Underwent Breast Reduction Surgery Research Articles

The Combination of Three Techniques for Breast Reduction: A Series of Ten Consecutive Cases

There is continuing controversy regarding the most effective and safest technique for breast reduction surgery. This case series describes our experience with a breast reduction approach that combines three techniques aimed at addressing three different aspects of breast reduction: skin reduction, shaping, and nipple areolar complex shaping. We assessed the perioperative course and postoperative outcomes (for a mean of 19 months) of 10 consecutive women who underwent breast reduction surgery involving a combination of three techniques: “inverted T” skin reduction, modified Hall-Findley supero-medial pedicle for glandular reduction, and inferior de-epithelialized flap (modified “Foustanos” flap) for molding and improved shaping of the breast. The final bra cup size was C or D in all patients. The overall results were graded as excellent in four patients and very good in six patients. Each patient was completely satisfied with her surgery. Six patients developed venous congestion of the nipple areolar complex, which resolved within 24 - 48 hours after surgery. Two patients had uneventful delayed wound healing in the vertical scar of the inverted T pattern. There was a 100% nipple areolar complex survival rate. No patient had a major adverse event, permanently altered nipple areolar complex sensitivity, or bottoming out of the lower pole. None required revision surgery. This case series confirms our expectations that the solution to questions about breast reduction methods may depend on melding different techniques into a single procedure. The combination of techniques herein described was both effective and safe. Level of Evidence: Level IV, therapeutic study.

Does Reduction Mammaplasty Revert Skeletal Disturbances in the Vertebral Column of Patients With Macromastia? A Preliminary Study

Enlarged breasts are associated with many physical and psychological symptoms. It is important to use objective criteria in documenting physical changes of a patient's body due to enlarged breasts and the benefits of surgery. This preliminary study aimed to determine whether the reduction mammaplasty procedure changes the angles of cervical lordosis, thoracic kyphosis, and lumbar lordosis. The study population consisted of 22 patients who underwent breast reduction surgery. All the patients had lateral cervicothoracolumbar radiographs taken preoperatively and at least 2months postoperatively. Cervical lordosis, thoracic kyphosis, and lumbar lordosis angles, as well as sagittal balance, were examined. The body mass index (BMI), breast tissue volume, and excised tissue amount of each patient were recorded. All the patients had increased cervical lordosis and thoracic kyphosis angles preoperatively, and the angles were significantly decreased postoperatively. Of the 22 patients, 7 had decreased and 8 had increased lumbar lordosis angles. All the lordosis angles showed significant improvement at the last examination. Seven patients had disturbed sagittal balance preoperatively, and all had normal sagittal balance postoperatively. Preoperative total breast tissue volume was positively correlated with the differences in cervical lordosis angles, BMI, preoperative cervical lordosis angles, and cervical lordosis angles. Hypertrophic breasts are not only a cosmetic but also a functional problem complicated by pathologic conditions in the vertebral column such as increased cervical lordosis, thoracic kyphosis, and increased or decreased lumbar lordosis. Breast reduction may improve these pathologic angles. Reducing the nonphysiologic weight of enlarged breasts located anterior to the main axis of the body may correct pathologic angulation and disturbed sagittal balance of the vertebral column. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Impact of Breast Reduction Surgery on the Vertebral Column

Although many studies have shown that breast reduction surgery is effective in reducing neck, back, and lumbar pain, most of these studies are subjective evaluations that usually provide data through pain scales. This study was undertaken to objectively evaluate the radiologic effects of breast reduction on the vertebral column. Thirty patients who underwent breast reduction surgery were included in the study. A lateral thoracolumbar radiograph was taken before and 3 months after surgery for each patient. The thoracic kyphosis, lumbar lordosis, and sacral inclination angles were measured for each radiograph. The impact of breast reduction surgery on posture was evaluated according to the comparison of these angles before and after surgery. The effect of age, body mass index, and the total amount of removed tissue was also taken into account, and the relationship between these parameters and their effects on the change in preoperative and postoperative angle measurements were evaluated. There was a significant decrease in all 3 angles after breast reduction surgery. A significant correlation was determined between body mass index and the total amount of removed tissue on the change in angle measurements, whereas a definite relationship was not observed between the angles and the patient's age. This study has shown the objective impact that breast reduction surgery has on the vertebral column. Although the symptomatic relief of breast reduction surgery on the musculoskeletal system is widely accepted, the objective assessment of this relief will be beneficial in persuading health insurance companies and those who think of this surgery as a purely aesthetic procedure.

