Key points

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 ).

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 ).

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.