A comparison of the patient and surgeon opinion on the long-term aesthetic outcome of reduction mammaplasty

British Journal of Plastic Surgery (1998), 51,444M49 9 1998 The British Association of Plastic Surgeons BRITISH JOURNAL OF \ ~ ) PLASTIC SURGERY A comparison of the patient and surgeon opinion on the long-term aesthetic outcome of reduction mammaplasty Y. Godwin, S. H. Wood and T. J. O'Neill Department of Plastic Surgery, The West Norwich Hospital Norwich, UK SUMMARY. The aim of this study was to assess the difference in opinion between patients and surgeons regarding the aesthetic outcome of reduction mammaplasty. A total of 34 women, who were more than 1 year post surgery, attended an outpatient clinic to assess their opinion of the aesthetic outcome of their breast reduction. A questionnaire was used to standardise their responses~ Photographic slides were taken to record the frontal, left oblique and recumbent view of their torso. These slides were assessed by four consultant plastic surgeons who completed the same questionnaire, and were blinded as to the surgeon and patient. The majority of patients rated the aesthetic outcomes of their surgery significantly higher than the consultants. Scarring was the most frequent cause of dissatisfaction for both surgeons and patients. The consultants considered the scarring following Lejour reduction to be significantly better than that following the inferior mound reduction. The nipple was considered to be too high on the breast by 12% of women but they did not request correction of this. However, consultants thought this was a problem in 27% of cases. The aesthetic outcome of reduction mammaplasty was acceptable to the patients although surgical assessment indicates that there is scope for improvement. The main area of aesthetic dissatisfaction remains the postoperative scarring. Reduction mammaplasty involves much judgment by the surgeon to meet the patient's desired outcome. The final size and shape of the breast will depend on the surgeon's interpretation of what size the patient wishes to be. The preoperative markings, the technique used and the nature of the patient's tissues will all affect the result. No previous studies have compared the patient's and surgeon's opinion of the long-term aesthetic outcome. However, this is of importance, as it has been reported that 65% of patients requesting reduction mammaplasty have cosmetic as well as functional concerns at the time of requesting surgery. 1 Once the preoperative upper torso symptoms of neck and back pain, strap furrows, submammary intertrigo have resolved, the cosmetic aspects such as scars become the main cause of patient dissatisfaction in the postoperative period. Maxwell Davis 1 states that poor scars, breast size error, odd shape and unequal breasts are the commonest causes of postoperative dissatisfaction. Pers 2 felt that dissatisfaction is frequently related to poor scars. SerlettP reminds us that overall patient satisfaction is high despite the poor aesthetic results. It seems clear that women request this operation for functional reasons and are willing to accept complications but obviously would like the best cosmetic outcome possible. The patient should not have to trade off her upper torso symptoms for a poor aesthetic result. The aim of this study was to assess the aesthetic result of reduction mammaplasty from both the patient's and surgeon's points of view. It investigated whether the patient was happy with the aesthetic appearance of the smaller breast the surgeon had designed, once the upper torso symptoms attributed to the large breast size had been resolved by the reduction of the breast tissue mass. Patients and methods A total of 63 consecutive patients who underwent reduction mammaplasty at least 1 year previously were invited to attend a clinic to assess their views on the aesthetic outcome of their surgery. The patient population was drawn in chronological order of their date of operation from the theatre log book. Thirtyfour (54%) of the women attended the clinic. Eighteen did not give a reason for the non-attendance. Some of these patients may not have received their letter due to a change of address in the postoperative period. Eleven patients tried to attend, but failed due to a variety of problems on the day. These patients offered to complete postal questionnaires, but this was not appropriate for the study. Four consultants were involved in elective breast surgery at The West Norwich Hospital. Three techniques of breast reduction were used: inferior mound 4 in 21 patients, Lejour s in 11 and breast amputation with free nipple graft in 2 patients. Demographic and operative details were recorded from the notes, Table 1. In the immediate postoperative period 3 patients suffered partial nipple-areolar necrosis on one side. 444

