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

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.


INTRODUCTION
P ost-morbid obesity plastic surgery resects the dermo- lipomatous 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 society 1 .
Breast ptosis and volumetric loss are common characteristics in women who had massive weight loss after bariatric procedures 2 .The mastopexy associated with breast implants insertion, also known as augmentation mastopexy, has proved to be an effective surgical solution in treating such dysmorphia 3 .
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-Capella 4 , 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 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 DOI: 10.1590/0100-69912016003005 Augmentation mastopexy after bariatric surgery: evaluation of patient satisfaction and surgical results.

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A B S T R A C T 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.

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

Statistical analysis, by applying the McNemar test (Table
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   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).
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 life 6 .
Various augmentation mastopexy techniques have been described to improve breasts shape and increase their volume [7][8][9] .It is characterized as a surgical procedure of difficult planning and low predictability of results [10][11][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 time 3,13 .
The use of nonrigid demarcation technique 14 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 Cintra Júnior Augmentation mastopexy after bariatric surgery: evaluation of patient satisfaction and surgical results 160-164  amount of elastin in the dermal matrix, which leads to lower retraction capacity and lower skin elasticity 15 .
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.

:
Mammoplasty.Breast Implants.Patient Satisfaction.Obesity, Morbid.Surgery, Plastic.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).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 result 5 .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 optimal 5 .
mean operative time was 229 minutes, ranging between 170 and 300.Surgical interventions were not carried out before the postoperative results evaluation.Cintra Júnior Augmentation mastopexy after bariatric surgery: evaluation of patient satisfaction and surgical results 160-164

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

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

Table 3 .
Percentage of patients and their results.