Abstract
Background
Reduction mammaplasty (RM) is a commonly performed plastic surgery procedure, but various postoperative complications have been noted. This study aims to identify and quantify the association between risk factors and the occurrence of postoperative complications following RM.
Methods
We systematically reviewed PubMed, Medline, Cochrane Library and Web of Science for relevant publications, extracting suspected risk factors and associated postoperative complications. Meta-analyses were then conducted to evaluate their associations.
Results
We included 61 articles encompassing 71,149 patients. Seven suspected risk factors and eighteen complications were identified. Five risk factors were significantly associated with any complications after RM: body mass index (BMI) ≥ 30 kg/m2 (OR 1.59, 95% CI 1.45–1.74, p = 0.000, I2 = 35.2%); smoking (OR 1.80, 95% CI 1.29–2.50, p = 0.000, I2 = 87.5%); diabetes (OR 1.41, 95% CI 1.11–1.79, p = 0.005, I2 = 11.2%); previous radiation therapy (OR 3.24, 95% CI 1.94–5.40, p = 0.000, I2 = 12.6%); and surgical techniques including inferior pedicle (IP) vs. superomedial pedicle (SMP) (OR 1.59, 95% CI 1.27–1.99, p = 0.000, I2 = 27.5%); IP vs. medial pedicle (MP) (OR 2.34, 95% CI 1.48–3.72, p = 0.000, I2 = 47.0%); and superior pedicle vs. SMP (OR 0.59, 95% CI 0.37–0.95, p = 0.028, I2 = 0.0%). Furthermore, BMI ≥ 30 kg/m2 was linked to higher risks of delayed healing, fat necrosis, wound infection, and dehiscence. Previous radiation therapy increased the risks of fat necrosis, wound infection, and seroma. Smoking was associated with higher risks of wound infection and dehiscence. Compared to MP, IP had a higher risk of wound dehiscence; compared to SMP, IP had a higher risk of wound infection but a lower risk of seroma (all P < 0.05).
Conclusions
These findings highlight the importance of comprehensive preoperative risk assessment and individualized surgical planning to minimize postoperative complications and improve patient outcomes.
Supplementary Information
The online version contains supplementary material available at 10.1186/s40001-025-02723-z.
Keywords: Reduction mammaplasty, Postoperative complications, Risk factors, Meta-analysis
Background
Reduction mammaplasty (RM) is frequently performed to alleviate symptomatic macromastia or achieve contralateral breast symmetry following breast cancer surgery, aiming to enhance appearance and quality of life. RM, first performed by Paulus Aegineta between 625 and 690 for the treatment of gynecomastia, has gained popularity over the years [1, 2]. Although RM effectively alleviates physical and psychological issues associated with symptomatic macromastia and postoperative asymmetry, complications can occur at rates as high as 40%−50% [3–5].
Common postoperative complications include abnormal bleeding, wound issues, nipple-areola complex necrosis (NAC), breast asymmetry, loss of sensation in the nipple and areola, hematoma, and hypertrophic scarring. Rare complications, such as back pain, deep vein thrombosis, urinary tract infection, unplanned intubation, myocardial infarction, and sepsis, have also been documented [6–8]. Although characteristics such as obesity, smoking, diabetes, and age may increase susceptibility to postoperative complications, existing literature provides controversial results due to small sample sizes or other research limitations [3, 5, 9–11].
Considering the ongoing controversies in the existing literature and the limited range of risk factors and postoperative complications examined in previous meta-analyses, we conducted this study to identify and quantify the associations between various risk factors and postoperative complications following RM. Our findings aim to provide valuable guidance for developing individualized surgical strategies, minimizing postoperative complications, and ultimately improving patient outcomes.
Methods
Our study was performed based on the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta Analyses Statement [12].
Criteria for inclusion and exclusion
Eligible articles met the following criteria: (i) patients must have undergone RM; (ii) studies must investigate the association between risk factors and complications post-RM; and (iii) articles must be full-text. Criteria for exclusion: (i) if other breast surgical procedures were mixed simultaneously; (ii) if the study was not a human-related case–control, cohort, cross sectional, or randomized controlled study; (iii) if there was a lack of essential data to calculate the odds ratios (OR) and 95% confidence intervals (CI); and (iv) if the articles were just case reports or letters to editors.
Search strategy
We searched publications about RM and risk factors of postoperative complications on PubMed, MEDLINE, Cochrane Library and Web of Science without language restrictions before April 25, 2025, using the following key words: reduction mammaplasty, reduction mammoplasty, breast reduction, macromastia, gigantomastia, complication, postoperative complication. The search format was tailored to the syntax of each database. Additionally, we used Web of Science to retrieve key articles and identify further relevant citations. We also reviewed the references of the selected studies to find any other relevant papers. Two investigators independently screened titles and abstracts to exclude studies that did not meet the eligibility criteria. Next, the full texts of the potentially relevant studies were examined to finalize the selection of articles. Any disagreements were resolved through discussion; if consensus could not be reached, a senior reviewer made the final decision.
Data extraction and quality assessment
Two investigators independently extracted raw data and assessed the quality of included studies using the Newcastle–Ottawa Scale (NOS). Any disagreements were resolved through discussion; if consensus could not be reached, a senior reviewer made the final decision. The NOS rating system evaluated studies based on three criteria: selection, comparability, and exposure. Respectively, these criteria included four, one, and three parameters. Scores ranged from 0 to 9, with studies considered high quality if they scored ≥ 7. For each eligible article, the following data were extracted: PMID, first author, publication year, study design, study duration, country or region, sample size, follow-up time, patient and treatment characteristics (including average age, average body mass index (BMI), proportion of smokers, average tissue resection weight per breast (TRW), proportion of patients with diabetes, proportion of patients with previous radiation therapy (PRT), and surgical techniques), and number of relevant complications. In view of sufficient data for meta-analysis, age, BMI, smoking, diabetes, TRW, surgical techniques (including inferior pedicle (IP), medial pedicle (MP), superior pedicle (SP), and superomedial pedicle (SMP)), and PRT were identified as suspected risk factors.
Statistical analysis
All statistical analyses were performed using STATA version 12.0 (StataCorp LP, College Station, TX, USA). Meta-analysis results were illustrated with a forest plot, showing crude odds ratios (ORs) and 95% confidence intervals (CIs) to demonstrate the association between risk factors and complications. Subgroup analyses were conducted using available data on risk factors and specific complications. For age, BMI, and TRW, subgrouping was conducted based on the following thresholds: age ≥ 50 years, BMI ≥ 30, and TRW ≥ 1000. A p-value of < 0.05 was considered statistically significant. Cochran’s Q test and the I2 test were used to assess heterogeneity across the studies. p < 0.1 for Cochran’s Q test and I2 ≥ 50% indicated significant heterogeneity; therefore, random-effects models were used; otherwise, fixed-effects models were applied [13, 14]. Sensitivity analysis was conducted for meta-analyses including more than five publications to evaluate the impact of excluding each study individually on the overall results. Funnel plots were used to assess publication bias. Egger’s test were also performed for meta-analyses with more than five publications, where p > 0.05 indicated no publication bias [15].
