Evaluation for national guideline adherence and patient-reported outcomes following breast reduction surgery in a public healthcare setting

Abstract

Background

Breast hypertrophy can lead to significant physical discomfort and reduced quality of life. In Denmark’s public healthcare system, access to reduction mammoplasty is guided by criteria including a minimum resection weight of 400–500 g per breast and relevant physical symptoms. This study evaluates adherence to national guidelines and explores patient-reported outcomes following breast reduction surgery.

Methods

We conducted a single center observational cohort study, including 44 women who underwent bilateralt breast reception for hypertrophy in 2023. Patients were classified based on resection weight (> 400 g vs. ≤ 400 g per breast). A questionnaire was distributed postoperatively to assess symptom relief, satisfaction, and perceived outcomes.

Results

Of the 44 patients, 52 % met the >400 g resection criterion. Thirty-one patients (70.5 %) completed the questionnaire. The most common preoperative symptoms were neck/shoulder pain (93.5 %) and physical activity limitations. Notably, 22.6 % of patients felt their breasts remained too large post-surgery.

Conclusions

Despite only partial adherence to resection weight guidelines, the majority of patients experienced substantial symptom relief and reported high satisfaction. The study also underscores the complexity of aligning surgical outcomes with patient selection. While adherence to national guidelines remains important, a more personalized approach to both preoperative assessment and surgical planning may be key to optimizing outcomes and better meeting individual patient needs.

Introduction

Breast hypertrophy is a condition where the breast tissue grows disproportionately to the rest of the body. It is frequently associated with physical discomfort which can substantially impair a patient's quality of life and limit overall functional capacity. Breast reduction surgery can be an effective method for relief of symptom.1, 2, 3 The surgical procedure includes reducing the breast volume and skin and repositioning the nipple thereby reducing pendulation. At the Department of Plastic- and Breast Surgery at Aarhus University Hospital, we adhere to national guidelines when assessing indications for breast reduction surgery. In order for a patient to qualify for a breast reduction surgery within the Danish public healthcare system, these guidelines require the presence of relevant physical symptoms such as neck or back pain, headache, skin rash, fungal infection, a normal BMI of 25 or less, and the expectation of removing at least 400–500 g of tissue per breast, We do, however, evaluate each patient individually regarding to proportions and body figure, the volume of breast and other complaints, and therefore exceptions can occur. In a public healthcare system under constant scrutiny, we found a need to evaluate the extent to which these guidelines were adhered to. Also, we wanted to investigate patient-reported outcomes such as symptom relief and satisfaction with surgery.

Materials and methods

This single-center observational cohort study was conducted at Aarhus University Hospital, Denmark, and received institutional approval as a quality assurance initiative. We included the data of women undergoing bilateral breast reduction for breast hypertrophy from January 1, 2023 to December 31, 2023.

Inclusion criteria

• •Bilateral reduction mammoplasties.
• •Breast hypertrophy (diagnosis due to criteria from the national guidelines).
• •All ages.

Exclusion criteria

• •Mastopexies.
• •Unilateral breast reductions.
• •Oncoplastic breast reductions.

The following data were collected from patient records; patient characteristics (age, BMI, breast volume (in milliliters), jugulum-nipple (JN) distance) and surgical data: date of surgery, and tissue weight removed (in grams). Breast volume was estimated using milliliter cups in different cup sizes.

We used a self-designed qualitative questionnaire (Appendix 1. Questionnaire) based on the above mentioned physical symptoms from the national guidelines, potential cosmetic complaints, whether the patients thought the breasts were reduced to a preferable size, and level of information in the preoperative evaluation and recovery period.

The questionnaire was distributed in April 2024, to relevant participants via the official secure digital communication platform in Denmark “E-boks.” A reminder was sent to non-respondents 2 weeks later. The study concluded on July 1, 2024. All data in the study was collected using a secure software database (RedCap).

Results

Patient characteristics

A total of 44 patients were identified. Age ranged from 17 to 67, with a median of 29 ± 16.3 and a mean of 35. BMI ranged from 19 to 32, with both mean and median of 24 ± 2.0.

Groups

Participants were classified into two groups based on tissue weight removal: those from whom 401 g or more were excised (n = 23, 52 %) and those from whom 400 g or less were removed (n = 21, 48 %) (Table 1). This cut-off was chosen as it corresponds with the national guideline of how much breast tissue should be removed with a breast reduction due to breast hypertrophy in the Danish public health system. The median age was lower in group B, where also the standard deviation in BMI was larger (B 24 ± 1.4 vs. A 24.5 ± 2.4). Also, jugulum-nipple distance was at a larger standard deviation in group B (29.3 ± 7.1) compared to group A (28 ± 1.5). Generally, patients in group B had larger breast volume before surgery and had more breast tissue removed during surgery.