Breast reduction surgery in Ontario: Changes in practice, 1992 to 2008

Symptomatic mammary hypertrophy impacts physical function and patient quality of life. Breast reduction mammoplasty, a surgical procedure performed to reduce breast size, has been used for many years to reduce these symptoms. To evaluate variations in the surgical practice of breast reduction mammoplasty among women ≥15 years of age (approximately 6.4 million population in 2008) over a 17-year period in Ontario. A population-based, cross-sectional time series analysis was conducted to examine temporal trends in 87,049 breast reduction surgeries performed between January 1, 1992 and December 30, 2008. Breast reduction rates have been relatively stable over time, with 83 per 100,000 of the female population undergoing breast reduction surgery annually. However, a significant decrease in the rate of inpatient surgeries were observed over the study period (from 69.3 per 100,000 in 1992 to 25.7 per 100,000 in 2008). At the beginning of the study period, the highest annual rates of this procedure were observed among women 21 to 30 years of age (116.6 procedures per 100,000); however, by the end of the observation period, this shifted to women 31 to 50 years of age (109.9 procedures per 100,000). Furthermore, the annual procedure rate among women ≥51 years of age almost doubled, rising from 36.4 procedures per 100,000 in 1992 to 66.6 procedures per 100,000 in 2008. This was likely related to changing demographics and social factors. These data suggest that breast reduction mammoplasty will continue to be requested, with an increased proportion of patients who are older and desire improved quality of life and physical function.

Quality of Life After Breast Reduction Surgery

Patient reported outcome studies are extremely valuable. We hypothesize that breast reduction surgery has a high satisfaction rate, and that body mass index (BMI), and the amount of breast tissue removed would not alter this outcome. The purpose of this study was to determine if there is an improvement in the quality of life in patients undergoing breast reduction surgery, and whether breast volume or patient size influences this outcome. A retrospective chart review was performed on 600 consecutive patients at a single institution from 2000 to 2010. Patients were mailed The Breast Q questionnaire to complete. Demographic, surgical, and clinical data were collected and entered into a database. Descriptive statistical analyses were conducted using SAS Software version 9.1.3 with statistical significance determined at P<0.05. A total of 178 surveys were returned and included in our study (a response rate of 29.6%). Patient data included a mean BMI of 28.3 (4.6) kg/m, and mean total amount of breast tissue removed of 1220.9 (665.4) g. The primary indications for patients having breast surgery were for symptomatic macromastia (85%), asymmetry (5.6%), and for cosmesis (2.5%). The Breast Q questionnaire demonstrated patients overwhelmingly agreed that they were satisfied with their breast surgery. The mean response was 2.8 with a standard deviation (SD) of 0.47 (where 1, disagree; 2, somewhat agree; and 3, definitely agree). Patient BMI and total amount of breast tissue removed had a statistically significant positive correlation (0.479; P<0.0001). There was no statistically significant difference between the amount of total breast tissue removed and patient response (P=0.57). The study supports a positive outcome after breast reduction surgery. Over 95% of the patients surveyed were satisfied and would do it again. It demonstrates the improvement of the patient's quality of life regardless of the amount of breast tissue removed. Furthermore, it suggests that the size and weight of the patient has no impact on this outcome. As we face new government and insurance restrictions for surgeries that have both cosmetic and reconstructive value, patient reported outcome studies may have an influence on future third-party payer.