Results
Study selection
As shown in Fig. 1, a total of 3467 records were identified. After screening titles and abstracts, 1179 duplicate records and 2190 ineligible records were excluded. Two publications could not be retrieved. The full texts of 96 publications were assessed for eligibility. Ten publications were excluded because they involved concurrent breast surgical procedures. Fifteen publications were excluded for not being case–control, cohort, randomized controlled, or cross-sectional studies. Nine publications were excluded due to insufficient data and one was excluded as a letter to the editor. A list of excluded articles and the reasons for their exclusion are shown in Supplementary Table 1. Ultimately, sixty-one publications [3–5, 8, 10, 11, 16–70] were included in our study. Meta-analyses were conducted based on seven studies for age, nineteen studies for BMI, seven studies for TRW, six studies for diabetes, five studies for PRT, and nineteen studies for smoking. Three studies compared IP and MP, twelve studies compared IP and SMP, six studies compared IP and SP, and three studies compared SP and SMP.
Fig. 1.
Flow diagram of search strategy and study selection
Characteristics of study and patient
The characteristics of the sixty-one publications are presented in Table 1. According to the NOS, the quality scores of the included studies ranged from six to nine. These publications, spanning from 1992 to 2024, provide evidence from six prospective studies, fifty-two retrospective studies, and three randomized controlled trials. A total of 71,149 patients were included in the sixty-one studies. Based on the reported data, the mean age of patients was 43.3 ± 8.9 years, the mean BMI was 30.7 ± 2.3 kg/m2, and the mean TRW was 848.5 ± 410.0 g. Across the reported studies, an average of 16.5% of patients were smokers, 4.5% had diabetes, and 24.0% had PRT. The most frequently used surgical techniques were IP, SMP, and SP, while MP and free nipple grafting were reported in five and four studies, respectively. Occasionally, other surgical techniques such as modified Robertson wide pattern, modified Lejour technique, vertical bi-pedicle, and central mound technique were employed. Based on the available data, the incidence of any complications ranged from 3.8% to 57.9%, with a mean of 12.3%. The incidences of the other seventeen specific complications are presented in Table 2.
Table 1.
Study characteristics
| References | NOS | Design | Years | Country | Sample size | Follow-up(month) | Age (year) | BMI (kg/m2) | Smokers (%) | TRW(g) | Diabetes (%) | Radiation therapy (%) | Techniques (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Hagen et al. [16] | 8 | R-COH | 2001–2002 | UK | 71 | 0.3–15.3 | 39.0 | 27.5 | 33.8 | 648.0 | NR | NR | NR |
| HEFTER et al. [17] | 7 | R-COH | 1985–2000 | Norway | 101 | NR | 37.9 | 27.0 | NR | 688.0 | NR | NR | NR |
| Chan et al. [18] | 7 | R-COH | 2002–2004 | UK | 169 | NR | 36.2 | 26.7 | 38.5 | 713.8 | NR | NR | IP:63.3; SP:29.0; VS:4.1; FNG:3.6 |
| Dex et al. [19] | 8 | R-COH | 1998–2003 | UK | 220 | 18.7 | 35.1 | 28.5 | NR | 789.0 | NR | NR | VS:37.2; Inverted-T:54.5; FNG:8.2 |
| Roehl et al. [20] | 8 | R-COH | 1996–2006 | USA | 179 | 1.0–12.0 | 35.0 | 34.0 | 4.2 | NR | NR | NR | IP:74.9; VS:4.5; FNG:20.6 |
| Gust et al. [8] | 8 | R-COH | 2006–2010 | USA | 2492 | NR | 42.2 | 31.7 | 12.0 | NR | NR | NR | NR |
| Nelson et al. [3] | 8 | R-COH | 2005–2011 | USA | 4545 | 1.0 | NR | NR | 11.7 | NR | 5.1 | NR | NR |
| Nelson et al. [21] | 8 | R-COH | 2005–2010 | USA | 3537 | 1.0 | 43.2 | 31.6 | 12.1 | NR | NR | NR | NR |
| Karamanos et al. [10] | 7 | R-COH | 2005–2010 | USA | 2779 | NR | 42.7 | 31.6 | 11.7 | NR | NR | NR | NR |
| Srinivasaiah et al. [22] | NA | RCT | 2001–2002 | UK | 67 | NR | 39.3 | 28.5 | 43.3 | 1386.7 | NR | NR | NR |
| Hillam et al. [23] | 7 | R-COH | 2009–2014 | USA | 13,503 | NR | 44.3 | 31.1 | 10.3 | NR | NR | NR | NR |
| Baltodano et al. [24] | 8 | R-COH | 2005–2012 | USA | 7068 | 1.0 | 43.7 | NR | 10.9 | NR | NR | NR | NR |
| Simpson et al. [25] | 8 | R-COH | 2006–2015 | USA | 16,812 | 1.0 | 43.3 | 31.2 | 10.1 | NR | NR | NR | NR |
| Young et al. [26] | 8 | R-COH | 2013–2015 | USA | 9110 | 1.0 | 42.1 | 29.9 | 9.4 | NR | 4.6 | NR | NR |
| Davé et al. [27] | 7 | R-COH | 2005–2017 | USA | 1854 | NR | 69.0 | NR | 3.7 | NR | 11.4 | NR | NR |
| Fairchild et al. [28] | 7 | R-COH | 2017–2020 | USA | 542 | 1.0 | 17.0 | 30.0 | NR | NR | NR | NR | NR |
| Toplu et al. [11] | 9 | R-COH | 2013–2018 | Turkey | 186 | 48.0 | 45.0 | 29.0 | 4.3 | 1100.0 | 5.9 | NR | IP: 17.2; SMP: 53.2; SP: 29.6 |
| Coady-Fariborzian et al. [29] | 8 | R-COH | 2000–2020 | USA | 115 | 3.0 | 43.0 | 30.0 | NR | 1272.0 | 2.6 | NR | IP: 45.2; SP: 54.8 |
| Setela et al. [30] | 9 | R-COH | 1998–2003 | Finland | 273 | 6.0 | 43.0 | 28.0 | NR | 730.5 | NR | NR | IP: 64.1; SP: 34.4 |