Table 1.

Characteristics from all patients, and groups A and B.

	Group A (≤ 400 g)	Group B (> 400 g)
Age
Median ± SD	32 ± 15.4	25 ± 17.4
Mean	34	36
BMI
Median ± SD	24 ± 1.4	24.5 ± 2.4
Mean	23.9	24.5
JN distance (cm)
Median ± SD	28 ± 1.5	29.3 ± 7.1
Mean	27.8	28.6
Breast volume (ml)
Median ± SD	1000 ± 118.6	1200 ± 272.3
Mean	975	1180
Breast tissue removed (g)
Median ± SD	300 ± 63.6	513.5 ± 138.1
Mean	293	531

Results from the questionnaire

31 of 44 patients (70.5 %) replied to the survey. Table 2 shows the most common symptom/reason for the procedure—from most to least; neck/shoulder pain (93.5 %), interference with physical activity (71 %), dissatisfaction with the appearance of breasts 51.6 %), rash (32.3 %) and headaches (25.8 %). The most improved symptom was rash (90 %) followed by dissatisfaction with the appearance of breasts (75 %) and interference with physical activity (72.7 %). No patient reported worsened symptoms after surgery, and a low percentage reported the same persisting symptoms.

Table 2.

Reasons for desiring breast reduction surgery and postoperative symptom outcomes.

Reason/Symptom	Count (n)	Percentage (%)	Worsened (n)	Partially worsened (n)	Same (n, %)	Partially improved (n, %)	Improved (n, %)
Headaches	8	25.8	0	0	1 (12.5 %)	4 (50.0 %)	3 (37.5 %)
Neck/Shoulder pain	29	93.5	0	0	1 (3.4 %)	10 (34.5 %)	18 (62.1 %)
Rash	10	32.3	0	0	1 (10.0 %)	0	9 (90.0 %)
Interference with physical activity	22	71.0	0	0	1 (4.5 %)	5 (22.7 %)	16 (72.7 %)
Dissatisfaction with appearance	16	51.6	0	0	0	4 (25.0 %)	12 (75.0 %)

The majority of patients (n = 25, 83 %) reported that the postoperative rehabilitation period met their expectations. Additionally, most patients (n = 27, 87 %) indicated that they felt adequately informed about the surgical procedure prior to undergoing surgery. A small proportion of patients (n = 2, 6.5 %) expressed regret regarding the surgery, citing dissatisfaction with the cosmetic outcomes. When asked about their perception of breast size following surgery, seven patients (22.6 %) reported that they felt the breasts remained too large, while only one patient (3.2 %) considered the breasts to be too small.

Most participants (29/31, 93.5 %) reported neck/shoulder pain, which we also investigated separately in groups A and B. Group A consisted of 14 participants who reported the pain was the same (n = 1, 7 %), partially improved (n = 6, 43 %) and improved (n = 7, 50 %). Group B consisted of 15 participants who reported the pain was partially improved (n = 3, 20 %) and improved (n = 12, 80 %).

Discussion

There is a substantial amount of research showing that breast reduction surgery effectively alleviates physical symptoms, improves satisfaction with breast appearance, and reduces emotional anxiety, resulting in an overall increase in quality of life. It is considered a common and safe procedure; however, complications may occur, such as hematoma, infection, nipple necrosis, wound dehiscence, skin and fat necrosis, delayed wound healing, and seroma.^4,5

In a healthcare system increasingly pressured by political and economic factors, it is essential to prioritize the right patients—those who will truly benefit from surgery. Surgeons must strike a careful balance between adhering to clinical guidelines, fulfilling their ethical responsibility to achieve the best outcomes, and considering the broader implications of resource allocation.

Our findings reveal that adherence to breast reduction surgery guidelines remains insufficient, a concern echoed in a Danish study conducted nearly a decade ago.⁶ which found that only 55 % of patients met the minimum resection weight of 400 g This inadequacy may be attributed to patient-specific factors such as anatomical variations, the level of experience of the surgeons examining preoperatively, and their operating skills. Diagnosing is also challenging, as there are no clear and reliable measures to distinguish between large breasts as a normal condition and “Breast Hypertrophy” as an anomaly.

Notably, approximately 20 % of patients report that their breasts still feel too large following surgery, even though only 52 % of patients met the resection weight criterion. This could suggest that surgeons may need to consider excising more breast tissue to achieve a sufficient reduction, rather than focusing on aesthetic outcomes. The findings highlight the critical importance of thorough preoperative consultations to properly address patient concerns and selection and set realistic patient expectations for the surgery.

