4)
European Journal of Obstetrics & Gynecology and Reproductive Biology	1 (4)
Year published
2019	4 (17)
2018	1 (4)
2017	1 (4)
2016	1 (4)
2015	3 (14)
2014	1 (4)
2013	2 (9)
2012	1 (4)
2010	1 (4)
2004	1 (4)
2003	1 (4)
2002	2 (9)
2001	1 (4)
1997	1 (4)
1995	1 (4)
1994	1 (4)
Country
United States	18 (78)
France	2 (9)
Germany	1 (4)
Spain	1 (4)
United Kingdom	1 (4)
Type of study
Single center	22 (96)
Multicenter	1 (4)

Table 3. Complications Described by 17 of the 23 Included Studies on Bilateral Reduction Mammaplasty for Macromastia in Adolescent Patients
Complication	Proportion of Patients* (95% CI)
Total complications	27.3 (14.4–42.5)
Minor complications	22.8 (10.2–38.5)
Major complications	4.2 (1.6–7.9)
Scar concerns	24.2 (9.8–42.5)
Nipple sensation changes	21.7 (7.2–41.1)
Delayed wound healing	19.9 (6.6–38.1)
Wound dehiscence	13.2 (4.7–25.2)
Hypertrophic or keloid scarring	10.0 (4.6–17.2)
Breast sensation changes	7.8 (NA)
Pain	7.6 (2.8–44.2)
Nipple inversion	6.0 (0.6–16.2)
Surgical-site infection	3.4 (1.9–5.4)
Asymmetry	3.3 (0.7–7.6)
Hematoma	2.7 (1.5–4.3)
Fat necrosis	2.6 (0.4–6.6)
Seroma	2.5 (1.5–3.7)
Altered nipple pigmentation	1.3 (0.3–2.9)
Nipple necrosis	1.2 (0.02–2.9)
Skin necrosis	0 (NA)

NA, not applicable.
*Pooled analysis of proportions.

Table 4. Rates of Breastfeeding Attempts and Success Reported by Eight of the 23 Included Studies
Study	Patients Who Became Pregnant	Patients Who Did Not Attempt Breastfeeding	Patients Who Did Attempt Breastfeeding
Study	Patients Who Became Pregnant	Patients Who Did Not Attempt Breastfeeding	Successful	Difficulties
Sharma et al., 2014	13/24 (54)	3/13 (23)	9/10 (90)	1/10 (10)
Nguyen et al., 2013	72/99 (73)	49/72 (68)	8/23 (35)	15/23 (65)
Losee et al., 2004	1/4 (25)	1/1 (100)	—	—
Lee et al., 2003	4/17* (24)	0/4 (0)	1/4 (25)	3/4 (75)
Aillet et al., 2002	17/65 (26)	5/17 (29)	11/12 (92)	1/12 (8)
Aillet et al., 2001	17/65 (26)	12/17 (71)	5/5 (100)	0/5 (0)
Kriepe et al., 1997	1/5 (20)	0/1 (0)	1/1 (100)	0/1 (0)
McMahan et al., 1995	9/48 (19)	5/9 (56)	1/4 (25)	3/4 (75)
Pooled analysis (random effects)	35.1% (95% CI, 18.8–53.5%)	52.8% (95% CI, 36.0–69.3%)	55.1% (95% CI, 34.4–74.9%)	39.0% (95% CI, 16.0–65.0%)