Vertical scar versus the inverted-T scar reduction mammaplasty: A 10-year follow-up

A retrospective study was undertaken to evaluate whether the initial outcome of two types of reduction mammaplasty techniques (vertical scar reduction mammaplasty vs. the inverted-T scar reduction mammaplasty) remains stable in the long term: Sixty-nine patients who had undergone breast reduction surgery in the period 1997-2000 at the Department of Reconstructive Plastic Surgery at the Medical Center of Leeuwarden were willing and able to participate in this study. A structured questionnaire was used to assess the degree of patient satisfaction. For subjective evaluation, the Strasser Grading System on photographs at the 3 months after surgery and after long-term follow-up (10 years) was used. The median general appreciation mark for the entire surgical procedure given by patients was 8 (1-10) on a scale from 1 to 10. Forty-six of the 69 patients could be scored according to Strasser: at 3 months in 17 patients (37%) the result was 'good', in 21 patients (46%) 'mediocre' and in eight patients (17%) 'poor'. After 10 years, in 37 of the patients (80%) the result was 'good', in six patients (13%) 'mediocre' and in three patients (7%) 'poor'. At 3 months, there was a higher incidence of bottoming out in the vertical scar group (one on two patients) as compared to the inverted-T scar group (one on 10 patients); however, at the 10-years follow-up bottoming out was 50% in the inverted-T scar group and 20% in the vertical scar group. Despite bottoming out, in both the vertical scar reduction mammaplasty technique and the inverted-T scar reduction mammaplasty technique, high patient satisfaction rates are achieved that remains for years.

Melatonin suppresses aromatase expression and activity in breast cancer associated fibroblasts

The main biological active substance secreted by the pineal gland, melatonin (MLT), counteracts the effects of estrogens in breast cancer via exerting a number of its own oncostatic properties. Recent studies of postmenopausal women have identified that the major metabolite of MLT is statistically significantly associated with a lower risk of developing breast cancer. While MLT production decreases with age, breast cancer risk, however, increases with age and obesity. We hypothesize that MLT inhibits estrogen production in breast adipose fibroblasts (BAFs), the main local source of estrogen in breast tumors of postmenopausal women, by inhibiting transcription of the CYP19A1 gene that encodes the key enzyme aromatase. Normal BAFs were cultured from women undergoing breast reduction surgery, while breast cancer-associated fibroblasts (CAFs) were isolated from three women with estrogen receptor (ER) positive invasive ductal carcinomas. MTNR1A and MTNR1B receptor expression and CYP19A1 mRNA expression following MLT treatments were determined by qRT-PCR. BAFs express the G-protein coupled MLT receptors MTNR1A and MTNR1B with elevated levels of MTNR1A found in CAFs. Treatment of BAFs and CAFs with MLT resulted in significant suppression of CYP19A1 transcription and aromatase activity at pharmacological, physiological and sub-physiological concentrations. MLT suppression occurred through promoter-specific PI.4-, PI.3- and PII-derived CYP19A1 mRNA. Stimulation of CYP19A1 PII-mRNA and aromatase activity by prostaglandin E(2) (PGE(2)) were significantly attenuated by physiological doses of MLT. Lower levels of MLT in aging women may increase the risk of progressing ER-positive breast cancer through a decreased ability to suppress CYP19A1 expression and subsequent local estrogen production in BAFs/CAFs.

Identification by SNP Analysis of a Major Role for Cayetana Blanca in the Genetic Network of Iberian Peninsula Grapevine Varieties

AIMS: To measure Langerhans9 cells in skin of patients treated by bone marrow transplantation who developed chronic graft versus host disease (GvHD); to determine whether the reduction in Langerhans9 cells resulted directly from the GvHD or from other factors, such as the immunosuppressive regimens used in bone marrow transplant patients. PATIENTS AND METHODS: Lesional and nonlesional skin specimens from nine patients with lichen planus-like lesions and three patients with sclerodermoid lesions were studied. Control skin specimens were taken from three patients undergoing breast reduction surgery. The number of Langerhans9 cells/mm2 and the area of Langerhans9 cells as a percentage of total epidermis were measured by counting cells labelled with antihuman CD1a. RESULTS: A significant reduction in Langerhans9 cell area and number were found in specimens with lesions (area 3.5%; number 507/mm2) compared with specimens without lesions (8.42%; 2375/mm2). In contrast, Langerhans9 cell area and number in skin without lesions were similar to controls (10.26%; 2968/mm2). CONCLUSIONS: Langerhans9 cells were significantly reduced in skin with lesions of chronic GvHD but not in skin without lesions from the same patient, suggesting that the reduction is a direct consequence of GvHD and not linked to immunosuppressive drugs or late effects of conditioning regimens. In long term bone marrow transplant recipients, Langerhans9 cells are derived mainly from the donor cells; therefore, this result suggests the occurrence of autoreactive phenomenon in chronic GvHD.

