INTRODUCTION
The breasts have great importance as both a physical and mental attribute for
women. Besides creating a body image that symbolizes sensuality and sexuality
and determining factors of women’s femininity, they are considered one of the
symbols of life and motherhood1.
Breast hypertrophy (BH) is one among the benign changes that affect the breasts
and is characterized by a bulky and disproportionate size of the breast to the
biotype of the woman. This disharmony between the idealized form and that which
is caused by hypertrophy causes physical and psychological changes, hindering
social interaction and successful interaction of women with the environment2. Patients with BH are more likely to have
decreased self-esteem and sexual activity, depression, and anxiety3,4.
Assessing improvement in the quality of life of patients undergoing reduction
mammoplasty has been necessary since the development of the technique, in order
to validate its use in patients with BH. The improvement of symptoms such as
cervical, thoracic, and shoulder pain, and headache indicates that quality of
life improves in patients undergoing this procedure5.
Several subjective and objective forms of evaluation were developed to measure
changes in the quality of life in patients undergoing reduction mammoplasty, by
assigning scores to increase the reliability of the results6. The application of these tools enabled assessment of
several variables related to the satisfaction of the patients undergoing this
surgery.
Although a high degree of satisfaction and improvement in quality of life has
been previously reported in the literature, few studies have used research
instruments that are specific for reduction mammoplasty or have reassessed the
same sample in the preoperative and late postoperative periods.
OBJECTIVE
To obtain reliable results, we decided to assess the results of reduction
mammoplasty and the physical, social, and psychological impact in patients
undergoing surgery by administering the BREAST-Q®7,8 questionnaire.
BREAST-Q® is a tool for evaluating the body image and quality
of life in patients undergoing breast surgery, consisting of four modules
specific for breast augmentation, breast reduction, breast reconstruction, and
mastectomy without reconstruction in addition to a common module comprising
relevant items for all patients undergoing breast surgery.
BREAST-Q® can be used to investigate the impact and
efficacy of breast surgery from the patient’s perspective pre- and
postoperatively7.
METHODS
For this prospective cohort study, 83 patients with BH were consecutively
selected and treated at the Plastic Surgery Service of the University Hospital
of the Federal University of Juiz de Fora (HU-UFJF) (Juiz de Fora, Minas Gerais,
Brazil, belonging to the Unified Health System of Brazil. The selected patients
had not undergone any other surgical procedure on the breasts or bariatric
surgery, were aged over 18 years, were literate, and underwent surgery from July
2013 to August 2015.
All participants signed an informed consent form approved by the Research Ethics
Committee of the HU-UFJF (number 309.134, dated June 24, 2013).
The patients were identified, and the module for reduction mammoplasty/mastopexy
of the BREAST-Q® questionnaire, an instrument validated in
Brazil, was used for data collection8,9 in the
preoperative period and 6 months after surgery. The questionnaire was
administered to 83 patients in the preoperative period and to 79 patients 6
months after surgery at the HU-UFJF Plastic Surgery Outpatient Clinic and at
predetermined times, according to the surgical schedule. The questionnaires were
self-administered with the supervision of one of the researchers, all previously
trained to clarify doubts and help patients with difficulties in understanding
it. Simultaneously with the administration of the BREAST-Q®,
data regarding age, color, body mass index (BMI), and subsequently, the amount
of breast resected were collected.
The surgical technique used was the inverted T associated with the techniques of
Silveira Neto, Skoog, or Torek for elevation of the areola pedicle, which varies
according to each breast.
For statistical evaluation, we used the Q-Score software6,7,9, a specific
program for analyzing the BREAST-Q® questionnaire. This
software provides clinicians and researchers with a simple and accurate analysis
of their data as the scores are calculated from the answers and graded on a
scale of 0-100: the higher the score, the better the quality of life related to
health and the greater the satisfaction. The paired t-test was used to assess
the significance of changes in breast satisfaction and psychosocial, physical,
and sexual well-being.
A p-value < 0.05 was considered significant. Statistical
analyses were performed using SPSS version 21.0 software.
