Assessing Risk and Avoiding Complications in Breast Reduction

Assessing risk and avoiding complications in breast reduction requires a meticulous history, systematic physical examination, management of expectations, and careful consideration and execution of operative technique. Attention should be paid to comorbidities. Shape, symmetry, contours, scar location, skin quality, nipple–areolar complex (NAC) shape, NAC position relative to inframammary fold, and NAC position relative to the volume of the breast should be evaluated. Because complications cannot always be anticipated, informed consent is a vital part of managing expectations. Intraoperative considerations include blood pressure control, limiting tension, delayed healing and tissue loss, and using applied anatomy to avoid malposition and asymmetry.

Key points

  • A thorough history and physical examination are fundamental in identifying patients at greater risk of complications after breast reduction and to guide risk reduction and planning.

  • Perioperative optimization and lifestyle modulation to mitigate risk, as well as technical considerations in preoperative planning and execution, can help to avoid complications.

  • Patient-appropriate technique selection and understanding of technical principles of breast reduction can help to avoid surgical complications.

  • Some patients experience complications; preoperative explanation of this should be part of the informed consent process, which helps in managing patient expectations for the procedure.

  • Overall, complications of breast reduction surgery are well-tolerated by patients, who are usually satisfied if their symptoms of macromastia are relieved.

Introduction

The surgical goal of breast reduction is the removal of breast tissue to treat the symptoms of macromastia. An ideal breast reduction surgery should also produce symmetric, well-shaped breasts with well-positioned, sensate nipple–areolar complexes (NACs). Furthermore, these results should have longevity and be achieved with an acceptable scar trade off.

Complications of breast reduction surgery include those that are inherent to any surgery, that is, things that affect the way a wound heals. In addition, there are anesthesia-related risks, for example, deep vein thrombosis and pulmonary embolism. There are also those that are not systemic, but rather plastic surgical complications related to the surgery of breast itself and the way this paired organ looks after surgery. This article focuses on the assessment of risk and avoidance of these complications. Such complications maybe acute, subacute, or long term ( Box 1 ). Delayed wound healing is usually cited as the most common complication ( Box 2 ).

Box 1

Acute Complications Subacute Complications Long-Term Complications
Hematoma
Seroma
Skin loss
Wound separation
Cellulitis
Nipple areola ischemia
Asymmetry
Hypertrophic scars
Fat necrosis
Contour deformities
Recurrent ptosis
Scar deformities/unfavorable scars
Loss of shape
Nipple malposition
Underresection
Overresection
Inability to breast feed
Failure to resolve symptoms of macromastia
Complications of breast reduction
From Shestak KC. Re-operative plastic surgery of the breast. Philadelphia: Lippincott Williams & Wilkins; 2006; with permission.

Box 2

Complication Incidence (%)
Delayed wound healing
Spitting sutures
Hematoma
Nipple necrosis
Hypertrophic scars
Fat necrosis
Seroma
Infection
21.6
9.2
3.7
3.6
2.5
1.8
1.2
1.2
Key Elements of History to Assess for Risk of Breast Reduction Complications
Patient symptoms and expectations
Comorbidities (including diabetes, hypertension, coagulopathy, connective tissue disorders, obesity)
Previous hypertrophic scarring/keloids
Smoking habits
Obstetric history
Medications
Mammogram status
Key Elements of Physical Examination to Assess for Risk of Breast Reduction Complications
Shape
Symmetry
Contours
Scar location
Skin quality and elasticity
NAC shape
NAC position relative to IMF
NAC position relative to the volume of the breast
Volume distribution of both skin and parenchyma.
Specific measurements (suprasternal notch to nipple distance, breast base width, Nipple to IMF distance, Nipple to midline distance)
Estimated volume of resection

Abbreviations: IMF, inframammary fold; NAC, nipple–areola complex.

Complications of breast reduction by incidence
From Cunningham BL, Gear AJ, Kerrigan CL, et al. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg 2005;115(6):1597–604; with permission.