| Shah et al. [5] | 7 | R-COH | 1999–2004 | UK | 306 | 3.0 | 36.8 | 27.6 | NR | NR | NR | NR | NR |
| Antony et al. [31] | 7 | R-COH | 2009–2012 | USA | 100 | 60.0 | 31.5 | 31.3 | 11.1 | 827.5 | NR | NR | SMP: 50.0; IFP: 50.0 |
| Palve et al. [32] | 7 | R-COH | 2014–2020 | Finland | 760 | 32.4 | 51.0 | 27.8 | 6.1 | 460.0 | 4.6 | NR | SMP: 63.2; IP: 26.5; SP: 10.3 |
| Ogunleye et al. [33] | 6 | R-COH | 2008–2015 | USA | 124 | NR | 39.2 | 30.5 | 3.2 | 692.1 | NR | NR | SMP: 73.4; IP: 26.6 |
| Cunning et al. [34] | 7 | R-COH | 2017–2019 | USA | 101 | 3.0 | 38.0 | 29.6 | NR | NR | NR | NR | SMP: 59.2; IP: 40.8 |
| Ulusal et al. [35] | 8 | R-COH | 2010–2016 | Turkey | 40 | 8.0–72.0 | 44.2 | 31.8 | NR | 1533.0 | NR | NR | SP: 100 |
| Bustos et al. [36] | 8 | R-COH | 2014–2019 | USA | 288 | 3.9 | 43.7 | 31.5 | 32.6 | 699.6 | NR | NR | IP: 100 |
| O’Grady et al. [37] | 9 | R-COH | 2000–2002 | Canada | 133 | 5.1 | NR | NR | NR | NR | NR | NR | IP: 100 |
| Cunningham et al. [4] | 8 | P-COH | 1997–1998 | USA | 179 | 9.0 | 39.4 | 29.7 | 12.6 | 1662.6 | NR | NR | IP: 77.5; SP: 20.3; MP: 1.1; Glandular: 1.1 |
| Bikhchandani et al. [38] | 7 | R-COH | 1999–2004 | UK | 402 | NR | 34.3 | 28.9 | 27.9 | 665.1 | NR | NR | IP: 100 |
| Chun et al. [39] | 8 | R-COH | 1995–2007 | USA | 675 | NR | 37.5 | 31.0 | 8.9 | 1696.0 | NR | NR | WP: 80.7; MR: 18.7; VS: 0.6 |
| Ngaage et al. [40] | 7 | R-COH | 2006–2013 | USA | 70 | 72.0 | 41.0 | 34.5 | NR | NR | NR | NR | NR |
| Azzam et al. [41] | 6 | R-COH | 1996–2002 | German | 115 | NR | 35.2 | 28.8 | 0.4 | 815.2 | NR | NR | ML: 100 |
| Parrett et al. [42] | 8 | R-COH | 2004–2008 | USA | 12 | 10.0 | 57.0 | 29.9 | 0.0 | 452.5 | NR | 50.0 | IP: 41.7; Others: 58.3 |
| Dal Cin [43] | 8 | R-CC | 1980–2007 | Canada | 9 | 32.9 | 56.2 | 30.0 | NR | 577.3 | NR | 50.0 | IP: 88.9; SP: 11.1 |
| Weichman [44] | 8 | R-COH | 2008–2013 | USA | 13 | NR | 50.2 | 26.8 | 0.0 | 320.5 | NR | 50.0 | CMT: 100 |
| Ercan [45] | 9 | R-COH | 2015–2023 | Turkey | 190 | 6.0 | 48.4 | 28.5 | 18.4 | 608.4 | 7.9 | NR | IP: 36.3; SP: 63.7 |
| Girard et al. [46] | 8 | R-COH | 2011–2016 | France | 1306 | 6.0 | 38.9 | 27.3 | 22.9 | 530.7 | 7.9 | NR | SP: 100 |
| Adebagbo et al. [47] | 8 | R-COH | 2017–2023 | USA | 178 | NR | 41.4 | 30.3 | 22.5 | 519.4 | 3.4 | NR | IP: 71.9; SP: 28.1 |
| Roje et al. [48] | 8 | R-COH | 1999–2011 | Croatia | 59 | 6.0 | 47.0 | NR | 22.0 | 1057.0 | NR | NR | VP: 72.9; SMP: 10.2; IP: 10.2; FNG: 6.8 |
| Güemes et al. [49] | 8 | P-COH | NR | Spain | 121 | 12.0 | 40.7 | 29.6 | 34.7 | 1785.5 | NR | NR | IP: 100 |
| Deliaert et al. [50] | 7 | P-COH | 2006–2007 | Netherlands | 43 | 9.0 | 35.9 | 26.2 | 30.2 | 437.3 | NR | NR | Mediocranial pedicle: 100 |
| Sandsmark et al. [51] | 6 | R-COH | 1984–1990 | Norway | 292 | 51.0 | 30.4 | NR | NR | 547.0 | NR | NR | SMP: 82.3; IP: 9.4; Other: 8.3 |
| Chang et al. [52] | 7 | R-COH | 1987–1994 | USA | 172 | 16.0 | 33.0 | 31.6 | NR | 1946.0 | NR | NR | IP: 100 |
| Platt et al. [53] | NA | RCT | NR | UK | 30 | 2.0 | 33.0 | 26.3 | NR | 635.0 | NR | NR | IP: 100 |
| Zoumaras et al. [54] | 6 | R-COH | 2002–2005 | Australia | 191 | 6.0 | 39.8 | 28.8 | NR | 1006.8 | NR | NR | IP: 49.7; MP: 50.3 |
| Cruz-Korchin et al. [55] | NA | RCT | 1999–2002 | USA | 208 | 6.0 | 30.0 | 26.5 | NR | 550.5 | NR | NR | IP: 50.5; MP: 49.5 |
| Kreithen et al. [56] | 6 | R-COH | 1999–2002 | USA | 112 | NR | 33.3 | 32.2 | 20.5 | 997.3 | NR | NR | IP: 62.5; SP: 37.5 |
| Gamboa-Bobadilla et al. [57] | 6 | R-COH | 2000–2003 | USA | 86 | 43.0 | 35.1 | 36.8 | NR | 1362.3 | NR | NR | IP: 100 |
| James et al. [58] | 6 | R-COH | 1997–2005 | USA | 84 | 18.0 | 38.0 | 29.0 | NR | 560.3 | NR | NR | IP: 58.3; MP: 41.7 |
| Eleanor et al. [59] | 8 | R-COH | 2007–2014 | USA | 236 | 6.0 | 38.3 | NR | 25.0 | 823.0 | 3.4 | NR | SMP: 100 |
| Webb et al. [60] | 7 | R-COH | 1997–2008 | USA | 67 | 3.0 | 17.1 | 27.9 | NR | 1358.3 | NR | NR | IP: 70.1 |
| Gulcelik et al. [61] | 7 | P-CC | NR | Turkey | 153 | 12.0 | 48.8 | 29.0 | 17.6 | 958.0 | NR | NR | LPF: 81.0; UPF: 19.0 |
| Braig et al. [62] | 7 | R-COH | 1998–2011 | German | 50 | 12.7 | 44.4 | 28.6 | 12.0 | 842.0 | NR | NR | SMP: 100 |
| Egro et al. [63] | 7 | R-COH | 2005–2012 | USA | 160 | 47.4 | 53.8 | 33.0 | 12.5 | 616.0 | 8.8 | 15.6 | IP: 19.4; SP: 71.3 |
| Mendonc et al. [64] | 8 | R-COH | 1999–2009 | Brazil | 144 | 47.0 | 49.4 | 25.9 | 19.4 | NR | 6.3 | 26.4 | SMP: 41.7; SP: 29.2; IP: 22.2; SLP:7.0 |
| Patel et al. [65] | 6 | R-COH | 2003–2009 | USA | 16 | 34.0 | 52.5 | 31.5 | 18.8 | 338.2 | 25.0 | 31.3 | SMP: 9.4; MP: 31.3; IP: 28.1; CMT:31.3 |
| Kemaloğlu et al. [66] | 7 | P-COH | NR | Turkey | 50 | 19.6 | 40.2 | 31.9 | 4.0 | 1341.3 | NR | NR | IP: 50.0; SMP: 50.0 |
| Kulkarni et al. [67] | 8 | R-COH | 2011–2017 | USA | 60 | 6.3 | 16.7 | 28.4 | 3.3 | 520.5 | NR | NR | IP: 80.0; SMP: 20.0 |
