Reduction Mammoplasty: A Comparison Between Operations Performed by Plastic Surgery and General Surgery

METHODS

Following institutional review board approval, the participant use files from the NSQIP database were analyzed for the years 2005–2012. Patients who had undergone a reduction mammoplasty were identified by Current Procedural Terminology codes, and these results were then refined to include only females with a International Classification of Diseases, Ninth Revision, code of 611.1 (hypertrophy of breasts). The database provided patient information including general demographics, surgical specialty performing the procedure, as well as other preoperative variables. To compare outcomes of the procedures, the variables utilized included presence of superficial surgical site infection, presence of deep surgical site infection, presence of wound dehiscence, postoperative respiratory compromise, pulmonary embolism, deep vein thrombosis, perioperative transfusion, operative time, reintubation, reoperation, and length of hospital stay. Chi-squared and t-test statistical analyses were utilized with a significance level of 5%.

RESULTS

During the time period, a total of 6239 reduction mammoplasties were performed and recorded within the NSQIP database, of which 339 were performed by general surgeons and 5900 by plastic surgeons. Table 1 describes the general demographics and preoperative variables analyzed for the patient cohort. Patients operated by general surgery tended to be younger with a greater body mass index. Postoperative analysis depicts that there were no statistically significant differences between the 2 groups with regard to superficial wound infections, deep wound infections, organ space infections, wound dehiscence, or systemic postoperative complications. This information is depicted in Table 2. However, there was a significant difference (P < .05) calculated in the number of patients experiencing a failure of skin flaps, which necessitated a return to the operating room. The mean operative time was longer for general surgeons (186 minutes) than for plastic surgeons (165 minutes), as depicted in Figure 1.

Figure 1. Mean operative time.

DISCUSSION

Analysis of the results indicates that general surgeons take a longer time to perform a reduction mammoplasty and may be prone to an increased rate of complications. During general surgery residency, exposure to procedures outside of the standard curriculum may vary between institutions. In comparison, reduction mammoplasty is a procedure that is required by the plastic surgery resident review committee. One study applied a unique set of quality and efficiency metrics, including a consideration of the learning curve for given procedures, elucidation of factors that influence operative performance, procedure-specific complications, and definitions of acceptable variance ranges from established norms for reduction mammoplasty.⁹ This study suggested a 3-phase learning curve for reduction mammoplasty procedures in which complication rates, variance in operative time, and operative time all are inversely correlated with surgeons’ experience. Most importantly, operative efficiency and quality did not reach a phase of stabilization until approximately the 12th year of operative experience.⁹ While plastic surgeons must be specifically trained in reduction mammoplasty, numerous other procedures performed on the breast provide a more comprehensive understanding of the aesthetic concerns specific for this anatomic area.

Other variables not assessed in the NSQIP database may also lead to greater patient success with a plastic surgeon. Functionally speaking, a decrease in breast mass and volume will achieve the basic goals of a reduction mammoplasty; however, there still remains subjective measures of outcomes including aesthetics as well as nipple and areola sensitivity. With regard to postsurgical breast sensitivity, studies have shown that there exists an inverse relationship between breast size and sensitivity, as well as an improvement in sensitivity after breast reduction.¹⁰

While most insurance carriers will not reimburse for procedures involving less than 1000 g, studies have shown that reduction mammoplasties involving less than 1000 g offer substantial relief of macromastia-associated symptoms and significant improvement in the patients’ quality of life.¹¹ It is clear that economic constraints and an increasing demand for reduction mammoplasty have placed a premium on increased efficiency and optimization of techniques. The data presented earlier support that the knowledge of various surgical techniques and comfort with the procedure lead to the efficient use of surgeon and operating room resources as well as optimal outcomes for patients.¹²

CONCLUSION

The focused training in reduction mammoplasty that plastic surgeons receive appears to benefit the patient. These results may be further emphasized with the increasing number of patients desiring reduction mammoplasty procedure due to knowledge and availability. The limitations of this study include an inability to monitor patient outcomes past the 30 day postoperative period, relatively low number of procedures performed by general surgery, and absence of variables such as nipple malposition, nipple sensation, aesthetic outcome, and late wound sequelae.