Adeno-associated virus type 2 infection activates caspase dependent and independent apoptosis in multiple breast cancer lines but not in normal mammary epithelial cells

BackgroundIn normal cells proliferation and apoptosis are tightly regulated, whereas in tumor cells the balance is shifted in favor of increased proliferation and reduced apoptosis. Anticancer agents mediate tumor cell death via targeting multiple pathways of programmed cell death. We have reported that the non-pathogenic, tumor suppressive Adeno-Associated Virus Type 2 (AAV2) induces apoptosis in Human Papillomavirus (HPV) positive cervical cancer cells, but not in normal keratinocytes. In the current study, we examined the potential of AAV2 to inhibit proliferation of MCF-7 and MDA-MB-468 (both weakly invasive), as well as MDA-MB-231 (highly invasive) human breast cancer derived cell lines. As controls, we used normal human mammary epithelial cells (nHMECs) isolated from tissue biopsies of patients undergoing breast reduction surgery.ResultsAAV2 infected MCF-7 line underwent caspase-independent, and MDA-MB-468 and MDA-MB-231 cell lines underwent caspase-dependent apoptosis. Death of MDA-MB-468 cells was marked by caspase-9 activation, whereas death of MDA-MB-231 cells was marked by activation of both caspase-8 and caspase-9, and resembled a mixture of apoptotic and necrotic cell death. Cellular demise was correlated with the ability of AAV2 to productively infect and differentially express AAV2 non-structural proteins: Rep78, Rep68 and Rep40, dependent on the cell line. Cell death in the MCF-7 and MDA-MB-231 lines coincided with increased S phase entry, whereas the MDA-MB-468 cells increasingly entered into G2. AAV2 infection led to decreased cell viability which correlated with increased expression of proliferation markers c-Myc and Ki-67. In contrast, nHMECs that were infected with AAV2 failed to establish productive infection or undergo apoptosis.ConclusionAAV2 regulated enrichment of cell cycle check-point functions in G1/S, S and G2 phases could create a favorable environment for Rep protein expression. Inherent Rep associated endonuclease activity and AAV2 genomic hair-pin ends have the potential to induce a cellular DNA damage response, which could act in tandem with c-Myc regulated/sensitized apoptosis induction. In contrast, failure of AAV2 to productively infect nHMECs could be clinically advantageous. Identifying the molecular mechanisms of AAV2 targeted cell cycle regulation of death inducing signals could be harnessed for developing novel therapeutics for weakly invasive as well as aggressive breast cancer types.

Occult breast carcinoma in breast reduction specimens in European women

Breast reduction is a common surgical procedure performed by plastic and oncoplastic breast surgeons. The authors report on the incidence and management of cancer and atypical hyperplasia in breast reduction specimens from one institution over a 10-year period. All patients who underwent breast reduction surgery at Northern General Hospital, Sheffield were identified from an electronic prospective database. The histopathology reports were analyzed. Case records of all patients with significant abnormalities were retrieved and examined to identify their management and follow-up. Between October 1999 and April 2010, 1,588 patients underwent breast reduction. Nine specimens showed atypical hyperplasia (0.57%). Five cancers were detected (0.31%). Four of the five patients had normal screening mammograms 1-3 years before the reduction operation. Of these cancers, four were invasive (three lobular, one ductal) (0.25%) and one was DCIS (0.06%). A lump was felt macroscopically by the pathologist in two of the four patients with invasive cancer. The patients with DCIS did not undergo further surgery, whereas those with invasive disease underwent mastectomy (three patients) and axillary nodal staging (four patients). None of the patients with normal post-reduction breast imaging had residual cancer on histology. The incidence of occult carcinoma in breast reduction specimens is low. Patients should be counseled with regards to the possible consequences preoperatively.