| Yeğin et al. [68] | 7 | R-COH | 2017–2020 | Turkey | 93 | NR | 35.8 | 33.5 | 54.8 | NR | NR | NR | IP: 28.0; SMP: 72.0 |
| Sapino et al. [69] | 9 | R-COH | 2015–2017 | Switzerland | 58 | 24.0 | 34.0 | 28.8 | 19.0 | 662.2 | NR | NR | IP: 37.9; SMP: 62.1 |
| Özçelik [70] | 8 | P-COH | 2010–2022 | Tu¨rkiye | 40 | 6.0 | 37.1 | 27.1 | NR | 643.3 | NR | NR | SP: 50.0; SMP: 50.0 |
R-COH: retrospective cohort; P-COH: prospective cohort; NOS: Newcastle–Ottawa Scale; RCT: randomized controlled trial; P-CC: prospective case control; R-CC: retrospective case control; TRW: tissue resection weight per breast; BMI: body mass index; NR: not reported; NA: not applicable; IP: inferior pedicle; SP: superior pedicle; SMP: superomedial pedicle; VS: verticle scar; FNG: free nipple graft; MP: medial pedicle; WP: wise pattern; MR: modified robertson; ML: modified Lejour technique; CMT: central mound technique; VP: Vertical bi-pedicle; LPF: lower pediculated flap; UPL: upper pediculated flap; SLP: superior lateral pedicle
Table 2.
Incidence of relevant complications after reduction mammoplasty
| References | AC (%) | WI (%) | WD (%) | MC (%) | HT (%) | NAC (%) | FN (%) | SM (%) | RP (%) | 30-D-R (%) | SN (%) | MSB (%) | NSL (%) | TN (%) | DI (%) | DH (%) | SR (%) | HS (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Hagen et al. [16] | 11 (15.5) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| HEFTER et al. [17] | 10 (9.9) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Chan et al. [18] | 71 (42.1) | 29 (17.2) | 27 (16.0) | NR | NR | NR | 6 (3.6) | NR | 9 (5.3) | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Dex et al. [19] | 31 (14.1) | NR | 26 (11.8) | NR | NR | 1 (0.5) | 4 (1.8) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Roehl et al. [20] | 90 (50.3) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Gust et al. [8] | 112 (4.5) | 78 (3.1) | 23 (0.9) | 14 (0.6) | NR | 3 0.1) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Nelson et al. [3] | 275 (6.1) | 148 (3.3) | 37 (0.8) | 43 (0.9) | NR | NR | NR | NR | 82 (1.8) | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Nelson et al. [21] | 206 (5.8) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Karamanos et al. [10] | 159 (5.7) | 84 (3.0) | 25 (0.9) | NR | 6 (0.2) | NR | NR | NR | 54 (1.9) | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Srinivasaiah et al. [22] | 16 (23.9) | 9 (13.4) | 2 (3.0) | NR | 1 (1.5) | NR | 3 (4.5) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Hillam et al. [23] | 587 (4.2) | 428 (3.2) | 96 (0.7) | 70 (0.5) | 43 (0.4) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Baltodano et al. [24] | 268 (3.8) | 218 (3.1) | 50 (0.7) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Simpson et al. [25] | 3535 (21.0) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Young et al. [26] | 641 (7.0) | 290 (3.2) | 61 (0.7) | 290 (3.2) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Davé et al. [27] | 114 (6.1) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Fairchild et al. [28] | 25 (4.6) | 13 (2.4) | 4 (0.7) | NR | NR | NR | NR | NR | NR | 10 (1.8) | NR | NR | NR | NR | NR | NR | NR | NR |
| Toplu et al. [11] | 13 (6.9) | 1 (0.53) | 2 (1.1) | NR | 3 (1.6) | 3 (1.6) | 2 (1.1) | NR | 6 (3.2) | NR | NR | NR | 1 (0.53) | NR | NR | NR | NR | 1 (0.53) |
| Coady-Fariborzian et al. [29] | 48 (41.7) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Setela et al. [30] | 143 (52.4) | 95 (34.8) | NR | NR | NR | 7 (2.6) | 8 (2.9) | NR | NR | NR | 49 (17.9) | NR | NR | NR | NR | NR | NR | NR |
| Shah et al. [5] | 165 (53.9) | 43 (14.1) | 81 (26.5) | NR | 52 (17.0) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Antony et al. [31] | 56 (56.0) | 3 (3.0) | NR | NR | 1 (1.0) | 1 (1.0) | NR | 7 (7.0) | 2 (2.0) | NR | NR | 18 (18.0) | 24 (24.0) | NR | NR | NR | NR | NR |
| Palve et al. [32] | 290 (38.2) | 242 (31.8) | NR | NR | 24 (3.2) | NR | NR | 27 (3.6) | NR | NR | NR | NR | NR | 4 (0.5) | 3 (0.4) | NR | NR | NR |
| Ogunleye et al. [33] | 39 (31.5) | 11 (8.9) | 11 (8.9) | NR | 10 (8.1) | NR | 7 (5.6) | 5 (4.0) | NR | NR | 2 (1.6) | NR | NR | NR | NR | NR | NR | NR |
| Cunning et al. [34] | 18 (17.8) | 2 (2.0) | 3 (3.0) | NR | 2 (2.0) | 1 (1.0) | 2 (2.0) | NR | NR | NR | NR | NR | NR | NR | NR | 10 (10.0) | NR | NR |
| Ulusal et al. [35] | 12 (30.0) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Bustos et al. [36] | 48 (16.7) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| O’Grady et al. [37] | 149 (56.0) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Cunningham et al. [4] | 77 (43.0) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Bikhchandani et al. [38] | 94 (23.4) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Chun et al. [39] | 75 (11.1) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Ngaage et al. [40] | 17 (24.3) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Azzam et al. [41] | 93 (40.4) | 8 (3.5) | 49 (21.3) | NR | 10 (4.3) | NR | NR | 13 (5.7) | NR | NR | NR | NR | NR | NR | NR | NR | 35 (15.2) | NR |