Aesthetic outcome of reduction mammaplasty 445 Table 1 Demographic data relating to the 34 patients who responded to the questionnaire (SD is standard deviation) Mean SD Range Age (years) Time of assessment (weeks postoperatively) Weight preoperatively (kg) Weight at clinic (kg) Weight of breast tissue excised (kg) 35 13.7 19-69 79 18.8 52 108 72.4 13.9 54-110 73.6 15.2 52 117 1.42 0.56 0.46 2.73 Figure 1 (A,B,C) Frontal, left oblique and recumbent views of inferior mound reduction: the views used by the surgeons to assess the results. The only early operative procedure was debridement and split thickness skin grafting of the lateral skin flap that necrosed following an inferior mound reduction. No haematomas were identified acutely but one patient had needle aspiration of a collection in the dressing clinic. Thirteen patients required antibiotics from their general practitioners for areas described as either wound infection or wound breakdown. Eight patients had healing problems at the inverted T junction of the scar in the inferior mound patients. One patient had a wound infection in the vertical scar of the Lejour reduction. One patient with a breast amputation developed infection around the free nipple graft and was admitted for intravenous antibiotics; the nipple remained viable. At the clinic each patient was interviewed by a female practitioner who was not present in the unit at the time of operation. The patients were asked standard questions that covered four aspects of the aesthetic result of their surgery. For each question they selected a single grade as stated in Tables 2-5. The first section asked the patient how they felt about the general appearance of their breasts with respect to their overall body shape and balance (Table 2). Patients were asked to rate their body harmony, their appearance with and without clothes as well as their overall body symmetry. The second part of the questionnaire asked the patient questions concerning the final shape of the breast, i.e. its size and position on the chest wall, how pendulous the breasts are and overall shape (Table 3). The third section asked for a rating of the nipple-areolar complex symmetry, projection, size, shape and position on the breast itself (Table 4). The patient was then asked to rate their scars as excellent, good, satisfactory, or unacceptable (Table 5). Finally, the patient was asked whether they would undergo further surgery if it was offered to revise any aspect of their current appearance. Each patient was asked whether they would have the operation again and would they recommend it to a friend. Three photographs were taken of the patient's torso (Fig. 1). A frontal view demonstrated the general appearance and symmetry, and an oblique view was taken to show ptosis. A recumbent view demonstrated the scars and also the shape and appearance the surgeon would perceive on the theatre table. The four consultant surgeons blindly assessed the three slides of each patient. They were not informed of the patient's identity or who had performed the surgery. They filled in the same questionnaire as the patients but omitted the question asking to grade appearance when dressed as no slides were taken of this. The surgeons were asked whether they would offer further surgery to the patient.

446 British Journal of Plastic Surgery Table 2 General appearance of patient's torso: patients' versus consultant opinion (%). No view of the patient in clothes was provided for the consultants Overall body harmony Appearance in clothes Appearance out of clothes Overall symmetry Patient Consultant Patient Consultant Patient Consultant Patient Consultant Excellent Good Satisfactory Poor Unacceptable Significance of difference 38 10 50-35 7 41 7 41 32 32-32 21 35 37 18 43 18-21 44 15 44 3 15 0 6 27 6 11 0 0 0-6 1 3 1 P<O.O01 P<O.O1 P<O.O1 Table 3 Appearance of breast itself: patients' versus consultants' opinion (%) Patient Consultant Significance of difference Size Too big 6 18 Slightly too big 31 11 About right 57 67 Slightly too small 6 3 Too small 0 1 Shape Excellent 32 12 Good 40 21 Satisfactory 18 38 Poor 6 28 Unacceptable 4 2 Position Too high 0 0 About right 84 74 Ptotic 9 16 Too low 7 10 Not significant P<O.O01 Not significant For the patient responses and surgeon responses, the number of patients in each category was expressed as a percentage. Statistical analysis was performed using the sign test for the ranked data, comparing paired results of the patient's score against the averaged consultant's score. The Chi-square test was used to compare non-ranked data. Results Figure 2 (A,B,C) Frontal, left oblique and recumbent views of Lejour reduction. Aesthetic outcome considered excellent by patient and surgeons. Most patients were pleased with their results. Figure 1 (A,B,C) shows an inferior mound breast reduction 18 months postoperatively; Figure 2 (A,B,C) a Lejour reduction 1 year postoperatively. Both women and surgeons graded these reductions with maximal results. The four facets of aesthetic concern to patients post reduction mammaplasty are shown in Tables 2-5. The surgeon's and patient views are listed. Table 2 shows patient and consultant opinion with respect to the patient's general postoperative appearance. The patients were photographed undressed, so no consultant opinion is available for the appearance in clothes. Overall the surgeons scored the results as significantly less satisfactory in all the categories compared to the patients. In Table 3, the overall scoring for the size, the shape and the position of the breast on the chest wall

