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Ewing JN, Niu EF, Amro C, Gala Z, Lemdani MS, Chang AE, Broach RB, Serletti JM, Fischer JP. Balancing the Scales: Caution in Reduction Mammaplasty Recommendations for Obesity Class III Patients. Ann Plast Surg 2024; 93:297-307. [PMID: 38896843 DOI: 10.1097/sap.0000000000004010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
INTRODUCTION The prevalence of obesity has risen worldwide, posing a problem to surgeons as obesity is a well-known risk factor for surgical outcomes. While prior studies have suggested performing reduction mammaplasty (RM) in patients with obesity, the variance in outcomes and quality of life (QoL) for obesity classes are ill-defined. We investigated whether obesity classes should be considered for RM by examining the surgical outcomes and QoL across different weight classes, aiming to pinpoint when outcomes become less favorable. METHODS Patients undergoing RM by nine surgeons from 2016 to 2022 were included. Body mass index (BMI) cohorts were formed according to the Center for Disease Control and Prevention (CDC) guidelines: Healthy (18.5-24.9 kg/m 2 ), overweight (25-29.9 kg/m 2 ), obesity class I (30-34.9 kg/m 2 ), II (35-39.9 kg/m 2 ), and III (>40 kg/m 2 ). QoL was assessed by comparing preoperative and postoperative BREAST-Q scores within cohorts. A comparison analysis was performed between weight classes. RESULTS A total of 461 RM patients were identified (healthy: 83, overweight: 178, I: 142, II: 39, III: 19). Percentage of Black patients, procedure length, weight of tissue removed, and inferior pedicle technique all significantly increased as BMI increased ( P < 0.001). Higher BMI cohorts, especially class III, had significantly higher rates of surgical site infections (healthy: 0%, overweight: 1.1%, I: 1.4%, II: 0%, III: 15.8%, P < 0.01), fat necrosis (healthy: 1.2%, overweight: 5.1%, I: 7%, II: 0%, III: 22.2%, P = 0.01), dehiscence (healthy: 3.6%, overweight: 2.8%, I: 2.1%, II: 5.1%, III: 31.6%, P < 0.01), delayed healing (health: 4.8%, overweight: 11.2%, I: 16.9%, II: 28.2%, III: 42.1%, P < 0.01), minor T-point breakdown (healthy: 10.8%, overweight: 15.7%, I: 23.9%, II: 23.1%, III: 52.6%, P = 0.01), and surgical site occurrence requiring procedural intervention (healthy: 6.0%, overweight: 5.6%, I: 6.3%, II: 15.4%, III: 21.1%, P < 0.05). When compared to the other weight classes independently, class III was associated with unfavorable outcomes ( P < 0.05). Significant improvement in average postoperative QoL scores in satisfaction with breast, psychosocial well-being, sexual well-being, and physical well-being were seen in all cohorts except class III ( P < 0.05). CONCLUSIONS Severe obesity class III patients undergoing RM have a higher yet still acceptable risk profile and should be counseled on the risks despite its improved quality of life.
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Affiliation(s)
- Jane N Ewing
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Pocock KS, Laikhter E, Hardy BW, Holtzman-Hayes N, Strauss LD, Pavlovic JM, David LR, Katz AJ, Kumar S, Pestana I, Calder B, Nye BL, Duet M, Wells RE. Enlarged Breast Size (Macromastia) and Associated Neurologic Risks: A Scoping Review. Neurology 2024; 103:e209660. [PMID: 39013127 DOI: 10.1212/wnl.0000000000209660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Symptomatic macromastia (enlarged breasts) is a syndrome of persistent headache, neck and shoulder pain, thoracic kyphosis, painful shoulder grooving from bra straps, inframammary rash, backache, and upper extremity paresthesias. Up to 89% of the 100,000 US women undergoing breast reduction surgery (reduction mammoplasty) annually report headache preoperatively with many endorsing postoperative headache improvement. Headache is one insurance indication to cover surgical reduction, and peak prevalence of migraine matches the average age of women with macromastia at time of surgery. Little is known about the influence of macromastia on headache. The goal of our narrative review is to understand the evidence for and potential mechanisms underlying macromastia-related headache. METHODS A literature search was performed in PubMed Medline using concepts "breast hypertrophy," "macromastia," "headache," "migraine," "breast reduction," and "reduction mammoplasty" excluding limits on age, language, publication date, or study type. Supplemental literature searches were performed to provide a comprehensive understanding of potential mechanisms underlying macromastia-related headache. RESULTS We identified 25 studies describing macromastia-associated headache in the setting of reduction mammoplasty, with 23 original research studies (retrospective, n = 12, prospective, n = 11) totaling 3,799 patients, 1 systematic review, and 1 meta-analysis. Most (24/25) were published in Plastic Surgery, one in Internal Medicine, and none in Neurology. Wide ranges were identified for preoperative headache prevalence (2%-89%) and postoperative headache improvement (34%-100%). Studies described headache as "myofascial" or "tension-type" without detailing headache definitions, chronicity, headache screening method, or neurologic examination. Potential pathophysiologic mechanisms of macromastia-associated headache include structural, mechanical, psychosocial, and hormonal. DISCUSSION No studies on macromastia-associated headache and reduction mammoplasty are published in Neurology. This important women's health topic remains unexplored in fields outside Plastic Surgery. Many questions remain unanswered that are important for neurologists to understand, including which headache type(s) women with macromastia experience and which headache type(s) respond to surgical intervention.
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Affiliation(s)
- Kristyn Spera Pocock
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Elizabeth Laikhter
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Brandy W Hardy
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Niki Holtzman-Hayes
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Lauren Doyle Strauss
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Jelena M Pavlovic
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Lisa R David
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Adam J Katz
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Sandhya Kumar
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Ivo Pestana
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Bennett Calder
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Barbara L Nye
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Mary Duet
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
| | - Rebecca Erwin Wells
- From the Department of Neurology (K.S.P., S.K., B.L.N., R.E.W.), and Department of Plastic Surgery (E.L., L.R.D., A.J.K., I.P., B.C., M.D.), Atrium Health Wake Forest Baptist; Wake Forest University School of Medicine (B.W.H., M.D.), Winston-Salem, NC; Department of Neurology (N.H.-H., J.M.P.), Albert Einstein College of Medicine, Montefiore Headache Center, Bronx, NY; and Department of Neurology (L.D.S.), Virginia Commonwealth University School of Medicine, Richmond
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