Abstract P6-03-02: Breast Reduction Mammoplasty and Incidence of Occult Carcinoma. A 10 Year Experience

Abstract Background: The aim of this study was to report the incidence of cancer in reduction mammoplasty specimens and suggest alternative pragmatic cost-effective way of identifying and treating patients with carcinoma. Methods: All patients who underwent breast reduction surgery at Northern General Hospital over a 10-year period were identified from a prospective database. The histopathology reports and case records of all patients with significant abnormalities were analysed. All breast reduction specimens were sliced at 1 cm intervals and examined macroscopically. At least 3 blocks per breast were examined microscopically in addition to sampling of any grossly abnormal tissue. Results: Between October 1999 and April 2010, 1,588 patients underwent reduction mammoplasty. The median age of patients was 38 years (range 16-75 years). Indications for surgery were macromastia in 1,194 (75.2%), congenital asymmetry in 182 (11.5%) and contralateral symmetry procedure post breast cancer surgery in 178 (11.2%). 9 specimens showed atypical hyperplasia (0.57%). 5 cancers were detected (0.31%). 4 of the 5 patients had normal mammograms 1-3 years before the reduction operation (not done in 1). Of these cancers, 4 were invasive (3 invasive lobular, 1 invasive ductal) (0.25%) (mean invasive tumour size 9 mm (SD 7.4)) and 1 was DCIS (4mm) (0.06%). A lump was felt macroscopically by the pathologist in 2 of the 4 patients with invasive cancer. The median age of patients with invasive cancer was 56 years (range 47-68 years). Patient found to have DCIS did not undergo further surgery while those with invasive disease underwent mastectomy (3) and axillary nodal staging (4). None of the patients with benign/normal post-reduction breast imaging had residual breast cancer on histology. Conclusion: The incidence of occult carcinoma in reduction mammoplasty specimens is less than 0.5%. Pre-operative mammogram is not useful as 4 of the 5 patients with cancer had a normal mammogram 1-3 years before surgery and invasive lobular cancers are often not detected on mammogram. Mastectomy may be avoided in patients with no residual breast disease on post-reduction imaging. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-03-02.

Women’s Reasons for Seeking Breast Reduction

This study explored experiences of women with large breasts who were considering or had had breast reduction surgery. Open-ended questionnaires were returned via email from 32 women, 13 of whom were seeking breast reduction and 19 who had already undergone breast reduction surgery. Transcripts were analyzed using Interpretative Phenomenological Analysis (IPA). Themes arising from this analysis included physical symptoms, information, and body image and self-esteem. Implications for Health Psychology are discussed, including the necessity to assist women to cope with pain prior to breast reduction, and assisting health professionals to develop more effective communication skills.

