Evaluation of the Impact of Physical Therapy on Patients With Macromastia Seeking Breast Reduction Surgery

Abstract

Background

Macromastia significantly impairs females’ quality of life, with treatments such as physical therapy (PT) often providing only temporary relief. Insurance routinely denies breast reduction surgery, despite little relief after conservative treatments. Research on the efficacy of PT for macromastia is limited.

Objectives

In this study, we investigated the efficacy of PT for macromastia and identified patient factors associated with progression to surgery.

Methods

We conducted a retrospective cohort study of patients with macromastia between 2017 and 2021. We collected data on presenting symptoms, attempted conservative treatments, PT duration, and whether surgery was performed. All patients were invited to participate in a survey regarding their symptoms, treatments, and responses to treatments. Symptoms associated with patients progressing to a breast reduction were evaluated with a multiple logistic regression.

Results

Among the 327 patients identified with macromastia, 312 (95.41%) reported back pain and 272 (83.18%) attempted PT. Of the 72 (22.02%) patients who responded to the survey, 152 (46.48%) underwent subsequent surgery. The mean time from initial consultation to surgery was 283 days. Bra strap grooving was associated with progression to surgery (odds ratio = 1.90, CI = 1.02-3.54). Mean patient-reported pain levels decreased after surgery compared to after PT (pre-PT = 7.1, post-PT = 7.1, post-surgery = 3.1, P < .001).

Conclusions

Patients frequently undergo PT before breast reduction surgery despite no significant reduction in pain, whereas those who undergo surgery experience permanent relief and significantly reduced pain. Patients with bra strap grooving are more likely to progress to surgery. The requirement for PT as a prerequisite for surgery by insurance companies should be reevaluated.

Level of Evidence: 3

Macromastia is the excessive growth of the breast gland and affects up to 5% of females.¹ Macromastia negatively impacts females’ health and quality of life in areas of physical, social, and psychological well-being.¹ The combination of pain and poor body perception has been shown to prevent females from participating in recreational and community activities, precipitating isolation and a deterioration in mood.^1,2 Previous studies have described improvement in the well-being of females after breast reduction in physical, psychological, and sexual areas of their life, yet the criteria for surgical approval have been arbitrary and contradictory.^3-5 Further impeding the approval process, some third party payers have increased the minimum weight in grams of tissue to be resected per body weight despite there being evidence that much lower weights have efficacy in reducing symptoms in these patients.^6,7

Conservative therapies are costly and introduce delays in care.¹ Before surgical approval, patients are required to undergo various conservative treatments such as supportive bras, weight loss, nonsteroidal anti-inflammatory drugs, and physical therapy (PT); however, these interventions seldom offer lasting relief.^1,3,8,9 Breast reduction candidates may find themselves waiting over a decade for surgery while undergoing expensive yearly nonoperative treatments.¹ PT is one of the mandated preoperative conservative therapies, with Medicaid requiring 6 months of documented conservative management before authorization, and private insurances frequently requiring these treatments as well.^{1,3,5,6,10,11} As a result, 30% of patients are denied surgery for not meeting medical criteria or inadequate documentation.⁵

The benefits of PT for breast hypertrophy have not been previously evaluated in high-quality literature. Smaller studies have not reported permanent relief with PT.¹ Because PT is both costly and a cause of surgical delay, it is important to fully understand the nature of this insurance requirement.¹

On a separate note, when patients opt in for surgical treatment, they require multimodal pain management for a successful postoperative course. There is strong evidence suggesting that a locoregional block can reduce immediate postoperative pain, nausea, and opioid use.^12,13 However, there has been little research on the administration of pregabalin in breast reduction patients. Despite that, previous studies have reported on pregabalin in patients with breast cancer undergoing mastectomy and reconstruction and showed reduced postoperative acute pain, decreased morphine milligram equivalents (MME), and decreased postoperative nausea and vomiting.^14-16

The aim of our study was to assess the impact of PT for patients with macromastia compared to breast reduction surgery and to characterize patient factors associated with the progression from PT to surgery. Another goal of this study was to evaluate the effect of postoperative pain management in patients undergoing breast reduction.