| Parrett et al. [42] | 5 (41.7) | 3 (25.0) | 1 (8.3) | NR | NR | 0 (0.0) | 2 (16.7) | 5 (41.7) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Dal Cin [43] | NR | 6 (66.7) | NR | NR | NR | 1 (11.1) | 0 (0.0) | NR | NR | NR | NR | NR | NR | NR | NR | NR | 3 (33.3) | 3 (33.3) |
| Weichman [44] | NR | 2 (15.4) | NR | NR | 1 (7.7) | 0 (0.0) | 2 (7.7) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | 4 (30.8) |
| Ercan [45] | 58 (30.5) | 19 (10.0) | 24 (12.6) | 0 (0.0) | 4 (2.1) | 1 (0.5) | 10 (5.3) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Girard et al. [46] | 284 (21.8) | 6 (0.5) | 221 (16.9) | 0 (0.0) | 32 (2.5) | 32 (2.5) | 176 (13.5) | NR | 0 (0.0) | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Adebagbo et al. [47] | 71 (39.9) | 28 (15.7) | 9 (5.1) | NR | 1 (0.6) | NR | NR | 5 (2.8) | 13 (7.3) | 1 (0.6) | NR | NR | 14 (8.0) | NR | NR | NR | NR | 6 (3.4) |
| Roje et al. [48] | 33 (55.9) | 4 (6.7) | NR | 3 (5.1) | 3 (5.1) | 2 (3.4) | 1 (1.7) | 9 (15.3) | NR | NR | NR | NR | 4 (6.7) | NR | NR | 8 (13.6) | NR | 3 (5.1) |
| Güemes et al. [49] | 70 (57.9) | 2 (1.7) | NR | NR | 4 (3.3) | 2 (1.7) | 3 (2.5) | NR | NR | NR | 1 (0.8) | NR | NR | NR | NR | 14 (11.6) | NR | 19 (15.7) |
| Deliaert et al. [50] | NR | NR | 20 (46.5) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Sandsmark et al. [51] | 94 (32.9) | 8 (2.9) | 20 (46.5) | NR | 40 (14.4) | 4 (1.4) | 11 (4.0) | NR | NR | NR | NR | NR | 18 (6.3) | NR | NR | NR | 13 (4.7) | NR |
| Chang et al. [52] | 72 (41.9) | 12 (7.0) | 5 (2.9) | NR | 4 (2.4) | 2 (1.2) | 2 (1.2) | NR | NR | NR | NR | NR | 7 (4.1) | NR | NR | NR | NR | 18 (10.5) |
| Platt et al. [53] | 16 (53.3) | NR | 13 (43.3) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Zoumaras et al. [54] | 102 (53.4) | 24 (12.6) | 48 (25.1) | NR | 11 (5.8) | 1 (0.5) | 10 (5.2) | 0 (0) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Cruz-Korchin et al. [55] | 16 (7.7) | 2 (1.0) | 7 (3.4) | NR | 2 (1.0) | 2 (1.0) | NR | 3 (1.4) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Kreithen et al. [56] | 82 (73.2) | NR | NR | NR | 4 (3.6) | 7 (6.2) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Gamboa-Bobadilla et al. [57] | NR | 16 (18.6) | NR | NR | NR | NR | 7 (8.1) | NR | NR | NR | NR | NR | NR | NR | NR | 24 (27.9) | NR | NR |
| James et al. [58] | 19 (22.6) | NR | NR | NR | 4 (4.8) | NR | 6 (7.1) | 3 (3.6) | 4 (4.8) | NR | NR | NR | NR | NR | NR | 15 (17.9) | NR | 13 (15.5) |
| Eleanor et al. [59] | 67 (28.4) | 12 (5.1) | NR | NR | 8 (3.4) | 0 (0.0) | 18 (7.6) | 5 (2.1) | NR | NR | NR | NR | NR | NR | NR | 27 (11.4) | NR | NR |
| Webb et al. [60] | 34 (50.7) | 2 (3.0) | 19 (28.4) | NR | −1.5 | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | 5 (7.5) |
| Gulcelik et al. [61] | 28 (18.3) | 4 (2.6) | 6 (4.0) | NR | 3 (1.9) | 1 (0.6) | NR | 8 (5.2) | NR | NR | NR | NR | NR | NR | NR | 6 (4%) | NR | NR |
| Braig et al. [62] | 21 (42.0) | 6 (12.0) | 3 (6.0) | NR | 3 (6.0) | 1 (2.0) | NR | NR | 18 (36.0) | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Egro et al. [63] | 45 (28.1) | 8 (5.0) | 5 (3.1) | NR | 4 (2.5) | 1 (0.6) | 3 (1.9) | 3 (1.9) | NR | NR | 2 (1.3) | NR | NR | NR | NR | 13 (8.1) | NR | 7 (4.4) |
| Mendonc et al. [64] | 44 (30.1) | 6 (4.2) | 8 (5.6) | NR | 1 (0.7) | 4 (2.8) | 10 (6.9) | NR | 17 (11.8) | NR | 15 (10.4) | NR | NR | NR | NR | NR | NR | NR |
| Patel et al. [65] | 7 (43.8) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Kemaloğlu et al. [66] | 6 (12.0) | NR | 3 (6.0) | NR | NR | 1 (2.0) | NR | NR | NR | NR | NR | NR | 2 (4.0) | NR | NR | NR | NR | NR |
| Kulkarni et al. [67] | 14 (23.3) | 1 (1.7) | 6 (10.0) | NR | 0 (0.0) | 1 (1.7) | 2 (3.3) | 0 (0.0) | 1 (1.7) | NR | 0 (0.0) | NR | 0 (0.0) | NR | NR | 7 (11.7) | NR | 1 (1.7) |
| Yeğin et al. [68] | 10 (10.8) | NR | NR | NR | NR | 2 (2.2) | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR | NR |
| Sapino et al. [69] | 30 (51.7) | 3 (5.2) | 2 (3.4) | NR | NR | 0 (0.0) | NR | 2 (3.4) | NR | NR | NR | NR | NR | NR | NR | NR | NR | 13 (22.8) |
| Özçelik [70] | 15 (30.0) | NR | 1 (2.0) | NR | 1 (2.0) | NR | NR | 2 (4.0) | NR | NR | NR | NR | NR | NR | NR | 2 (4.0) | NR | NR |
NR: not reported; AC: any complications; WI: wound infection; WD: wound dehiscence; MC: medical complications; HT: haematoma; NAC: nipple-areola complex necrosis; FN: fat necrosis; SM: seroma; RP: reoperation; 30-D-R: 30-day-readmission; SN: skin necrosis; MSB: minor skin breakdown; NSL: nipple sensory loss; TN: tissue necrosis; DI: deep infection; DH: delayed healing; SR: scar revision; HS: hypertrophic scarring
Association between risk factors and complications
A total of fifty-nine associations were evaluated. A summary of meta-analysis results on suspected risk factors and complications is shown in Table 3.
Table 3.