Use of Patient Body Mass Index as a Rationing Tool in Breast Reduction Surgery

Sir: Breast reduction surgery, although regarded as a low-priority cosmetic procedure by most National Health Service trusts, has been shown to result in high patient satisfaction and better quality of life.1 Most health trusts have set the upper body mass index limit of between 26 (overweight) and 30 (obese) as a selection tool for patients considering surgery. It remains unclear whether these limits are based purely on operative complications or as a rationing tool. Our aim was to assess whether overweight patients with a body mass index greater than 26 have higher complication rates after breast reduction and should thus be excluded from surgery. Two hundred six consecutive patients in one tertiary plastic surgery center who underwent breast reduction surgery were reviewed retrospectively. Of all patients, 38 percent had a body mass index less than 26 and 62 percent had a body mass index of 26 or more (range, 21 to 32; mean, 26.3) (Fig. 1). Mean age was 36 years (range, 14 to 65 years). The most common risk factors were the use of oral contraceptive pills (26 percent) and smoking (22 percent). Most operations (82 percent) were performed using the inferior pedicle technique, half of which were performed by a consultant.Fig. 1.: Distribution of body mass index among the 206 patients in the study.Overall, 72 complications were noted in 56 patients, with wound infection, wound breakdown, hematoma, and fat necrosis accounting for 89 percent of the complications. Twenty-eight of the complications were in the lower body mass index group (35 percent) and 44 were in the higher body mass index group (35 percent) (Table 1). There was no statistically significant difference between the two groups (p > 0.05). In addition, there was no difference in length of hospital stay (mean, 2.5 days) or postoperative follow-up noted (p > 0.05).Table 1: Incidence of Major Complications in Patients with a BMI < 26 and a BMI between 26 and 32Obesity is becoming one of the fastest growing public health problems, with 32 percent of women in the United Kingdom being overweight and 23 percent obese. Our study is the largest to date investigating the risk of postoperative complications following breast reduction surgery in patients with a body mass index of less than 26 and in those with a body mass index between 26 and 32. It confirms that overweight patients are not at increased risk of any complications, and the length of hospital stay and postoperative follow-up are not prolonged as a result. Our study, however, did not have patients with a body mass index greater than 32. The literature investigating the postoperative complication rates after breast reduction surgery in relation to body mass index is sparse and shows contradicting outcomes. Platt et al.,2 in a study of 30 patients, noted an increased wound breakdown rate in those with a body mass index greater than 26.3 (10 percent versus 33 percent; p < 0.05). Similarly, Zubowski et al.3 found a statistically significant increase in local complications in obese patients (11.3 percent versus 7.2 percent). However, Wagner and Alfonso,4 in a study of 186 patients, found that obese patients achieved as much symptom relief and with similar complication rates as the nonobese group. Breast reduction surgery is becoming increasingly restricted by the National Health Service, with variability in rationing across the United Kingdom. Reasons for restriction of surgery should be clear and based on good clinical evidence; otherwise, it represents inequality in the provision of health care. This study showed that overweight patients did not suffer from a higher rate of postoperative complications following breast reduction surgery. Overweight patients are not at increased risk of surgical complications after breast reduction surgery, and a body mass index less than 26 should not be used as a rationing tool with which to restrict surgery. Sujatha Tadiparthi, M.R.C.S. S. H. Liew, F.R.C.S.(Plast.) Department of Plastic and Reconstructive Surgery Whiston Hospital Liverpool, United Kingdom

A Prospective Study of Patients Undergoing Breast Reduction Surgery: Health-Related Quality of Life and Clinical Outcomes

This study assessed the health-related quality of life experienced by breast reduction patients using four reliable and validated health-related quality-of-life measures. Consecutive patients with breast hypertrophy completed the Health Utilities Index Mark 2, the Health Utilities Index Mark 3, and the Breast Reduction Assessment Value and Outcomes instruments (the Short Form 36, the Multidimensional Body-Self Rating Questionnaire Appearance Assessment, and the Breast-Related Symptom Questionnaire) at 1 week and 1 day before surgery and at 1, 6, and 12 months after surgery. For the 52 patients in the study, mean scores for all quality-of-life instruments increased from the preoperative assessments to the postoperative assessments. The mean quality-adjusted life years gained per patient because of the surgery was 0.12 during the 1-year follow-up period. There was a positive relationship (p < 0.001) between breast resection weight and body mass index. However, body mass index and tissue resection weight were not significantly associated with Health Utilities Index Mark 3 change scores (p > 0.05). Patients who undergo breast reduction experience an important improvement in health-related quality of life according to four established measures. The improvement is most noticeable between 1 day before surgery and 1 month after surgery, after which it stabilizes for up to 1 year. The health-related quality-of-life effect of the surgery translates into an expected lifetime gain of 5.32 quality-adjusted life years, which is equivalent to each patient living an additional 5.32 years in perfect health. The authors conclude that there is no justification for the ongoing restriction or denials of third-party payments based on body mass index.