METHODS

Study Design

A retrospective cohort study was performed on patients who sought care for macromastia at a large academic institution between January 2017 and December 2021. To evaluate the efficacy of PT and the patient characteristics associated with progressing from conservative treatment to a breast reduction surgery, the patients were split into 2 cohorts: macromastia patients who underwent breast reduction and those who did not undergo surgery. The Colorado Multiple Institutional Review Board (COMIRB) approved the study before any study-related activities (IRB number: 22-1307).

Participants

Inclusion criteria for the study were patients who sought care for macromastia at our institution between January 2017 and December 2021. Exclusion criteria included patients younger than 18 years of age or those who were incarcerated.

Data Collection

The electronic medical record (EMR) for each patient was manually reviewed. Patient demographics including age, BMI, Charleston comorbidity index (CCI), race, ethnicity, insurance status, American Society of Anesthesiology (ASA) classification, and smoking status were collected. Disease characteristics collected included the reason for consultation, bra size, personal or family history of breast cancer, previous procedures, and macromastia treatment. The date when macromastia was initially mentioned in the patient's chart served as a surrogate for the diagnosis date, determining the duration until surgery. Treatment characteristics offered by the plastic surgeon were collected. If PT was recommended, the length of PT was recorded. For patients who underwent surgery, data on time to surgery, postoperative medications, prescribed MME, opioid refills, complications, and patient-reported relief were collected.

Survey

All patients included were invited to participate in a survey aimed at gathering insights into their initial concerns for macromastia consultation, initial pain levels, the efficacy of their PT regimen, and postoperative outcomes if they underwent surgery (Appendix). This unvalidated survey was distributed by email and completed independently by the patients. Written informed consent was acquired from all patients in the survey. We followed COMIRB consent guidelines. To assess for relief after PT and surgery, patients rated their relief based on a 5-point scale (see Table 1). Patient-reported pain levels were collected with a numerical rating scale from 0 to 10, with 0 indicating no pain and 10 representing very severe pain.

Statistical Analysis

Patient characteristics were summarized with descriptive statistics. Chi-square tests and Fisher's exact tests were performed to compare patient and clinical characteristics between the breast reduction and no breast reduction cohorts. A multiple logistic regression was performed to evaluate symptoms associated with patients progressing from conservative treatment to undergoing a breast reduction. For all statistical tests, the significance level was .05. Statistical analysis was performed with R Software, version 4.3.0, and R Studio, version 2023.03.1 (I 2022 Posit Software, public-benefit corporation).

RESULTS

A total of 327 patients were included during the study period, of whom 152 (46.5%) underwent breast reduction and 175 (53.5%) did not undergo surgery for macromastia. The patient characteristics are summarized in Table 2. All patients were female. The mean age in the control and breast reduction cohorts were 39.6 (18-67) years and 39.3 (18-72) years, respectively (P = .85). In patients who did not undergo a breast reduction, the BMI was higher (32.7 ± 8.1 vs 29.8 ± 5.3, P < .001). Smoking was also higher in the non–breast reduction cohort (14.3% vs 2.0%, P < .001). ASA class was higher in the cohort that did not undergo surgery with 42 (24%) patients having an ASA class of 3 or 4 compared to 22 (14.5%) patients with the same ASA classes in the breast reduction cohort (P < .001).

The time from diagnosis to initial consultation with a plastic surgeon averaged 283.0 ± 252.3 days, with a range from 12 days to 1460 days (4 years). The time from diagnosis to surgery had a mean of 912.5 ± 1533 days (2.5 ± 4.2 years), with a range spanning from 20 days to 12,601 days (34.5 years). There were no associations found between race, ethnicity, insurance type, and time from diagnosis to plastic surgeon consultation or surgery. Patients with an ASA of 4 were more likely to wait longer for surgery (P = .03).

When inquired about the reasons for seeking a breast reduction, 312 (95.4%) patients cited back pain as the causative factor (Table 3). Other reasons included neck pain (83.2%), rash (70.9%), skin wounds (8.0%), bra strap grooving (77.7%), difficulty maneuvering life (39.8%), and aesthetic concerns (5.8%). Bra strap grooving between the 2 groups was found to be significantly different, with 127 (72.6%) patients reporting bra strap grooving in the control group and 127 (83.6%) patients reporting bra strap grooving in the breast reduction cohort (P = .02). The multiple logistic regression (Table 4) demonstrated that patients with the complaint of bra strap grooving were more likely to undergo surgery (odds ratio [OR] 1.90, CI 1.02-3.54).

