The Effect of Reduction Mammaplasty on Quality of Life in ... · 03/11/2017 · Reduction...

Article

Nuzzi et alThe Effect of Reduction Mammaplasty on Quality of Life in Adolescents With Macromastia

2017https://doi.org/10.1542/peds.2017-1103

5Pediatrics

ROUGH GALLEY PROOFNovember 2017

140

The Effect of Reduction Mammaplasty on Quality of Life in Adolescents With MacromastiaLaura C. Nuzzi, BA, a, b Joseph M. Firriolo, MD, a, b Carolyn M. Pike, MPH, a, b Felecia E. Cerrato, MPH, a, b Michelle L. Webb, PA-C, a, b Heather R. Faulkner, MD, MPH, c Amy D. DiVasta, MD, MMSc, a, d Brian I. Labow, MDa, b

OBJECTIVES: To measure changes in health-related quality of life and breast-related symptoms after reduction mammaplasty in adolescents.METHODS: In this longitudinal cohort study, we administered the Short-Form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), Breast-Related Symptoms Questionnaire (BRSQ), and Eating Attitudes Test-26 to 102 adolescents with macromastia and 84 female controls, aged 12 to 21 years. Patients with macromastia completed surveys preoperatively and after reduction mammaplasty at 6 months and 1, 3, and 5 years. Controls completed baseline and follow-up surveys at the same intervals.RESULTS: Patients with macromastia demonstrated significant score improvements postoperatively from baseline on the RSES, BRSQ, and in 7 out of 8 SF-36 domains: physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, mental health (P < .001, all). By the 6-month follow-up visit, postoperative subjects scored similarly to or more favorably than controls on the RSES, BRSQ, Eating Attitudes Test-26 , and SF-36; these benefits persisted for at least 5 years and were not significantly affected by BMI category or age.CONCLUSIONS: Reduction mammaplasty was significantly associated with improvements in health-related quality of life and breast-related symptoms of adolescent patients, with measureable improvements in physical and psychosocial well-being evident by 6 months postoperatively and still demonstrable after 5-years. These results largely do not vary by BMI category or age. Patients and providers should be aware of the potential positive impact that reduction mammaplasty can provide adolescents with symptomatic macromastia. Historic concerns regarding age and BMI category at the time of surgery should be reconsidered.

abstract

aAdolescent Breast Clinic, bDepartment of Plastic and Oral Surgery, and dDivision of Adolescent/Young Adult Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts; and cDivision of Plastic and Reconstructive Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Drs Labow (principal investigator) and DiVasta (coinvestigator) made significant contributions to the study conception and design, acquisition of data, interpretation of data, and revision of the article; Dr Faulkner and Ms Webb made substantial contributions to the conception and design of this study; Ms Nuzzi drafted the manuscript and made substantial contributions to the acquisition, analysis, and interpretation of data; Dr Firriolo, Ms Pike, and Ms Cerrato made substantial contributions to the acquisition, analysis, and interpretation of data; and all authors revised the article for intellectual content, approved the final manuscript as submitted, and have sufficiently participated in the work to take public responsibility for appropriate portions of the content.

PEDIATRICS Volume 140, number 5, November 2017:e20171103

What’s KnoWn on this subject: Macromastia causes significant morbidity for affected adolescents. Reduction mammaplasty remains controversial in this age group. The physical and psychosocial effects of surgical intervention are largely unknown; concerns exist regarding age, psychological maturity, comorbidity with obesity, and body image.

What this study adds: Reduction mammaplasty has positive and lasting effects on quality of life and breast-related symptoms for adolescents with symptomatic macromastia. These benefits largely persist across differences in patient age and BMI category.

to cite: Nuzzi LC, Firriolo JM, Pike CM, et al. The Effect of Reduction Mammaplasty on Quality of Life in Adolescents With Macromastia. Pediatrics. 2017;140(5):e20171103

by guest on October 26, 2020www.aappublications.org/newsDownloaded from

Macromastia, the benign overgrowth of 1 or both breasts, is a common condition affecting adolescent and adult women.1 The negative physical and psychosocial impacts of macromastia have been well documented.1 – 33 Those affected often suffer from chronic musculoskeletal pain as a result of their enlarged breasts. Patients frequently report brassiere strap grooving, inframammary fold intertrigo, and difficulty with exercising and finding properly fitted clothing.1 – 7 Many studies have established the association between macromastia and impaired mental and physical health in adults.8 –11

As part of an ongoing adolescent breast study, the physical and psychological burdens of macromastia in an adolescent cohort were measured by using validated survey methodologies.1 These findings were consistent with those of adult studies and smaller adolescent case series.1 – 33 Adolescent girls with macromastia were found to have significantly diminished physical functioning, vitality, social functioning, emotional well-being, mental health, and self-esteem compared with their unaffected female peers.1

In adults, reduction mammaplasty has proven to be an effective treatment for the physical and psychological burdens of macromastia. Adult women have reported resolution of breast symptoms and musculoskeletal pain, as well as improvements in quality of life, after intervention.3 – 24 In contrast, reduction mammaplasty during adolescence remains controversial, with the psychological effects of treatment in this age group largely unknown.25 – 29 The few studies in which the efficacy of reduction mammaplasty in the female adolescent has been examined have been limited to retrospective chart reviews or investigations without validated survey methods.25 – 33 Given

the lack of evidence-based data, providers may delay recommending adolescent patients for surgical treatment.

In this prospective, longitudinal study, we sought to measure the changes in the health-related quality of life (HRQoL) of adolescents with symptomatic macromastia after reduction mammaplasty by using validated surveys. We compared these changes in HRQoL to those of age-matched female control subjects, and we explored the effects of age and BMI category at the time of surgery on postoperative quality of life outcomes.

Methods

breast subjects

This study was approved by the Boston Children’s Hospital Committee on Clinical Investigation, protocol number X08-10-0492.