It is challenging to achieve the required resection weight when preoperative measurements are based on breast volume. In 1991, Schnur et al.⁷ developed a predictive formula that uses body surface area to estimate resection weight in breast reduction surgery. This formula remains widely employed by insurance companies in the United States, which often require a minimum resection weight of 500 g However, Yan et al.⁸ enlighten that the Schnur scale is not only an inaccurate estimator, but also tends to overestimate resection amount in cases that require smaller reduction weights, and underestimates for higher resection weights. The surgeon then may feel obligated to remove enough breast tissue to comply with insurance coverages. Also, patients with lower BMI may be denied access to breast reduction surgery due to low body surface area. Several other formulas, including those developed by Appel, Descamps, and Galveston, have also been proposed to estimate resection weight in breast reduction surgery. However, none have proven to accurately predict the actual resection weight.⁹ Moreover, research indicates that the amount of tissue removed does not consistently correlate with symptomatic improvement in macromastia. As a result, some studies have called for a shift in focus toward evaluating the symptomatic presentation of patients, rather than relying solely on the weight of the tissue excised.^10,11

This study presents both limitations and strengths that must be considered when interpreting its findings. One key limitation is the sample size, which is relatively small, consisting of only 44 patients. This may limit the generalizability of the results. Another limitation is the potential for recall bias. Since no baseline symptom assessments were performed, patients’ recollections of their preoperative conditions may not be entirely accurate, which could affect the validity of reported outcomes. Selection bias is another concern as the study relies on self-reported data from participants who chose to respond to the survey. The study also faces limitations related to the timing of follow-up. Participants completed the survey at varying intervals after surgery, which may introduce variability in the reported benefits. A more standardized follow-up period could have provided more consistent data. Another limitation is the short follow-up period, which may not fully capture long-term patient satisfaction or potential complications. A longer follow-up would provide a clearer picture of the durability of the reported outcomes. Additionally, the questionnaire used in this study was not validated, which may affect the reliability of the data. While established tools like the Breast Q were considered, they were deemed too comprehensive for the focused nature of this study. Finally, the study did not account for differences in experience levels among the surgeons, which may have influenced the clinical outcomes. However, most of these surgeries in our department are conducted by senior registrars rather than specialist plastic surgeons.

Despite these limitations, the study has several notable strengths. First, the targeted questionnaire provided a focused approach to assessing specific symptoms and aesthetic concerns, offering valuable insights into patient experiences. This focused approach enhanced the relevance and precision of the data. The study’s clinical relevance is another strength. It was conducted in a real-world setting, it reflects typical surgical outcomes and provides insight into patient satisfaction outside of controlled clinical trials. The high patient satisfaction rates reported in the study, with minimal dissatisfaction and a majority of participants indicating that the surgical process met their expectations, underscore the positive impact of the procedure. The study also benefits from a high response rate of 70.45 % which strengthens the validity of the study’s findings by ensuring a representative sample. Meyer et al.¹² reported a similar response rate (average of 70 %) in their survey of 811 patients. They found that in-person surveys yield an average 76 % response rate, followed by postal (65 % response rate) and online (46 % web-based vs. 51 % email response rate) surveys.

We found that, in only 52 % of cases, the resection of breast tissue exceeded the 400 g threshold recommended by national guidelines. However, the study showed that symptom relief was generally achieved, with common symptoms such as neck/shoulder pain improving postoperatively. This discrepancy emphasizes the need for a more individualized approach to tissue resection, one that takes into account both the patient's physical symptoms and their subjective satisfaction with the outcomes. Notably, approximately 20 % of patients still reported that their breasts felt too large after surgery, raising the question of whether further tissue removal could be appropriate for certain patients. Although patient satisfaction was high, with the majority feeling well-informed preoperatively and experiencing symptom improvement, there was no consistent correlation between the volume of tissue excised and the degree of symptom relief or satisfaction. This suggests that factors beyond tissue resection volume, such as; patient expectations, individual anatomical factors and the quality of the preoperative consultation, play a critical role in determining outcomes.

Conclusion

In conclusion, while the study demonstrates that breast reduction surgery can provide significant symptom relief and lead to high patient satisfaction, it also underscores the complexity of aligning surgical outcomes with patient selection. While adherence to national guidelines remains important, a more personalized approach to both preoperative assessment and surgical planning may be key to optimizing outcomes and better meeting individual patient needs.

Informed consent

Informed consent was obtained for the questionnaire and data collection.

Funding

None.

Conflict of interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.