At the time of consultation, 211 (64.5%) patients had previously received PT for their macromastia, with 43 (20.4%) requiring additional PT due to insurance company requirements. There were 270 (82.6%) of the 327 patients who underwent PT, of which 156 (58.1%) had PT for longer than 12 weeks. No significant difference was observed in the length of PT between the cohorts (P = .08). A total of 255 (94.4%) patients did not experience any relief from the PT, whereas 15 (5.6%) reported partial temporary relief.

There were 48 (31.6%) patients who experienced a postoperative complication (Table 5). Of those, 32 (21.1%) patients experienced wound dehiscence, 17 (11.2%) had a surgical site infection, and 9 (5.9%) developed a hematoma or seroma. Patients with a BMI of greater than 30 had an increased rate of wound dehiscence (P = .03). Smoking status and diabetes were not associated with postoperative complications. Compared to patients who were not prescribed pregabalin for postoperative pain, those who were prescribed pregabalin were more likely to have ceased opiate use before their first postoperative visit (P = .006). There was no association between pregabalin use and the need for opioid refills (P = .08).

A total of 72 (22.0%) patients completed the survey. Of those, 54 (75.0%) completed PT, and 35 (48.6%) underwent breast reduction. There was no change in the average reported pain level before PT (7.1 ± 1.8) and after PT (7.1 ± 2.1; P = 1.0). There was a significantly lower average pain level following breast reduction surgery (3.1 ± 2.5) compared to both pre-PT (P < .001) and post-PT (P < .001) (Figure 1). After PT there were 22 (40.7%) patients who reported no relief, 31 (57.4%) patients who reported partial temporary relief, and 1 (1.9%) patient who reported partial permanent relief (Figure 2). Of the patients who underwent a breast reduction, 4 (11.4%) patients reported partial temporary relief, 8 (22.9%) patients reported partial permanent relief, 5 (14.3%) patients reported full temporary relief, and 18 (51.4%) patients reported full permanent relief (Figure 3).

DISCUSSION

Breast reduction surgery is a sought-after option for many females with macromastia; however, they are required to undergo a series of conservative treatments with little research on efficacy before surgery for the purpose of insurance approval.^3,5,17 Understanding the effectiveness of these costly and time-consuming treatments is crucial to appropriately managing macromastia. In this study we demonstrated that patients with macromastia who undergo PT had similar pain levels after completing the therapy and were no less likely to pursue breast reduction surgery, irrespective of PT duration. In contrast, those who underwent a breast reduction had a markedly reduced pain level and permanent relief of their symptoms.

We found that PT provides limited relief for patients with macromastia. In 2002, Collins et al in a study in which they evaluated the effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia also found that PT did not provide effective permanent relief of symptoms associated with macromastia.¹⁷ More recent reports on patients with macromastia continue to describe the lack of appreciable benefit of PT.¹⁸ This is likely because PT does not address the underlying problem of macromastia, but instead focuses on improving the patient's physical strength. While increased strength may provide temporary pain relief, it does not affect the root cause of the problem, which is excessive breast tissue. Similarly, the higher BMI in the no surgery cohort may have led to persistent pain after PT, because a higher BMI has been associated with dorsopathies and back pain.¹⁹ The relief that a breast reduction can have for these patients is demonstrated in a study by Foreman et al, which showed that patients who undergo a breast reduction have a 35% reduction in low back compressive forces and a 76% reduction in overall disability, as measured by the Functional Rating Index.²⁰ Collins et al in a different study also demonstrated that breast reduction surgery provides permanent relief and enhances overall quality of life.¹⁷ This emphasizes the role that breast reduction surgery plays in alleviating symptoms of macromastia compared to symptom relief achieved by PT alone.

