Reduction Mammaplasty is not Associated with a Decrease in BMI for Overweight or Obese Women

Paige Myers* and Jose Guillherme Christiano

University of Rochester Medical Center, Rochester, NY 14642, USA

*Corresponding Author:
Paige Myers
Plastic Surgery Resident
University of Rochester Medical Center
Rochester, NY 14642, USA.
Tel: 315-286-3481
E-mail: [email protected]

Received Date: January 26, 2016; Accepted Date: February 07, 2017; Published Date: February 20, 2017

Citation: Myers P, Christiano JG. Reduction Mammaplasty is not Associated with a Decrease in BMI for Overweight or Obese Women. J Aesthet Reconstr Surg. 2017, 3:2. doi: 10.4172/2472-1905.100025

 
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Abstract

Abstract

Introduction: Reduction mammaplasty can be a life-changing event for women with symptomatic macromastia. Many women experience improvement in physical symptoms, including resolution of neck, back and shoulder pain. There are other reported positive changes, including more physical activity, improved glucose control and a self-confidence. Adolescents have demonstrated weight loss following reduction mammaplasty but there is little objective data in the adult population.

Methods: After obtaining institutional review board approval, eligible patients were identified in our institution's electronic record database, eRecord (Epic; Madison, WI). Eligible subjects were identified using i2b2 software for the diagnosis of macromastia (ICD-9 611.1) and the CPT code for reduction mammaplasty (19318). A retrospective study chart review was performed from June 1, 2011 to time September 30, 2015 for97 women. The mean BMI was calculated at different time intervals post-operatively, including 1 week, 1 month, 3 months, 6 months, 12 months, 1 year, 2 years and 2+ years. The BMI values for each patient were then compared to the 1 week postoperative BMI. The change was then analyzed to determine if there was any significant weight loss.

Results: There is a slight increase in BMI with increasing post-operative time (mean of 31.934 at one week compared to 33.255 2+ years) although this is not statistically significant. The lowest 50% of patients based on baseline-BMI was compared with the highest 50% of patients; each group showing no significant difference over time. Similar analyses using a mixed-effects model were performed given the longitudinal nature of the data, however this also showed that there was no significant change.

Conclusion: Despite well-document physical and psychological improvements following reduction mammaplasty, there is no statistically significant BMI decrease for women of all BMIs at time points from 1 month to more than 2 years when compared to their 1- week post-op BMI.

Keywords

Mammaplasty; Adolescents; Diagnosis; Psychological

Introduction

Reduction mammaplasty can be a life-changing event for women with symptomatic macromastia. Many patients experience after surgery improvement or resolution of physical symptoms and other preoperative complaints, including neck, back and shoulder pain, intertrigo and shoulder grooving [1-5]. There is also evidence that reduction mammaplasty may result in correction of vertebral abnormalities [6,7]. Women presenting with macromastia are often less healthy, engage in less physical activity, and exhibit lower levels of self-esteem when compared to age-matched controls without the diagnosis [3]. This could set the stage for postoperative benefits beyond physical pain relief. In fact, other authors have reported increase in physical postactivity, improvement in glucose control with decreased insulin resistance, and increase in level of self-confidence [1-9]. The goal of our study was to determine whether reduction mammaplasty was associated with a drop in BMI in macromastia patients.

Methods

Approval for retrospective chart review was obtained from our institutional review board (RSRB 00059571). Eligible patients were identified in our institution’s electronic record database, eRecord (Epic; Madison, WI), using i2b2 software (Partners Health Care; Boston, MA) for querying. All women who underwent bilateral reduction mammaplasty for macromastia between June of 2011 (implementation of eRecord in our institution) and September of 2015 were included. They were identified by searching for the diagnosis of macromastia (ICD-9 611.1) under Encounter Diagnoses, Past Medical History, or Problem List, and the CPT code for reduction mammaplasty (19318) under Procedures. Women were excluded from analysis if they were under the age of 18, if they became pregnant, or were diagnosed with malignancy within the study period, or if there was insufficient documentation in the electronic record database.

