Frequency of Headaches in Macromastia Patients and Relief After Reduction Mammoplasty

Enlarged Breast Size (Macromastia) and Associated Neurologic Risks: A Scoping Review

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.

Three-Pedicle Reduction Mammaplasty Technique in the Treatment of Greater Breast Hypertrophy Patients With or Without Breast Cancer: Surgical and Patient-reported outcomes

BACKGROUND

Reduction mammoplasty (RM) is an important procedure in the management of symptomatic greater breast hypertrophy with or without early-stage breast cancer. We aim to introduce a new procedure: the three-pedicle reduction mammaplasty technique.

METHODS

A prospectively maintained database was reviewed, and two prospectively registered clinical studies were included of all breast hypertrophy patients with or without breast cancer who underwent three-pedicle RM with inverted T incision at West China Hospital or the Fourth People's Hospital of Sichuan Province from 2018 to 2022. Patient demographics, patient-reported cosmetic results, quality of life (QoL), surgical outcomes and complications were assessed.

RESULTS

During a median period of 22.5 months, 101 reduction mammaplasties were performed (Mage= 35.80; MBMI= 27.05). Mean reduction weight was 880.9 g ranging from 423-1630 g per breast. The nipple-to-sternal notch distance (N-SN) at post-operation was significantly shorter than preoperatively (left, 34.51 cm; right, 34.69 cm). Major complications and minor complications were 1.9% (1/52 patients) and 13.5% (7/52 patients), respectively. Multivariate logistic regression analyses showed that BMI > 30 was independent risk factors for a complication. Except for sexual and physical well-being at 1-month post-operation, patients gave a higher score on the BREAST-Q (breast satisfaction, physical well-being, psychosocial well-being) after the operation than before the operation (P<0.001).

CONCLUSIONS

The three-pedicle RM technique was demonstrated to be an effective and safe RM procedure for moderate to severe breast hypertrophy patients with or without breast cancer, with the advantages of removing the lesions, reducing hypertrophic breasts and accomplishing mammoplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   http://www.springer.com/00266.

Outcomes of Extended Pedicle Technique vs Free Nipple Graft Reduction Mammoplasty for Patients With Gigantomastia

BACKGROUND

Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG).

OBJECTIVES

The authors compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty employing EP vs FNG.

METHODS

A multi-institutional, retrospective study of adult patients with gigantomastia who underwent reduction mammoplasty at 2 tertiary care centers from 2017 to 2020 was performed. Gigantomastia was defined as reduction weight >1500 g per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at 1 institution employed the EP technique, whereas those at the other utilized FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes.

RESULTS

Fifty-two patients met the inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, P < 0.05) but no other differences in surgical or medical complications. Baseline BREAST-Q scores did not differ between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (P < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (P < 0.05), independent of institution or surgical experience.

CONCLUSIONS

This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia.

LEVEL OF EVIDENCE: 4

[Does reduction mammoplasty improve neck pain and quality of life?]

INTRODUCTION AND OBJECTIVE

Macromastia often leads to physical complaints involving pain in the shoulder/neck area. In Germany, there are virtually no reliable data on the effects of breast reduction surgery with regard to neck and spine complaints. Therefore, the authors carried out a retrospective study to investigate the effect of breast-reducing surgery on neck pain and quality of life.

METHODS

Between January 1, 2014 and December 31, 2019, 107 breast reductions were performed for macromastia. Medical records and OP reports were evaluated, and the indication for breast reduction documented. Pain was recorded preoperatively on a visual analog scale (VAS). Pretreatments and perioperative complications were also documented and evaluated. All patients were sent a questionnaire, which determined whether the objective of the operation had been achieved, how satisfied the patients were with the result of the operation, and how severe the current pain (VAS) was. The EQ-5D 3L health questionnaire was used to assess quality of life, and the Neck-Disability Index was used to assess neck complaints. Statistical analysis was carried out using the Wilcoxon test.

RESULTS

After an average of 56.5 months (min: 18, max: 90), 76/107 (71%) patients could be re-examined. There were 15 complications. Pain improved from an average of 7.2 preoperatively (min: 0, max: 10) to an average of 1.6 postoperatively (min: 0, max: 4; p < 0.001). The Neck-Disability Index improved from an average of 43.8% (Min: 0, Max: 82) to an average of 10.8% (Min: 0, Max: 52) postoperatively (p < 0.001). In all, 71/76 (93%) of the examined patients were very satisfied or satisfied with the result of the operation.

DISCUSSION AND CONCLUSION

With this study, the authors were able to show that there are often several reasons why breast reduction surgery is performed in patients with macromastia. A high patient satisfaction rate can be achieved and orthopedic clinical complaints associated with macromastia can be treated with a very high success rate.