Aesthetic outcome of reduction mammaplasty 447 Table 4 Appearance of the nipple-areolar complex: patients' versus consultants' opinion (%) Patient ~imsultant SigniJicance of diffi, rence Overall symmetry Excellent 35 7 Good 47 32 Satisfactory 6 42 Poor 9 18 Unacceptable 3 1 Projection Good 68 40 Satisfactory 20 47 Poor 12 13 Size Correct 93 66 Too big 4 17 Too small 3 17 Shape Satisfactory 71 68 Position About right 84 55 Too high 12 27 Too low 3 9 Too lateral 1 3 Too medial 0 4 P<O.01 P=0,03 P<0.001 P<0.001 Table 5 Appearance of the postoperative scars: patients' versus consultants' opinion (%) Scztr,~ Patient Consuhant si,~.!hon,'; qf d(t)~i-'rence P=O.07 Figure 3 (A,B) Patient with marked keloid formation at site of reduction mammaplasty scars. Excellent 31 l0 Good 24 33 Satisfactory 21 34 Poor 13 14 Unacceptable 12 9 is presented. The consultants were significantly less impressed by the shape of the breast following surgery (P<0.01). Table 4 summarises the opinions on the nipple areolar complex. Patients rated all features questioned more highly than the surgeons. This was significant for the overall symmetry (P<0.01) and the projection of the nipple areolar complex (P=0.03). The position of the nipple and its size were scored as significantly incorrect in comparison to the patients (P<0.001) using the Chi square test. The assessment of the resultant scars is shown in Table 5. Patients were less critical of the scars than the surgeons when considering the better results, although this was not significant (P=0.07). However, of all the features considered in the questionnaire, scars have the highest number of 'unacceptable' gradings from the patients. All patients who rated their scars as unacceptable had had some postoperative complication including infection, wound breakdown or hypertrophic scar formation. The scars following Lejour reduction were rated by consultants as excellent or good in 60% of cases compared to 32% of inferior mound reductions (P<0.05). Table 6 lists the procedures undertaken in the late postoperative period to correct any complications. In all, 18 (53%) patients underwent some form of adjustment, almost half of which were for medial or lateral wound dog ears. Fourteen (41%) patients were offered further operations at the time of their postoperative follow-up clinics but declined, because their appearance was acceptable and they did not want more surgery. Three patients required intralesional triamcinalone injections for hypertrophic scarring. Of these, one patient of Negroid descent went on to keloid formation (Fig. 3 A,B). Three patients requested further reduction. A teenage patient had further hypertrophy and was booked for further reduction once her growth seemed complete. A patient with marked synmastia still present after a small reduction was reduced further and her medial scars revised with correction of the central web. Further reduction was refused in the case of the patient with keloid scar formation. Thirty-two (94%) of the patients would have the operation again or recommend it to a friend. The two patients who would not do so are both young and suffered severe scarring complications.

448 British Journal of Plastic Surgery Table 6 Patients in whom secondary surgery is requested, planned or performed (some patients had more than one deficit) Planned or Acknowledged Requested but performed but refused by refused by patient surgeon Scar revision/inframammary Trimming of medial/lateral dog ears Further reduction Liposuction for lateral bulge Liposuction for asymmetry Poor breast shape Triamcinolone injection for hypertrophic scars 3 1 10 4 2 2 5 1 4 Discussion The long-term satisfaction gained by women following reduction mammaplasty has been documented by numerous authorsj,3,~ Some regard the operation as functional and aesthetic, 3,7 others as an operation that relieves functional disability only? This study was undertaken to assess whether the long-term aesthetic needs as well as the functional needs are met following reduction mammaplasty in British women. This is then contrasted with the consultant opinion of the aesthetic appearance of their surgery. Due to limited resources, Regional Health Authorities in Britain can exclude reduction mammaplasty as a state funded operation by classifying it as a cosmetic procedure? This has led to authors concentrating on the functional benefits of reduction mammaplasty as the main reason for patient satisfaction rather than addressing the patient's view of the long-term aesthetic result. Patient attendance in this study matches that to postal questionnaires sent by other authors? 