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.
- BRSQ —
- Breast-Related Symptoms Questionnaire
- EAT-26 —
- Eating Attitudes Test-26
- HRQoL —
- health-related quality of life
- RSES —
- Rosenberg Self-Esteem Scale
- SF-36 —
- Short-Form 36v2
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.
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.
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 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 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.
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 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.
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).
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).
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 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, 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 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).
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 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.
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 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.
- Accepted August 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:
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.
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- Centers for Disease Control and Prevention
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- Copyright © 2017 by the American Academy of Pediatrics