RESULTS
Eighty-three patients underwent reduction mammoplasty between July 2013 and
August 2015. Seventy-nine patients (95.1%) completed the pre- and postoperative
questionnaires. Demographic data are presented in Table 1. The mean age was 38.97 ± 12.97. The mean
weight of resected tissue in the right and left breast was 812.91 ±
477.79 g and 831.11 ± 497.44 g, respectively. The highest total weight of
breast resected was 5445 ± 12.97 g. The mean BMI of patients in the
preoperative period was 29.9 ± 3.74 kg/m2.
Table 1 - Demographic data and descriptive statistics.
|
n |
Minimum |
Maximum |
Mean |
Standard deviation |
Age, years |
83 |
18.00 |
64.00 |
38.9700 |
12.97838 |
BMI, kg/m2 |
74 |
22.40 |
39.69 |
29.9000 |
3.74741 |
Right breast |
81 |
85.00 |
2885.00 |
812.9100 |
477.79552 |
Left breast |
81 |
60.00 |
2560.00 |
831.1100 |
497.44540 |
Total |
81 |
145.00 |
5445.00 |
1644.0200 |
956.22670 |
Table 1 - Demographic data and descriptive statistics.
Postoperatively, statistically significant improvements were observed in breast
satisfaction, and psychosocial, physical, and sexual well-being (Table 2).
Table 2 - Results and changes in the pre- and postoperative scores.
|
Preoperative |
Postoperative |
p
|
|
n |
Mean |
Standard deviation |
n |
Mean |
Standard deviation |
Satisfaction with breasts |
79 |
16.557 |
10.5996 |
79 |
78.37 |
16.369 |
0.001 |
Psychosocial well-being |
78 |
27.051 |
16.4292 |
78 |
84.54 |
17.829 |
0.001 |
Sexual well-being |
65 |
27.40 |
16.692 |
65 |
78.86 |
23.720 |
0.001 |
Physical well-being |
76 |
52.14 |
16.011 |
76 |
77.26 |
13.528 |
0.001 |
Table 2 - Results and changes in the pre- and postoperative scores.
Preoperative and postoperative scores were 16.5 ± 10.59 and 78.37 ±
16.36 for breast satisfaction, 27.05 ± 16.42 and 84.54 ± 17.82 for
psychosocial well-being, 27.40 ± 16.69 and 78.86 ± 23.72 for
sexual well-being, and 52.14 ± 16.01 and 77.26 ± 13.52 for
physical well-being, respectively (all p < 0.001) (Table 2).
The sample was divided into two groups to assess the impact of nutritional status
on the results: patients with a BMI below the median (29.7 kg/m2) and patients with a BMI above the median.
Although statistical significance was not observed, patients with a BMI below
the median had a higher degree of satisfaction in psychosocial (88.45 vs. 81.47,
p = 0.11) and sexual (81.78 vs. 78.47, p =
0.57) well-being. On the other hand, patients with a BMI above the median showed
superior improvement in physical well-being (77.88 vs. 77.06, p
= 0.808). There were no differences between groups in the evaluation of the
surgeon, surgical team, and hospital care, and all items received scores close
to 100.
Patients above the median age were slightly more satisfied with the result than
those below the median. Physical well-being was higher in the postoperative
period of older patients vs. younger patients (78.26 vs. 76.93,
p = 0.667) while breast satisfaction (80.46 vs. 76.33,
p = 0.26), psychosocial well-being (85.34 vs. 83.78 p =
0.701), and sexual well-being (83.53 vs. 76, p = 0.176) were
higher in younger patients, despite the lack of statistical significance.
Patients with a total reduction in breast weight below the median (1502.5 g) had
a more marked improvement in psychosocial well-being (20.0 vs. 25.17,
p = 0.29) and were slightly more satisfied with the result
than those whose reduction in breast weight was above the median (91.54 vs.
90.36, p = 0.72). In these patients, the scores for breast
satisfaction (75.67 vs. 81.28, p = 0.133), physical well-being
(75.36 vs. 79.61, p = 0.174), and sexual well-being (78.92 vs.
81.68, p = 0.622) were higher postoperatively.