Informed consent was obtained from all subjects and a parent or guardian, as applicable. From 2008 to 2015, female patients aged 12 to 21 years who presented with symptomatic bilateral macromastia were prospectively enrolled during initial consultation. Patients with a history of previous breast surgery were excluded. Macromastia was determined by using a symptom profile, a physical examination, and modified Schnur criteria (Fig 1)., 34, 35 All patients were evaluated by a pediatric plastic surgeon and underwent reduction mammaplasty at our institution; all received insurance coverage (Fig 2).

Female controls

Female control subjects of the same age range were concurrently enrolled at clinics associated with either the Department of Plastic and Oral Surgery or the Division of Adolescent/Young Adult Medicine at

NuzzI et al2



5Pediatrics


140

FiGuRe 1The modified Schnur criteria (also known as the Schnur sliding scale) is used to determine if the motivation for reduction mammaplasty is primarily medical or cosmetic. A clinician must measure patient height and weight, and then calculate body surface area (BSA) by using the following formula: BSA (m2) = 0.007184 × [height (cm)]0.725 × [weight (kg)]0.425. Resection masses greater than the 22nd percentile for a given BSA (values above the curve in this figure) are considered to be medically necessary.


the same institution. Requirements for eligibility included having a current state of good health without having the following: considerable medical or surgical history, a current breast complaint or previous breast diagnosis, or diagnosis of an eating or psychiatric disorder.

clinical Presentation and biometrics

Clinical staff administered intake forms to macromastia patients

to collect information regarding baseline symptoms. Height and weight were measured at clinic visits for all patients.36 For subjects aged 20 years or older, BMI category was determined by using the Centers for Disease Control and Prevention Adult BMI Calculator.37 For participants younger than 20 years, BMI-for-age percentiles were calculated by using the Centers for Disease Control and Prevention Child and Teen BMI

Calculator.38 Because of the age range of our samples, BMI category (underweight, normal weight, overweight, obese) was used as a covariate in subsequent analyses.

survey Measures

All participants completed 4 self-administered surveys: the Short-Form 36v2 (SF-36), 39 the Rosenberg Self-Esteem Scale (RSES), 40 the Breast-Related Symptoms Questionnaire (BRSQ), 2 and the Eating Attitudes Test-26 (EAT-26).41 These validated surveys (although not all necessarily validated for patients in the 12- to 21-year age group) were selected for their extensive use in previous studies concerned with female adolescents and adults with benign breast conditions.1, 2, 9, 10, 14, 19, 20, 24, 42 The SF-36 measures HRQoL in 8 domains: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health.39 Domain scores are transformed to a scale of 0 to 100, with higher SF-36 domain scores associated with better HRQoL. The RSES assesses global self-esteem40; scores range from 10 to 40, with a higher score indicating greater self-esteem.43 The BRSQ quantifies the physical symptoms of patients with breast conditions; a higher score corresponds to fewer, less severe symptoms.2, 44 The EAT-26 scale assesses eating and body image attitudes and behaviors; higher scores are more indicative of disordered eating, thoughts, and behaviors.41 Control subjects completed an additional investigator-designed survey at baseline to determine if there were unaddressed breast concerns.

All subjects completed surveys at a baseline and/or preoperative visit, and were again administered surveys at the following postoperative or follow-up intervals: 6 months and 1, 3, and 5 years. To be included in analyses, patients and controls must have

PEDIATRICS Volume 140, number 5, November 2017 3



5Pediatrics


140

FiGuRe 2Adolescent reduction mammaplasty: operative decision-making criteria, operative technique, and postoperative complications. Note that it is important to provide psychosocial, nutritional, and weight loss support throughout the duration of care, as required.


completed a preoperative or baseline survey and at least 1 follow-up survey, respectively.

data Management and statistical Methods

Data were collected by using the secure, Web-based application REDCap (Research Electronic Data Capture) hosted at Boston Children’s Hospital.45 Statistical analyses were performed by using SPSS Statistics software, version 23 (IBM Corporation, Armonk, NY). Demographics and clinical information were compared between groups by using independent 2-sample t tests or Pearson χ2 tests, as appropriate. Scores for the SF-36 domains and the RSES, BRSQ, and EAT-26 were generated according to algorithms provided by Ware et al, 46 Rosenberg, 40 Kerrigan and co-workers, 14, 42 and Garner et al, 41 respectively. Linear regression models were fit to determine the effect of macromastia on baseline and follow-up survey scores, with the baseline BMI category as a covariate. Within-subject baseline and follow-up comparisons of survey scores were analyzed for both macromastia and control groups by using a dependent t test for paired samples. In our analyses stratifying groups by BMI category and age, we used the most recent follow-up survey data for each patient. A P value <.05 was considered statistically significant for all analyses.

Results

demographics

Adolescents with bilateral macromastia (n = 102) and female controls (n = 84) completed baseline and follow-up surveys. At baseline, macromastia and control subjects were of comparable age (17.6 and 17.1 years, respectively). However, a greater proportion of macromastia patients had overweight or obesity

(62%), compared with control subjects (30%; P < .001; Table 1).

baseline comparisons

After controlling for differences in BMI category, the mean baseline score on the RSES was significantly lower for macromastia subjects (30.2 ± 5.3) than for controls (33.2 ± 5.1; P < .001) (Table 2). Similarly, baseline BRSQ survey scores were lower for patients with macromastia (34.9 ± 17.0) than for controls (93.4 ± 11.9; P < .001), as were scores in 7 SF-36 domains: physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health (P ≤ .01, all). Compared with control subjects, patients with macromastia had a mean EAT-26 score that was higher by a statistically significant measure (P = .01). At baseline, the SF-36 general health domain did not significantly differ between the groups (P = .16).

