Extent of symptoms preoperatively and success of breast reduction for symptomatic macromastia: Personal experiences

Abstract

There has been more than enough published data written over the last 15 years to put to rest the question of whether or not reduction mammoplasty alleviates the symptoms of excessively large breasts. In 1989, the medical director of Nationwide Insurance Company challenged me by refusing to authorize re-imbursement for breast reductions on the grounds that there was nothing in the literature proving its effectiveness, a stance that, in today's milieu of evidence-based medicine, was, though counter-intuitive, correct. The following quotes are from the Group Claims and Cost Containment office of Nationwide Insurance and from Dr. Paul Metzger, then the medical director of Nationwide Insurance, in response to a preauthorization request for reduction mammoplasty, respectively. It is the opinion of our Medical Director that all breast reduction is cosmetic in nature unless there has been evidence of breast disease, documented endocrine dysfunction, breast asymmetry, or hypertrophy related to puberty. The medical staffhas reviewed all of the information received for the claim, again and can find no evidence of any of the above listed conditions as pre-operative diagnosis. Also, while this information does indicate complaints of back and shoulder pain, we have no medical literature on file to document that breast size and weight contribute to this type of pain. Therefore, no benefits can be allowed for this reduction mammoplasty procedure. In the particular issue with reduction mammoplasty, the literature supplied to us and a review of the world literature as obtained from MEDLARS has failed, in our opinion, to document that reduction mammoplasty is other then cosmetic surgery. The issue of back, neck, and shoulder pain remains controversial. Our experience suggests that most patients undergoing reduction mammoplasty for these symptoms develop the same or similar symptoms several years after the plastic procedure. I have personally reviewed the literature that we obtained from MEDLARS and can find no statistical studies as a 3 or 5 year follow-up. In fact, the longest follow-up that I find is six months. This attitude stimulated my colleagues, Drs. Ronald Berggren and Ann Miller, and I to answer the implied challenge Nationwide Insurance gave us, with one of the early studies proving how wrong they were. A review of over 20 articles published since the late 1980s demonstrates the fact that mostly all patients get significant relief of symptoms of macromastia after their surgery, that the results are long lasting, that there is no reliable predictor of who will benefit the most, and that most women report a much higher quality of life postoperatively. All techniques of breast reduction, whether the more common Wise pattern [1], short scar [2], or liposuction technique [3], are equally successful in relieving the symptoms if an appropriate amount of weight is removed. © 2009 Springer-Verlag Berlin Heidelberg.