The charts of ninety-seven patients who met our study’s inclusion criteria were reviewed. The mean BMI was calculated for all 97 patients included in the study at different time intervals postoperatively, including 1 week, 1 month, 3 months, 6 months, 12 months, 1 year, 2 years and greater than two years. The BMI values for each patient at the aforementioned time intervals were then compared to the 1 week post-operative BMI (to account for the weight of the tissue removed). This change in BMI was then analyzed to determine if there was any significant change. All analyses were carried out using SAS/STAT v9.4 (SAS Institute Inc.; Cary, NC).

Results

For preliminary exploration, the change in mean BMI was examined at each follow-up time, using 1-week post-operative BMI as the baseline and following through 2 years and greater post-operative BMI. There is a slight increase in BMI with increasing post-operative time (mean of 31.934 at one week post-operative compared to 33.255 2+ years post-operative) although this relationship is not significant (Table 1).

Time (post-op) N N Miss Mean Std Dev Lower 95%
CL for Mean
Upper 95%
CL for Mean
1 week 97 0 31.9337073 5.8901688 30.7465755 33.1208392
1 month 85 12 31.9928383 5.8646335 30.7278662 33.2578104
3 months 73 24 32.4581355 6.3609511 30.9740158 33.9422552
6 months 56 41 32.5591754 5.5282797 31.0786925 34.0396584
12 months 42 55 33.3060786 5.8668998 31.4778240 35.1343333
2 years 42 55 33.0400511 6.2180927 31.1023570 34.9777452
+2 years 37 60 33.2545510 5.6579919 31.3680826 35.1410194

Table 1: Mean BMI from 1 week post-op to +2 years post-op.

To investigate this relationship further, the time trend of the lowest 50% of patients based on baseline-BMI was compared with the highest 50% of patients based on BMI. Looking at patients who comprise the lower 50% of baseline BMIs, it is apparent that through three months after surgery, the average BMI is relatively maintained and unchanging. This is followed by an increase in BMI after three months post-operatively. There is large variability in these estimates, as illustrated in the 95% confidence interval bands, indicating no significant difference over time (Table 2).

Time of Visit (post-operative) N Obs N N Miss Mean Std Dev Lower 95%
CL for Mean
Upper 95%
CL for Mean
1 week 49 49 0 27.4588956 2.5256041 26.7334574 28.1843338
1 month 49 43 6 27.4041576 2.4996681 26.6348733 28.1734419
3 months 49 35 14 27.4854026 2.8609938 26.5026168 28.4681883
6 months 49 25 24 27.9292590 3.1596298 26.6250279 29.2334900
12 months 49 18 31 28.1025020 3.0719489 26.5748578 29.6301463
2 years 49 20 29 28.4694471 3.0051369 27.0629997 29.8758944
2+ years 49 16 33 28.5031039 3.1541137 26.8223953 30.1838125

Table 2: Trend of mean BMI from 1 week post-op to +2 years post-op, lower 50% BMI category.

For patients who comprise the higher 50% of baseline BMIs, there is an increase in BMI over time, with a slight decrease at six months after surgery (Table 3). Note that as more time elapses from date of the operation, there is less BMI information for fewer patients. In particular, the fewest observations at later time points are for patients who originally were in the lowest 50% of BMIs. Thus, when looking at later time periods, most of the subjects examined already started with a higher BMI. As a result, overall summary results to also appear higher than what may have been the case if all BMI measurements were observed. Additionally, by twelve months after surgery, there is only a total of 37 observations—16 of which were from the lower 50% and 21 were from the higher 50%—compared to the 97 observations at one week after surgery. With such small samples sizes, there is no significant change in BMI over time.

Time of Visit (post-operative) N Obs N N Miss Mean Std Dev Lower 95%
CL for Mean
Upper 95%
CL for Mean
1 week 48 48 0 36.5017443 4.7077772 35.1347483 37.8687403
1 month 48 42 6 36.6907733 4.4014602 35.3191818 38.0623649
3 months 48 38 10 37.0382843 5.1262575 35.3533254 38.7232432
6 months 48 31 17 36.2929790 3.9716571 34.8361634 37.7497946
12 months 48 24 24 37.2087611 4.1592336 35.4524708 38.9650514
2 years 48 22 26 37.1951457 5.4161635 34.7937534 39.5965381
2+ years 48 21 27 36.8747012 4.2825323 34.9253159 38.8240865

Table 3: Trend of mean BMI from 1 week post-op to +2 years post-op, upper 50% BMI category.