A higher proportion of macromastia subjects indicated having breast, shoulder, neck, and upper and/or lower back pain, compared with controls (P < .001, all; Fig 3A). Significantly more adolescents with macromastia reported brassiere

strap grooving, inframammary intertrigo, difficulty finding properly fitting brassieres and clothing, and difficulty participating in sports as a result of their breast size, compared with controls (P < .001, all; Fig 3B).

Follow-up comparisons

Mean age at the time of reduction mammaplasty was 17.9 ± 1.7 years (Table 1). Postoperative follow-up time was skewed with a median of 31.0 months (interquartile range: 35.6 months, range: 5.7–89.8 months), whereas control follow-up time was normally distributed with a mean of 36.6 ± 17.8 months (range: 6.0–68.2 months). The majority of the 186 subjects completed 6-month and 1-year follow-up surveys (94% and 75% response rates, respectively); 41% of eligible patients responded at the 3-year time point (Table 1). Note that many patients in the current study were operated on or recruited <3 to 5 years ago and have therefore not yet been offered 3- or 5-year postoperative and/or follow-up surveys. By using patients’ most recent follow-up survey data, we performed within-subject analyses of macromastia patients and found significant score improvements

NuzzI et al4



5Pediatrics


140

table 1 Characteristics of Macromastia and Control Subjects

Macromastia (n = 102) Control (n = 84) P

Baseline mean (SD) age, y 17.6 (1.7) 17.1 (2.7) .10a

Baseline mean (SD) BMI 27.4 (5.8) 25.0 (6.4) .009a

Baseline mean (SD) BMI percentile (only applicable to patients <20 y of age)

81.2 (19.5) 67.7 (25.6) .001a

Baseline BMI category, N (%) <.001b

Healthy 38 (37%) 51 (69%) Overweight 34 (33%) 9 (12%) Obese 30 (29%) 13 (17%) Mean (SD) age at surgery, y 17.9 (1.7) — — Follow-up time, moc 31.0 (35.6, 5.7–89.8) 36.6 (17.8, 6.0–68.2) — Follow-up mean (SD) age, y 20.4 (2.3) 20.1 (3.3) 0.49a

Survey response rate Baseline 102/102 (100%) 84/84 (100%) — 6 mo 102/102 (100%) 72/84 (86%) — 1 y 83/102 (81%) 57/84 (68%) — 3 y 41/97 (42%) 33/83 (40%) — 5 y 12/49 (25%) 9/55 (16%) —

—, not applicable.a Two-sided P value for independent t test.b P value for Pearson χ2 (healthy versus overweight versus obese).c Median (interquartile range, range) reported for macromastia subjects; mean (SD, range) reported for control subjects.


after surgery, both on the RSES and BRSQ surveys and in 7 out of 8 SF-36 domains (physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health; P < .001, all; Table 3). SF-36 general health domain (P = .33) and EAT-26 (P = .06) scores remained stable from baseline to postoperative follow-up.

From baseline to their most recent follow-up, controls had statistically significant declines in RSES scores (P = .03), BRSQ scores (P = .02), and the SF-36 general health and mental health domains (P = .02, both; Table 3). EAT-26 scores and the other 6 SF-36 domain scores did not vary from baseline to follow-up (P > .05, all).

Postoperative subjects scored significantly higher than controls at their most recent follow-up in 6 SF-36 domains (physical functioning, bodily pain, general health, social functioning, role-emotional, and mental health), when controlling for differences in baseline BMI category (P ≤ .04, all; Table 4). Follow-up scores on the RSES, EAT-26, and BRSQ and in 2 SF-36 domains (role-physical and vitality) did not differ between the 2 groups (P ≥ .05, all). At the 6-months follow-up, when compared with controls, postoperative patients had superior scores on the RSES and in 3 SF-36 domains (vitality, social functioning, and mental health) (P ≤ .04, all; Table 2). Postoperative patients maintained survey scores that were similar to or more favorable than controls at the 1-, 3-, and 5-year follow-ups (Table 2).

After operation, the proportion of postoperative patients experiencing breast, shoulder, neck, and upper and lower back pain was significantly lower than at baseline (P < .001, all), with postoperative rates similar to those seen in control subjects (P ≥ .05, all; Fig 3A). Likewise,




5Pediatrics


140

tabl

e 2

Com

pari

sons

of B

asel

ine

and

Follo

w-u

p Su

rvey

Sco

res

Betw

een

Patie

nts

With

Mac

rom

astia

Who

und

erw

ent R

educ

tion

Mam

map

last

y an

d He

alth

y Fe

mal

e Ad

oles

cent

s at

6 M

onth

s, 1

, 3, a

nd 5

Yea

rs

SF-3

6 Do

mai

nsBa

selin

e6

mo

1 y

3 y

5 y

M-C

Mea

n (9

5% C

I) Fo

llow

-up

Diffe

renc

ePa

M-C

Mea

n (9

5% C

I) Fo

llow

-up

Diffe

renc

ePa

M-C

Mea

n (9

5% C

I) Fo

llow

-up

Diffe

renc

ePa

M-C

Mea

n (9

5% C

I) Fo

llow

-up

Diffe

renc

ePa

M-C

Mea

n (9

5% C

I) Fo

llow

-up

Diffe

renc

ePa

Phys

ical

func

tioni

ng−

19.8

(−

26.2

to −

13.4

)<.

001

2.8

(−2.

3 to

7.8

).2

8−

8.5

(−22

.2 to

5.1

).2

22.

3 (−

6.1

to 1

0.8)

.58

6.1

(−3.

0 to

15.

2).1

6Ro

le-p

hysi

cal

−21

.8 (

−28

.2 to

−15

.4)

<.00

11.

6 (−

3.2

to 6

.3)

.51

−6.

7 (−

18.5

to 5

.1)

.26

−0.

3 (−

8.2

to 7

.7)

.95

9.3

(−7.

3 to

25.

7).2

6Bo

dily

pai

n−

28.1

(−

33.8

to −

22.5

)<.