A meticulous history and examination are necessary to assess the risk of these complications as well as careful operative planning and technical considerations to avoid them. Complications cannot always be avoided; said another way, only the surgeon who does not operate has no complications (anonymous; but quoted by many experienced surgeons). Nonetheless, identification of those patients at relatively greater risk enables the surgeon to optimize these patients preoperatively. Although it is not always possible to eliminate complications, preoperatively educating patients and counseling them appropriately, with full disclosure of these risks as part of an informed consenting process, is vital in managing expectations for a patient who chooses to pursue surgery with a potential benefit that may outweigh the risk or reality of a complication.

Introduction

The surgical goal of breast reduction is the removal of breast tissue to treat the symptoms of macromastia. An ideal breast reduction surgery should also produce symmetric, well-shaped breasts with well-positioned, sensate nipple–areolar complexes (NACs). Furthermore, these results should have longevity and be achieved with an acceptable scar trade off.

Complications of breast reduction surgery include those that are inherent to any surgery, that is, things that affect the way a wound heals. In addition, there are anesthesia-related risks, for example, deep vein thrombosis and pulmonary embolism. There are also those that are not systemic, but rather plastic surgical complications related to the surgery of breast itself and the way this paired organ looks after surgery. This article focuses on the assessment of risk and avoidance of these complications. Such complications maybe acute, subacute, or long term ( Box 1 ). Delayed wound healing is usually cited as the most common complication ( Box 2 ).

Box 1

Acute Complications Subacute Complications Long-Term Complications
Hematoma
Seroma
Skin loss
Wound separation
Cellulitis
Nipple areola ischemia
Asymmetry
Hypertrophic scars
Fat necrosis
Contour deformities
Recurrent ptosis
Scar deformities/unfavorable scars
Loss of shape
Nipple malposition
Underresection
Overresection
Inability to breast feed
Failure to resolve symptoms of macromastia
Complications of breast reduction
From Shestak KC. Re-operative plastic surgery of the breast. Philadelphia: Lippincott Williams & Wilkins; 2006; with permission.

Box 2

Complication Incidence (%)
Delayed wound healing
Spitting sutures
Hematoma
Nipple necrosis
Hypertrophic scars
Fat necrosis
Seroma
Infection
21.6
9.2
3.7
3.6
2.5
1.8
1.2
1.2
Key Elements of History to Assess for Risk of Breast Reduction Complications
Patient symptoms and expectations
Comorbidities (including diabetes, hypertension, coagulopathy, connective tissue disorders, obesity)
Previous hypertrophic scarring/keloids
Smoking habits
Obstetric history
Medications
Mammogram status
Key Elements of Physical Examination to Assess for Risk of Breast Reduction Complications
Shape
Symmetry
Contours
Scar location
Skin quality and elasticity
NAC shape
NAC position relative to IMF
NAC position relative to the volume of the breast
Volume distribution of both skin and parenchyma.
Specific measurements (suprasternal notch to nipple distance, breast base width, Nipple to IMF distance, Nipple to midline distance)
Estimated volume of resection

Abbreviations: IMF, inframammary fold; NAC, nipple–areola complex.

Complications of breast reduction by incidence
From Cunningham BL, Gear AJ, Kerrigan CL, et al. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg 2005;115(6):1597–604; with permission.

A meticulous history and examination are necessary to assess the risk of these complications as well as careful operative planning and technical considerations to avoid them. Complications cannot always be avoided; said another way, only the surgeon who does not operate has no complications (anonymous; but quoted by many experienced surgeons). Nonetheless, identification of those patients at relatively greater risk enables the surgeon to optimize these patients preoperatively. Although it is not always possible to eliminate complications, preoperatively educating patients and counseling them appropriately, with full disclosure of these risks as part of an informed consenting process, is vital in managing expectations for a patient who chooses to pursue surgery with a potential benefit that may outweigh the risk or reality of a complication.