Summary of meta-analysis results on suspected risk factors and complications
| Suspected risk factors | Complications | No. of study | OR | 95% CI | P | I2 (%) | PH | P (Egger) |
|---|---|---|---|---|---|---|---|---|
| Age | Any complications | 7 | 0.99 | 0.64–1.52 | 0.961 | 74.8 | 0.001 | 0.200 |
| BMI | Any complications | 19 | 1.59 | 1.45–1.74 | 0.000 | 35.2 | 0.066 | 0.503 |
| Delayed healing | 3 | 1.93 | 1.03–3.63 | 0.041 | 0.0 | 0.683 | – | |
| Fat necrosis | 3 | 2.56 | 1.01–6.51 | 0.048 | 0.0 | 0.607 | – | |
| Hematoma | 3 | 0.64 | 0.22–1.84 | 0.410 | 34.9 | 0.215 | – | |
| Hypertrophic scarring | 2 | 1.46 | 0.61–3.50 | 0.397 | 14.2 | 0.280 | – | |
| Medical complications | 2 | 1.56 | 0.90–2.69 | 0.111 | 0.0 | 0.423 | – | |
| Nipple-areola complex necrosis | 2 | 0.24 | 0.01–5.11 | 0.361 | – | – | – | |
| Wound infection | 10 | 1.54 | 1.29–1.84 | 0.000 | 0.0 | 0.924 | 0.044 | |
| Wound dehiscence | 8 | 2.19 | 1.27–3.78 | 0.005 | 60.8 | 0.013 | 0.161 | |
| Diabetes | Any complications | 6 | 1.41 | 1.11–1.79 | 0.005 | 11.2 | 0.344 | 0.957 |
| Radiation | Any complications | 5 | 3.24 | 1.94–5.40 | 0.000 | 12.6 | 0.334 | 0.423 |
| Delayed healing | 2 | 1.50 | 0.42–5.30 | 0.532 | 11.0 | 0.289 | – | |
| Fat necrosis | 4 | 2.74 | 1.03–7.33 | 0.045 | 0.0 | 0.526 | – | |
| Hematoma | 3 | 0.53 | 0.09–3.29 | 0.499 | 0.0 | 0.899 | – | |
| Hypertrophic scarring | 3 | 1.60 | 0.52–4.96 | 0.416 | 42.8 | 0.174 | – | |
| Wound infection | 4 | 4.62 | 1.57–13.63 | 0.005 | 13.0 | 0.328 | – | |
| Nipple-areola complex necrosis | 5 | 2.52 | 0.60–10.59 | 0.207 | 0.7 | 0.365 | 0.544 | |
| Seroma | 2 | 7.65 | 1.39–41.93 | 0.019 | 3.4 | 0.309 | – | |
| Wound dehiscence | 3 | 2.45 | 0.81–7.40 | 0.113 | 0.0 | 0.817 | – | |
| Smoking | Any complications | 19 | 1.80 | 1.29–2.50 | 0.000 | 87.5 | 0.000 | 0.148 |
| Hematoma | 5 | 0.66 | 0.29–1.49 | 0.319 | 16.6 | 0.309 | 0.843 | |
| Medical complications | 2 | 0.61 | 0.15–2.47 | 0.488 | 74.2 | 0.049 | – | |
| Wound dehiscence | 8 | 1.84 | 1.35–2.52 | 0.000 | 36.5 | 0.138 | 0.606 | |
| Wound infection | 7 | 1.86 | 1.57–2.22 | 0.000 | 0.0 | 0.516 | 0.365 | |
| TRW | Any complications | 7 | 1.64 | 0.99–2.71 | 0.053 | 63.2 | 0.012 | 0.983 |
| Surgical technique (IP VS MP) | Any complications | 3 | 2.34 | 1.48–3.72 | 0.000 | 47.0 | 0.152 | – |
| Fat necrosis | 2 | 0.88 | 0.32–2.44 | 0.805 | 0.0 | 0.473 | – | |
| Hematoma | 3 | 0.37 | 0.13–1.07 | 0.067 | 0.0 | 0.719 | – | |
| Nipple-areola complex necrosis | 2 | 0.59 | 0.08–4.55 | 0.616 | 0.0 | 0.618 | – | |
| Seroma | 3 | 0.41 | 0.07–2.28 | 0.309 | 0.0 | 0.844 | – | |
| Wound dehiscence | 2 | 3.39 | 1.83–6.29 | 0.000 | 43.5 | 0.183 | – | |
| Wound infection | 2 | 2.06 | 0.88–4.85 | 0.096 | 0.0 | 0.583 | – | |
| Surgical technique (IP VS SMP) | Any complications | 12 | 1.59 | 1.27–1.99 | 0.000 | 27.5 | 0.175 | 0.979 |
| Fat necrosis | 5 | 1.48 | 0.55–3.95 | 0.435 | 0.0 | 0.953 | 0.470 | |
| Hematoma | 6 | 1.05 | 0.59–1.85 | 0.879 | 36.1 | 0.166 | 0.432 | |
| Wound infection | 8 | 2.15 | 1.57–2.94 | 0.000 | 7.8 | 0.370 | 0.789 | |
| Nipple-areola complex necrosis | 10 | 1.50 | 0.62–3.66 | 0.369 | 0.0 | 0.902 | 0.886 | |
| Nipple sensory loss | 3 | 0.70 | 0.19–2.62 | 0.593 | 42.6 | 0.175 | – | |
| Seroma | 4 | 0.28 | 0.09–0.80 | 0.018 | 0.0 | 0.430 | – | |
| Skin necrosis | 2 | 0.41 | 0.05–3.33 | 0.407 | 0.0 | 0.864 | – | |
| Wound dehiscence | 5 | 1.55 | 0.67–3.57 | 0.304 | 45.3 | 0.120 | 0.558 | |
| Hypertrophic scarring | 3 | 1.37 | 0.46–4.12 | 0.575 | 0.0 | 0.913 | – | |
| Reoperation | 3 | 0.53 | 0.16–1.77 | 0.298 | 1.0 | 0.364 | – | |
| Surgical technique (IP VS SP) | Any complications | 6 | 1.32 | 0.74–2.36 | 0.346 | 75.1 | 0.001 | 0.944 |
| Nipple sensory loss | 2 | 0.91 | 0.32–2.64 | 0.865 | 27.9 | 0.239 | – | |
| Fat necrosis | 3 | 0.79 | 0.32–1.99 | 0.617 | 0.0 | 0.695 | – | |
| Hematoma | 4 | 0.95 | 0.28–3.28 | 0.936 | 0.0 | 0.892 | – | |
| Hypertrophic scarring | 2 | 5.36 | 0.30–96.92 | 0.256 | – | – | – | |
| Wound infection | 5 | 1.50 | 0.61–3.69 | 0.377 | 84.4 | 0.000 | 0.775 | |
| Nipple-areola complex necrosis | 4 | 0.38 | 0.14–1.00 | 0.050 | 0.0 | 0.823 | – | |
| Reoperation | 2 | 0.41 | 0.14–1.19 | 0.100 | 0.0 | 0.878 | – | |
| Seroma | 2 | 0.99 | 0.19–5.19 | 0.989 | 0.0 | 0.451 | – | |
| Wound dehiscence | 3 | 0.94 | 0.45–1.96 | 0.873 | 0.0 | 0.546 | – | |
| Surgical technique (SP VS SMP) | Any complications | 3 | 0.59 | 0.37–0.95 | 0.028 | 0.0 | 0.417 | – |
| Hematoma | 3 | 0.43 | 0.11–1.65 | 0.220 | 19.7 | 0.288 | – | |
| Wound infection | 2 | 0.68 | 0.39–1.19 | 0.179 | 0.0 | 0.931 | – | |
| Nipple-areola complex necrosis | 2 | 9.30 | 0.44–197.24 | 0.152 | – | – | – | |
| Wound dehiscence | 2 | 0.43 | 0.04–4.27 | 0.473 | 0.0 | 0.790 | – |
BMI: body mass index; IP: inferior pedicle; MP: medial pedicle; SMP: superomedial pedicle; SP: superior pedicle; TRW: tissue resection weight per breast
Bold values indicate statistically significant associations (p＜0.05 or as defined by the 95% confidence interval excluding the null value) in the meta-analysis
Associations of age, diabetes, and TRW with complications
Meta-analyses were conducted using the available data to evaluate risk factors based on ORs, 95% CIs, and p-values. Pooled results from seven studies showed that age ≥ 50 years was not significantly associated with risk of any complications (OR = 0.99, 95% CI 0.64–1.52, p = 0.961; I2 = 74.8%). A meta-analysis of six studies demonstrated a significantly higher incidence of any complications in diabetic patients following RM (OR = 1.41, 95% CI 1.11–1.79, p = 0.005; I2 = 11.2%). Another meta-analysis including seven studies found no significant association between TRW ≥ 1000 g and any complications (OR = 1.64, 95% CI 0.99–2.71, p = 0.053; I2 = 63.2%). However, there were insufficient data to support subgroup analyses for these three risk factors.