3.9 Unlike postal questionnaires, it gave the patient the opportunity to ask questions and express any other opinions/problems they had in the postoperative period. The questionnaire was designed to address aesthetic features only. As the interview was performed by a female practitioner who was not present at the time of the operation it allowed the patients to express their true feelings with respect to their aesthetic appearance, without embarrassment, or the worry of offending their surgeon if they were dissatisfied with the result. The general review shows that patients are satisfied with their general appearance, the breast shape and size and the projection and position of the nipple areolar complex. In all, 94% would undergo the procedure again and recommend it to a friend. This corresponds with percentages found in other studiesj,3,8 Unsightly scars are still the main source of dissatisfaction for both patient and surgeon. The fact that the surgeons do not significantly grade the scars more severely than the patients (unlike most categories) is an indication of the patient's concern. The two patients who stated they would not undergo reduction again, nor recommend it, had disfiguring scars due to skin flap necrosis or keloid formation. This study confirms that surgeons are more critical of the aesthetic outcome of their surgery than the patients but it was rare for either patients or surgeons to consider a result to be unacceptable. The main areas criticised were the shape of the breast (30% poor or unsatisfactory), the nipple projection (13% poor), and the position of the nipple on the chest wall (55% about right, 27% too high). The surgical correction of a nipple placed too high is extremely complex and this result emphasises the need for caution in planning the new nipple height. Fortunately, only 12% of patients thought their nipples were placed high and none requested correction of this. It is clear from this study that there is potential for improvement in the quality of the aesthetic result. The operations in this study were performed by several surgeons and it is consequently not possible to determine factors that influence the quality of the aesthetic result. At present, little is known as to the effects the quality of skin elasticity, vascular supply or the proportions of fat to breast tissue have on the result in reduction mammaplasty. A prospective study of the changes that occur could provide information to improve the effectiveness of preoperative planning. Results will be further advanced by the developments of simple clinical techniques to measure the appropriate variables preoperatively. The surgeons did agree on to whom they would be prepared to offer further corrective surgery based on this photographic assessment alone. Some patients who would have been offered surgery acknowledged there was an aesthetic problem but did not want further treatment. Probably the fact that they all considered that their appearance was at least satisfactory in clothes was a factor in their lack of desire for further treatment. Statistically, the scar following the Lejour procedure was rated as superior to that of the inferior mound reduction by the consultant panel. Subjectively, they all also considered the Lejour to give the best overall aesthetic result, but this was not proven statistically. Georgiade 1~ states the essential goals of breast reduction are to get a predictable result, retain nipple sensitivity, the possibility of lactation and to give an excellent aesthetic result. Despite the aesthetic complications of poor scars, asymmetry of breast shape and the nipple areolar complex, this operation shows a high degree of patient long-term satisfaction. We must not slip into complacency as the high patient satisfaction from the functional benefits can distract us from the cosmetic results. As surgeons we should endeavour to improve the aesthetic outcome as it is not perfect.

Aesthetic outcome of reduction mammaplasty 449 References 1. Maxwell Davis G, Ringler SL, Short K, Sherrick D, Bengtson BE Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg 1995; 96: 1106 10. 2. Pers M, Nielsen IM, Gerner N. Results following reduction mammaplasty as evaluated by the patients. Ann Plast Surg 1986; 17:449 55. 3. Serletti JM, Reading G, Cadwell E, Wray RC. Long-term patient satisfaction following reduction mammaplasty. Ann Plast Surg 1992; 28: 363-5. 4. Robbins TH. A reduction mammaplasty with the areolar-nipple based on an inferior dermal pedicle. Plast Reconst Surg 1977; 59: 6+-7. 5. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 1994; 1: 100-14. 6. Klassen A, Fitzpatrick R, Jenkinson C, Goodacre T. Should breast reduction surgery be rationed? A comparison of the health status of patients before and after treatment; postal questionnaire survey. BMJ 1996; 313: 45+-57. 7. Pickford MA, Boorman JG. Early experience with the Lejour vertical scar reduction mammaplasty technique. Br J Plast Surg 1993; 46: 516-22. 8. McMahan JD, Wolfe JA, Cromer BA, Ruberg RL. Lasting success in teenage reduction mammaplasty. Ann Plast Surg 1995; 35: 227-31. 9. Miller AP, Zacker JB, Berggren RB, Falcone RE, Monk JB. Breast reduction for symptomatic macromastia: can objective predictors for operative success be identified? Plast Reconstr Surg 1995; 95: 77-83. 10. Georgiade GS, Riefkohl RE, Georgiade NG. The inferior dermal-pyramidal type breast reduction: long-term evaluation. Ann Plast Surg 1989; 23:203-11. 11. Hughes LA, Mahoney JL. Patient satisfaction with reduction mammaplasty: an early survey. Aesth Plast Surg 1993; 17: 345-9. The Authors Y. Godwin FRCS S. H. Wood FRCS (Plast) T. J. O'Neill FRCS Department of Plastic Surgery, The West Norwich Hospital, Bowthorpe Road, Norwich NR2 3TU, UK. Correspondence to Y. Godwin, Department of Plastic Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK. Paper received 24 March 1997. Accepted 20 April 1998, after revision.