Low prevalence of (pre) malignant lesions in the breast and high prevalence in the ovary and Fallopian tube in women at hereditary high risk of breast and ovarian cancer

To analyse the prevalence of (pre) malignant lesions occurring in breast and adnexal tissue at prophylactic surgery in women at hereditary high risk of breast and/or ovarian cancers. Tissue was obtained from 85 women who underwent prophylactic bilateral salpingo-oophorectomy (pBSO) and from 59 women who underwent prophylactic mastectomy (pM). Control tissue samples were obtained from women undergoing breast reduction surgery (N = 99) or adnexal surgery for benign reasons (N = 72). In women with a BRCA1/2 mutation, the prevalence of a (pre) malignant adnexal lesion was 50% (95% CI 26-74) if older than 40 years and 14% (95% CI 0-58) if younger. The prevalences of (pre) malignant breast lesions in women older than 40 years, with and without a BRCA1/2 mutation, were 0% (95% CI 0-16) and 47% (95% CI 21-73), respectively. No association was found between (pre) malignant lesions in breast and adnexal tissue occurring in 28 women who underwent surgery on both organs (R = 0.155, p = 0.432), but the prevalence of lesions was significantly higher in adnexal tissue than in the breast (p = 0.023). Compared to controls, women at hereditary high risk had a higher chance of (pre) malignant lesions in the breast and an even higher chance of such lesions in the adnexal tissue. There was no indication for concomitant presence of such lesions in both organs at the time of prophylactic surgery. The high frequency of (pre) malignant lesions in the adnexal tissue stresses further the importance of pBSO from the age of 40 onwards in women at hereditary high risk.

A nationwide epidemiologic study of breast cancer incidence following breast reduction surgery in a large cohort of Swedish women

While it has been demonstrated that prophylactic mastectomy reduces breast cancer incidence among women at high risk, many women often consider this disfiguring surgery unacceptable. One alternative approach may be breast reduction surgery. In order to evaluate the long-term incidence of breast cancer following surgical removal of breast tissue, we have extended by 9 years the follow-up period of our earlier retrospective cohort study of Swedish women electing cosmetic breast reduction surgery (n=30,444) between 1965 and 1993, yielding an average of nearly 16 years of follow-up. Cancer incidence through 2002 was ascertained via the Swedish Cancer Registry. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated comparing women who underwent breast reduction surgery with women in the general Swedish population. Breast cancer was observed in 443 women versus 624 expected for a statistically significant reduced SIR of 0.71 (95% CI=0.65-0.78). Analyses by age at surgery, time since surgery or calendar year of surgery revealed similar reductions in risk. Our study of over 30,000 women with long-term follow-up offers further evidence that women undergoing breast reduction surgery have reduced breast cancer risk. As the evidence from large-scale cohort studies accumulates, direct testing of this reduction in risk through clinical trials should be considered.

Breast Reduction with Inferior Pedicle Fascial Suspension

The ultimate aim of breast reduction surgery is to reduce breast tissue with long-term maintenance of good breast shape. A technique using interwoven fascial flap suspension of the inferior pedicle through the pectoralis muscle and fascia is described. For this study, 25 patients were followed for 1 year after surgery. The vertical length of the breast between the lower midline of the areola and the new inframammary fold was measured 10 days after surgery and compared with a follow-up measurement 1 year later. These measurements were expressed as a ratio and compared with visual impressions. A ratio of more than 1.3 or a 2-cm difference in length or more was considered representative of breast "bottoming out." This was the case with two patients, both of whom had put on substantial weight after the procedure. The author contends that a consistently reliable technique that maintains good breast shape with more extensive scarring is preferable to a technique that occasionally "gets it right" with less scarring. Good scar management and variations in technique such as the fascial flap suspension described in this report have been of considerable benefit to the author's patients undergoing breast reduction surgery.