Assessment of risk history

As with all operations, an understanding of the primary complaint(s) of the patient is necessary. Patients must have symptomatic macromastia to undergo breast reduction surgery, because fundamentally this is a “functional” surgical intervention aimed at addressing these symptoms. Specific symptoms may include back pain, neck, pain, rashes/skin irritation, and bra strap grooving. These symptoms should be probed to ensure there is no other etiology aside from the breast that is the cause. If the patient is not significantly burdened by this symptomatology or if symptoms are not owing to macromastia, then reduction mammaplasty may not result in an optimal outcome but rather an unsatisfied patient. Surgery in the absence of symptoms, but merely to address a patient’s size concerns requires a careful discussion of the “tradeoff of size and shape for scars” to ensure a patient’s expectations are appropriately managed.

Particular attention must be paid to past medical history. A history of hypertrophic scarring or keloids risks this occurring after breast reduction; connective tissue disorders risks delayed wound healing; diabetes increases risk of infection; hypercoagulopathy (which may be suggested by multiple spontaneous abortions or miscarriages) may increase risk of thromboembolic complications or bleeding/hematoma, as can hypertension; and a prior methicillin-resistant Staphylococcus aureus infection or similar can also increase risk of infective complications. In each instance, preoperative optimization must be ensured; otherwise, complications should be anticipated.

The impact of obesity on complications in breast reduction surgery remains unclear. The overall complication rate has been shown by some to be greater in obese patients with increased rates of delayed healing, seroma, infection, skin and/or nipple–areola necrosis, hematoma, fat necrosis, stitch abscesses, diminished nipple sensation, and hypertrophic scarring. However, studies have failed to show this consistently. Analysis of complication data derived from the Breast Reduction Assessment: Value and Outcomes (BRAVO) study, a 9-month prospective, multicenter trial, demonstrated no relation between obesity and complications after breast reduction. Although breast reduction has been shown to be safe in the morbidly obese, careful consideration is needed in the decision over breast reduction in morbidly obese patients, who often have other major health problems, including increased anesthesia-related risk. In any event, the health benefits of breast reduction surgery in these patients are long term and may far exceed the risks of local complications.

An additional important factor is smoking. The perioperative morbidity associated with ongoing smoking is well-established. In breast reduction, specifically, there is an abundance of evidence to support an increased complication rate among smokers in the region of 3-fold that of nonsmokers. The cessation time period necessary to prevent wound healing complications is not known. In the absence of research-proven guidelines concerning smoking and elective surgery, a wide variability of treatment algorithms have been developed among individual surgeons. A common recommendation is a 4-week period of no smoking both before and after surgery. If the surgeon suspects noncompliance, a urine nicotinine test is recommended by many surgeons preoperatively and can detect if a patient has smoked within the last 4 days.

Obtaining an accurate obstetric history is also important in these patients. As alluded to, a history of miscarriage may suggest an underlying coagulopathy. From a more commonly encountered empiric perspective, breast size most often enlarges with pregnancy. Therefore, if the patient is planning for children in the near future then consideration of delaying until planned pregnancies are completed might be prudent to ultimately ensure a desirable surgical outcome. Similarly, given the uncertainty regarding the possible negative impact on breast feeding performance of reduction mammaplasty, to avoid disappointment and inability to breast feed, delaying surgery until after nursing should be a consideration. On a related issue, patients desiring breast reduction surgery over the age of 40 should have had a mammogram within the last year given the incidence of occult breast cancer in breast reduction specimens is 0.06% to 0.4%.

A careful review of a patient’s medications is necessary. Nonsteroidal antiinflammatory drugs including aspirin and ibuprofen, as well as herbal supplements and prescribed anticoagulants, increase bleeding risk. Oral contraceptives are associated with thrombosis and can increase the risk slightly. Steroids can impair wound healing. This is by no means an exhaustive list but demonstrative of the importance of appropriate awareness and planning for perioperative medication management.

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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Assessing Risk and Avoiding Complications in Breast Reduction
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