Associations of BMI with complications
Pooled results from nineteen studies showed that BMI ≥ 30 kg/m2 was significantly associated with an increased risk of any complications (OR = 1.59, 95% CI 1.45–1.74, p = 0.000; I2 = 35.2%) Fig. 2. Subgroup analyses demonstrated a significantly higher incidence of delayed healing (OR = 1.93, 95% CI 1.03–3.63, p = 0.041; I2 = 0.0%), fat necrosis (OR = 2.56, 95% CI 1.01–6.56, p = 0.048; I2 = 0.0%), wound infection (OR = 1.54, 95% CI 1.29–1.84, p = 0.000; I2 = 0.0%), and wound dehiscence (OR = 2.19, 95% CI 1.27–3.78, p = 0.005; I2 = 60.8%) in patients with BMI ≥ 30 kg/m2 following RM. No significant associations were found between BMI and hematoma, hypertrophic scarring, medical complications, or NAC.
Fig. 2.
Association between body mass index ≥ 30 kg/m2 and any complications
Associations of PRT with complications
Pooled results from five studies showed that PRT was significantly associated with an increased risk of any complications (OR = 3.24, 95% CI 1.94–5.40, p = 0.000; I2 = 12.6%). Subgroup analyses demonstrated a significantly higher incidence of fat necrosis (OR = 2.74, 95% CI 1.03–7.33, p = 0.045; I2 = 0.0%), wound infection (OR = 4.62, 95% CI 1.57–13.63, p = 0.005; I2 = 13.0%), and seroma (OR = 7.65, 95% CI 1.39–41.93, p = 0.019; I2 = 3.4%) in patients with PRT following RM. No significant associations were found between PRT and delayed healing, hematoma, hypertrophic scarring, or NAC.
Associations of smoking with complications
Pooled results from nineteen studies showed that smoking was significantly associated with an increased risk of any complications (OR = 1.80, 95% CI 1.29–2.50, p = 0.000; I2 = 87.5%) Fig. 3. Subgroup analyses demonstrated a significantly higher incidence of wound dehiscence (OR = 1.84, 95% CI 1.35–2.52, p = 0.000; I2 = 36.5%), and wound infection (OR = 1.86, 95% CI 1.57–2.22, p = 0.000; I2 = 0.0%) in smokers following RM. No significant associations were found between smoking and hematoma, or medical complications.
Fig. 3.
Association between smoking and any complications
Associations of surgical techniques with complications
Pooled results from three studies showed that IP was significantly associated with an increased risk of any complications compared to MP (OR = 2.34, 95% CI 1.48–3.72, p = 0.000; I2 = 47.0%). Subgroup analyses demonstrated a significantly higher incidence of wound dehiscence (OR = 3.39, 95% CI 1.83–6.29, p = 0.000; I2 = 43.5%) in patients who underwent IP. No significant differences were observed between the two surgical techniques in terms of fat necrosis, hematoma, seroma, wound infection, or NAC.
Pooled results from twelve studies showed that IP was significantly associated with an increased risk of any complications compared to SMP (OR = 1.59, 95% CI 1.27–1.99, p = 0.000; I2 = 27.5%). Subgroup analyses demonstrated a significantly higher incidence of wound infection (OR = 2.15, 95% CI 1.57–2.94, p = 0.000; I2 = 7.8%) and a significantly lower incidence of seroma (OR = 0.28, 95% CI 0.09–0.80, p = 0.018; I2 = 0.0%) in patients who underwent IP. No significant differences were observed between the two surgical techniques in terms of fat necrosis, hematoma, nipple sensory loss, skin necrosis, wound dehiscence, hypertrophic scarring, reoperation, or NAC.
No significant differences were observed between IP and SP in terms of any complications, nipple sensory loss, fat necrosis, hematoma, hypertrophic scarring, wound infection, NAC, reoperation, seroma, or wound dehiscence.
Pooled results from three studies showed that SP was significantly associated with an decreased risk of any complications compared to SMP (OR = 0.59, 95% CI 0.37–0.95, p = 0.028; I2 = 0.0%). No significant differences were observed between the two surgical techniques in terms of hematoma, wound infection, NAC, or wound dehiscence.
Sensitivity analysis
We conducted sensitivity analyses for all meta-analyses involving at least five studies by removing each study individually (Supplementary Fig. 1). Only one study affected result stability in analyses of diabetes and any complications, surgical techniques (IP vs SMP) and wound dehiscence, surgical techniques (IP vs SMP) and wound infection, and surgical techniques (IP vs SP) and wound infection. Sensitivity analyses indicated that most results were robust. However, in certain comparisons, the overall effect estimates were sensitive to the exclusion of individual studies, suggesting potential instability. These associations should therefore be interpreted with caution, and further studies are warranted to confirm these findings.
Publication bias
Publication bias was evaluated using funnel plots and Egger’s test (Fig. 4 and Table 3). According to Egger’s test, evidence of publication bias was found only in the analysis of BMI and wound infection (p = 0.044).
Fig. 4.