The β3-Adrenergic Agonist CL316,243 Inhibits Insulin Signaling but not Glucose Uptake in Primary Human Adipocytes

Insulin resistance and obesity are central components of the metabolic syndrome which has become the leading cause of cardiovascular morbidity and mortality worldwide. Direct interactions of the beta (3)-adrenoceptor system with adipocyte signaling and function in humans remain poorly understood. However, this might have important consequences for the regulation of energy homeostasis and insulin resistance in states of hyperinsulinemia and sympatho-adrenergic overactivity. We therefore investigated beta (3)-adrenoceptor-mediated effects on insulin signaling and glucose uptake in mammary adipocytes of healthy women that underwent breast reduction surgery. Glucose uptake was strongly induced by insulin stimulation. This was paralleled by robust induction of insulin receptor kinase activity, insulin receptor substrate-1-associated phosphatidylinositol-3 kinase activity, and protein kinase B phosphorylation. Treatment with the beta (3)-adrenoceptor-selective agonist CL316,243 alone, neither induced alterations in the early insulin signaling cascade nor changed the basal level of glucose uptake. By contrast, pretreatment with the beta (3)-adrenoceptor agonist inhibited the insulin-induced insulin receptor substrate-1-associated phosphatidylinositol-3 kinase activity by 50 % and protein kinase B phosphorylation by 40 % without affecting insulin receptor kinase activity upstream. However, on the functional level insulin-induced glucose uptake remained unchanged by beta (3)-adrenoceptor stimulation. Our data demonstrate an insulin receptor-independent negative influence of beta (3)-adrenoceptor stimulation on proximal insulin signaling. This inhibition is apparently dissociated from glucose uptake in human adipocytes.

Methodology and measurement properties of health-related quality of life instruments: A prospective study of patients undergoing breast reduction surgery

BackgroundBreast hypertrophy is associated with clinically important morbidity. A prospective study was conducted to assess the change in health-related quality of life (HRQL) following breast reduction mammoplasty. This paper describes the measurement properties of each of the HRQL questionnaires used.MethodsThe reliability, responsiveness, and the construct validity of each HRQL instrument (the Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3) and the Breast Reduction Assessment Value and Outcomes (BRAVO) instruments) were assessed. The BRAVO instruments are a set of separate instruments including the Short Form-36 (SF-36), the Multidimensional Body Self Relations Questionnaire Appearance Assessment (MBSRQ-AS), and the Breast Related Symptoms Questionnaire (BRSQ).ResultsThe HUI2, the HUI3, the MBSRQ-AS, and the breast severity symptom (BSS) score from the BRSQ all demonstrated good test-retest reliability. The SF-36 physical component summary, the MBSRQ-AS, and the BSS score demonstrated high responsiveness. The SF-36 mental component summary and the HUI3 had a moderate effect size and the HUI2 had a small effect size. All of the changes in scales are correlated in the same direction except for the SF-36 physical component summary and the SF-36 mental component summary.ConclusionAll four instruments were found to be reliable and responsive. These instruments can be used in similar clinical settings to evaluate the change in patients' HRQL.

Lobulitis is a frequent finding in prophylactically removed breast tissue from women at hereditary high risk of breast cancer

The aim of this study was to investigate closely the nature of premalignant lesions that occur in prophylactically removed breast tissue from patients at hereditary high risk of breast cancer. Breast tissues obtained from 41 patients who underwent prophylactic mastectomy (pM) because of a hereditary high risk of breast cancer and control tissues from 82 age-matched healthy controls who underwent breast reduction surgery were screened for premalignant lesions. Premalignant and malignant lesions were more frequent (p = 0.0016) in pM samples (5/41) than in controls (1/82). Interestingly, lobulitis, defined as more than 100 lymphocytes and/or plasma cells per lobule in more than one section in morphologically normal lobules, was encountered in 21 of 41 (51%) pM patients, in contrast to only 8 of 82 (10%) controls (p < 0.0001). Preliminary observations indicate a predominance of T-cells in these infiltrates, in agreement with the already known frequent presence of lymphocytic infiltration in hereditary ductal in situ and infiltrating ductal/medullary carcinomas. This novel finding implies an immune reaction to an as yet unidentified antigen frequently present in women at hereditary high risk of breast cancer, possibly as part of an early carcinogenic event.