Complications were observed in 10 patients (12.04%) who had some type of
intercurrence, one with a hematoma that was drained in an outpatient setting,
one with a keloid scar that was treated with resection and infiltration with
intralesional corticosteroids, three with some degree of fat necrosis, one with
a hypertensive pneumothorax treated with thoracic drainage, and four with areola
necrosis (one with bilateral and three with unilateral necrosis), two of whom
were treated surgically.
DISCUSSION
The breast represents femininity, symbolizing motherhood and the female
sexuality. Breastfeeding, a function of the mammary gland, creates a close
relationship between the organ and the reproduction of the species3,4.
BH is a benign alteration that affects the breasts, causing an increase in volume
that is disproportionate to the biotype of the woman. Thus, this deformity
causes physical and psychological consequences, such as depression and anxiety,
leading to social isolation and suffering with the loss of self-esteem and
libido.
Surgery aims to reduce breast volume, improve aesthetics, and helps correct
postural problems, back pain, and ptosis, especially after pregnancy and
lactation2,10. Mammoplasty has also been used to
obtain aesthetic or postural balance in patients undergoing mastectomy or
sectionectomy/quadrantectomy for contralateral breast cancer.
Surgical therapy results in an increase in the quality of life, which has been
used since the end of the previous decade as an indicator in the assessment of
healthcare services provided to the population. Moreover, the quality of life
has been incorporated into care services and has been influencing therapeutic
decisions and behaviors of health teams11.
Several evaluations were made with more specific samples of patients in order to
assess the relationship between quality of life and reduction mammoplasty in the
groups studied. Patients under 18 years of age undergoing surgery were
retrospectively analyzed, and a significant prevalence of limiting symptoms was
found in these patients preoperatively, encouraging early surgery to attenuate
them12.
Although the analyses of the above-mentioned instruments follow rigid
methodologies that have already been exhaustively validated and used, any
attempt to address quality of life is challenging. The use of several
instruments in the same study may be due to the difficulty in finding an ideal
instrument for this type of analysis. Hermans et al.13, Mello et al.14,
and O’ Blenes et al.15 used the Rosenberg
self-esteem scale and the SF-36 (Short Form Health Survey) and found a positive
effect on the quality of life of patients undergoing reduction mammoplasty.
Hermans et al.13 assessed pain using the
EQ-5D (European Quality of Life-5 Dimensions) questionnaire. Saariniemi et
al.16, in turn, used specific
instruments to determine whether breast augmentation significantly reduced pain
as well as reduced limitations on daily activities, which is in agreement with
the results of Sabino Neto et al.17
Additional evidence of pain reduction after breast reduction was the decrease in
the use of analgesics and nonsteroidal anti-inflammatory drugs by 92 patients
undergoing this procedure16.
It should also be emphasized that the samples assessed with the instruments had
different characteristics, making the general conclusions obtained in these
analyses less reliable6.
The BREAST-Q®18 is a new
instrument for assessing body image and quality of life in patients undergoing
breast surgery. It was developed at the Memorial Sloan Kettering Cancer Center
and the University of British Columbia, following strict rules of international
guidelines, such as those of the U.S. Food and Drug Administration and
Scientific Advisory Committee of the Medical Outcomes Trust6,7,19-21. It was
translated into Portuguese after authorization and compliance with the norms of
the institution that holds the questionnaire’s copyright9.
The BREAST-Q®, the analysis tool used in this study, has
already been used in a study that compared preoperative and 6-week postoperative
results and found that breast reduction increases satisfaction with the
appearance of the breasts as well as physical, sexual, and psychosocial
well-being and that the satisfaction of patients is strongly related to
satisfaction with their appearance5.
Coriddi et al.5 indicate as a limitation
of their study the cross-sectional design and state that further studies
evaluating patients 6 weeks after breast reduction should be conducted to
evaluate the results in the long term.
The patients’ answers to the questionnaires were included in the Q-score, which
consolidates the answers into a single numerical value for each category,
ranging from 0 to 1007,8.