Since the data is longitudinal in structure, with patients being followed over time, a mixed-effects model with independent correlation structure was employed to incorporate the correlated nature of the data. This analysis was restricted to include BMI observations up through and including twelve months post operatively to alleviate some issues with missing data at later time periods. Although again, there is no significance in this study (p=0.5656). These analyses also indicate that no significant change occurs in BMI over time. In fact, there is no significant pairwise difference between any two time points (Table 4) Examining each of the BMI groups (i.e., lower 50% and upper 50%) separately, similar results of no significant change in BMI over time were discovered (Tables 5 and 6).

  Time of Visit (post-op) Estimate Standard
Error
DF t Value Pr>|t|
1 month 1 week 0.04470 0.1824 251 0.25 0.8065
1 month 12 months -0.1760 0.2427 251 -0.73 0.4690
1 month 3 months -0.2184 0.1993 251 -1.10 0.2741
1 month 6 months -0.2145 0.2184 251 -0.98 0.3269
1 week 12 months -0.2207 0.2374 251 -0.93 0.3534
1 week 3 months -0.2631 0.1929 251 -1.36 0.1739
1 week 6 months -0.2592 0.2141 251 -1.21 0.2271
12 months 3 months -0.04244 0.2466 251 -0.17 0.8635
12 months 6 months -0.03854 0.2581 251 -0.15 0.8814
3 months 6 months 0.003899 0.2249 251 0.02 0.9862

Table 4: Pairwise comparison of post-operative BMI at all-time points post-operatively.

Time of Visit (post-op) Time of Visit (post-op) Estimate Standard
Error
DF t Value Pr>|t|
1 month 1 week 0.05848 0.1412 116 0.41 0.6796
1 month 12 months -0.2338 0.2013 116 -1.16 0.2478
1 month 3 months -0.09282 0.1570 116 -0.59 0.5554
1 month 6 months -0.2740 0.1783 116 -1.54 0.1270
1 week 12 months -0.2922 0.1969 116 -1.48 0.1405
1 week 3 months -0.1513 0.1527 116 -0.99 0.3238
1 week 6 months -0.3325 0.1755 116 -1.89 0.0607
12 months 3 months 0.1409 0.2045 116 0.69 0.4921
12 months 6 months -0.04024 0.2189 116 -0.18 0.8545
3 months 6 months -0.1812 0.1839 116 -0.99 0.3265

Table 5: Lower 50% pairwise comparison of mean BMIs at all-time points post-operatively.

Time of Visit (post-op) Time of Visit (post-op) Estimate Standard
Error
DF t Value Pr>|t|
1 month 1 week 0.03650 0.3318 131 0.11 0.9126
1 month 12 months -0.1323 0.4165 131 -0.32 0.7513
1 month 3 months -0.3261 0.3567 131 -0.91 0.3623
1 month 6 months -0.1507 0.3795 131 -0.40 0.6921
1 week 12 months -0.1688 0.4072 131 -0.41 0.6792
1 week 3 months -0.3626 0.3439 131 -1.05 0.2935
1 week 6 months -0.1872 0.3705 131 -0.51 0.6143
12 month 3 months -0.1939 0.4229 131 -0.46 0.6474
12 months 6 months -0.01840 0.4344 131 -0.04 0.9663
3 months 6 months 0.1755 0.3898 131 0.45 0.6533

Table 6: Upper 50% pairwise comparison of mean BMIs at all-time points post-operatively.

Discussion

Many other authors have reported physical and psychological improvements following reduction mammoplasty [1-9]. However, we found no statistically significant decrease in BMI following breast reduction in women of all included BMIs at any time interval. At 1 month, the mean BMI was 31.9928, compared to 31.9337 at one week, which is not significant. Similarly, at 3 months (BMI 32.4581), 6 months (BMI 32.5591), 1 year (BMI 33.3060), 2 years (BMI 33.0401) and more than 2 years (BMI 33.2545) there was no statistically significant change in BMI compared with 1 week post-op (BMI 31.9337) (Table 1). Clinically, there was a slight increase in BMI, although this was not statistically significant (mean of 31.9928 at one week postoperative compared to 33.0401) greater than 2+ years postoperatively. Given the correlated nature of the data following patients over a period of time, all intervals were compared to assess if a relationship exists with BMI, however there was no pairwise significance in this study (p=0.5656).