Funnel plot of the association between body mass index ≥ 30 kg/m2 and any complications
Discussion
As RM becomes more popular in clinics, postoperative complications have received increasing attention. We conducted meta-analyses of sixty-one studies to identify risk factors for complications following RM, finding that BMI ≥ 30 kg/m2, smoking, diabetes, surgical techniques, and PRT were significantly associated with risk of any complications. Furthermore, associations between risk factors and specific complications were also researched. BMI ≥ 30 kg/m2 was linked to higher risks of delayed healing, fat necrosis, wound infection, and dehiscence. PRT increased the risks of fat necrosis, infection, and seroma. Smoking was associated with higher risks of wound infection and dehiscence. Compared to MP, IP had a higher risk of dehiscence; compared to SMP, IP had a higher risk of infection but a lower risk of seroma.
BMI is commonly considered a risk factor for postoperative complications [1, 71]. According to the WHO BMI classification, we categorized patients into a non-obesity group (BMI < 30 kg/m2) and an obesity group (BMI ≥ 30 kg/m2) [25, 72]. Consistent with previous study [40, 57], our results showed that obesity significantly increased postoperative complications, particularly wound complications. The increased postoperative complications may be attributed to more challenging surgical exposure, longer operative time, and a higher incidence of wound fat liquefaction in obese patients. However, most patients with macromastia are obese, which presents challenges for surgeons in both preoperative assessment and postoperative management to prevent wound complications.
Smoking was a significant risk factor for postoperative complications, particularly affecting wound healing. Our study found that smoking increased the risk of wound infection by 1.86-fold and wound dehiscence by 1.84-fold. Nicotine can damage the endothelial wall and reduce the blood's ability to transport oxygen. Nicotine-induced vasoconstriction leads to poor wound perfusion, which delays healing and contributes to wound infection and dehiscence [1, 73]. Moreover, smoking can weaken the immune system's ability to combat infections [74]. Poor wound healing increases patients'economic burden and induces anxiety and negative emotions. Therefore, patients are advised to quit smoking, with a general recommendation to abstain from tobacco use for at least four weeks prior to RM surgery [26].
Our study identified diabetes as a risk factor, increasing the incidence of any complications by 1.41-fold after RM. However, previous studies have reported inconsistent results, possibly due to insufficient data and the absence of subgroup analyses for specific complications [27, 75]. Diabetes is a major factor contributing to delayed wound healing. Normally, macrophages are crucial for tissue repair and the transition from pro-inflammatory to anti-inflammatory phenotypes [76–78]. However, diabetes disrupts macrophage function, impeding monocyte recruitment, reducing phagocytosis, and preventing this transition [79]. Furthermore, diabetes impairs keratinocyte and fibroblast function, hindering wound epithelialization [10]. Therefore, blood glucose levels should be monitored and controlled to optimize perioperative management in diabetic patients and improve postoperative outcomes.
PRT can impair tissue healing after RM, increasing the risk of wound infection [42]. Radiation causes fibrosis, reduced vascularity, and altered immune response, which hinder tissue regeneration and healing. This makes irradiated skin more susceptible to complications. The tension on incision sites in RM, particularly after large tissue resections, can further exacerbate these risks. Careful surgical planning and postoperative management, including minimizing tension on incisions and ensuring proper wound care, are essential to reduce infection risks in patients with a history of PRT.
Various techniques are used in RM; however, due to limited data, only the IP, MP, SMP, and SP techniques were included in our study. Clinically, IP remains one of the most commonly used methods [80]. We found that IP was associated with a higher risk of wound dehiscence compared to MP, likely due to its longer and heavier pedicle, which increases tension at the incision site and may compromise perfusion. In contrast, the MP technique preserves medial blood supply and requires less tissue undermining, thereby promoting better healing and reducing wound stress [64].
Compared to SMP, IP was linked to a higher risk of wound infection but a lower risk of seroma. The increased infection risk may result from the longer pedicle and more extensive dissection involved in IP, especially in large-volume reductions, which can impair perfusion and increase tissue tension at the inferior pole [81]. Additionally, more extensive tissue handling may elevate the risk of contamination. However, IP may disrupt fewer lymphatic channels and preserve more surrounding tissue, promoting better lymphatic drainage and reducing fluid accumulation, thus lowering the risk of seroma. In contrast, SMP involves more extensive mobilization of medial and superior tissues, which may create larger dead spaces and compromise lymphatic flow [82].
Furthermore, our study showed that SP was associated with fewer overall complications than SMP. This could be attributed to SP’s shorter pedicle and limited dissection, which help preserve vascular integrity and reduce tension. A retrospective study supports this finding, reporting a complication rate of 22% for SP versus 36% for SMP [32]. Nonetheless, no single technique suits all patients; individualized surgical planning based on breast anatomy, patient preferences, and healing potential remains essential for optimal outcomes.
This meta-analysis has several limitations. The majority of the included studies were retrospective, which reduces the strength of the evidence supporting our conclusions. The included studies varied in design, sample size, and quality, which may contribute to heterogeneity and affect the overall reliability of the pooled results. Potential publication bias could not be entirely excluded, as studies with negative or inconclusive results are less likely to be published. Some studies lacked complete data on important covariates or outcome measures, limiting our ability to perform more detailed subgroup or sensitivity analyses. Despite using rigorous inclusion criteria and a comprehensive search strategy, the possibility of missing relevant studies remains. Finally, as with all meta-analyses, our findings are inherently dependent on the quality and accuracy of the original studies, and residual confounding may still exist. Future studies should focus on high-quality, prospective, and multicenter designs to validate the associations identified in this meta-analysis. Standardized definitions of complications and surgical techniques are needed to reduce heterogeneity. Moreover, individual patient data meta-analyses could allow for more precise risk stratification and adjustment for confounding factors.
Conclusions
In conclusion, BMI, smoking, diabetes, PRT, and surgical techniques significantly influence the risk of complications after RM. These findings highlight the importance of comprehensive preoperative risk assessment and individualized surgical planning to minimize postoperative complications and improve patient outcomes.
Supplementary Information
Acknowledgements
Not applicable.
Abbreviations
- RM
Reduction mammaplasty
- NAC
Nipple-areola complex necrosis
- NOS
Newcastle–Ottawa Scale
- BMI
Body mass index
- TRW
Tissue resection weight per breast
- PRT
Previous radiation therapy
- IP
Inferior pedicle
- MP
Medial pedicle
- SP
Superior pedicle
- SMP
Superomedial pedicle
- OR
Odds ratio
- CI
Confidence interval
Author contributions
RR and HW: study design, draft the initial manuscript, revision of the manuscript, searching the databases, data collection; XH: statistical analysis, drawing the tables; MY: statistical analysis; JJL: statistical analysis; EXM: statistical analysis, revision of the manuscript; CYL: supervision of data collection, draft the initial manuscript, design and conceptualization of the study. All authors read and approved the final manuscript and are responsible for data review.
Funding
This work was supported by Health Commission of Sichuan Province Medical Science and Technology Program [Grant Numbers 24 WSXT047].
Availability of data and materials
The datasets supporting the conclusions of this article are included within the article and its additional files.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Ran Ran and Hao Wang have contributed to this work equally and thus are co-first authors.
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Associated Data
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Supplementary Materials
Data Availability Statement
The datasets supporting the conclusions of this article are included within the article and its additional files.