It is important to emphasize that, in the study conducted by our institution, the
second questionnaire was assessed 6 months postoperatively, a period in which
the surgical outcome tends to be more similar to the permanent result and
therefore ruling out the bias of gratitude, as the closer the postoperative
period is to the surgery the stronger are the memories of breast deformity in
these individuals.
Although one of the biggest complaints of mammoplasty is the size of the scars,
the degree of satisfaction (mean score of 79.4 ± 16.2) indicates that
patients are satisfied with the scars of the breasts, as in the
BREAST-Q®, questions about satisfaction with the size and
quality of the scar are included.
Romeo et al.22 evaluated 51 patients using
five questionnaires (the SF-36, Hamilton Anxiety Rating Scale, Hamilton
Depression Scale, Female Sexual Function Index, and a cicatricial evaluation)
and found that the surgery led to a better perception of body self-esteem and
interpersonal relationships and that the scar did not influence the perception
of sexuality of women, given that their postoperative satisfaction was greater
as time went on.
Age, nutritional status, and weight of the resected tissue did not influence the
perception of quality of life assessed using the BREAST-Q®,
although the results suggest further investigations.
The use of several questionnaires leads to results similar to those achieved
using the BREAST-Q®, which allows us to affirm the range of
information obtained with a single method, making this a reliable tool for
evaluating the results of breast surgery. We highlight in this study the
administration of pre- and postoperative questionnaires in the same sample;
i.e., the patients who answered the BREAST-Q® preoperative
module were the same patients who underwent surgery and subsequently answered
the BREAST-Q® postoperative module for reduction
mammoplasty/mastopexy 6 months after surgery.
CONCLUSION
BH continues to be a body alteration that impairs women’s quality of life,
worsening their self-image, work activities, and body aesthetics. This study
demonstrated, using the BREAST-Q® questionnaire, that breast
reduction mammoplasty significantly improved breast satisfaction and physical,
psychosocial, and sexual well-being. This study also assessed the satisfaction
of patients with the results of the surgery, the information provided to them,
the nipples, the plastic surgeon, the team, and the hospital reception, showing
high scores in their evaluations.
This study showed that patients with BH undergoing surgery to reduce breast
volume had a significant improvement in the various aspects of quality of life
and evaluated as positive the surgical results, the medical hospital team, and
their nipples.
The development and validation of the BREAST-Q® represents an
important advance for plastic and reconstructive breast surgery because it is a
specific method to assess these surgeries in addition to serving as a reference
for comparing different studies and populations undergoing surgery.
COLLABORATIONS
MPDC
|
Conception and design study, data curation, final manuscript
approval, project administration, realization of operations and/or
trials, supervision, visualization, writing - original draft
preparation.
|
AMDC
|
Conceptualization, final manuscript approval, visualization, writing
- review & editing.
|
LDC
|
Conceptualization, final manuscript approval, visualization, writing
- original draft preparation, writing - review & editing.
|
MTD
|
Conceptualization, data curation, final manuscript approval,
realization of operations and/or trials, supervision, visualization,
writing - review & editing.
|
EPVJ
|
Conceptualization, final manuscript approval, visualization, writing
- review & editing.
|
AC
|
Analysis and/or data interpretation, final manuscript approval,
formal analysis, methodology, realization of operations and/ or
trials, software, validation, visualization.
|
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20207212
1. Universidade Federal de Juiz de Fora, Hospital
Universitário, Juiz de Fora, MG, Brazil.
2. Universidade Federal de Juiz de Fora,
Faculdade de Medicina, Juiz de Fora, MG, Brazil.
3. Hospital Maternidade Therezinha de Jesus, Juiz
de Fora, MG, Brazil.
4. Hospital Federal de Ipanema, Rio de Janeiro,
RJ, Brazil.
5. Universidade Federal de Juiz de Fora, Juiz de
Fora, MG, Brazil.
Corresponding author: Marilia de Pádua Dornelas
Côrrea, Rua Dom Viçoso, nº 20, Alto dos Passos, Juiz de Fora, Minas
Gerais, Brazil. Zip Code: 36026-390. E-mail:
marilia.dornelasc@gmail.com
Article received: November 07, 2018.
Article accepted: April 21, 2019.
Conflicts of interest: none.