Similar results have been reported by Pauzenberger et al. [10]. In this study, only 50 women were retrospectively studied. It was discovered that 26 subjects gained weight and 18 lost weight, while 6 remained stable. The average weight loss was 3.5 kg (7.72 pounds) and the average weight gain was 4.5 kg (9.92 pounds). Neither weight gain nor loss was statistically significant.

Pike et al. studied adolescents undergoing breast reduction and also found no significant difference between mean pre-operative and post-operative BMIs overall, although overweight and obese patients progressed with significant weight gain post-operatively (22% of them increased BMI by at least 10%). These authors observed that 24% of overweight patients at surgery (BMI 25.0- 29.9 kg/m2) dropped post-operatively to the “healthy BMI” category (18.5-24.9 kg/m2), and 38% of obese patients (BMI ≥30 kg/m2) migrated down to the overweight category, with only 8% and 12% of patients changing BMI categories in the opposite direction, respectively [11]. As such, we also tiered the groups into the lowest 50% of patients based on baseline BMI was and the highest 50% of patients based on BMI. In the lower cohort, the 1 week post-operate mean BMI was 27.4589 (Table 2). This value was not statistically significantly higher than the mean BMI values at all other time points, specifically 1 month (BMI 27.4042), 3 months (BMI 27.4854), 6 months (BMI 27.9292), 1 year (BMI 28.1025), 2 years (BMI 28.4694) and greater than 2 years (BMI 28.5031). Table 5 illustrates no pairwise significance with any two time points and BMI within the lower 50% BMI cohort. The 1 week post-operative BMI for the higher 50% cohort was 36.5017 (Table 3). Compared to the time intervals at 1 month (BMI 36.6908), 3 months (BMI 37.0383), 6 months (BMI 36.2928), 1 year (BMI 37.2088), 2 years (BMI 37.1951) and greater than 2 years (BMI 36.8747), this value was not statistically significant. Again, there is no pairwise significant difference between any two time points for the higher 50% BMI cohort (Table 6). In contrast to the work by Pike et al, there was no clinical (or statistical) weight gain with time for this cohort.

Coriddi et al. reported that obese patients who underwent reduction mammaplasty with the intention of losing weight ultimately required bariatric surgery to achieve their weight loss goals [12]. Interestingly, Singh et al. divided their study participants in two groups based on whether or not patients perceived the upcoming surgery as a stimulus for future weight loss, and later found significant postoperative weight loss only in the group who did [3] We did not preoperatively screen our patients’ motivation, but it could quite possibly be the most important factor towards meaningful weight loss in macromastia patients, with reduction mammaplasty taking an enabling role. Further studies in this direction are needed.

A shortcoming of the current analyses is the relatively small sample size, although to our knowledge this is the largest series of objective adult data in this population. Additionally, there is more missing BMI data for patients farther away from the date of surgery, specifically for patients who have the lowest BMI. This is likely due to the lack of follow-up in eRecord for healthy patients. Our method of collecting BMI data through eRecord is through all encounters where a weight was obtained, not just within Plastic Surgery. Therefore, patients with higher BMIs may have additional co-morbidities that warrant more frequent health care provider encounters for all reasons. Presumably healthier patients with lower BMIs, although still overnight (BMI 25.00-29.99) were lost to a relatively short follow-up period. Because of this non-ignorable missingness pattern and the relatively small sample of patients for which complete data is present, we are not able to find significant changes in BMI over time. Additionally, other factors that affect weight loss were not analyzed, such as other medical co-morbidities or age, level of physical activity and diet. Women may have experienced improvements in their health and cardiovascular status, although their BMI remained unchanged. A prospective study, specifically with strict BMI collection, different co-morbidities and exercise regimens over time tracked would be useful. Inclusion of a control group (perhaps nonsurgical patients with macromastia), which our current study lacks, could also provide an interesting comparison of weight changes and BMI over time.

Conclusion

Reduction mammoplasty is not associated with a decrease in BMI in patients with symptomatic macromastia. There was also no significant increase in BMI. Further studies are needed to compare the operated population to the nonoperated population as well as monitoring other metrics of health following surgery.

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