001

3.2

(−2.

1 to

8.5

).2

3−

3.0

(−34

.6 to

28.

5).7

81.

1 (−

5.2

to 7

.5)

.73

17.2

(4.

1 to

30.

3).0

2Ge

nera

l hea

lth−

3.8

(−9.

1 to

1.5

).1

61.

4 (−

4.3

to 7

.1)

.63

−1.

9 (−

20.5

to 1

6.7)

.84

4.5

(−4.

3 to

13.

3).3

112

.0 (

−3.

6 to

27.

5).1

3Vi

talit

y−

10.7

(−

15.4

to −

6.1)

<.00

14.

6 (0

.2 to

9.0

).0

4−

9.0

(−26

.2 to

8.3

).3

07.

0 (−

1.2

to 1

5.2)

.10

7.6

(−5.

8 to

21.

1).2

5So

cial

func

tioni

ng−

18.2

(−

25.0

to −

11.5

)<.

001

7.3

(0.7

to 1

3.9)

.03

−2.

5 (−

19.3

to 1

4.2)

.76

0.4

(−11

.0 to

10.

2).9

418

.4 (

−6.

6 to

43.

4).1

3Ro

le-e

mot

iona

l−

12.9

(−

19.7

to −

6.1)

<.00

12.

8 (−

2.5

to 8

.2)

.30

4.2

(−10

.5 to

18.

9).5

75.

8 (−

4.5

to 1

6.2)

.26

16.0

(−

11.4

to 4

3.3)

.23

Men

tal h

ealth

−6.

6 (−

11.8

to −

1.4)

.01

10.8

(4.

9 to

16.

7)<.

001

−7.

9 (−

26.8

to 1

0.9)

.40

7.4

(−1.

5 to

16.

3).1

09.

7 (−

13.0

to 3

2.4)

.37

RSES

−3.

0 (−

4.5

to −

1.5)

<.00

11.

9 (0

.3 to

3.5

).0

20.

1 (−

5.5

to 5

.3)

.96

2.4

(−0.

1 to

4.9

).0

62.

6 (−

1.8

to 7

.0)

.23

BRSQ

−58

.5 (

−62

.8 to

−54

.1)

<.00

13.

9 (−

1.7

to 9

.6)

.17

−1.

4 (−

15.8

to 1

3.0)

.85

2.8

(−3.

7 to

9.2

).3

94.

8 (−

11.8

to 2

1.4)

.53

EAT-2

63.

2 (0

.8 to

5.7

).0

10.

4 (2

.5 to

3.3

).7

96.

9 (−

3.1

to 1

6.9)

.18

1.64

(−

1.4

to 4

.7)

.28

2.1

(−2.

2 to

6.3

).3

3

CI, c

onfid

ence

inte

rval

; M-C

Mea

n, m

ean

diffe

renc

e be

twee

n m

acro

mas

tia a

nd c

ontr

ol s

urve

y sc

ores

at a

giv

en ti

me

poin

t.a

Two-

side

d P

valu

e fo

r in

depe

nden

t t te

st.


the proportion of postoperative patients reporting brassiere strap grooving, inframammary intertrigo, difficulty finding properly fitting brassieres and clothing, and difficulty participating in sports as a result of their breast size was significantly lower than at baseline (P < .001), with proportions similar to or lower than those of controls (Fig 3B).

effect of bMi and age on outcomes after Reduction Mammaplasty

Both younger (<18 years, n = 54) and older patients (≥18 years, n = 48) had significant postoperative improvements, both in RSES and BRSQ scores and in 7 SF-36 domains. Although older subjects (P < .001) had improvements in mental health scores after mammaplasty,

younger subjects did not experience this benefit (P = .40). When the macromastia group was stratified by BMI category, both healthy-weighted (n = 38) and overweight or obese patients (n = 64) had significant postoperative improvements on the RSES and BRSQ scores and in the 6 SF-36 domains. However, overweight or obese patients did not have improvements in SF-36 general health (P = .50) or mental health (P = .10) scores after reduction mammoplasty, unlike their healthy-weighted counterparts (P < .01).

effect of bMi and age on control Patient Follow-up data

Control subjects aged <18 and ≥18 years demonstrated no statistically significant changes in scores pertaining to RSES, BRSQ, EAT-26, and 6 of the 8 SF-36 domains. Among controls, younger patients experienced declines in the SF-36 general health (P = .01) and mental health (P = .03) subscales, neither of which changed by a statistically significant amount in older subjects (P ≥ .05, both). Over the follow-up period, healthy weighted controls demonstrated statistically significant score decreases in RSES (P < .01), BRSQ (P = .02), and the mental health domain of SF-36 (P < .01); in contrast, overweight and obese controls exhibited no significant changes in these HRQoL measures (P ≥ .05, all).

characterization of nonresponders

At the 1-year follow-up, postoperative nonresponders had a higher mean BMI percentile than those that completed surveys by a statistically significant measure (P < .001); this was not observed at other time points (P ≥ .05, all). Among control subjects, at the 1-year follow-up, nonresponders had a mean BMI percentile that was higher by a statistically significant amount (P = .037), and at the 5-year follow-up nonresponders had a baseline age (P = .003) that was lower by

NuzzI et al6



5Pediatrics


140

FiGuRe 3A, Percent (%) of macromastia and control subjects experiencing breast-related pain. B, Percent (%) of macromastia and control subjects experiencing breast-related symptoms.

table 3 Within-Subject Comparisons of Baseline and Most Recent Follow-up Survey Scores for Patients With Macromastia Who underwent Reduction Mammaplasty and Healthy Female Adolescents Managed Over Time

SF-36 Domains Macromastia Postoperative-Preoperative Difference, a

Mean (95% CI)

Pb Control F/u-Baseline Difference, c Mean (95% CI)