Patients are often delayed for long periods of time before surgery to fulfill insurance company requirements. In our study, the duration from the first mention of macromastia in a patient's chart to surgery was 912.5 ± 1533 days (2.5 ± 4.2 years). In Europe these extended delays can result in substantial costs for patients, as high as €9450.54 (around $10,300) per year, whereas a breast reduction on average costs $6771.^1,21 During these delays, patients also experience undue financial burden from days of lost work. Cruz et al found that patients who underwent conservative treatment with PT missed an average of 6 days of work every 6 months, resulting in a yearly income loss of about $1642.²²

Macromastia, when treated with reduction mammaplasty, may also improve a patient's psychosocial health. Previous studies have reported a history of depression and anxiety as high as 33% in patients with macromastia when compared to control groups without macromastia.^23,24 In 2012, Cerrato et al showed that macromastia is associated with lower self-esteem and eating disorders in adolescents.²⁵ A more recent study published in 2017 of 119 symptomatic macromastia patients reported statistically significant improvements in anxiety, depression, and body image as early as 1 month after surgery.²⁶ Despite strong evidence that patient satisfaction and quality of life are not impacted by tissue weight resected, this continues to be a source of insurance preauthorization denial.^5,7,27 Insurance companies may consider earlier referrals for surgical reduction to improve patient psychosocial well-being, which may ultimately decrease the financial burden on both the patient and the healthcare system.

Presenting symptoms that were associated with progression to a breast reduction were evaluated with a multiple regression analysis. Females presenting to the clinic with bra strap grooving were significantly more likely to undergo all the necessary insurance company requirements and proceed to a breast reduction (OR 1.90, CI 1.02-3.54). Surgeons may apply our findings to better evaluate patients and accurately document symptoms or patient lifestyle modifications made to provide symptomatic relief to increase odds of insurance authorization. Insurance companies may consider streamlining the approval process for patients with bra strap grooving seeking a breast reduction.

Several studies have described risk factors for complications following breast reduction.^28-31 Common comorbidities discussed include smoking and obesity. In contrast, we found that smoking was not associated with postoperative complications. This is likely because the surgeons in this study required their patients to quit smoking before surgery. This suggests that patients who quit smoking before surgery can effectively mitigate the complications that are associated with smoking. It is not a surprise that our results showed that obesity was associated with increased rates of wound dehiscence postoperatively. Surgeons should counsel patients with obesity on their increased risk and encourage weight loss before surgery. Further studies are needed to determine the optimal weight before surgery to avoid such complications.

Although several studies have reported on the benefits of locoregional blocks for immediate postoperative pain, sustained pain relief during the postoperative period has not been thoroughly explored in this population.^12,13 In our study, we demonstrated that patients who were prescribed pregabalin as part of a multimodal pain strategy had lower rates of persistent opiate use at their first postoperative visit (P = .006). Similarly, Freedman et al demonstrated that pregabalin postoperatively decreased pain scores and patients’ MME requirements.³² Prescribing pregabalin postoperatively as an opioid-sparing strategy can help surgeons mitigate opioid reliance and adverse effects in their patients.^14-16

This study had several limitations. This study was done at a single institution, which may limit the generalizability of the findings. The retrospective nature of the study introduced potential sources of bias, such as selection bias and incomplete data collection. For example, some patients may have sought surgery at other institutions, changing their designation from control cohort to surgery cohort. Additionally, the duration between diagnosis, consultation, and surgery was derived from the first mention of macromastia in the patient's EMR, possibly underestimating the actual duration of macromastia. Selection bias was mitigated by identifying all patients with macromastia before chart review. Another limitation of this study was that the patients in the breast reduction cohort had a significantly lower BMI. This was most likely due to some surgeons requiring weight loss before surgery or having a strict BMI cutoff of 35 kg/m². Additionally, the survey in this study was not validated, and patients may have had recall bias regarding their pain reduction levels with either PT or surgery.

CONCLUSIONS

In conclusion, in this study we demonstrated the limited efficacy of PT in alleviating pain associated with macromastia, with the duration of PT having no impact on the likelihood of undergoing surgery. Our results also suggest that females with bra strap grooving are more likely to undergo a breast reduction, emphasizing the need for insurance companies to streamline approval for individuals presenting with this particular symptom. Breast reduction significantly alleviates the pain experienced from macromastia; about 75% of patients reported permanent relief after surgery. Surgeons should also counsel patients with obesity that they are at a higher risk for wound dehiscence, in addition to considering prescribing pregabalin postoperatively to minimize opioid use.

Supplemental Material

This article contains supplemental material located online at www.aestheticsurgeryjournal.com.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes