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Revista do Colégio Brasileiro de Cirurgiões

versão impressa ISSN 0100-6991versão On-line ISSN 1809-4546

Rev. Col. Bras. Cir. vol.43 no.3 Rio de Janeiro mai./jun. 2016

http://dx.doi.org/10.1590/0100-69912016003005 

Original Article

Augmentation mastopexy after bariatric surgery: evaluation of patient satisfaction and surgical results.

WILSON CINTRA JUNIOR1 

MIGUEL LUIZ ANTONIO MODOLIN1 

RODRIGO ITOCAZO ROCHA1 

ROLF GEMPERLI1 

1- Divisão de Cirurgia Plástica e Queimaduras do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil.

ABSTRACT

Objective:

to evaluate patient satisfaction and surgical results obtained after mastopexy with breast implant inclusion.

Methods:

we conducted a prospective study of 20 consecutive female patients with a mean age of 39.9 years, submitted to augmentation mastopexy. We applied semi-directed psychological interviews pre and postoperatively. The answers to the evaluations were tabulated, categorized, and allowed patient satisfaction analysis. We evaluated surgical results through photographic analysis of three independent plastic surgeons, in the pre and postoperative periods, when scores were attributed to the following items: breasts shape, breasts volume, breasts symmetry, nipple-areolar complex position, and scar quality and extent.

Results:

nineteen patients (95%) referred satisfaction with the surgical results attained (p<0,001). The mean sum of the scores attributed by the three surgeons to each patient varied between 4.7 and 10, with an overall mean of 7.28. The results were considered good or great for 65% of the sample and poor for 8.4%.

Conclusion:

there was a 95% satisfaction rate among patients with the results obtained through augmentation mastopexy. The photographic analysis of the results obtained a mean score of 7.28, considered as a good result, albeit the weak correlation among evaluators.

Keywords: Mammoplasty. Breast Implants. Patient Satisfaction. Obesity; Morbid. Surgery; Plastic.

INTRODUCTION

Post-morbid obesity plastic surgery resects the dermolipomatous excesses and improves body contouring. Brachioplasty, abdominoplasty, cruroplasty, rhytidectomy, mammaplasty and mastopexy are procedures that enhance self-esteem and reduce health-related problems of these patients, which can again be productive members of society1.

Breast ptosis and volumetric loss are common characteristics in women who had massive weight loss after bariatric procedures2. The mastopexy associated with breast implants insertion, also known as augmentation mastopexy, has proved to be an effective surgical solution in treating such dysmorphia3.

We conducted this prospective study to evaluate the satisfaction of patients and the surgical results obtained.

METHODS

Patients (n=20, 100% women, mean age 39.9 years, range 21-63) underwent augmentation mastopexy in a single operative time. All had undergone malabsorptive-restrictive bariatric surgery by the technique of Fobi-Capella4, between 19 and 96 months before plastic surgery, showed stable weight for a minimum of 12 months and had not had other plastic surgery before.

The average height of patients was 1.63m (1.56-1.70); the average pre-bariatric surgery body weight was 116.5kg (100-135); and the average pre-plastic surgery body weight was 68kg (57.5-78).

The mastopexies with inclusion of breast implants were not associated with other surgeries and were performed by the same surgical team, at the same institution, over a period of seven months.

Patient satisfaction assessment

We invited the twenty patients to participate in semi-structured psychological interviews in the preoperative period and six months postoperatively. The interviews were applied by a single psychologist in a suitable environment, when patients were assured that nothing would interfere in their treatment. After all interviews, open answers and spontaneous utterances were recorded and grouped by similarity, in categories, raised from the qualitative analysis. We then compared the answers obtained pre and postoperatively.

Assessment of surgical outcomes

Surgical results underwent critical and qualitative evaluation based on the pre and postoperative photographic documentation (Figure 1).

Figure 1  Mastopexy with inclusion of breast implants (volume: 240ml). Preoperative: A) anterior view; B) obliquely right; C) right profile. Postoperative: D) right view; E) right oblique; F) right profile. 

A standardized questionnaire formulated by the author was sent to three plastic surgeons with experience in the surgical treatment of breast deformities after massive weight loss, who were unaware of the clinical cases to be evaluated. This questionnaire was accompanied by pre and postoperative photographic images in five positions: frontal, right oblique, left oblique, right profile and left profile.

The evaluators assigned values zero, one or two for each following item: shape, volume, symmetry, position of the areola-papillary complex and quality and extent of scarring. Zero score corresponded to bad result; one, regular; and two, good result5.

The sum of scores of the five items assessed varied between zero and ten. When the sum was between zero and four, the result was considered poor; five or six, regular or acceptable outcome. The sum of scores between seven and nine was considered a good result, and ten was considered optimal5.

RESULTS

The interviews showed a positive interference of breasts plastic surgery in various sectors of the patients' life, as shown in Table 1.

Table 1 Summary of the items evaluated in the pre and postoperative interviews. 

Item assessed Patients (n=20)
Preoperative Postoperative
Result close to expectations - 100%
Improved professional life - 20%
Improved social life - 60%
Improved affective life - 50%
Improved sexual life - 50%
Improved body comfort - 60%
Satisfaction with own body 50% 50%
Improved body care - 85%
Satisfaction with breasts 25% 95%

Statistical analysis, by applying the McNemar test (Table 2), showed inferential results that proved a statistically larger percentage of patients satisfied after breast surgery (95%) when compared with the time prior to surgery (25% - p < 0.001).

Table 2 Distribution of patients according to satisfaction with breasts before and after surgery. 

Satisfaction with breasts after surgery TOTAL
satisfied unsatisfied
Satisfaction with breasts before surgery Satisfied 5 - 5
25% - 25%
Unsatisfied 14 1 15
5% 75%
TOTAL 19 1 20
95% 5% 100%

The volume of the breast implants ranged between 200 and 280 ml, with a mean of 236ml. The volume of 240ml was the most used, for eight patients. The mean operative time was 229 minutes, ranging between 170 and 300. Surgical interventions were not carried out before the postoperative results evaluation.

Two patients had postoperative complications. The first presented local hyperemia with serous secretion output through the surgical incision, was hospitalized and treated with intravenous antibiotics despite negative cultures for bacterial growth. The second patient presented dynamic asymmetry of the breasts at arms abduction, caused by a position of the left implant more cranial relative to the right one, which was addressed through surgical reintervention after postoperative evaluation.

The average of the sums of the grades given by the three surgeons for each patient varied between 4.7 and 10, and the overall average of the sums of the scores was 7.28.

The results were rated on average as good or excellent in 65% of patients, and bad in 8.4% (Table 3).

Table 3 Percentage of patients and their results. 

Result Surgeon 1 N (% patients) Surgeon 2 N (% patients) Surgeon 3 N (% patients) Average
Poor 1 (5%) 1 (5%) 3 (15%) 1.7 (8,4%)
Regular 4 (20%) 5 (25%) 7 (35%) 5.3 (26,6%)
Good 12 (60%) 9 (40%) 9 (45%) 10.0 (50%)
Optimal 3 (15%) 5 (25%) 1 (5%) 3.0 (15%)

The intraclass correlation coefficient, estimated between the three surgeons for the final score, was 0.494, (95% CI 0.227-0.731), which confirmed a moderate reproducibility of the final grades among surgeons. The observed agreement between the three surgeons was 30% and the general Kappa coefficient was 23% (95% CI 6.6-39.4%), confirming a weak agreement among surgeons as to the final score.

DISCUSSION

Plastic surgery after massive weight loss aims at resecting skin excess, facilitating personal hygiene, increasing satisfaction with the body, improving sexual, social and interpersonal relationships, increasing self-esteem, and providing better quality of life6.

Various augmentation mastopexy techniques have been described to improve breasts shape and increase their volume7-9. It is characterized as a surgical procedure of difficult planning and low predictability of results10-12.

In the medical literature, there is conflict of views between performing the procudure in a single time or at different times, ie performing the mastopexy and later the inclusion of breast implants. Those who advocate the realization of mastopexy with the inclusion of implants in a single time cite as its advantages the lower physician and hospital costs, sole hospitalization and the low occurrence of additional surgeries. On the other hand, those who support the procedure at two different times cite as advantages the greater predictability of results and the possibility to associate procedures to refine results in the second surgical time3,13.

The use of nonrigid demarcation technique14 provided more freedom to the nipple-papillary complex repositioning and the resulting scars. Eighteen patients had a scar in the shape of inverted T; one patient had an only vertical scar; and one only periareolar.

The histological changes that occur in the skin of patients with massive weight lossmay be responsible for this discrepancy, being mainly characterized by the smaller amount of elastin in the dermal matrix, which leads to lower retraction capacity and lower skin elasticity15.

An important data found in the qualitative evaluation was the improvement in body care, which occurred for 17 patients (85%), demonstrating that they had become more vain, began to better observe their own body and to be concerned with it.

In the postoperative period, 95% of patients demonstrated to be satisfied with the breast surgery (p<0.001). The only patient considered dissatisfied with the surgical outcome, in fact, was partially satisfied, longing for greater breasts volume.

The objective assessment of surgical outcomes seem difficult to achieve. Even with the grading by assessors with the same qualification, ie, experienced plastic surgeons in the study subject, the assessment seems to be subjective and particular to each rater-observer. The weak correlation between the scores awarded by the evaluators does not invalidate the results, where only 8.4% of patients had poor results; and the overall average of the sums of the scores for all patients was 7.28, considered a good result.

In conclusion, the inferential results showed that there was a statistically higher percentage of satisfied patients after mastopexy with the inclusion of breast implants (95%) when compared with the preoperative period (25%). Surgical results, on average, were regarded as good, with the average of the sums of the scores assigned by the three assessors equal to 7.28, despite the poor agreement between them.

REFERENCES

1. Scheufler O, Erdmann D. Current concepts and trends in post-bariatric plastic surgery. Chirurg. 2007;78(4):316-25. [ Links ]

2. Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA, Rubin JP. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg. 2005;116(5):1535-44; discussion 1545-6. [ Links ]

3. Stevens WG, Freeman ME, Stoker DA, Quardt SM, Cohen R, Hirsch EM. One-staged mastopexy with breast augmentation: a review of 321 patients. Plast Reconstr Surg. 2007;120(6):1674-9. [ Links ]

4. Capella RF, Capella JF. Reducing early technical complication in gastric bypass surgery. Obes Surg. 1997;7(2):149-56; discussion 157. [ Links ]

5. Ferreira MC. Evaluation of results in aesthetic plastic surgery: preliminary observations on mammaplasty. Plast Reconstr Surg. 2000;106(7):1630-5; discussion 1636-9. [ Links ]

6. Cintra W Jr, Modolin ML, Gemperli R, Gobbi CI, Faintuch J, Ferreira MC. Quality of life after abdominoplasty in women after bariatric surgery. Obes Surg. 2008;18(6):728-32. [ Links ]

7. Regnault P. The hypoplastic and ptotic breast: a combined operation with prosthetic augmentation. Plast Reconstr Surg. 1996;37(1):31-7. [ Links ]

8. Rubin JP, Khachi G. Mastopexy after massive weight loss: dermal suspension and selective auto-augmentation. Clin Plast Surg. 2008;35(1):123-9. [ Links ]

9. Lockwood T. Reduction mammaplasty and mastopexy with superficial fascial system suspension. Plast Reconstr Surg. 1999;103(5):1411-20. [ Links ]

10. Gonzales-Ulloa M. Correction of hypotrophy of the breast by means of exogenous material. Plast Reconstr Surg Transplant Bull. 1960;25:15-26. [ Links ]

11. Kenkel JM. Marking and operative techniques. Plast Reconstr Surg. 2006;117(1 Suppl):45S-73S. [ Links ]

12. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg. 2006;56(5):481-6; discussion 486. [ Links ]

13. Codner MA, Weinfeld AB. Pr51 Augmentation mastopexy. ANZ J Surg. 2007;77(Suppl S1):A72-3. [ Links ]

14. Ferreira MC, Ishida J, Gemperli R, Besteiro JM, Monteiro Júnior AA, Tuma Júnior P. Reduction mammoplasty with shortened scars: surgical technique. Rev Hosp Clin Fac Med Sao Paulo. 1995;50 Suppl:22-4. [ Links ]

15. Orpheu SC, Coltro PS, Scopel GP, Gomez DS, Rodrigues CJ, Modolin ML, et al. Collagen and elastic content of abdominal skin after surgical weight loss. Obes Surg. 2010;20(4):480-6. [ Links ]

Received: February 22, 2016; Accepted: April 08, 2016

Endereço para correspondência: Wilson Cintra Junior E-mail: wcintra@terra.com.br

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