Pb

Physical functioning 23.7 (18.4 to 29.1) <.001 −1.3 (−5.1 to 2.4) .48Role-physical 27.5 (22.3 to 32.8) <.001 3.3 (−1.2 to 7.9) .15Bodily pain 32.9 (27.8 to 38.0) <.001 0.6 (−3.8 to 5.0) .79General health 1.9 (−1.9 to 5.7) .33 −4.6 (−8.6 to −0.7) .02Vitality 12.0 (7.6 to 16.4) <.001 −3.0 (−6.6 to 0.5) .09Social functioning 21.0 (14.0 to 27.9) <.001 −2.3 (−7.1 to 2.6) .36Role-emotional 16.4 (9.8 to 23.0) <.001 −1.6 (−7.2 to 3.9) .56Mental health 8.0 (3.3 to 12.8) <.001 −4.9 (−9.2 to −0.7) .02RSES 3.1 (1.8 to 4.5) <.001 −1.3 (−2.5 to −0.1) .03BRSQ 59.1 (55.4 to 63.0) <.001 −4.4 (−8.0 to −0.8) .02EAT-26 −1.8 (−3.7 to 0.1) .06 1.5 (−0.5 to 3.5) .15

CI, confidence interval; F/u, follow-up.a Mean difference between preoperative and postoperative survey scores for patients with macromastia who underwent reduction mammaplasty. A positive change in the mean indicates a preoperative to postoperative increase in score.b P value for dependent t test for paired samples.c Mean difference between control subject baseline and follow-up survey scores. A positive change in the mean indicates a baseline to follow-up increase in score.


a statistically significant amount. All other demographic features (including BMI and BMI category) at all other time points (for both postoperative and control subjects) demonstrated no statistically significant difference between responders and nonresponders (P ≥ .05, all).

discussion

Few studies have examined the efficacy of reduction mammaplasty in alleviating the physical and emotional symptoms of macromastia in adolescent patients. In the current study, we prospectively managed a cohort of adolescents with macromastia undergoing surgical treatment concurrently with a group of age-matched unaffected healthy female controls. Validated surveys were administered to quantify the effect of macromastia on the physical and emotional health of adolescents. Our sample confirmed the well-established association between adolescent macromastia and negative self-perception of HRQoL.1 – 33 In accordance with the existing literature, our cohort of adolescents with macromastia suffered diminished self-esteem and lowered physical, emotional, and social well-being, while having increased breast-related complaints compared with their female peers. After reduction mammaplasty, patients

demonstrated marked improvements in physical well-being, bodily pain, vitality, social functioning, emotional well-being, mental health, self-esteem, and breast-related pain and symptoms. Our findings are consistent with the current adult1 – 24 and adolescent literature.25 – 33 On the basis of our results, early surgical intervention appears not only to reduce the physical and psychosocial burdens of macromastia but also to return patients to a quality of life commensurate with that of their unaffected peers. Improvement is evident by the 6-month follow-up visit, and persists 5 years postoperatively. This is indicative of sustained long-term physical and psychosocial gains and is not simply an artifact of a postoperative “honeymoon” period in which patient excitement may exaggerate the perceived benefits of surgery.

Reduction mammaplasty in the adolescent is a safe, effective outpatient procedure with few major complications in the healthy patient.33 Despite the well-established association between macromastia and negative HRQoL, adolescents with macromastia remain relatively undertreated compared with their adult counterparts.27 Elective breast surgery in the adolescent continues to be a source of controversy.25 – 29 Pediatricians and surgeons alike share a reluctance to seek surgical

intervention for their young patients, citing concerns of age, psychological maturity, comorbidity with obesity, and effect on body image.25, 26

Insurance coverage continues to impede access to surgery for young women with macromastia. Third-party payors often impose age restrictions and request physical therapy and substantial weight loss before approval. However, our results demonstrate that surgical treatment of macromastia decreases complaints of breast-related pain independent of these factors. Although the authors of some studies have found BMI to be positively associated with postoperative complications, 21 we have found that surgical intervention in overweight and obese patients is still advantageous. In our sample, overweight and obese patients exhibited considerable improvements in mental and physical well-being similar to their healthy-weighted counterparts. Our data suggest that overweight and obese patients derive an HRQoL benefit equal to that of their healthy-weighted peers. Although weight control is an essential part of good health, BMI alone should not be a strict exclusion criterion.

Patient age and tissue resection cutoffs imposed by insurance companies also serve to delay surgery, while prolonging and exacerbating the burden of macromastia. It is estimated that 80% of adults with macromastia developed symptoms during early adolescence.27 We found that younger adolescents (<18 years) experienced the same postoperative improvements in physical well-being, vitality, psychosocial well-being, and breast-related pain and symptoms as their older peers after reduction mammaplasty. Traditional concerns regarding negatively altered self-esteem in younger patients after breast surgery were largely unfounded in our sample; in fact, younger patients demonstrated




5Pediatrics


140

table 4 Linear Regression Models for the Mean Follow-up Survey Scores, Comparing Postoperative Subjects to Follow-up Controls

SF-36 Domains Macromastia Postoperative Mean (SD)

Control Follow-up Mean (SD) Pa

Physical functioning 95.2 (14.0) 90.4 (20.7) .01Role-physical 94.4 (12.1) 92.3 (16.5) .05Bodily pain 79.9 (14.7) 76.0 (17.5) .02General health 75.1 (19.0) 72.4 (19.0) .04Vitality 51.8 (16.3) 48.3 (17.0) .11Social functioning 86.9 (20.4) 82.3 (24.2) .02Role-emotional 89.7 (17.8) 83.8 (25.3) .02Mental health 75.6 (18.6) 69.0 (22.8) .01RSES 33.3 (5.5) 32.2 (6.0) .08BRSQ 93.5 (10.4) 89.6 (18.1) .09EAT-26 7.6 (8.2) 7.7 (10.0) .43

a P value for linear regression coefficient (β) for case status, adjusted for baseline BMI category.


significant improvements in self-esteem postoperatively.

There are concerns that younger patients may be at an increased risk for reoperation as a result of continued pubertal breast growth. However, adult women are also susceptible to changes in breast morphology caused by factors such as weight gain or loss, gestational breast growth, and breastfeeding. Given that the majority of adults with symptomatic macromastia experience negative symptoms during adolescence, 27 it may be argued that the physical and psychological benefits of earlier reduction mammaplasty outweigh the risk of repeat operation and double payment later in life. As such, BMI category and age should not preclude otherwise healthy, skeletally and psychologically mature adolescents from seeking surgical treatment of macromastia.

Treatment of adolescent macromastia should not be limited to reduction mammaplasty alone; those who treat the condition should apply multidisciplinary expertise to address obesity, eating behaviors, mental health, social functioning, and breastfeeding support, as required.1 For instance, at our institution, overweight and obese patients receive weight loss counseling and referrals to dieticians and/or weight loss clinics. When indicated, psychosocial support and referrals to psychological and/or psychiatric services are also provided (Fig 2). All patients bring a unique set of parameters, and no simple treatment algorithm can be applied to all women seeking treatment. If nonsurgical treatment does not provide adequate symptom relief, surgical treatment should be considered.

In the adult population, studies have revealed no significant difference in the lactational performance of

patients who underwent reduction mammaplasty compared with those with untreated macromastia.47, 48 Successful breastfeeding has been found highly probable as long as functioning glandular breast tissue is left attached to the nipple.49 Women who have undergone reduction mammaplasty should be encouraged to breastfeed, as difficulty breastfeeding is typically overcome with education, encouragement, and psychosocial support.48

Study limitations must be acknowledged. Follow-up BMI data were largely unavailable for both control and macromastia subjects, requiring the use of the baseline BMI category as a covariate in linear regression models. As some of our survey measures lack validation and normative values for younger adolescents, we relied on baseline and follow-up comparisons within subjects and across groups. Control subject scores decreased for the RSES, BRSQ, and 2 SF-36 domains during the follow-up period. In an adult control group, scores would likely remain stable over a 5-year time period. However, adolescence comes with its own unique set of psychosocial stressors, perhaps explaining why control survey scores fluctuated over time. This finding may also be indicative of possible sampling bias or the natural progression of self-reported health during adolescence.50 – 53 As such, differences in postoperative versus follow-up control scores may be amplified. Analyses stratifying the macromastia sample by age and BMI category may not be as statistically robust because of reduced sample size. Sample sizes for follow-up analyses at 3 and 5 years were smaller than those of baseline, 6 months, and 1 year. In part, this is because many patients were operated on or recruited <3 to 5 years ago and have therefore not yet been offered

3- or 5-year postoperative and/or follow-up surveys. Three- and 5-year follow-up surveys also had lower response rates than surveys given at earlier time points. However, in our characterization of nonresponders, we observed no trends in the demographic features of those who did not complete surveys; demographic differences between responders and nonresponders were uncommon, were isolated, and did not demonstrate any consistency across time points. It must be noted that, as a result of the greater response rates for surveys administered at earlier time points, comparisons in which the most recently acquired data were used (ie, Table 4) may be skewed to reflect more favorable results in the postoperative subjects than would be observed with a longer-term follow-up (Table 1). Furthermore, because most patients remained nulliparous at follow-up and the surveys used do not inquire about breastfeeding, we are unable to accurately comment on postoperative breastfeeding experiences and remain uncertain as to how potential future breastfeeding difficulties may impact HRQoL. A self-reported breastfeeding assessment should be incorporated in future long-term outcomes studies to accurately comment on our patients’ breastfeeding experiences. Lastly, the results of this study may not be generalizable because subjects were recruited from a single large tertiary care facility.

conclusions

Reduction mammaplasty significantly improves the breast-related symptoms and self-reported physical and psychosocial well-being of adolescent patients with macromastia. After surgery, patients report levels of well-being similar to, if not higher than, that of unaffected

NuzzI et al8



5Pediatrics


140


age-matched female peers, with benefits evident by 6 months after operation and still demonstrable at the 5-year follow-up. Younger patients and those who were overweight or obese at the time of surgery also experienced broad improvements in quality of life and symptomatology. Patients, parents, and providers should be aware of

the potential positive impact that reduction mammaplasty can provide for adolescents with symptomatic macromastia and should consider early intervention. BMI category and chronological age should not preclude otherwise healthy, physically and psychologically mature adolescents from seeking surgical treatment of macromastia.

ReFeRences

1. Cerrato F, Webb ML, Rosen H, et al. The impact of macromastia on adolescents: a cross-sectional study. Pediatrics. 2012;130(2). Available at: www. pediatrics. org/ cgi/ content/ full/ 130/ 2/ e339

2. Kerrigan CL, Collins ED, Striplin D, et al. The health burden of breast hypertrophy. Plast Reconstr Surg. 2001;108(6):1591–1599

3. Spector JA, Karp NS. Reduction mammaplasty: a significant improvement at any size. Plast Reconstr Surg. 2007;120(4):845–850

4. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg. 2012;129(3):562–570

5. Freire M, Neto MS, Garcia EB, Quaresma MR, Ferreira LM. Functional capacity and postural pain outcomes after reduction mammaplasty. Plast Reconstr Surg. 2007;119(4):1149–1156; discussion 1157–1158

6. Chao JD, Memmel HC, Redding JF, Egan L, Odom LC, Casas LA. Reduction mammaplasty is a functional operation, improving quality of life in

symptomatic women: a prospective, single-center breast reduction outcome study. Plast Reconstr Surg. 2002;110(7):1644–1652; discussion 1653–1654

7. Hermans BJ, Boeckx WD, De Lorenzi F, van der Hulst RR. Quality of life after breast reduction. Ann Plast Surg. 2005;55(3):227–231

8. Eggert E, Schuss R, Edsander-Nord A. Clinical outcome, quality of life, patients’ satisfaction, and aesthetic results, after reduction mammaplasty. Scand J Plast Reconstr Surg Hand Surg. 2009;43(4):201–206

9. Sabino Neto M, Demattê MF, Freire M, Garcia EB, Quaresma M, Ferreira LM. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthet Surg J. 2008;28(4):417–420

10. Mello AA, Domingos NA, Miyazaki MC. Improvement in quality of life and self-esteem after breast reduction surgery. Aesthetic Plast Surg. 2010;34(1):59–64

11. Iwuagwu OC, Walker LG, Stanley PW, Hart NB, Platt AJ, Drew PJ. Randomized clinical trial examining psychosocial and quality of life benefits of bilateral

breast reduction surgery. Br J Surg. 2006;93(3):291–294

12. Blomqvist L, Eriksson A, Brandberg Y. Reduction mammaplasty provides long-term improvement in health status and quality of life. Plast Reconstr Surg. 2000;106(5):991–997

13. Blomqvist L, Brandberg Y. Three-year follow-up on clinical symptoms and health-related quality of life after reduction mammaplasty. Plast Reconstr Surg. 2004;114(1):49–54

14. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. 2002;109(5):1556–1566

15. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes. Plast Reconstr Surg. 2007;120(1):13–26

16. Chadbourne EB, zhang S, Gordon MJ, et al. Clinical outcomes in reduction mammaplasty: a systematic review and meta-analysis of published studies. Mayo Clin Proc. 2001;76(5):503–510




5Pediatrics


140

doi: https:// doi. org/ 10. 1542/ peds. 2017- 1103

Accepted for publication Aug 2, 2017

Address correspondence to Brian I. Labow, MD, FACS, FAAP, Department of Plastic and Oral Surgery, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics

Financial disclosuRe: The authors have indicated they have no financial relationships relevant to this article to disclose.

FundinG: Supported in part by the Plastic Surgery Foundation (July 2011), grant 192776.

Potential conFlict oF inteRest: The authors have indicated they have no potential conflicts of interest to disclose.

abbReviations

BRSQ: Breast-Related Symptoms Questionnaire

EAT-26: Eating Attitudes Test-26HRQoL: health-related quality of

lifeRSES: Rosenberg Self-Esteem

ScaleSF-36: Short-Form 36v2


www.pediatrics.org/cgi/content/full/130/2/e339

www.pediatrics.org/cgi/content/full/130/2/e339

https://doi.org/10.1542/peds.2017-1103

mailto:

17. Miller BJ, Morris SF, Sigurdson LL, et al. Prospective study of outcomes after reduction mammaplasty. Plast Reconstr Surg. 2005;115(4):1025–1031; discussion 1032–1033

18. O’Blenes CA, Delbridge CL, Miller BJ, Pantelis A, Morris SF. Prospective study of outcomes after reduction mammaplasty: long-term follow-up. Plast Reconstr Surg. 2006;117(2):351–358

19. Shakespeare V, Cole RP. Measuring patient-based outcomes in a plastic surgery service: breast reduction surgical patients. Br J Plast Surg. 1997;50(4):242–248

20. Faria FS, Guthrie E, Bradbury E, Brain AN. Psychosocial outcome and patient satisfaction following breast reduction surgery. Br J Plast Surg. 1999;52(6):448–452

21. Atterhem H, Holmner S, Janson PE. Reduction mammaplasty: symptoms, complications, and late results. A retrospective study on 242 patients. Scand J Plast Reconstr Surg Hand Surg. 1998;32(3):281–286

22. Brühlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Ann Plast Surg. 1998;41(3):240–245

23. Gonzalez F, Walton RL, Shafer B, Matory WE Jr, Borah GL. Reduction mammaplasty improves symptoms of macromastia. Plast Reconstr Surg. 1993;91(7):1270–1276

24. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. Ann Plast Surg. 2000;45(6):575–580

25. Evans GR, Ryan JJ. Reduction mammaplasty for the teenage patient: a critical analysis. Aesthetic Plast Surg. 1994;18(3):291–297

26. Lee MC, Lehman JA Jr, Tantri MD, Parker MG, Wagner DS. Bilateral reduction mammoplasty in an adolescent population: adolescent bilateral reduction mammoplasty. J Craniofac Surg. 2003;14(5):691–695

27. Nguyen JT, Palladino H, Sonnema AJ, Petty PM. Long-term satisfaction of reduction mammaplasty for bilateral symptomatic macromastia in younger patients. J Adolesc Health. 2013;53(1):112–117

28. Crerand CE, Magee L. Cosmetic and reconstructive breast surgery in adolescents: psychological, ethical, and legal considerations. Semin Plast Surg. 2013;27(1):72–78

29. Corriveau S, Jacobs JS. Macromastia in adolescence. Clin Plast Surg. 1990;17(1):151–160

30. McMahan JD, Wolfe JA, Cromer BA, Ruberg RL. Lasting success in teenage reduction mammaplasty. Ann Plast Surg. 1995;35(3):227–231

31. Sigurdson L, Mykhalovskiy E, Kirkland SA, Pallen A. Symptoms and related severity experienced by women with breast hypertrophy. Plast Reconstr Surg. 2007;119(2):481–486

32. Koltz PF, Sbitany H, Myers RP, Shaw RB, Patel N, Girotto JA. Reduction mammaplasty in the adolescent female: the uRMC experience. Int J Surg. 2011;9(3):229–232

33. Xue AS, Wolfswinkel EM, Weathers WM, Chike-Obi C, Heller L. Breast reduction in adolescents: indication, timing, and a review of the literature. J Pediatr Adolesc Gynecol. 2013;26(4):228–233

34. Schnur PL, Hoehn JG, Ilstrup DM, Cahoy MJ, Chu CP. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. 1991;27(3):232–237

35. Schnur PL. Reduction mammaplasty-the schnur sliding scale revisited. Ann Plast Surg. 1999;42(1):107–108

36. Du Bois D, Du Bois EF. A formula to estimate the approximate surface area if height and weight be known. Arch Intern Med (Chic). 1916;17(6):863–871

37. Centers for Disease Control and Prevention. Adult BMI calculator. Available at: www. cdc. gov/ healthyweight/ assessing/ bmi/ adult_ bmi/ metric_ bmi_ calculator/ bmi_ calculator. html. Accessed December 12, 2016

38. Centers for Disease Control and Prevention. BMI percentile calculator for child and teen. Available at: http:// nccd. cdc. gov/ dnpabmi/ Calculator. aspx. Accessed December 12, 2016

39. Ware JE Jr. SF-36 health survey update. Spine. 2000;25(24):3130–3139

40. Rosenberg M. Society and the Adolescent Self-Image. Princeton, NJ: Princeton university Press; 1965:326

41. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The eating attitudes test: psychometric features and clinical correlates. Psychol Med. 1982;12(4):871–878

42. Kerrigan CL, Collins ED, Kneeland TS, et al. Measuring health state preferences in women with breast hypertrophy. Plast Reconstr Surg. 2000;106(2):280–288

43. Poston WSC, Goodrick GK, Foreyt JP. The rosenberg self-esteem scale. In: St. Jeor ST, ed. Obesity Assessment: Tools, Methods, Interpretations: A Reference Case: The RENO Diet-Heart Study. New York, NY: International Thomson Publishing; 1997:425

44. Pusic AL, Chen CM, Cano S, et al. Measuring quality of life in cosmetic and reconstructive breast surgery: a systematic review of patient-reported outcomes instruments. Plast Reconstr Surg. 2007;120(4):823–837; discussion 838–839

45. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381

46. Ware JE Jr, Kosinski M, Bjorner JB, Turner-Bowker DM, Gandek B, Maruish ME. User’s Manual for the SF-36v2TM Health Survey. 2nd ed. Lincoln, RI: QualityMetric Incorporated; 2007

47. Cruz NI, Korchin L. Lactational performance after breast reduction with different pedicles. Plast Reconstr Surg. 2007;120(1):35–40

48. Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful breastfeeding: a systematic review. J Plast Reconstr Aesthet Surg. 2010;63(10):1688–1693

49. Marshall DR, Callan PP, Nicholson W. Breastfeeding after reduction mammaplasty. Br J Plast Surg. 1994;47(3):167–169

50. Vingilis ER, Wade TJ, Seeley JS. Predictors of adolescent self-rated health. Analysis of the National Population Health Survey. Can J Public Health. 2002;93(3):193–197

NuzzI et al10



5Pediatrics


140


www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/metric_bmi_calculator/bmi_calculator.html




http://nccd.cdc.gov/dnpabmi/Calculator.aspx

http://nccd.cdc.gov/dnpabmi/Calculator.aspx

51. Slap GB, Khalid N, Paikoff RL, Brooks-Gunn J, Warren MP. Evolving self-image, pubertal manifestations, and pubertal hormones: preliminary findings in young adolescent girls.

J Adolesc Health. 1994;15(4): 327–335

52. Boardman JD. Self-rated health among u.S. adolescents. J Adolesc Health. 2006;38(4):401–408

53. Breidablik HJ, Meland E, Lydersen S. Self-rated health during adolescence: stability and predictors of change (Young-HuNT study, Norway). Eur J Public Health. 2009;19(1):73–78




5Pediatrics


140


DOI: 10.1542/peds.2017-1103 originally published online October 6, 2017; 2017;140;Pediatrics

Webb, Heather R. Faulkner, Amy D. DiVasta and Brian I. LabowLaura C. Nuzzi, Joseph M. Firriolo, Carolyn M. Pike, Felecia E. Cerrato, Michelle L.

MacromastiaThe Effect of Reduction Mammaplasty on Quality of Life in Adolescents With

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/140/5/e20171103including high resolution figures, can be found at:

Referenceshttp://pediatrics.aappublications.org/content/140/5/e20171103#BIBLThis article cites 48 articles, 1 of which you can access for free at:

Subspecialty Collections

http://www.aappublications.org/cgi/collection/plastic_surgery_subPlastic Surgeryhttp://www.aappublications.org/cgi/collection/surgery_subSurgeryicine_subhttp://www.aappublications.org/cgi/collection/adolescent_health:medAdolescent Health/Medicinefollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:


http://http://pediatrics.aappublications.org/content/140/5/e20171103

http://pediatrics.aappublications.org/content/140/5/e20171103#BIBL

http://www.aappublications.org/cgi/collection/adolescent_health:medicine_sub

http://www.aappublications.org/cgi/collection/adolescent_health:medicine_sub

http://www.aappublications.org/cgi/collection/surgery_sub

http://www.aappublications.org/cgi/collection/plastic_surgery_sub

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml

DOI: 10.1542/peds.2017-1103 originally published online October 6, 2017; 2017;140;Pediatrics

Webb, Heather R. Faulkner, Amy D. DiVasta and Brian I. LabowLaura C. Nuzzi, Joseph M. Firriolo, Carolyn M. Pike, Felecia E. Cerrato, Michelle L.

MacromastiaThe Effect of Reduction Mammaplasty on Quality of Life in Adolescents With

http://pediatrics.aappublications.org/content/140/5/e20171103located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it


http://pediatrics.aappublications.org/content/140/5/e20171103

The Effect of Reduction Mammaplasty on Quality of Life in ... · 03/11/2017 · Reduction...

Documents

Transcript of The Effect of Reduction Mammaplasty on Quality of Life in ... · 03/11/2017 · Reduction...